Estimating migration timing and abundance in partial migratory systems by integrating continuous antenna detections with physical captures

Many populations migrate between two different habitats (e.g. wintering/foraging to breeding area, mainstem-tributary, river-lake, river-ocean, river-side channel) as part of their life history. Detection technologies, such as passive integrated transponder (PIT) antennas or sonic receivers, can be placed at boundaries between habitats (e.g. near the confluence of rivers) to detect migratory movements of marked animals. Often, these detection systems have high detection probabilities and detect many individuals but are limited in their ability to make inferences about abundance because only marked individuals can be detected. Here, we introduce a mark-recapture modelling approach that uses detections from a double-array PIT antenna system to imply movement directionality from arrays and estimate migration timing. Additionally, when combined with physical captures, the model can be used to estimate abundances for both migratory and non-migratory groups and help quantify partial migration. We first test our approach using simulation, and results indicate our approach displayed negligible bias for total abundance (less than ±1%) and slight biases for state-specific abundance estimates (±1%-6%). We fit our model to array detections and physical captures of three native fishes (humpback chub [Gila cypha], flannelmouth sucker [Catostomus latipinnis] and bluehead sucker [Catostomus discobolus]) in the Little Colorado River (LCR) in Grand Canyon, AZ, a system that exhibits partial migration (i.e. includes residents and migrants). Abundance estimates from our model confirm that, for all three species, migratory individuals are much more numerous than residents. There was little difference in movement timing between 2021 (a year without preceding winter/spring floods) and 2022 (a year with a small flood occurring in early April). In both years, flannelmouth sucker arrived in mid-March whereas humpback chub and bluehead sucker arrivals occurred early- to mid-April. With humpback chub and flannelmouth sucker, movement timing was influenced by body size so that large individuals were more likely to arrive early compared to smaller individuals. With more years of data, this model framework could be used to evaluate ecological questions pertaining to flow cues and movement timing or intensity, relative trends in migrants versus residents and ecological drivers of skipped spawning.

Improving the Quality of Magnetic Resonance Cholangiopancreatography Images

The purpose of this study was to address the variability in quality of magnetic resonance cholangiopancreatography (MRCP) images by examining differences in quality grades before and after modifying the MRCP protocol to include placement of physical bellows while scanning. This single institution quality improvement initiative included 727 MRCP examinations performed from July 2019 to December 2020 in patients 18 years and older. The Define, Measure, Analyze, Improve, and Control (DMAIC) strategy was utilized to explore factors related to MRCP image quality and identify solutions that could create effective change. Based on the results of this analysis, MRCP protocols were changed in December 2019 to include physical bellows. Examinations were grouped as occurring either pre- or postintervention as well as whether they occurred in an inpatient or outpatient setting. MRCP examinations were evaluated for quality and labeled either nondiagnostic or diagnostic. A logistic regression model was fit to compare the odds of a diagnostic QA grade between preintervention and postintervention groups and inpatient and outpatient settings. The preintervention group had 41.12% of MRCP studies of diagnostic quality, and the postintervention group had 60.57% of studies of diagnostic quality. The estimated odds of an image being of diagnostic quality in the postintervention group were 2.46 times the odds for the preintervention group across all departments and patient classes (P < 0.001). The estimated odds of an image being of diagnostic quality in the outpatient group were 2.01 times the odds for those in the inpatient group (P < 0.001). Utilizing a standardized quality improvement method can lead to sustained improvements in the diagnostic quality of MRCP studies.

Geriatric Oncology in the Instagram Era: Feasibility and Acceptability Randomised Controlled Trial on Adopting PhotoVoice to Enable Empowerment, Patient-Centred Care, and Shared Decision Making-Study Protocol

Geriatric assessment (GA) is fundamental to optimising cancer care in older adults, yet implementing comprehensive GA tools in real-world clinical settings remains a challenge. This study aims to assess the feasibility and acceptability of integrating information from patient-derived photographs (PhotoVoice) into enhanced supportive care (ESC) for older adults with cancer. A feasibility randomised controlled trial will be conducted at a regional cancer care centre in Australia. Participants aged 70 and above will be randomised into two groups: PhotoVoice plus ESC or usual care (ESC) alone. In the PhotoVoice group, participants will provide four photographs for deduction of representations of different aspects of their lives using photo-elicitation techniques. ESC will be conducted for both groups, incorporating PhotoVoice analysis in the intervention group. PhotoVoice may improve patient-centred care outcomes, including enhanced communication, shared decision making, and identification of patient priorities and barriers. Findings will provide insights into implementing PhotoVoice in geriatric assessment and guide future trials in cancer among older adults.

IMPLEMENTING AND MEASURING IMPACT OF A FIVE-YEAR TRANSLATIONAL GERIATRIC ONCOLOGY RESEARCH PROGRAM

The Geriatric Oncology Regional Victorian Trials Alliance, Linkages, Special populations, Equity program (GO ReViTALISE) is part of a five-year state-wide grant to increase access to cancer clinical trials in regional Victoria, Australia. The initiative covers engagement with key stakeholders and trial sites, co-design of research programs with consumers, implementation of multiple interventional and non-interventional research, and capacity building. Employing a framework prospectively is critical to guide and scaffold implementation of complex interventions and capture the process of how several activities interact. Likewise, there is a need to show research impact beyond successful implementation and clinical outcomes. Using the GO ReViTALISE as a case study, we will demonstrate how an implementation framework and the Framework to Assess the Impact from Translational health research can deliver a cohesive, impactful and measurable program of research to increase older adults’ participation in cancer clinical trials, trials availability and build capacity in regional cancer sites.

Relationship between cardiovascular symptoms, health status assessment and cardiomyopathy in the obstetric population

Background

Pregnancy related cardiomyopathy is a significant cause of maternal morbidity and mortality globally. A presumed overlap between normal pregnancy-associated symptoms and clinical symptoms of cardiomyopathy contributes to delays in diagnosis and increased risk of maternal mortality.

Purpose

We sought to evaluate the association between patient-reported cardiovascular symptoms and the presence of cardiomyopathy among pregnant and postpartum patients. We hypothesize that individual cardiovascular symptoms are unrelated to the presence of cardiomyopathy. We also evaluated the use of a novel adaptation of a validated health status questionnaire in relation to cardiomyopathy.

Methods

We enrolled 48 pregnant (&gt;13 weeks) and postpartum (up to 12 months) participants in a prospective study between October 2021 and February 2022. All study participants completed a baseline questionnaire, which included current cardiovascular symptoms, an assessment of health status using an adapted version of the Kansas City Cardiomyopathy Questionnaire (KCCQ-12), followed by a resting transthoracic echocardiogram on the same day. We defined cardiomyopathy as a left ventricular ejection fraction (LVEF) &lt;50% based on 2-D echocardiography. Fisher's exact and Wilcoxon rank-sum tests were employed to evaluate the association between reported cardiovascular symptoms, the adapted KCCQ-12 (KCC-A) score, and cardiomyopathy.

Results

At the time of enrollment, 67% were pregnant and 33% postpartum. Forty-eight percent identified as White, 31% as Black, 10% as Asian, and 10% as other race. The median age was 31 years (Q1: 28, Q3: 35) and 6% had an LVEF &lt;50%. We found no statistically significant association between four reported cardiovascular symptoms (shortness of breath, orthopnea, fast breathing, and episodes of “asthma” that did not improve with inhalers or other treatment) and cardiomyopathy or medial E/e' ratio. KCC-A scores were low in the study population overall (median 52; Q1:40, Q3: 61). We demonstrated a significantly lower KCC-A score among women with LVEF &lt;50% (median 24; Q1: 15, Q3: 44) compared to women with LVEF ≥50% (median 54; Q1: 44, Q3: 61) p=0.02.

Conclusions

We showed no significant association between individual cardiovascular symptoms and cardiomyopathy in an obstetric population. However, we demonstrate for the first time that an adapted KCCQ-12 questionnaire for health status assessment could potentially identify women with a high-likelihood of cardiomyopathy during the peripartum period who may benefit from additional evaluation including echocardiography. Larger studies are needed to validate this finding.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): This study was funded by a research grant from the Miami Heart Research Institute, Florida Heart Foundation. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health

A Short Report Examining the Introduction of Routine Use of Patient-Reported Outcome Measures in a Mixed Oncology Population

AIMS

People living with treatable but not curable cancer often experience a range of symptoms related to their cancer and its treatment. During the COVID-19 pandemic, face-to-face consultations were reduced and so remote monitoring of these needs was necessary. University Hospitals Sussex implemented the routine use of electronic remote patient-reported outcome measures (PROMs) in a mixed oncology population, focusing on those with treatable but not curable cancers.

MATERIALS AND METHODS

Over a 9-month period, patients were invited to register with My Clinical Outcomes (MCO) - a secure online platform for the collection of electronic PROMs. They were prompted by e-mail to complete assessments (EORTC QLQ-C30, EQ-5D-3L and EQ-5D VAS) routinely every 2 weeks. The team monitored patient scores and changes in these prompted clinical interventions.

RESULTS

In total, 324 patients completed at least one assessment. The median number of assessments completed by each patient was eight. The most represented tumour groups were secondary breast (28%), prostate (25%) and other (32%). Median scores for the assessments did not deteriorate in a clinically or numerically significant way for patients living with non-curable conditions for the majority of patients monitored.

CONCLUSION

Routine collection of electronic remote PROMs is an effective and useful strategy to provide real-time clinical feedback to teams. With integration into existing systems, online platforms (such as MCO) could provide efficient and patient-centred information for those providing care for people with cancer.

Sonographic and genetic findings in a case of asymptomatic spontaneous uterine rupture

An asymptomatic 25-year-old G4P0120 with history significant for cervical insufficiency and classical cesarean delivery 12.5 months prior to conception underwent routine transabdominal ultrasound at 36w4d; umbilical cord was found to be protruding into a fluid-filled pouch extruding from the lower uterine segment. During emergent cesarean delivery, a full-thickness uterine rupture was confirmed; the fetal cranium and umbilical cord were extrauterine. Maternal genotype revealed greater than expected minor allele frequencies for several collagen genes. Maternal gene expression (mRNA) and corresponding microRNA expression of these collagen genes differed several-fold between her G3 (cervical insufficiency, classical cesarean delivery) and G4 (uterine rupture) pregnancies. This case highlights that (1) cervical insufficiency, poor myometrial wound healing, and uterine rupture may co-occur and pathophysiology may be related to collagen abnormalities and (2) asymptomatic uterine rupture can be detected sonographically, even in late pregnancy. Clinicians should remain vigilant for the possibility of uterine rupture, particularly among high-risk patients.

DNMT3A R882 Mutations Confer Unique Clinicopathologic Features in MDS Including a High Risk of AML Transformation

DNMT3A mutations play a prominent role in clonal hematopoiesis and myeloid neoplasms with arginine (R)882 as a hotspot, however the clinical implications of R882 vs. non-R882 mutations in myeloid neoplasms like myelodysplastic syndrome (MDS) is unclear. By data mining with publicly accessible cancer genomics databases and a clinical genomic database from a tertiary medical institution, DNMT3A R882 mutations were found to be enriched in AML (53% of all DNMT3A mutations) but decreased in frequency in clonal hematopoiesis of indeterminate potential (CHIP) (10.6%) or other myeloid neoplasms including MDS (27%) (p<.001). Next with the largest cohort of patients with DNMT3A R882 mutant MDS known to date from multiple institutions, DNMT3A R882 mutant MDS cases were shown to have more severe leukopenia, enriched SRSF2 and IDH2 mutations, increased cases with excess blasts (47% vs 22.5%, p=.004), markedly increased risk of AML transformation (25.8%, vs. 1.7%, p=.0001) and a worse progression-free survival (PFS) (median 20.3, vs. >50 months, p=.009) than non-R882 mutant MDS cases. DNMT3A R882 mutation is an independent risk factor for worse PFS, and importantly the differences in the risk of AML transformation between R882 vs. non-R882 mutant patients cannot be explained by different treatment approaches. Interestingly the higher risk of AML transformation and the worse PFS in DNMT3A R882 mutant MDS cases are mitigated by coexisting SF3B1 or SRSF2 mutations. The unique clinicopathologic features of DNMT3A R882 mutant MDS shed light on the prognostic and therapeutic implications of DNMT3A R882 mutations.

Breast biomechanics, exercise induced breast pain (mastalgia), breast support condition and its impact on riding position in female equestrians

Breast biomechanics, exercise-induced breast pain (EIBP) and performance effects in female athletes are established. Wearing sports bras during exercise reduces breast movement and EIBP. Despite the prevalence of female equestrians, little investigation of breast movement during horse riding exists, yet excessive breast movement, embarrassment and EIBP are reported. Breast movement relative to the torso is linked to EIBP, associated with magnitude and direction of forces generated. Equestrians may experience novel breast and upper-body movement patterns in response to large vertical excursions of the horse. This study aimed to establish relative vertical breast displacement (RVBD), EIBP and positional changes in three support conditions: ‘no support’, ‘low support’ and ‘high support’. Thirty-eight female equestrians rode a Racewood™ Equine Simulator in each breast support condition in medium walk, medium trot (sitting) and medium canter. Trials were filmed and analysed using Quintic® Biomechanics V29. Significant reductions in RVBD (P<0.001) and EIBP (P<0.001) were identified with increased breast support in all gaits. In medium trot (sitting) a significant reduction in range of movement (ROM) of shoulder-elbow-wrist (P<0.001) was seen from low to high support. ROM of torso-vertical angles were reduced from no support to low support (P<0.001) and further by high support (P<0.001). This reduction in ROM was significantly greater in large breasted riders (cup size DD-FF) (n=21) (P<0.001) compared to small breasted (cup size AA-D) (n=17). These results suggest that appropriate breast support positively impacts EIBP and riding position in female riders possibly enhancing performance. As RVBD and reported EIBP were not wholly comparative with results in female runners, further research is warranted to establish breast movement in equestrianism in three dimensions.

Geriatric Oncology in the Instagram Era: PhotoVoice to Enable Patient-Centered Care and Shared Decision Making

Evidence shows that multidimensional assessment of older adults with cancer yields more holistic care and results in better communication about age-related concerns; as well as enables personalised, patient-centered supportive care. Geriatric assessment (GA) captures clinical, physical and psychological factors, with limited opportunity to gather information about the patient’s environment, personal contexts and priorities. We trialed the feasibility and acceptability of geriatric assessment (GA)-guided enhanced supportive care (ESC) among 20 adults aged over 70 years in a regional cancer center. We then studied the impact of the integration of four patient-derived photographs (with PhotoVoice analysis) to this ESC on patient satisfaction with communication with the oncologist regarding age-related concerns and on facilitating empowerment, patient-centered care and shared decision making. The use of PhotoVoice analysis of patient-derived photographs is a novel strategy that can facilitate gathering patient-centered information during the assessment process.

POS0051 THE IMPACT OF COVID-19 ON RHEUMATOLOGY TRAINING: RESULTS FROM THE COVID-19 GLOBAL RHEUMATOLOGY ALLIANCE TRAINEE SURVEY

Background:

The COVID-19 pandemic has disrupted healthcare delivery and education of physicians, including rheumatology trainees.

Objectives:

To assess the impact of the COVID-19 pandemic on the clinical experiences, research opportunities, and well-being of rheumatology trainees.

Methods:

A voluntary, anonymous, web-based survey was administered in English, Spanish, or French from 19/08/2020 to 05/10/2020. Adult and paediatric rheumatology trainees worldwide in training in 2020 were invited to participate via social media and email. Using multiple choice questions, Likert scales, and free text answers, we assessed trainee patient care activities, redeployment, research, and well-being.

Results:

The 302 respondents were from 33 countries, with most (83%, 252/302) in adult rheumatology training. Many trainees (45%, 135/300) reported an increase in non-rheumatology clinical work (e.g. care of COVID-19 patients), with 52% of these (70/135) also continuing rheumatology clinical work. COVID-19 redeployment was not optional for 68% (91/134).

Trainees reported a negative impact of the pandemic in their growth in rheumatology (Figure 1). They also reported a substantial impact on several training areas: outpatient clinics (79%, 238/302), inpatient consultations (59%, 177/302), formal teaching (55%, 167/302), procedures (53%, 147/302), teaching opportunities (52%, 157/302), and ultrasonography (36%, 110/302), with 87-96% perceiving a negative impact on these areas. Only 54% (159/294) reported feeling comfortable with their level of clinical supervision during the pandemic (Figure 1).

Many trainees (46%, 128/280) reported changes in research experiences during the pandemic; 39% (110/285) reported that COVID-19 negatively affected their ability to continue their pre-pandemic research and 50% (142/285) reported difficulty maintaining research goals (Figure 1).

Some rheumatology trainees reported having health condition(s) putting them at high risk for COVID-19 (10%, 30/302) and 14% of trainees (41/302) reported having had COVID-19 (Table 1). Only 53% (160/302) reported feeling physically safe in the workplace while 25% (76/302) reported not feeling physically safe; reasons included lack of training about COVID-19, lack of comfort in the clinical setting, insufficient personal protective equipment, immunocompromised state, and pregnancy. Half (151/302) reported burnout and 68% (204/302) an increase in stress from work during the pandemic (Figure 1), whilst 25% (75/302) reported that changes to their training programme negatively impacted their physical health.

Conclusion:

The COVID-19 pandemic has negatively impacted the experience of rheumatology training as well as the well-being of trainees globally. Our data highlight concerns for rheumatology trainees including research opportunities and clinical care which should be a focus for curriculum planning.

Figure 1.

Rheumatology trainee perceptions of pandemic impact and changes in training programme.

Table 1.

Estimated hazard ratios, adjusted for age and gender, for individuals with rheumatoid arthritis

Europen = 89ROWn = 213Combinedn = 302Disability1 (1)9 (4)10 (3)High risk7 (8)23 (11)30 (10)Pregnant4 (5)15 (7)19 (6)Shielding/Quarantining12 (13)70 (33)82 (27)Acquired COVID-1920 (22)21 (10)41 (14)

Disclosure of Interests:

Kristen Young: None declared, Su-Ann Yeoh: None declared, Michael Putman: None declared, Elizabeth Graef: None declared, Francis Berenbaum: None declared, Richard Conway: None declared, Rebecca Grainger Speakers bureau: Speaker fees from Abbvie, Janssen, Novartis, Pfizer, Cornerstones, all not related to this work, Consultant of: Consultancy fees from Abbvie, Janssen, Novartis, Pfizer, Cornerstones, all not related to this work, Grant/research support from: Travel assistance from Pfizer, not related to this work, Adam Kilian: None declared, Maximilian Konig: None declared, Jean Liew Grant/research support from: Research grant from Pfizer unrelated to this manuscript, Pedro M Machado Speakers bureau: Speaker fees from Abbvie, BMS, Celgene, Eli Lilly, Janssen, MSD, Novartis, Orphazyme, Pfizer, Roche and UCB, all unrelated to this manuscript, Consultant of: Consulting fees from Abbvie, BMS, Celgene, Eli Lilly, Janssen, MSD, Novartis, Orphazyme, Pfizer, Roche and UCB, all unrelated to this manuscript, Sebastian E. Sattui: None declared, Jeffrey Sparks Consultant of: Consultancy for Bristol-Myers Squibb, Gilead, Inova Diagnostics, Optum, and Pfizer unrelated to this manuscript, Grant/research support from: Research support from Bristol-Myers Squibb unrelated to this manuscript, Paul Sufka: None declared, Manuel Ugarte-Gil Grant/research support from: Research grants from Janssen and Pfizer unrelated to this manuscript, Laura Upton: None declared, Zachary Wallace: None declared, Jinoos Yazdany Consultant of: Consultancy for Astra Zeneca, Eli Lilly, and Pfizer, not related to this work, Grant/research support from: Research grants from Gilead and Pfizer, not related to this work, Arundathi Jayatilleke: None declared.

AB0674 RAPID ADOPTION OF TELEMEDICINE IN RHEUMATOLOGY TRAINING: RESULTS FROM THE COVID-19 GLOBAL RHEUMATOLOGY ALLIANCE TRAINEE SURVEY

Background:

The COVID-19 pandemic led to a rapid increase in remote consultations in rheumatology care. Due to the potential impact of this change on rheumatology clinical training, we investigated trainees’ experiences with telemedicine.

Objectives:

To assess the impact of telemedicine use during the COVID-19 pandemic on rheumatology training, including supervision.

Methods:

A voluntary, anonymous web-based survey was administered in English, Spanish, or French from 19/08/2020 to 05/10/2020. Adult and paediatric rheumatology trainees worldwide in training in 2020 were invited to participate via social media and email. Using multiple choice questions, Likert scales, and free text answers, we collected data regarding prior and current telemedicine use, training, and supervision.

Results:

302 respondents from 33 countries completed the survey, with most (83%, 252/302) in adult rheumatology training. Reported use of telemedicine increased from 13% (39/302) pre-pandemic to 82% (247/302) (Table 1). European trainees predominantly utilised audio-only compared to trainees from the rest of the world (ROW) who predominantly utilised audio-video telemedicine.

Most trainees continued to evaluate new patients using telemedicine (65%, 161/247). A larger proportion of trainees were comfortable using telemedicine to evaluate follow-up (69% 170/247) versus new patients (25%, 41/161) (Figure 1).

Only 32% (97/302) were trained in telemedicine, with the highest proportion among United States (US) trainees (59%, 69/116); subjects included software, clinical skills, and billing. The majority of trainees found this helpful (92%, 89/97).

Supervision was most frequently in the form of verbal discussion after the consultation (Table 1); 24% (59/247) had no telemedicine supervision during the pandemic. In general, trainees found telemedicine negatively impacted their supervision (51%, 123/242) and clinical teaching quality (70%, 171/244); only 9% reported a positive impact on these areas.

Conclusion:

Adoption of telemedicine during the COVID-19 pandemic has led to areas of concern for rheumatology trainees including inadequate supervision and clinical teaching. Our results suggest a need for education on evaluation of new patients using telemedicine, increasing telemedicine training, and ensuring adequate supervisory arrangements.

Table 1.

Telemedicine use, supervision, and training by region. Data is presented as n (%). Rest of the world (ROW) data includes Asia (50), Central and South America (23), Canada (12), Australia (8), and Africa (4).

Europen = 89USn = 116ROWn = 97Combinedn = 302Telemedicine usePre-pandemic15 (17)9 (8)15 (15)39 (13)During pandemic64 (72)112 (97)71 (73)247 (82)Telemedicine modalitypre-pandemicAudio-only14 (93)3 (33)8 (53)25 (64)Audio-video1 (7)7 (78)7 (47)15 (38)Telemedicine modality during pandemicAudio-only56 (88)47 (42)51 (72)154 (62)Audio-video7 (11)100 (89)29 (41)136 (55)Supervisionpre-pandemicReal-time observation (part of visit)0 (0)4 (44)3 (20)7 (18)Real-time observation (full visit)0 (0)2 (22)2 (13)4 (10)Verbal discussion after8 (53)3 (33)7 (47)18 (46)Written communication after0 (0)0 (0)1 (7)1 (3)None7 (47)2 (22)5 (33)14 (36)Supervision during pandemicReal-time observation (part of visit)2 (3)54 (48)15 (21)71 (29)Real-time observation (full visit)3 (5)32 (29)8 (11)43 (17)Verbal discussion after32 (50)65 (58)28 (39)125 (51)Written communication after7 (11)15 (13)9 (13)31 (13)None28 (44)9 (8)22 (31)59 (24)Figure 1.

Rheumatology trainee comfort levels in using telemedicine during the pandemic.

Disclosure of Interests:

Su-Ann Yeoh: None declared, Kristen Young: None declared, Michael Putman: None declared, Elizabeth Graef: None declared, Francis Berenbaum: None declared, Richard Conway: None declared, Rebecca Grainger Speakers bureau: Speaker fees from Abbvie, Janssen, Novartis, Pfizer, Cornerstones, all not related to this work, Consultant of: Consultancy fees from Abbvie, Janssen, Novartis, Pfizer, Cornerstones, all not related to this work, Grant/research support from: Travel assistance from Pfizer, not related to this work, Adam Kilian: None declared, Maximilian Konig: None declared, Jean Liew Grant/research support from: Research grant from Pfizer unrelated to this manuscript, Pedro M Machado Speakers bureau: Speaker fees from Abbvie, BMS, Celgene, Eli Lilly, Janssen, MSD, Novartis, Orphazyme, Pfizer, Roche and UCB, all unrelated to this manuscript, Consultant of: Consulting fees from Abbvie, BMS, Celgene, Eli Lilly, Janssen, MSD, Novartis, Orphazyme, Pfizer, Roche and UCB, all unrelated to this manuscript, Sebastian E. Sattui: None declared, Jeffrey Sparks Consultant of: Consultancy for Bristol-Myers Squibb, Gilead, Inova Diagnostics, Optum, and Pfizer unrelated to this manuscript, Grant/research support from: Research support from Bristol-Myers Squibb unrelated to this manuscript, Paul Sufka: None declared, Manuel Ugarte-Gil Grant/research support from: Research grants from Janssen and Pfizer unrelated to this manuscript, Laura Upton: None declared, Zachary Wallace: None declared, Jinoos Yazdany Consultant of: Consultancy for Astra Zeneca, Eli Lilly, and Pfizer, not related to this work, Grant/research support from: Research grants from Gilead and Pfizer, not related to this work, Arundathi Jayatilleke: None declared

540 Point of Care Testing for Tetanus Immunity: A Systematic Review

Introduction

All patients presenting to emergency departments (EDs) with traumatic injuries require tetanus immunity assessments. Inaccurate tetanus vaccination history based on patient recall incurs unnecessary costs on the NHS. Point-of-care immunochromatographic tests (Tetanus Quick Sticks [TQS]) quickly identify tetanus immunity status. We aim to evaluate the diagnostic accuracy and cost-efficacy of TQS to assess their relevance in emergency care.

Method

The systematic review followed PRISMA guidelines. A retrospective search of MEDLINE, Embase, Global Health, HMIC and The Cochrane Library was conducted. Studies were eligible if sensitivity, specificity, or cost-efficacy of TQS were reported. At least two authors independently analysed the data from each study.

Results

12 studies were suitable for inclusion (n = 1,662,865 participants): one retrospective and 11 prospective observational cohort studies. Eight studies assessed diagnostic accuracy with the median sensitivity at 86% (55-100) and the median specificity at 97.5% (1-100). All six studies investigating cost-efficacy reported greater savings when using TQS instead of using vaccination history, due to a decrease in unnecessary tetanus vaccine and immunoglobulin administration.

Conclusions

TQS is a safe diagnostic tool, especially when used by trained operators. TQS widely reduces costs in comparison to traditional vaccination history. We recommend the use of TQS in Emergency Departments throughout the NHS.

Nasal Trauma: Who Nose what happens to the non-manipulated?

BACKGROUND

Nasal trauma is the most common facial injury worldwide. Prompt assessment allows for recognition of injuries requiring surgical intervention in the form of nasal bone manipulation. The literature is unclear to what extent patients undergoing conservative management subsequently require surgical intervention.

METHODS

A retrospective chart review of all patients presenting with nasal injury between July 2017 and July 2018 who underwent conservative and surgical management was undertaken. Re-referral and subsequent surgical intervention were documented.

RESULTS

In a cohort of 390 patients with nasal injury 229 patients underwent conservative management. Average age was 29 years. Males comprised 60% of our conservative cohort and 81% of the manipulated cohort. 8.3% of patients managed conservatively and 12% of those undergoing manipulation were re-referred.

CONCLUSION

Nasal trauma assessment is a significant workload for an ENT unit. Conservative management is appropriate following clinical assessment and does not lead to increased intervention compared with those who are surgically manipulated.

Higher Resolution Charge Detection Mass Spectrometry

Charge detection mass spectrometry is a single particle technique where the masses of individual ions are determined from simultaneous measurements of each ion's m/z ratio and charge. The ions pass through a conducting cylinder, and the charge induced on the cylinder is detected. The cylinder is usually placed inside an electrostatic linear ion trap so that the ions oscillate back and forth through the cylinder. The resulting time domain signal is analyzed by fast Fourier transformation; the oscillation frequency yields the m/z, and the charge is determined from the magnitudes. The mass resolving power depends on the uncertainties in both quantities. In previous work, the mass resolving power was modest, around 30-40. In this work we report around an order of magnitude improvement. The improvement was achieved by coupling high-accuracy charge measurements (obtained with dynamic calibration) with higher resolution m/z measurements. The performance was benchmarked by monitoring the assembly of the hepatitis B virus (HBV) capsid. The HBV capsid assembly reaction can result in a heterogeneous mixture of intermediates extending from the capsid protein dimer to the icosahedral T = 4 capsid with 120 dimers. Intermediates of all possible sizes were resolved, as well as some overgrown species. Despite the improved mass resolving power, the measured peak widths are still dominated by instrumental resolution. Heterogeneity makes only a small contribution. Resonances were observed in some of the m/z spectra. They result from ions with different masses and charges having similar m/z values. Analogous resonances are expected whenever the sample is a heterogeneous mixture assembled from a common building block.

Revision of Alberta's Provincial Insulin Pump Therapy Criteria for Adults and Children With Type 1 Diabetes: Process, Rationale and Framework for Evaluation

OBJECTIVES

Insulin pump therapy is a valuable, but costly approach, with public funding in Alberta for eligible individuals since 2013. The Provincial Insulin Pump Therapy Program Clinical Advisory Committee has revised and updated the clinical criteria, integrating current literature, best practice and feedback from clinicians. The objective was to develop criteria that would: 1) optimize safety and effectiveness of insulin pump therapy, while 2) carefully stewarding resources available to care for people with type 1 diabetes.

METHODS

The Clinical Advisory Committee comprised health-care professionals with expertise in pump therapy and included adult and pediatric endocrinologists, an internist, a pediatrician, certified pump trainers, diabetes educators and clinic managers. The group meets regularly by teleconference. Decisions are made by consensus.

RESULTS

Indications for insulin pump therapy for adults and children with insulin-deficient diabetes were divided into 4 hierarchical levels: 1) problematic hypoglycemia, inability to achieve acceptable control or progressive complications; 2) unpredictable activity, dawn phenomenon or children for whom use of multiple daily injections is not appropriate; 3) individual preference and 4) clinical exception, with priority given to indications with clear evidence of benefit. The criteria emphasize the importance of: 1) adequate education in diabetes self-management; 2) adequate trial of flexible insulin therapy with modern analogues and 3) evidence of active, safe diabetes self-management. Tools to facilitate effective and efficient annual review and surveillance were developed incorporating biological, behavioural evaluation and self-reflection to provide a framework for program evaluation. The recommendations were implemented in January 2019.

CONCLUSIONS

The process and revised criteria may be valuable for jurisdictions considering how to develop and implement a publicly funded insulin pump program.

Ecological drivers of female lion (Panthera leo) reproduction in the Kruger National Park

The role of social cues in the reproduction of social mammals, particularly carnivores, has been thoroughly studied and documented in literature. However, environmental cues such as resources of water, food, and shelter have been identified to a lesser extent. Pregnant lions (Panthera leo) are notoriously secretive during the final stages of pregnancy and postpartum. Behavioral indicators depicted by movement patterns obtained by remote detection of collared female lions in the Kruger National Park were necessary for the monitoring of birth timing. Over the study period, eight plus a potential three parturition incidences of collared females were recorded. Of the variables measured (step length, range size, duration, prey biomass, and rainfall), range size during the month of parturition was the most indicative movement pattern of a successful birth. By backdating the potential birth month of the litters, date of conception was calculated and our results revealed a correlation between the birthing peaks of preferred prey during the month of conception. Birth timing in conjunction with remote sensing and ecological factors were thus identified behaviors associated with denning.

Clinical Validation of Targeted and Untargeted Metabolomics Testing for Genetic Disorders: A 3 Year Comparative Study

Global untargeted metabolomics (GUM) has entered clinical diagnostics for genetic disorders. We compared the clinical utility of GUM with traditional targeted metabolomics (TM) as a screening tool in patients with established genetic disorders and determined the scope of GUM as a discovery tool in patients with no diagnosis under investigation. We compared TM and GUM data in 226 patients. The first cohort (n = 87) included patients with confirmed inborn errors of metabolism (IEM) and genetic syndromes; the second cohort (n = 139) included patients without diagnosis who were undergoing evaluation for a genetic disorder. In patients with known disorders (n = 87), GUM performed with a sensitivity of 86% (95% CI: 78–91) compared with TM for the detection of 51 diagnostic metabolites. The diagnostic yield of GUM in patients under evaluation with no established diagnosis (n = 139) was 0.7%. GUM successfully detected the majority of diagnostic compounds associated with known IEMs. The diagnostic yield of both targeted and untargeted metabolomics studies is low when assessing patients with non-specific, neurological phenotypes. GUM shows promise as a validation tool for variants of unknown significance in candidate genes in patients with non-specific phenotypes.

The synergy of TLR and STING in cancer immunity

Adjuvants are essential components of cancer vaccine formulations to promote effective immune responses. We initially screened multiple immune-activating targets, including TLR and STING adjuvants using in-vitro assays to test their ability to activate bone marrow DC (BMDC) and showed STING had the most potent activation (i.e., MHC and co-stimulatory molecules) on DCs. Since STING and TLR signaling is non-redundant, TLR and STING adjuvants were combined to enhance DC activation. We utilized the multidimensional synergy of combinations (MuSyc), a novel synergy algorithm, to assess molecular synergy in combining STING and TLR adjuvants, and we noted that the combination of R848 (TLR7-8) plus STING agonists provided a synergistic efficacious and potent response on BMDCs. From this data-set, we generated a MuSYC synergy strategy where we will utilize max signal dose for STING adjuvant and ten times less of max signal dose for R848 (TLR7-8) to determine synergy for other assays. We tested this same MuSYC strategy for activation of human monocytic cell line THP-1 and determined that the synergy strategy induced similar or better activation effects compared to the max signal dose for both adjuvants. Finally, we tested the in-vivo anti-tumor immune response for the B16 melanoma and MOC2 head/neck tumor-bearing vaccination models that resulted in an improved anti-tumor response for the combinatorial STING-TLR adjuvanted vaccines compared to the single agents.

Metabolic barriers imposed on tumor associated macrophages

Macrophages comprise a broad spectrum of heterogeneous cell population with diverse functions in immune responses in pathological conditions including cancer, inflammation and infection. Macrophages are extremely plastic in nature and highly specialized in sensing their microenvironment which governs their functional phenotype. Simplistically, macrophages can be categorized into classical inflammatory or M1 type and anti-inflammatory or M2 type. While the M1 macrophages play a crucial role in activating immune responses and release a wide array of pro-inflammatory and cytotoxic molecules, M2 macrophages facilitate resolution of inflammation by secreting immunosuppressive anti-inflammatory factors, phagocytosing and clearing apoptotic debris and promoting sustainability of regulatory T cells while suppressing effector T cells. Emerging evidences indicate an intimate connection between a robust switch in metabolic adaptations and different classes of macrophages. Tumor associated macrophages (TAM) are abundantly present in tumor microenvironments and can account for up to 50% of myeloid infiltrate in some types of human solid malignancies and contribute to disease progression, therapy resistance and clinical outcome. However, the metabolic circuitries in TAM underlying their ability to sustain tumor evolution and influence their own functional polarization is complicated and less characterized in many tumor types. In the current study, using multi-prong approaches like bulk myeloid as well as single cell RNA sequencing as well as functional assays, we highlight the metabolic pattern of TAMs in head and neck cancer and melanoma and propose immunometabolic strategies to harness TAM for controlling tumor growth.

Longitudinal optic neuritis-unrelated visual evoked potential changes in NMO spectrum disorders

OBJECTIVE

To investigate if patients with neuromyelitis optica spectrum disorder (NMOSD) develop subclinical visual pathway impairment independent of acute attacks.

METHODS

A total of 548 longitudinally assessed full-field visual evoked potentials (VEP) of 167 patients with NMOSD from 16 centers were retrospectively evaluated for changes of P100 latencies and P100-N140 amplitudes. Rates of change in latencies (RCL) and amplitudes (RCA) over time were analyzed for each individual eye using linear regression and compared using generalized estimating equation models.

RESULTS

The rates of change in the absence of optic neuritis (ON) for minimal VEP intervals of ≥3 months between baseline and last follow-up were +1.951 ms/y (n = 101 eyes; SD = 6.274; p = 0.012) for the P100 latencies and -2.149 µV/y (n = 64 eyes; SD = 5.013; p = 0.005) for the P100-N140 amplitudes. For minimal VEP intervals of ≥12 months, the RCL was +1.768 ms/y (n = 59 eyes; SD = 4.558; p = 0.024) and the RCA was -0.527 µV/y (n = 44 eyes; SD = 2.123; p = 0.111). The history of a previous ON >6 months before baseline VEP had no influence on RCL and RCA. ONs during the observational period led to mean RCL and RCA of +11.689 ms/y (n = 16 eyes; SD = 17.593; p = 0.003) and -1.238 µV/y (n = 11 eyes; SD = 3.708; p = 0.308), respectively.

CONCLUSION

This first longitudinal VEP study of patients with NMOSD provides evidence of progressive VEP latency delay occurring independently of acute ON. Prospective longitudinal studies are needed to corroborate these findings and help to interpret the clinical relevance.

Virtual Student Collaboration: Connecting Student Health Professionals

This pilot study aimed to provide students with a learning activity to develop a global perspective of health care. Senior nursing students from New Zealand and the United Kingdom (n=15) were allocated to eNetwork small-groups. Students met weekly for one month via audio/video-conferencing for discussions. Students reported that this collaborative activity enabled them to engage purposefully with other students. While cultural differences were noted, similarities were also found and multiplestudents expressed interest in working overseas.

Should individuals use influenza vaccine effectiveness studies to inform their decision to get vaccinated?

Studies on the effectiveness of seasonal influenza vaccine can affect an individual's perception of the ability of this vaccine to protect against influenza. However, vaccine effectiveness studies are designed to inform public health decisions rather than for individual decision-making. This overview explains what vaccine effectiveness means and why vaccine effectiveness estimates can vary. Individual variation in the response to seasonal influenza vaccine is based upon risk factors such as age, underlying health conditions, immune status and risk of infection and complications. Therefore, an individual's decision to get vaccinated should be primarily informed by their risk of influenza illness and their risk of transmitting influenza to vulnerable people.

Decision-centred design in healthcare: The process of identifying a decision support tool for airway management

Current decision support interventions for airway management in anaesthesia lack the application of Human Factors Engineering; leading to interventions that can be disruptive, inefficient and error-inducing. This study followed a decision-centred design process to identify decision support that can assist anaesthesia teams with challenging airway management situations. Field observations, Critical Decision Method interviews and focus groups were conducted to identify the most difficult decisions and their requirements. Data triangulation narrowed the focus to key decisions related to preparation and planning, and the transitioning between airway techniques during difficulties. Five decision-support interventions were identified and positively rated by anaesthesia team members in relation to their perceived effectiveness. An organized airway equipment trolley was chosen as the most beneficial decision support intervention. This study reiterated the key importance of both Human Factors Engineering and data triangulation when designing for healthcare.