Analysis of the yearly transition function in measles disease modeling

Globally, there were an estimated 9.8 million measles cases and 207 500 measles deaths in 2019. As the effort to eliminate measles around the world continues, modeling remains a valuable tool for public health decision-makers and program implementers. This study presents a novel approach to the use of a yearly transition function that formulates mathematically the vaccine schedules for different age groups while accounting for the effects of the age of vaccination, the timing of vaccination, and disease seasonality on the yearly number of measles cases in a country. The methodology presented adds to an existing modeling framework and expands its analysis, making its utilization more adjustable for the user and contributing to its conceptual clarity. This article also adjusts for the temporal interaction between vaccination and exposure to disease, applying adjustments to estimated yearly counts of cases and the number of vaccines administered that increase population immunity. These new model features provide the ability to forecast and compare the effects of different vaccination timing scenarios and seasonality of transmission on the expected disease incidence. Although the work presented is applied to the example of measles, it has potential relevance to modeling other vaccine-preventable diseases.

Studies on the novel effects of electron beam treated pollen on colony reproductive output in commercially-reared bumblebees (Bombus terrestris) for mass pollination applications

Commercially-reared bumblebees provide an important pollinator service that helps support food production and security. The deployment of an appropriate non-thermal disinfection technology for the bulk treatment of pollen collected from honeybees for the feeding of commercial bumblebees is important in order to mitigate against complex diseases and unwanted pathogen spillover to native bees. High level disinfection of pollen was achieved using an electron (e)-beam dose of 100 kGy that corresponded to 78 % loss of cellular viability of bee pathogens before feeding to bumblebees as measured by the novel in vitro use of flow cytometry (FCM). Novel findings showed that e-beam treated-pollen that was fed to bumblebees produced fewer females, gynes and exhibited an absence of males when compared to control bumblebee colonies that were fed untreated commercial pollen. A similar trend emerged in bumblebee colony reproductive outputs when using membrane filtered washed pollen. Proteomic analysis of bumblebees from individual colonies fed with treated-pollen revealed a differential abundance of proteins associated with stress, immunity and metabolism when compared to the untreated pollen control group. Microbiome analysis of the bumblebee gut content revealed differences in microbiota between treated and untreated pollen in bumblebee colony studies. This novel study evaluated the impact of industrial e-beam treated-pollen on complex bee disease mitigation where physically treated-pollen fed to bumblebees was shown to substantially affect colony reproductive outputs.

Biological and JAK inhibitor therapy outcomes for severe psoriasis in trisomy 21

Little is known about biological outcomes for severe psoriasis in trisomy 21 (T21). Our aim was to review outcomes of patients with T21 and severe psoriasis treated with biologic or Janus kinase inhibitors (JAKi). Information on demographics, co-morbidities, and therapeutic responses was retrospectively collated. Twenty-one patients were identified (mean age 24.7 years). Ninety percent (18/20) of TNFα inhibitor trials failed. Almost two-thirds (7/11) of patients achieved an adequate response with ustekinumab. All three patients treated with tofacitinib achieved an adequate response following at least three biologic failures. The mean number of biologic/JAKi therapies received was 2.1 with overall survival of 36%. Eighty-one percent (17/21) of patients required conversion from their index biologic treatment due to failure. In patients with T21 and severe psoriasis, failure of TNFα inhibition is common and ustekinumab therapy should be considered as first-line therapy. The role of JAKi is emerging.

Palliative care for persons with late-stage Alzheimer's and related dementias and their caregivers: protocol for a randomized clinical trial

BACKGROUND

Limited access to specialized palliative care exposes persons with late-stage Alzheimer's disease and related dementias (ADRD) to burdensome treatment and unnecessary hospitalization and their caregivers to avoidable strain and financial burden. Addressing this unmet need, the purpose of this study was to conduct a randomized clinical trial (RCT) of the ADRD-Palliative Care (ADRD-PC) program.

METHODS

The study will use a multisite, RCT design and will be set in five geographically diverse US hospitals. Lead investigators and outcome assessors will be masked. The study will use 1:1 randomization of patient-caregiver dyads, and sites will enroll N = 424 dyads of hospitalized patients with late-stage ADRD with their family caregivers. Intervention dyads will receive the ADRD-PC program of (1) dementia-specific palliative care, (2) standardized caregiver education, and (3) transitional care. Control dyads will receive publicly available educational material on dementia caregiving. Outcomes will be measured at 30 days (interim) and 60 days post-discharge. The primary outcome will be 60-day hospital transfers, defined as visits to an emergency department or hospitalization ascertained from health record reviews and caregiver interviews (aim 1). Secondary patient-centered outcomes, ascertained from 30- and 60-day health record reviews and caregiver telephone interviews, will be symptom treatment, symptom control, use of community palliative care or hospice, and new nursing home transitions (aim 2). Secondary caregiver-centered outcomes will be communication about prognosis and goals of care, shared decision-making about hospitalization and other treatments, and caregiver distress (aim 3). Analyses will use intention-to-treat, and pre-specified exploratory analyses will examine the effects of sex as a biologic variable and the GDS stage.

DISCUSSION

The study results will determine the efficacy of an intervention that addresses the extraordinary public health impact of late-stage ADRD and suffering due to symptom distress, burdensome treatments, and caregiver strain. While many caregivers prioritize comfort in late-stage ADRD, shared decision-making is rare. Hospitalization creates an opportunity for dementia-specific palliative care, and the study findings will inform care redesign to advance comprehensive dementia-specific palliative care plus transitional care.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04948866. Registered on July 2, 2021.

Evolution of a minimal cell

Possessing only essential genes, a minimal cell can reveal mechanisms and processes that are critical for the persistence and stability of life1,2. Here we report on how an engineered minimal cell3,4 contends with the forces of evolution compared with the Mycoplasma mycoides non-minimal cell from which it was synthetically derived. Mutation rates were the highest among all reported bacteria, but were not affected by genome minimization. Genome streamlining was costly, leading to a decrease in fitness of greater than 50%, but this deficit was regained during 2,000 generations of evolution. Despite selection acting on distinct genetic targets, increases in the maximum growth rate of the synthetic cells were comparable. Moreover, when performance was assessed by relative fitness, the minimal cell evolved 39% faster than the non-minimal cell. The only apparent constraint involved the evolution of cell size. The size of the non-minimal cell increased by 80%, whereas the minimal cell remained the same. This pattern reflected epistatic effects of mutations in ftsZ, which encodes a tubulin-homologue protein that regulates cell division and morphology5,6. Our findings demonstrate that natural selection can rapidly increase the fitness of one of the simplest autonomously growing organisms. Understanding how species with small genomes overcome evolutionary challenges provides critical insights into the persistence of host-associated endosymbionts, the stability of streamlined chassis for biotechnology and the targeted refinement of synthetically engineered cells2,7-9.

Update of penetrance estimates in Birt-Hogg-Dubé syndrome

BACKGROUND

Birt-Hogg-Dubé (BHD) syndrome is a rare genetic syndrome caused by pathogenic or likely pathogenic germline variants in the FLCN gene. Patients with BHD syndrome have an increased risk of fibrofolliculomas, pulmonary cysts, pneumothorax and renal cell carcinoma. There is debate regarding whether colonic polyps should be added to the criteria. Previous risk estimates have mostly been based on small clinical case series.

METHODS

A comprehensive review was conducted to identify studies that had recruited families carrying pathogenic or likely pathogenic variants in FLCN. Pedigree data were requested from these studies and pooled. Segregation analysis was used to estimate the cumulative risk of each manifestation for carriers of FLCN pathogenic variants.

RESULTS

Our final dataset contained 204 families that were informative for at least one manifestation of BHD (67 families informative for skin manifestations, 63 for lung, 88 for renal carcinoma and 29 for polyps). By age 70 years, male carriers of the FLCN variant have an estimated 19% (95% CI 12% to 31%) risk of renal tumours, 87% (95% CI 80% to 92%) of lung involvement and 87% (95% CI 78% to 93%) of skin lesions, while female carriers had an estimated 21% (95% CI 13% to 32%) risk of renal tumours, 82% (95% CI 73% to 88%) of lung involvement and 78% (95% CI 67% to 85%) of skin lesions. The cumulative risk of colonic polyps by age 70 years old was 21% (95% CI 8% to 45%) for male carriers and 32% (95% CI 16% to 53%) for female carriers.

CONCLUSIONS

These updated penetrance estimates, based on a large number of families, are important for the genetic counselling and clinical management of BHD syndrome.

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

12 VACCINATION UP-TAKE IN DERMATOLOGY PATIENTS OVER THE AGE OF 65 YEARS ON BIOLOGICAL TREATMENT

Background

Biologic and immunosuppressive therapies play important roles in the management of a wide variety of dermatologic diseases. However, immunotherapies can negatively affect normal immune functioning, placing these patients at high risk of infection. The strength of the immune system also declines with increasing age. Thus, in accordance with the British Association of Dermatology guidelines (August 2021), patients taking biologic therapy can and should have their covid, influenza and pneumococcal vaccinations.

Methods

We conducted a retrospective audit of all patients over the age of 65 years on biological therapy in the dermatology clinic between March 2021 to March 2022. Data on patients covid, influenza and pneumococcal vaccination status was obtained from Dermatology database and patients medical records.

Results

A total of 18 patients over the age of 65 years, were on biological therapy in the Dermatology Department, between March 2021 to March 2022. The mean age was found to be 71 years with a standard deviation of 5.2 and there was equal gender distribution. 94% (n=17) of patients had psoriasis and 6% (n=1) had eczema. With regards to biological treatments, 17% (n=3) of patients were on Adalimumab,11% (n=2) on Etanercept and 28% (n=5) on Cosntyx. 100% (n=18) had all three of their covid-19 vaccines. 50% (n=8) are awaiting their 4th covid vaccination. 94% (n=17) of patients had their influenza vaccine. 66% (n=12) had their pneumococcal vaccination, the patients who had not had their pneumococcal vaccination were recommended and advised to have it.

Conclusion

This audit confirms dermatology patients over the age of sixty-five years, are compliant on receiving their covid vaccinations, as recommended by the BAD. However, only 66% of patients had their pneumococcal vaccination and 94% had their influenza vaccine, illustrating the need for educational intervention on the importance of vaccination. This will then be followed by a reaudit next year to complete the audit cycle.

SARS-CoV-2 Testing and Patient Waiting Times in the Emergency Department

Aim Emergency Departments (EDs) were impacted early in the coronavirus disease 2019 (COVID-19) pandemic, with high attendance numbers. EDs relied upon SARS-CoV-2 reverse-transcriptase polymerase chain reaction (RT-PCR) tests to triage patients and facilitate admission to appropriate wards, meaning positive patients were isolated as early as possible. In October 2020, we introduced a 24-hour SARS-CoV-2 testing service. We examined the impact of this on patient experience times (PETs) in the ED, and on healthcare-associated (HA) COVID-19 infections. Methods Data on PETs before and after the introduction of 24-hour testing were available from the ED. HA COVID-19 infections were reported weekly to the Health Services Executive as a key performance indicator. Results Mean PET prior to the pandemic was 20 hours and dropped to 10 and 13 hours respectively in the first and second wave. A surge in case numbers and ED attendances during the third wave was not reflected in a rise in PETs, with a mean PET of 11 hours, significantly below pre-pandemic levels. HA-COVID-19 infections remained stable between wave one and three (83 v 92). Conclusion The introduction of 24-hour SARS-CoV-2 testing in our ED contributed to a reduction in PETs, facilitated appropriate patient placement at ward level, and kept HA-COVID-19 infections at acceptably low levels.

Urticated plaques in a child

We present a case of an acute urticated eruption in a child, associated with acral oedema in the setting of recent infection and antibiotic therapy. There are a limited number of differential diagnoses, which we discuss in this article, while also highlighting distinguishing features and management considerations.

A blistering eruption of the head and neck in an 18-year-old

An 18-year-old presented with an atypical blistering eruption. Direct immunofluorescence microscopy of perilesional skin showed strong linear deposition of IgG and C3 at the dermoepidermal junction. Her presentation was unusual and posed a diagnostic challenge, as this condition is very rare in this age group.

OP0259-HPR THE EFFECT OF OSTEOARTHRITIS ON HEALTHY WORKING LIFE EXPECTANCY AT AGE 50 IN ENGLAND

Background:

Retirement ages are rising in many countries due to population ageing and increasing life expectancy. However, poor health, comorbidity and workplace factors are major reasons for work absence and it is unclear if people in later working-age life (age ≥50) are able to work for longer. Osteoarthritis (OA), the most common joint condition in adults, is the fastest increasing major health condition globally and is a leading cause of disability (especially in adults age ≥50).

Objectives:

We aimed to estimate healthy working life expectancy (HWLE; defined as the average number of years that adults from age 50 can expect to be healthy and in paid work) for adults with and without osteoarthritis and investigate the role of mental health problems as a comorbidity and the role of workplace factors through examining whether there is a sense of having any control over what happens at work.

Methods:

Longitudinal survey data of adults aged ≥50 years were used from six waves (2002-2013) of the English Longitudinal Study of Ageing with linked mortality data from the National Health Service Central Register. HWLE was defined using two self-report variables; health was defined as no long-standing illness or no activity limitation if long-standing illness was present, and work was defined being in employment or self-employment. OA status was identified by self-report of ever receiving a diagnosis from a doctor. Mental health and control of work were measured by self-report. Continuous-time multistate models with three states (healthy and working [state 1], other alive [2], dead [3]) were fitted in R (version 3.6.1) to investigate factors driving transitions out of the healthy and working state. Models included age and combinations of sex, OA, control at work, and mental health problems. Age-adjusted hazards of transitions between states were estimated using the ‘msm’ R package. HWLE for adults with different factors (OA, control of work, mental health) was estimated with the ‘elect’ R package using models fitted with ‘msm’. Missing data was handled using multiple imputation by predictive mean matching.

Results:

There were 11,540 adults with at least two observations (including survey and mortality data) for the study period (5251 males, 6289 females). Life expectancy at age 50 was 29.7 years for men and 33.4 years for women with HWLE being 9.9 years (men) and 8.3 years (women). HWLE at age 50 for adults with osteoarthritis was 7.3 years (men: 8.2, women: 6.8), and for adults without osteoarthritis was higher at 9.9 years (men: 10.6, women: 9.1). After adjusting for age, the instantaneous risk of ceasing to be both healthy and in work (not due to death) for people with OA was 1.5 times that of people without OA (hazard rate ratio 1.5 with 95% CI [1.3, 1.6]). For adults without OA, HWLE at age 50 was 13.2 years if they felt they had control at work and 4.1 years without control at work, whilst for adults with OA, HWLE was 10.4 years if they felt they had control at work and 3.1 years without. The effect of mental health problems as a comorbidity on HWLE was smaller; for adults without OA, HWLE at age 50 was 11.0 years for those without mental health problems and 8.3 years for those with, whilst for adults with OA, HWLE was 8.6 years for those without mental health problems and 6.2 years with.

Conclusion:

While the average HWLE for men and women in England is lower than State Pension age, HWLE at age 50 is even lower (by approximately 25%) in adults with OA compared to adults without OA. Poor mental health further reduces HWLE. However, good quality work environments significantly lessen the impact of osteoarthritis (there is a 7.3 year difference in HWLE for those with OA who do and do not experience control at work). These results suggest that interventions and policies that create appropriate job opportunities and supportive workplaces for older workers with health conditions are key to the feasibility and success of extended working life policies.

Disclosure of Interests:

None declared

Mitigation policies, community mobility, and COVID-19 case counts in Australia, Japan, Hong Kong, and Singapore

OBJECTIVES

The objective of the study was to characterize the timing and trends of select mitigation policies, changes in community mobility, and coronavirus disease 2019 (COVID-19) epidemiology in Australia, Japan, Hong Kong, and Singapore.

STUDY DESIGN

Prospective abstraction of publicly available mitigation policies obtained from media reports and government websites.

METHODS

Data analyzed include seven kinds of mitigation policies (mass gathering restrictions, international travel restrictions, passenger screening, traveler isolation/quarantine, school closures, business closures, and domestic movement restrictions) implemented between January 1 and April 26, 2020, changes in selected measures of community mobility assessed by Google Community Mobility Reports data, and COVID-19 epidemiology in Australia, Japan, Hong Kong, and Singapore.

RESULTS

During the study period, community mobility decreased in Australia, Japan, and Singapore; there was little change in Hong Kong. The largest declines in mobility were seen in places that enforced mitigation policies. Across settings, transit-associated mobility declined the most and workplace-associated mobility the least. Singapore experienced an increase in cases despite the presence of stay-at-home orders, as migrant workers living in dormitories faced challenges to safely quarantine.

CONCLUSIONS

Public policies may have different impacts on mobility and transmission of severe acute respiratory coronavirus-2 transmission. When enacting mitigation policies, decision makers should consider the possible impact of enforcement measures, the influence on transmission of factors other than movement restrictions, and the differential impact of mitigation policies on subpopulations.

Sitagliptin and Narrow-Band Ultraviolet-B for Moderate Psoriasis (DINUP): A Randomised Controlled Clinical Trial

BACKGROUND

Sitagliptin, a dipeptidyl peptidase-4 (DPP-4) inhibitor licensed for the treatment of type 2 diabetes mellitus (T2DM), has been reported to improve psoriasis.

OBJECTIVE

We compared the effects of sitagliptin treatment, a DPP-4 inhibitor, in combination with narrow-band ultraviolet-B (NB-UVB) phototherapy compared to NB-UVB alone on psoriasis severity, quality of life, cardiovascular disease risk factors and immune parameters in people with moderate psoriasis without T2DM.

METHODS

In this 39-week, single-centre, randomised controlled trial, people were allocated randomly to receive sitagliptin for 24 weeks with NB-UVB or NB-UVB alone. The primary endpoint was the change in Psoriasis Area and Severity Index (PASI) from baseline to 24 weeks. We estimated that 120 participants would be needed to have 80% power to find a significant difference between the groups.

RESULTS

A total of 118 patients were randomised. The median (IQR) baseline PASI was 8.8 (7.5-11.6). At 24 weeks, the mean difference from baseline in PASI (-1.0 [95% CI -2.0 to 0.0]) was significantly larger in the sitagliptin/NB-UVB arm than in the NB-UVB-alone arm (p = 0.044). There were significant differences in the change in Hospital Anxiety and Depression Scale (-2.5 [95% CI -4.0 to -1.0]; p = 0.002) and EuroQol 5-item questionnaire (0.1 [95% CI 0.0-0.1]; p = 0.036) values from baseline to 24 weeks between the sitagliptin/NB-UVB and the NB-UVB-alone arm. There were no treatment-related serious adverse events.

CONCLUSION

Sitagliptin therapy combined with NB-UVB phototherapy significantly improved psoriasis severity, albeit modestly, compared to NB-UVB phototherapy alone in patients with moderate psoriasis without T2DM.

Genome-wide surveillance of transcription errors in response to genotoxic stress

Mutagenic compounds are a potent source of human disease. By inducing genetic instability, they can accelerate the evolution of human cancers or lead to the development of genetically inherited diseases. Here, we show that in addition to genetic mutations, mutagens are also a powerful source of transcription errors. These errors arise in dividing and nondividing cells alike, affect every class of transcripts inside cells, and, in certain cases, greatly exceed the number of mutations that arise in the genome. In addition, we reveal the kinetics of transcription errors in response to mutagen exposure and find that DNA repair is required to mitigate transcriptional mutagenesis after exposure. Together, these observations have far-reaching consequences for our understanding of mutagenesis in human aging and disease, and suggest that the impact of DNA damage on human physiology has been greatly underestimated.

Opportunities for the application of real-time bacterial cell analysis using flow cytometry for the advancement of sterilization microbiology

Medical devices provide critical care and diagnostic applications through patient contact. Sterility assurance level (SAL) may be defined as the probability of a single viable micro-organism occurring on an item after a sterilization process. Sterilization microbiology often relies upon using an overkill validation method where a 12-log reduction in recalcitrant bacterial endospore population occurs during the process that exploits conventional laboratory-based culture media for enumeration. This timely review explores key assumptions underpinning use of conventional culture-based methods in sterilization microbiology. Consideration is given to how such methods may limit the ability to fully appreciate the inactivation kinetics of a sterilization process such as vaporized hydrogen peroxide (VH2O2) sterilization, and consequently design efficient sterilization processes. Specific use of the real-time flow cytometry (FCM) is described by way of elucidating the practical relevance of these limitation factors with implications and opportunities for the sterilization industry discussed. Application of FCM to address these culture-based limitation factors will inform real-time kinetic inactivation modelling and unlock potential to embrace emerging opportunities for pharma, medical device and sterilization industries including potentially disruptive applications that may involve reduced usage of sterilant.

A retrospective review of pregnancies on biologics for the treatment of dermatological conditions

Psoriasis often first presents in young adulthood, with the average age of diagnosis in women being 28 years, thus in the prime reproductive years. In addition, approximately 50% of pregnancies worldwide are unplanned. Although biologic therapies have revolutionized the treatment of moderate-to-severe psoriasis, there are no controlled studies of biologics in pregnant women. The increasing use of these agents in women of childbearing age highlights the need to further assess their safety during pregnancy. Postmarketing experience regarding the safety of these drugs is accumulating and being published, with largely reassuring results. We present our real-world experience of 17 pregnancies occurring in women on treatment with biologic agents for dermatological conditions to further add to the body of knowledge.

PARENTS 2 study: consensus report for parental engagement in the perinatal mortality review process

OBJECTIVE

The PARENTS 1 study (Parents' Active Role and ENgagement in The review of their Stillbirth/perinatal death) found that parents would endorse the opportunity to give feedback into the perinatal mortality review (PNMR) process. In subsequent focus groups, healthcare professionals were positive about parental engagement, although they considered that there may be significant challenges. The objective of this study was to develop core principles and recommendations for parental engagement in PNMR in the UK.

METHODS

A two-round Delphi technique was followed to reach consensus on core principles for parental engagement in the PNMR process; Round 1 included a national consensus workshop and Round 2 an online questionnaire. The consensus meeting was attended by a national panel of stakeholders (clinical and academic experts, parent advocates, managers and commissioners) in stillbirth and neonatal and bereavement care. To develop recommendations for parental engagement, participants discussed four key areas comprising: communication with parents, including receiving feedback; the format of the PNMR meeting; the parental engagement pathway; and challenging aspects of engaging with parents in reviews. Content analysis was conducted to generate recommendations from the meeting for a subsequent anonymous web-based survey. Attendees of the consensus workshop and members of the PARENTS 2 Project Advisory Board were asked to rank recommendations using a 9-point Likert scale from 1 (not important) to 9 (critically important). It had been agreed a priori, in compliance with established Grading of Recommendations, Assessment, Development and Evaluation (GRADE) criteria, that 'consensus' would be achieved if over 70% of participants scored the principle as 'critical' (score of 7-9) and fewer than 15% scored the principle as 'not important' (score of 1-3). Principles for which consensus was achieved were included in the core recommendations.

RESULTS

Of the 29 invited stakeholders, 22 participated in the consensus meeting and 25 (86% response rate) in the subsequent online questionnaire in June 2017. Consensus was agreed on 12 core principles. Of the 25 participants, 96% agreed that a face-to-face explanation of the PNMR process was of critical importance, 72% considered that parents should be offered the opportunity to nominate a suitable advocate, 92% believed that responses to parents' comments should be formally documented, 96% indicated that it was vital for action plans to be translated into lessons learnt and that this process should be monitored, and 100% of stakeholders voted that a plain-English summary should be produced for the parents following the meeting. There was good agreement on a further seven principles.

CONCLUSIONS

Key national stakeholders were unanimously supportive of parental engagement in the PNMR process and agreed on core principles to make this process feasible, meaningful and robust. A 6-month pilot of parental engagement in the PNMR process (PARENTS 2 study) in two UK units took place after the consensus on core principles. In collaboration with the National Perinatal Epidemiology Unit, the findings will inform the national standardized PNMR tool. © 2018 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.

Explant of aortic stent grafts following endovascular aneurysm repair

Background

Failure of endovascular aneurysm repair may require explant of the stent graft in a subset of patients. We sought to assess outcomes in a cohort of patients undergoing explant of endovascular aneurysm repair in both emergency and elective settings.

Methods

Patients undergoing explant of endovascular aneurysm repair were identified from a prospectively maintained database, with additional information obtained through retrospective analysis of medical records.

Results

Over a 21-year period, 1997–2018 (May), there were 597 endovascular aneurysm repair procedures performed in our institution for abdominal aortic aneurysm. There were 19 endovascular aneurysm repair explants; five of these were referrals from other vascular centres. The median age was 73 years (range 46–81). The median length of time from insertion to explant was 39.2 months (range 0–153). Indications for elective explant were type Ia endoleak (n = 4), type 1b endoleak (n = 1), type II endoleak with increasing sac size (n = 1), type I/III endoleak (n = 1), type IV endoleak (n = 1), and increasing sac size without evident endoleak (type V, n = 2). The remaining nine cases were emergency procedures, with four patients presenting with rupture post endovascular aneurysm repair, four patients presenting with acute stent thrombosis, of which one also had a type 1a endoleak and one aorto-enteric fistula. There were no mortalities in the elective group and three mortalities in the emergency group (0 vs 33.3%, p = 0.087). Overall 30-day mortality was 15.8%

Conclusion

Explant of aortic stent grafts can be associated with high mortality and morbidity rates, especially in the emergent setting. Patient and device selection and post-operative surveillance remain vitally important to optimise outcomes post endovascular aneurysm repair.

Zika and travel in the news: a content analysis of US news stories during the outbreak in 2016-2017

OBJECTIVES

This study aimed to understand what information the US media communicated about Zika virus (ZIKV) and travel in 2016 and 2017.

STUDY DESIGN

We conducted a content analysis of news coverage about ZIKV and travel from April 5, 2016 to March 31, 2017.

METHODS

We obtained a stratified, random sample of English language, US print newspaper and television news coverage about ZIKV and travel. We developed a coding scheme to assess key messages in the news, including how ZIKV is transmitted, the symptoms and outcomes of ZIKV infection, and recommended prevention behaviors.

RESULTS

Almost all news stories mentioned mosquito-borne transmission (96.8%) and just over half mentioned sexual transmission (55.3%). News stories were more likely to talk about ZIKV outcomes (78.8%) than ZIKV symptoms (40.6%). However, outcomes affecting babies were mentioned more frequently than outcomes affecting adults. Recommendations included a wide array of protective behaviors, such as delaying or avoiding travel (77.6%) and using mosquito repellent (41.0%). However, few studies (10.9%) mentioned barriers to practicing ZIKV prevention behaviors.

CONCLUSIONS

Public health organizations and professionals can use these findings to help improve communication about future outbreaks of mosquito-borne illnesses. We also recommend conducting real-time monitoring of news media and frequent content analysis of news stories to ensure coverage provides the information the public needs.

Parents' and healthcare professionals' experiences of care after stillbirth in low- and middle-income countries: a systematic review and meta-summary

BACKGROUND

Stillbirth has a profound impact on women, families, and healthcare workers. The burden is highest in low- and middle-income countries (LMICs). There is need for respectful and supportive care for women, partners, and families after bereavement.

OBJECTIVE

To perform a qualitative meta-summary of parents' and healthcare professionals' experiences of care after stillbirth in LMICs.

SEARCH STRATEGY

Search terms were formulated by identifying all synonyms, thesaurus terms, and variations for stillbirth. Databases searched were AMED, EMBASE, MEDLINE, PsychINFO, BNI, CINAHL.

SELECTION CRITERIA

Qualitative, quantitative, and mixed method studies that addressed parents' or healthcare professionals' experience of care after stillbirth in LMICs.

DATA COLLECTION AND ANALYSIS

Studies were screened, and data extracted in duplicate. Data were analysed using the Sandelowski meta-summary technique that calculates frequency and intensity effect sizes (FES/IES).

MAIN RESULTS

In all, 118 full texts were screened, and 34 studies from 17 countries were included. FES range was 15-68%. Most studies had IES 1.5-4.5. Women experience a broad range of manifestations of grief following stillbirth, which may not be recognised by healthcare workers or in their communities. Lack of recognition exacerbates negative experiences of stigmatisation, blame, devaluation, and loss of social status. Adequately developed health systems, with trained and supported staff, are best equipped to provide the support and information that women want after stillbirth.

CONCLUSIONS

Basic interventions could have an immediate impact on the experiences of women and their families after stillbirth. Examples include public education to reduce stigma, promoting the respectful maternity care agenda, and investigating stillbirth appropriately.

TWEETABLE ABSTRACT

Reducing stigma, promoting respectful care and investigating stillbirth have a positive impact after stillbirth for women and families in LMICs.

Differential binding affinity of mutated peptides for MHC class I is a predictor of survival in advanced lung cancer and melanoma

Background

Cancer mutations generate novel (neo-)peptides recognised by T cells, but the determinants of recognition are not well characterised. The difference in predicted class I major histocompatibility complex (MHC-I) binding affinity between wild-type and corresponding mutant peptides (differential agretopicity index; DAI) may reflect clinically relevant cancer peptide immunogenicity. Our aim was to explore the relationship between DAI, measures of immune infiltration and patient outcomes in advanced cancer.

Patients and methods

Cohorts of patients with advanced non-small-cell lung cancer (NSCLC; LUAD, n = 66) and melanoma (SKCM, n = 72) were obtained from The Cancer Genome Atlas. Three additional cohorts of immunotherapy treated patients with advanced melanoma (total n = 131) and NSCLC (n = 31) were analysed. Neopeptides and their clonal status were defined using genomic data. MHC-I binding affinity was predicted for each neopeptide and DAI values summarised as the sample mean DAI. Correlations between mean DAI and markers of immune activity were evaluated using measures of lymphocyte infiltration and immune gene expression.

Results

In univariate and multivariate analyses, mean DAI significantly correlated with overall survival in 3/5 cohorts, with evidence of superiority over nonsynonymous mutational and neoantigen burden. In these cohorts, the effect was seen for mean DAI of clonal but not subclonal peptides. In SKCM, the association between mean DAI and survival bordered significance (P = 0.068), reaching significance in an immunotherapy-treated melanoma cohort (P = 0.003). Mean DAI but not mutational nor neoantigen burden was positively correlated with independently derived markers of immune infiltration in both SKCM (P = 0.027) and LUAD (P = 0.024).

Conclusions

The association between mean DAI, survival and measures of immune activity support the hypothesis that DAI is a determinant of cancer peptide immunogenicity. Investigation of DAI as a marker of immunologically relevant peptides in further datasets and future clinical studies of neoantigen based immunotherapies is warranted.

Mycobacterium marinum infection contracted from seaweed wrap in a psoriasis patient undergoing treatment with adalimumab

We report a patient with psoriasis who developed Mycobacterium marinum (M. marinum) infection after seven years of treatment with adalimumab, a human anti-TNF (tumor necrosis factor) monoclonal antibody. TNF is a pro-inflammatory cytokine that plays a central role in the pathogenesis of psoriasis and a number of other immune-mediated inflammatory diseases. TNF plays an important role in granuloma formation and host defense against mycobacterial infections. Several cases of atypical mycobacterial infections in patients on TNF inhibitors have been reported. To our knowledge, this is the second reported case of M. marinum infection in a patient on adalimumab for the treatment of psoriasis.

MULLER'S RATCHET AND MUTATIONAL MELTDOWNS

We extend our earlier work on the role of deleterious mutations in the extinction of obligately asexual populations. First, we develop analytical models for mutation accumulation that obviate the need for time-consuming computer simulations in certain ranges of the parameter space. When the number of mutations entering the population each generation is fairly high, the number of mutations per individual and the mean time to extinction can be predicted using classical approaches in quantitative genetics. However, when the mutation rate is very low, a fixation-probability approach is quite effective. Second, we show that an intermediate selection coefficient (s) minimizes the time to extinction. The critical value of s can be quite low, and we discuss the evolutionary implications of this, showing that increased sensitivity to mutation and loss of capacity for DNA repair can be selectively advantageous in asexual organisms. Finally, we consider the consequences of the mutational meltdown for the extinction of mitochondrial lineages in sexual species.