Genotyping of European Toxoplasma gondii strains by a new high-resolution next-generation sequencing-based method

PURPOSE

A new high-resolution next-generation sequencing (NGS)-based method was established to type closely related European type II Toxoplasma gondii strains.

METHODS

T. gondii field isolates were collected from different parts of Europe and assessed by whole genome sequencing (WGS). In comparison to ME49 (a type II reference strain), highly polymorphic regions (HPRs) were identified, showing a considerable number of single nucleotide polymorphisms (SNPs). After confirmation by Sanger sequencing, 18 HPRs were used to design a primer panel for multiplex PCR to establish a multilocus Ion AmpliSeq typing method. Toxoplasma gondii isolates and T. gondii present in clinical samples were typed with the new method. The sensitivity of the method was tested with serially diluted reference DNA samples.

RESULTS

Among type II specimens, the method could differentiate the same number of haplotypes as the reference standard, microsatellite (MS) typing. Passages of the same isolates and specimens originating from abortion outbreaks were identified as identical. In addition, seven different genotypes, two atypical and two recombinant specimens were clearly distinguished from each other by the method. Furthermore, almost all SNPs detected by the Ion AmpliSeq method corresponded to those expected based on WGS. By testing serially diluted DNA samples, the method exhibited a similar analytical sensitivity as MS typing.

CONCLUSION

The new method can distinguish different T. gondii genotypes and detect intra-genotype variability among European type II T. gondii strains. Furthermore, with WGS data additional target regions can be added to the method to potentially increase typing resolution.

High prevalence of heavy menstrual bleeding in women with rare bleeding disorders in the Netherlands: retrospective data from the RBiN study

BACKGROUND

Heavy menstrual bleeding (HMB) is associated with a reduced quality of life and limitations in social and physical functioning. Data on HMB in women with rare bleeding disorders (RBDs), including coagulation factor deficiencies and fibrinolytic disorders, are scarce.

OBJECTIVES

To analyze the prevalence, severity, and treatment of HMB in Dutch women with an RBD.

METHODS

The Rare Bleeding Disorders in the Netherlands (RBiN) study included 263 patients with an RBD from all 6 hemophilia treatment centers (October 2017-November 2019). In this analysis, data of 111 women aged ≥16 years were studied. According to the International Society on Thrombosis and Haemostasis bleeding assessment tool, HMB symptoms were scored from 0 (no/trivial) to 4 (severe symptoms requiring medical intervention). HMB was defined as a score ≥1. Age at RBD diagnosis was extracted from patient files.

RESULTS

HMB was reported by 80% of women (89/111) and was more prevalent in women with a fibrinolytic disorder (33/35; 94%) than in women with a coagulation factor deficiency (56/76; 74%) (P = .011). Of the 89 women with HMB, 82% (n = 73) ever required treatment. Multiple treatment modalities were frequently used, both in severe and mild deficiencies. Hormonal treatment was mostly used (n = 64; 88%), while antifibrinolytics were prescribed less frequently (n = 18; 25%). In women with HMB since menarche (n = 61; 69%), median age at RBD diagnosis was 28 years (IQR, 14-41).

CONCLUSION

HMB is common in women with RBDs. Women with mild deficiencies also frequently reported HMB. Only a minority of women were treated with hemostatic agents. A significant diagnostic delay was observed after the onset of HMB symptoms.

Long-lived spin waves in a metallic antiferromagnet

Collective spin excitations in magnetically ordered crystals, called magnons or spin waves, can serve as carriers in novel spintronic devices with ultralow energy consumption. The generation of well-detectable spin flows requires long lifetimes of high-frequency magnons. In general, the lifetime of spin waves in a metal is substantially reduced due to a strong coupling of magnons to the Stoner continuum. This makes metals unattractive for use as components for magnonic devices. Here, we present the metallic antiferromagnet CeCo2P2, which exhibits long-living magnons even in the terahertz (THz) regime. For CeCo2P2, our first-principle calculations predict a suppression of low-energy spin-flip Stoner excitations, which is verified by resonant inelastic X-ray scattering measurements. By comparison to the isostructural compound LaCo2P2, we show how small structural changes can dramatically alter the electronic structure around the Fermi level leading to the classical picture of the strongly damped magnons intrinsic to metallic systems. Our results not only demonstrate that long-lived magnons in the THz regime can exist in bulk metallic systems, but they also open a path for an efficient search for metallic magnetic systems in which undamped THz magnons can be excited.

Psychometrics of the patient-reported outcomes measurement information system measures in hemophilia: the applicability of the pediatric item banks

Background

The use of patient-reported outcomes measures (PROMs) is important in hemophilia care, as it facilitates communication between patients and clinicians and promotes patient-centered care. Currently, a variety of PROMs with insufficient psychometric properties are used. Patient-reported outcomes measurement information system (PROMIS) measures, including Computer Adaptive Tests, were designed to measure generically and more efficiently and, therefore, are an alternative for the existing PROMs.

Objectives

To assess the feasibility, measurement properties, and outcomes of 8 PROMIS pediatric measures for boys with hemophilia.

Methods

In this multicenter study, boys with hemophilia completed 8 PROMIS measures and 2 legacy instruments. Feasibility was determined by the number of completed items and floor or ceiling effects (percentage of participants that achieved the lowest or highest possible score). Reliability was assessed as the percentage of scores with a SE ≤ 4.5. Construct validity was evaluated by comparing the PROMIS measures with the legacy instruments. Mean PROMIS T-scores were calculated and compared with the Dutch general population.

Results

In total, 77 boys with hemophilia participated. Reliability was good for almost all PROMIS measures and legacy instruments. The total number of completed items varied from 49 to 90 for the PROMIS pediatric measures, while the legacy instruments contained 117 to 130 items. Floor and ceiling effects were observed in both the PROMIS measures (0-39.5%) and legacy instruments (0-66.7%), but were higher for the legacy instruments.

Conclusions

The PROMIS pediatric measures are feasible to use for boys with hemophilia. With the use of the PROMIS measures in clinical care and research, a step toward worldwide standardization of PROM administration can be taken.

Microbial Indicators of Dental Health, Dysbiosis, and Early Childhood Caries

Dental caries lesions are a clinical manifestation of disease, preceded by microbial dysbiosis, which is poorly characterized and thought to be associated with saccharolytic taxa. Here, we assessed the associations between the oral microbiome of children and various caries risk factors such as demographics and behavioral and clinical data across early childhood and characterized over time the salivary and dental plaque microbiome of children before clinical diagnosis of caries lesions. Children (N = 266) were examined clinically at ~1, 2.5, 4, and 6.5 y of age. The microbiome samples were collected at 1, 2.5, and 4 y. Caries groups consisted of children who remained caries free (International Caries Detection and Assessment System [ICDAS] = 0) at all time points (CFAT) (n = 50); children diagnosed with caries (ICDAS ≥ 1) at 6.5 y (C6.5), 4 y (C4), or 2.5 y of age (C2.5); and children with early caries or advanced caries lesions at specific time points. Microbial community analyses were performed on zero-radius operational taxonomic units (zOTUs) obtained from V4 of 16S ribosomal RNA gene amplicon sequences. The oral microbiome of the children was affected by various factors, including antibiotic use, demographics, and dietary habits of the children and their caregivers. At all time points, various risk factors explained more of the variation in the dental plaque microbiome than in saliva. At 1 y, composition of saliva of the C4 group differed from that of the CFAT group, while at 2.5 y, this difference was observed only in plaque. At 4 y, multiple salivary and plaque zOTUs of genera Prevotella and Leptotrichia were significantly higher in samples of the C6.5 group than those of the CFAT group. In conclusion, up to 3 y prior to clinical caries detection, the oral microbial communities were already in a state of dysbiosis that was dominated by proteolytic taxa. Plaque discriminated dysbiotic oral ecosystems from healthy ones better than saliva.

Efficacy of non-pharmacological interventions to reduce pain in children with sickle cell disease: A systematic review

BACKGROUND

Pain is the clinical hallmark of sickle cell disease (SCD) leading to hospitalization, psychological sequelae and a decreased health-related quality of life. The aim of this systematic literature review is to evaluate the efficacy of non-pharmacological interventions in reducing sickle cell related pain in children with SCD.

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, a comprehensive literature search up until October 2022 was performed to identify studies that investigated the efficacy of non-pharmacological interventions on (1) pain frequency and/or intensity, and (2) analgesic and health service use in children with SCD until the age of 21. Both randomized controlled trials (RCTs) and quasi-experimental designed (QED) studies were considered for inclusion.

RESULTS

Ten articles (five RCTs and five QED studies) with 422 participants were included. They investigated cognitive behavioural therapy (CBT) (n = 5), biofeedback (n = 2), massage (n = 1), virtual reality (n = 1) and yoga (n = 1). The majority of the interventions were psychological (n = 7) and were performed in the outpatient clinic (n = 6). CBT and biofeedback significantly reduced frequency and/or intensity of SCD-related pain in outpatient settings, while virtual reality and yoga significantly reduced pain in inpatient settings. Biofeedback also significantly reduced analgesic use. None of the included articles reported reduced health service use.

CONCLUSION

Non-pharmacological interventions may be effective in reducing pain in paediatric patients with SCD. However, due to the heterogeneity of the included studies a quantitative analysis could not be performed. Awaiting further supporting evidence, healthcare providers should consider implementing these interventions as valuable part of a comprehensive pain management strategy plan.

High prevalence of postpartum hemorrhage in women with rare bleeding disorders in the Netherlands: retrospective data from the RBiN study

BACKGROUND

Women with rare bleeding disorders (RBDs), including coagulation factor deficiencies and fibrinolytic disorders, may have a higher risk of postpartum hemorrhage (PPH). Information on this patient category is lacking in the existing PPH guidelines because data on PPH in patients with RBDs are scarce.

OBJECTIVE

To describe the prevalence of PPH in women with an RBD and evaluate the use of peripartum hemostatic prophylaxis.

METHODS

In the Rare Bleeding Disorders in the Netherlands (RBiN) study, patients with RBDs (n = 263) were included from all 6 Dutch hemophilia treatment centers. Patient-reported information on delivery, peripartum hemostatic prophylaxis, and occurrence of PPH was collected retrospectively. If available, information about the precise volume of postpartum blood loss was extracted from electronic patient files. PPH was defined as blood loss ≥500 mL (World Health Organization guideline).

RESULTS

A total of 244 pregnancies, including 193 livebirths, were reported by 85 women. A considerable proportion of these women experienced PPH, ranging from 30% in factor V deficiency to 100% in hyperfibrinolysis. Overall, PPH was reported in 44% of deliveries performed with and 53% of deliveries performed without administration of peripartum hemostatic prophylaxis. Blood loss was significantly higher in deliveries without administration of hemostatic prophylaxis (median 1000 mL) compared to deliveries with administration of prophylaxis (median 400 mL) (p = 0.011). Patients with relatively mild deficiencies also frequently experienced PPH when peripartum hemostatic prophylaxis was omitted.

CONCLUSION

PPH is common in rare coagulation factor deficiencies, both severe and mild, and fibrinolytic disorders, especially when peripartum prophylactic hemostatic treatment was not administered. The use of prophylactic hemostatic treatment was associated with less postpartum blood loss.

[Liver metastases of neuroendocrine tumors]

Neuroendocrine liver metastases (NELM) are very heterogeneous with respect to the clinical presentation and the prognosis. The treatment of NELMs requires a multidisciplinary approach and patients with NELM should be referred to a specialized center. When possible, the resection of NELMs provides the best long-term results. The general selection criteria for liver resection include an acceptable general physical condition for a large liver operation, tumors with a favorable differentiation grade 1 or 2, a lack of extrahepatic lesions, a sufficient residual liver volume and the possibility to resect at least 70% of the metastases. Supplementary treatment, including simultaneous liver ablation, are generally safe and can increase the number of patients who can be considered for surgery. For patients with resectable NELM, the resection of the primary tumor is recommended either in a 2-stage or combined procedure. In selected patients with nonresectable NELM a liver transplantation can be carried out, which can be associated with excellent long-term results.

P-322 Does endometrium age? The endometrial transcriptome of advanced reproductive age patients reveals the signs of cellular ageing, altered immune response and compromised receptivity

Study question

What changes occur in the endometrium during ageing and how they may affect fertility?

Summary answer

The endometrial transcriptome of women of advanced maternal age is significantly different from the young women, indicating specific pathways involved in endometrial ageing.

What is known already

A woman’s peak reproductive years are considered in her twenties. Trending postponed family planning, unfortunately, brings more women in their late forties to fertility specialists to seek for assisted conception. In vitro fertilization (IVF) using donated oocytes is a common approach to overcome the impact of maternal age on ovarian reserve. However, even with the implementation of embryo that underwent pre-implantation genetic testing, the IVF success rate drops significantly in the late forties. It still remains unclear which age-related molecular processes take place in the endometrium and whether it may impact the ability to support embryo implantation.

Study design, size, duration

Endometrial transcriptome profiling was done in 44 women undergoing endometrial receptivity evaluation at hormonal replacement therapy before IVF. Patients younger than 29 were considered as young maternal age group (YMA, age 23-27) and women older than 45 were considered as advanced maternal age group (AMA, age 47-50).

Participants/materials, setting, methods

Endometrial biopsies were obtained on day 5 of progesterone treatment and RNA was extracted. All endometrial samples were evaluated as receptive based on the expression of 57 common endometrial receptivity markers. Study group samples (12 YMA + 12 AMA) were subject to Illumina RNA sequencing. The sequences were annotated using the RefSeq database and differential expression analysis was performed using DeSeq2.We validated our results (10 YMA + 10 AMA) usingquantitative-PCR and histological validation.

Main results and the role of chance

A total of 37228 mRNA transcripts were expressed in the analyzed endometrial samples. After multiple testing corrections, 144 significantly differentially expressed(DE) transcripts (92 up-regulated, 52 down-regulated) were identified in the endometrium of the AMA versus YMAgroup. Overexpressed genes were associated with decidualization (ALDH3A1), endometrial receptivity (EML5, GALNT12), cell cycle (CDKN2A) and signal transduction, while down-regulated genes included sugar metabolism and inflammation (C2CD4B, NFKB), cellular motility (SPAG6)and progesterone signaling (RPL9). The pathways most affected by age were cellular remodeling, cell motility and migration, and immune response. Interestingly, some of the identified DE genes have been previously associated with ageing. Our results suggest the involvement of p16-associated cellular senescence and the suppression of metabolic and inflammatory processes essential for endometrial preparation for embryo transfer.

Limitations, reasons for caution

The study includes only patients undergoing hormonal replacement therapy and it is unclear whether the same processes are affected by age in the natural cycles.

Wider implications of the findings

These findings allow us to explain the age-related molecular changes that take place in the endometrial tissue. Understanding these alterations and using them in assisted reproductive technology may help to improve infertility management in women with advanced reproductive age.

Trial registration number

None

P-420 Dysregulated microRNAs in uterine fluid from women with recurrent implantation failure are linked to endometrial receptivity and implantation

Study question

Is the microRNA content different in uterine fluid (UF) from women with recurrent implantation failure (RIF) compared to healthy fertile women?

Summary answer

The miRNA content is altered in the UF of women with RIF compared to healthy fertile women.

What is known already

Previous studies indicate that microRNAs secreted from endometrial cells into the UF are involved in endometrial receptivity and embryo implantation. Moreover, endometrial miRNAs are dysregulated in women with RIF and poor endometrial receptivity has been suggested as a putative cause of the condition.

Study design, size, duration

This is a descriptive experimental case-control study where microRNA abundancy in UF was compared between women with RIF (n = 34) and healthy fertile women (n = 17). Study participants were recruited at two university clinics in Stockholm, Sweden, and Tartu, Estonia. UF samples were collected vaginally in the receptive phase on day LH + 7-9 by flushing the uterine cavity with sterile saline. RIF was defined as three failed in vitro fertilization (IVF) cycles with good-quality embryos.

Participants/materials, setting, methods

To identify miRNAs in UF we performed small RNA sequencing. Differential expression analysis (DESeq2) was used to compare the abundancy of miRNAs in UF between the two groups. Dysregulated miRNAs were externally validated using relevant published datasets and further analyzed using tools such as target gene prediction (miRTarBase) and biological KEGG pathway analysis (g:Profiler). Technical validation was performed on two miRNAs with quantitative real-time PCR (RT-PCR).

Main results and the role of chance

In total, we identified 61 differentially abundant UF microRNAs with a false discovery rate of < 0.05 and fold change (FC) of -2 or 2. Out of these, 34 were up-regulated and 27 were down-regulated. External validation based on published literature showed that several of the dysregulated miRNAs are expressed in endometrial epithelial cells and have been described in extracellular vesicles from the endometrium and in the context of endometrial receptivity and RIF. Using publicly available single-cell transcriptome data, we found that the predicted target genes of our microRNAs are expressed both in the trophectoderm of human blastocysts and in epithelial cells of mid-secretory endometrium. Furthermore, the predicted miRNA target genes were significantly enriched in 25 pathways critical for endometrial receptivity and embryo implantation. Technical validation of hsa-miR-486-5p (FC -20.32; p-value=0.004) and hsa-miR-92b-3p (FC -9.72; p-value=0.004) were successfully in line with the sequencing data.

Limitations, reasons for caution

The sample size of this descriptive study was limited. A larger study cohort should be used to validate the differentially abundant microRNAs. Moreover, further in-vitro and in-vivo studies are needed to establish the role of identified miRNAs and their predicted target genes and enriched pathways in the pathogenesis of RIF.

Wider implications of the findings

RIF represents a true challenge in the IVF clinic. We show that total miRNAs can be comprehensively mapped in UF and constitute a promising source of non-invasive biomarkers for RIF that could be further evaluated for its clinical utility. Our findings also give insight into the molecular mechanisms of RIF.

Trial registration number

Not applicable

Endometriosis and irritable bowel syndrome: similarities and differences in the spectrum of comorbidities

STUDY QUESTION

Do the spectrum and prevalence of comorbidities of endometriosis and irritable bowel syndrome (IBS) overlap?

SUMMARY ANSWER

Despite several overlapping symptoms, the most significantly associated comorbidities of endometriosis and IBS are different and are rather related to the organ systems primarily involved in the index diagnosis.

WHAT IS KNOWN ALREADY

Endometriosis and IBS both have several similar unspecific symptoms, such as recurrent abdominal pain, cramping and anxiety, and both diseases affect young women and are associated with a number of comorbidities causing a poor quality of life. However, a detailed study, revealing the full spectrum of endometriosis and IBS comorbidities in the same study population, is lacking.

STUDY DESIGN, SIZE, DURATION

This article presents a retrospective in silico analysis of the data from a large nationwide biobank-based cohort consisting of 121 773 women. After excluding all first- and second-degree relatives, the data of up to 65 421 women were analyzed.

PARTICIPANTS/MATERIALS, SETTING, METHODS

International Classification of Disease-10 diagnosis main codes associated with endometriosis (N80) and IBS (K58) diagnoses were identified from the Estonian Biobank dataset by linking with the Estonian Health Insurance Fund and other relevant registries. The associations between N80 and K58 and other diagnosis codes were tested using logistic regression, adjusting for age at recruitment and 10 genetic principal components to account for potential population stratification. Bonferroni correction was applied to account for multiple testing.

MAIN RESULTS AND THE ROLE OF CHANCE

Both women with endometriosis and IBS suffered from more conditions compared to the control group, with 226 and 428 diagnosis codes statistically significantly more frequent in women with respective diagnosis compared to controls. Women suffering from both conditions had 275 significantly associated comorbidities. A remarkable proportion of women with IBS or endometriosis suffered also from endometriosis (9.0%) or IBS (13.6%), respectively. In endometriosis, the most prevalent diagnoses were related to diseases of the genitourinary system (33 N-category codes) and in women with IBS, the most associated diagnoses were related to digestive disorders and gastrointestinal tract (52 codes from K-category). Among the most significant diagnoses in endometriosis were uterine leiomyomas (D25), menstrual disorders (N92) and infertility (N97) (P < 1 × 10-315 for all), and in IBS, lactose intolerance (E73), gastritis and duodenitis (K29) and functional dyspepsia (K30) were in the top list of most significant comorbidities (P < 1 × 10-315 for all).

LIMITATIONS, REASONS FOR CAUTION

The information about the severity stages of endometriosis and subtypes of IBS was not available for analysis. The findings may not be fully extrapolated to all female populations, because all participants were from one geographic area and had good access to health services.

WIDER IMPLICATIONS OF THE FINDINGS

These findings support previous studies that have found a high prevalence of pre-selected comorbidities in women with endometriosis and IBS. However, taking into account the differences in the full spectrum of comorbidities of endometriosis and IBS may aid in diagnosing these disorders. Women and healthcare providers need to be aware that women with endometriosis are at high risks of complications during pregnancy and should be carefully monitored.

STUDY FUNDING/COMPETING INTEREST(S)

This research was funded by the Estonian Research Council (grant PRG1076), Horizon 2020 innovation grant (ERIN, grant no. EU952516), Enterprise Estonia (grant no. EU48695), MSCA-RISE-2020 project TRENDO (grant no. 101008193) and by the European Union through the European Regional Development Fund (Projects no. 2014-2020.4.01.15-0012 and no. 2014-2020.4.01.16-0125). The authors have no conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

N/A.

Neuroimaging Correlates of Post-Traumatic Stress Disorder in Traumatic Brain Injury: A Systematic Review of the Literature

Introduction

Neuroimaging has been a highly utilized technique for studying traumatic brain injury (TBI) and post-traumatic stress disorder (PTSD) independently of one another, however, neuroimaging has increasingly been identified as a useful tool in better understanding TBI-related psychiatric conditions, such as PTSD.

Objectives

To complete a systematic review of the literature examining neuroimaging findings in TBI-related PTSD and to highlight the current literature’s limitations in order to strengthen future research.

Methods

A PRISMA compliant literature search was conducted in PubMed (MEDLINE), PsychINFO, EMBASE, and Scopus databases prior to May of 2019. The initial database query yielded 4388 unique articles, which were narrowed down based on specified inclusion criteria (e.g., clear TBI definition, clinician-diagnosed PTSD, statistically analyzed relationship between neuroimaging and PTSD, quantified time interval between TBI and neuroimaging).

Results

A final cohort of 10 articles met inclusion criteria, comprising the findings of 482 participants with TBI. Key neuroanatomical findings among the included articles suggest that PTSD is associated with significant changes in whole-brain networks of resting state connectivity and disruptions in bilateral frontal and temporal white matter tracts, fronto-limbic pathways, the internal capsule, and the uncinate fasciculus (Figure 1). Figure 1a:

Traumatic brain injury alters presentation of mild behavioral impairment domains across progression of all-cause dementia

Introduction

Traumatic brain injury (TBI) may alter dementia progression, although co-occurring neuropsychiatric symptoms (NPS) have received less attention. The mild behavioral impairment (MBI) construct relates NPS to underlying neural circuit disruptions, representing an important area of inquiry regarding TBI and dementia.

Objectives

(1) to examine the influence of prior TBI history (preceding study enrollment) on MBI incidence in all-cause dementia (prior to dementia diagnosis, i.e. MBI’s original definition) and (2) to utilize MBI domains as a construct for examining the influence of TBI on related NPS across the course of dementia onset and progression.

Methods

Using National Alzheimer’s Coordinating Center data, individuals progressing from normal cognition to all-cause dementia over 7.6±3.0 years were studied to estimate MBI incidence and symptom domains in 124 participants with prior TBI history compared to 822 without.

Results

Moderate-severe TBI was associated with the social inappropriateness MBI domain (OR_adj.=4.034; p=0.024) prior to dementia onset, and the abnormal perception/thought content domain looking across dementia progression (HR_adj.=3.703, p=0.005). TBI (all severities) was associated with the decreased motivation domain looking throughout dementia progression (HR_adj.=1.546, p=0.014).

Conclusions

TBI history is associated with particular MBI domains prior to onset and throughout progression of dementia. Understanding TBI’s impact on inter-related NPS may help elucidate underlying neuropathology.

Disclosure

No significant relationships.

Polysomnography Following Traumatic Brain Injury: A Systematic Review and Meta-Analysis

Introduction

Sleep disturbances are common following traumatic brain injury (TBI) worsening morbidity and other neuropsychiatric symptoms. Post-TBI alterations in sleep architecture require further study.

Objectives

(1) To evaluate polysomnographic measures of sleep architecture in participants with history of TBI compared to controls and as meta-analyses of pooled means. (2) To evaluate effects of timing and severity of TBI on polysomnographic outcomes.

Methods

PRISMA compliant systematic review was conducted of MEDLINE, PsycINFO, EMBASE and Scopus. Inclusion criteria: 1) reporting polysomnography in the context of TBI and 2) operationalizing TBI using clear/formalized criteria. Data were pooled in random-effects meta-analyses with outcomes expressed as mean differences (MD).

Results

In participants with TBI, sleep was comprised of 19.39% REM sleep, 8.13% N1, 51.18% N2, and 17.53% N3, as determined by meta-analyses of single means. Total sleep time was reduced in chronic (>6 months) TBI compared to acute-intermediate TBI (<6 months) (p=0.01). Compared to controls, participants with TBI differed with increased N1 sleep (MD=0.64%; 95%CI=0.02,1.25; p=0.04), reduced sleep efficiency (MD=-1.65%; 95%CI=-3.18,-0.12; p=0.03), and reduced sleep latency on the multiple sleep latency test (MD=-5.90mins; 95%CI=-10.09,-1.72; p<0.01). On sub-group analyses, participants with mild TBI differed from controls with reduced total sleep time (MD=-29.22mins, 95%CI=-54.16,-4.27; p=0.02). Similarly, participants with acute-intermediate TBI exhibited increased sleep latency compared to controls (MD=8.96mins; 95%CI=4.07,13.85; p<0.01) and differed significantly from participants with chronic TBI (X2(1,N=608)=6.54; p=0.01).

Conclusions

Sleep architecture is altered following TBI with potential implications regarding functional outcomes and recovery. These alterations appear to differ based on severity of injury and time since injury.

Disclosure

No significant relationships.

Treatment of patients with rare bleeding disorders in the Netherlands: Real-life data from the RBiN study

BACKGROUND

Patients with rare inherited bleeding disorders (RBDs) exhibit hemorrhagic symptoms, varying in type and severity, often requiring only on-demand treatment. Prolonged bleeding after invasive procedures is common. Adequate peri-procedural therapy may reduce this bleeding risk.

OBJECTIVE

To describe general treatment plans of RBD patients and evaluate the use of peri-procedural hemostatic therapy.

METHODS

In the Rare Bleeding Disorders in the Netherlands (RBiN) study, RBD patients from all six Dutch Hemophilia Treatment Centers were included. General treatment plans were extracted from patient files. Patients with a dental or surgical procedure in their history were interviewed about use of peri-procedural treatment and bleeding complications.

RESULTS

Two-hundred sixty-three patients with a rare coagulation factor deficiency or fibrinolytic disorder were included. Eighty-four percent had a documented general treatment plan. General treatment plans of patients with the same RBD were heterogeneous, particularly in factor XI deficiency. Overall, 308 dental and 408 surgical procedures were reported. Bleeding occurred in 50% of dental and 53% of surgical procedures performed without hemostatic treatment and in 28% of dental and 19% of surgical procedures performed with hemostatic treatment. Not only patients with severe RBDs, but also patients with mild deficiencies, experienced increased bleeding without proper hemostatic treatment.

CONCLUSION

Large heterogeneity in general treatment plans of RBD patients was found. Bleeding after invasive procedures was reported frequently, both before and after RBD diagnosis, irrespective of factor activity levels and particularly when peri-procedural treatment was omitted. Improved guidelines should include uniform recommendations for most appropriate hemostatic products per RBD and emphasize the relevance of individual bleeding history.

Generic PROMIS item banks in adults with hemophilia for patient-reported outcome assessment: Feasibility, measurement properties, and relevance

BACKGROUND

Legacy hemophilia-specific questionnaires are considered too long, show floor-/ceiling effects, and/or include irrelevant questions. Patient Reported Outcomes Measurement Information System (PROMIS) item banks, including Computer Adaptive Tests (CATs) and short forms, were designed for more efficient outcome assessment.

OBJECTIVES

Evaluate the feasibility, measurement properties, and relevance of seven PROMIS CATs and two short forms in patients with hemophilia.

PATIENTS/METHODS

In this cross-sectional study, Dutch adults with hemophilia completed nine PROMIS item banks electronically. Feasibility was assessed by number of items and floor/ceiling effects. Reliability was determined as the proportion of reliable scores (standard error ≤3.2). Construct validity was assessed by comparison with legacy instruments and expected differences between subgroups. Relevance of item banks was determined by proportions of limited scores.

RESULTS

Overall, 142 of 373 invited patients (mean age, 47 [range, 18-79], 49% severe hemophilia, 46% receiving prophylaxis) responded. Per CAT item bank, mean number of items answered varied from 5 (range, 3-12) to 9 (range, 5-12), with floor effects in pain interference (26% lowest scores) and depression (18% lowest scores). Construct validity and reliability were good for physical function, pain interference, satisfaction with social roles and activities, and fatigue. The CAT physical function showed the most limited scores (38%). The self-efficacy short forms showed ceiling effects (22%-28%) and no relation with the legacy instruments.

CONCLUSIONS

The PROMIS CATs physical function, pain interference, satisfaction with social roles and activities, and fatigue are feasible, reliable, and valid alternatives to legacy instruments for patients with hemophilia, with few items and low floor-/ceiling effects.

Work-related support in clinical care for patients with chronic diseases: intervention development

Background

Labor participation among patients with chronic diseases is lagging behind, particularly in the Netherlands. Most workers with a chronic disease might be able to deal with their disease and work participation, but a specific group needs support preferably. This study focuses on the development of a work-related support intervention in clinical care to promote sustainable work participation of patients with chronic diseases who regularly visit the outpatient clinic.

Methods

The first four steps of the Intervention Mapping (IM) approach were used to develop the intervention for a Dutch university hospital. A needs assessment based on a literature review, expert opinions and experiences, a qualitative study with healthcare professionals (n = 9) and consultation with financial staff (Step 1) was used to formulate objectives of the intervention (Step 2). Guided by theory-based methods and practical applications (Step 3), an intervention program, including training and tools for healthcare professionals (medical specialists and nurse specialists), was developed (Step 4).

Results

The needs assessment revealed the importance of stepped care comprising: screening; risk stratification; and if targeted, a problem assessment and providing tailored work-related support, including follow-up. In order to provide work-related support in clinical care, behavioral change of healthcare professionals is necessary. To change their behavior, a program, two training sessions for healthcare professionals and practical tools (screening list, conversation cards and a map with work-related support options) were developed.

Conclusions

To provide work-related support in clinical care for patients with chronic diseases, healthcare professionals need information, skill building training and tools. Despite providing support in care-as-usual, additional time is needed and must be financed. Cost effectiveness evaluation of the intervention is a necessary next step.

Key messages

Healthcare professionals should discuss ‘work’ with targeted patients. To provide work-related support in clinical care, healthcare professionals need knowledge, skills, tools and time.

Prevalence of Major Depressive Episode in 27 European Countries

Background

Information about the prevalence of current Major Depressive Episode (MDE) across European countries is essential for its monitoring and for the development of evidence- based mental health policies. The aims were to: 1) estimate the prevalence of MDE by country in Europe; and 2) assess variations in prevalence between countries.

Methods

Data from participants of 27 countries that completed the questionnaire of the second wave of the European Health Interview Survey (EHIS-2) were analysed (n = 258,888). The prevalence of MDE was quantified using the Patient Health Questionnaire-8 (PHQ-8) with a cut-off score of ≥ 10. Prevalence and 95% Confidence Intervals (CI) were estimated for each country. Variation in prevalence (country vs the rest) was evaluated using bivariable and multivariable negative binomial regression models considering the specific country as the main explanatory variable. From these models, crude Prevalence Ratios (PR) and adjusted Prevalence Ratios (aPR) were obtained.

Results

The overall prevalence of current MDE in Europe was 6.38% (6.24%-6.52%). The country with the lowest prevalence was the Czech Republic (2.58%, 2.14%-3.02%) and the country with highest prevalence Iceland (10.33%, 9.33%-11.32%). In all the countries (except for Finland and Croatia) prevalence was higher in women than in men. The countries with the highest aPR were Germany (aPR: 1.80, 95% CI: 1.71-1.89) and Luxembourg (aPR: 1.50, 95% CI: 1.35-1.66), while Slovakia (aPR: 0.28, 95% CI: 0.24-0.33) and the Czech Republic (aPR: 0.32, 95% CI: 0.27-0.38) exhibited the lowest aPR.

Conclusions

Considerable variability in the prevalence of MDE by country in Europe was observed without a clear pattern. These results serve as baseline for monitoring the prevalence of MDE at a European level and suggest a need for developing preventive strategies against depression, particularly in those countries identified with the highest prevalence.

Key messages

The results of this study show that the overall prevalence of MDE is high (6.38%), with important variation across countries (ranging from 2.58% in the Czech Republic to 10.33% in Iceland). The results found could serve as a reference for the monitoring of MDE in Europe and for the development of screening and preventive strategies both at European level as well as at a country level.

MR compatibility, safety and accuracy of the redesigned UMC Utrecht single needle implant device

Purpose. The Utrecht single needle implant device (SNID) was redesigned to increase needle insertion velocity. The purpose of this study is to evaluate the magnetic resonance compatibility, safety and accuracy of the implant device preparing its application in a patient study to investigate the feasibility of inserting a brachytherapy needle into the prostate to a defined tumor target point.Methods. Several experiments were performed to evaluate the mechanical and radiofrequency safety of the needle system, the magnetic field perturbation, the calibration of the implant device in the MR coordinate system, functioning of the implant device during imaging and accuracy of needle insertion.Results. Endurance experiments showed the mechanical safety of the needle system. Magnetic field perturbation was acceptable with induced image distortions smaller than 0.5 mm for clinical MR sequences. Calibration of the implant device in the MR coordinate system was reproducible with average error (mean±standard deviation) of 0.2 ± 0.4 mm, 0.1 ± 0.3 mm and 0.6 ± 0.6 mm in thex,y- andz- direction, respectively. The RF safety measurement showed for clinical MR imaging sequences maximum temperature rises of 0.2 °C at the entry and tip points of the needle. Simultaneous functioning of the implant device and imaging is possible albeit with some intensity band artifacts in the fast field echo images. Finally, phantom measurements showed deviations amounting 2.5-3.6 mm measured as target-to-needle distance at a depth of 12 cm.Conclusions. This preclinical evaluation showed that the MR compatibility, safety and accuracy of the redesigned UMC Utrecht SNID allow its application in a patient study on the feasibility of inserting a brachytherapy needle into the prostate to a defined tumor target point.

POS0615 TOCILIZUMAB IS SAFE AND EFFECTIVE IN ELDERLY PATIENTS WITH RHEUMATOID ARTHRITIS

Background:

Average life spans of patients with rheumatoid arthritis (RA) are approaching those of the general population. This results in a large proportion of RA patients being elderly at some point and underlines effective RA treatments needed for this population. Pivotal clinical trials have demonstrated the efficacy of tocilizumab (TCZ) for the treatment of RA. However, real-world studies that explore the effectiveness of TCZ especially in the elderly are lacking. ICHIBAN was a large, observational study that followed patients with RA treated with TCZ under real-world conditions in Germany for up to 2 years.

Objectives:

In this analysis of ICHIBAN, we examined the safety and effectiveness of long-term TCZ treatment according to patient baseline (BL) age (<50, 50–65, >65 years).

Methods:

ICHIBAN (NCT01194401) was a prospective, non-interventional study that observed adult patients with active moderate to severe RA in German rheumatology clinics and practices. Patients were treated with TCZ according to the local label. The safety analyses set (SAF) included all patients who received at least one dose of TCZ. The effectiveness set (EFF) included all patients from the SAF who had no prior TCZ therapy. Patient-reported outcomes (PROs) were assessed using the visual analogue scale. Last observation carried forward was used to substitute for missing values.

Results:

At baseline (BL), 3,164 patients were included in the SAF: 29.2% <50 years, 47.3% 50–65 years, and 23.5% >65 years old (1.2% ≥80 years). Patients >65 years old were not only the most likely to have comorbidities such as hypertension, anaemia, renal insufficiency, osteoporosis, diabetes, and coronary heart disease, but also had the highest BL disease activity according to Disease Activity Score-28 erythrocyte sedimentation rate (DAS28-ESR) and Clinical Disease Activity Index (CDAI) (Table 1).

Proportions of patients with adverse events (AEs) considered related to treatment were similar in patients <50 (22.3%), 50–65 (21.9%) and >65 years (22.2%). More patients >65 years (20.2%) and 50–65 years (14.4%) experienced serious AEs (SAEs) than patients <50 years (11.5%). Slightly more patients >65 years old experienced infectious SAEs (4.8%) than younger patients (<50 years, 3.2% and 50–65 years, 3.1%). Yet, similar proportions of patients across all age groups discontinued TCZ due to AE (7.0% <50 years; 9.6% 50–65 years; 7.8% >65 years).

2,902 patients were included in the EFF. Patients <50 years experienced DAS28-ESR remission at least once during the treatment period (65.4%) more often than patients aged 50–65 years (59.8%) or >65 years (59.5%). However, patients >65 years had numerically greater improvements in DAS28-ESR (Table 1). Patients <50 years had the best physical functioning at BL and the greatest reduction in Health Assessment Questionnaire Disease Index (HAQ-DI) score (Figure 1A). All age groups had similar improvements in PROs such as fatigue, strength of pain, and sleep disturbances (Figure 1B).

Table 1.

Model summary for prediction of DAS28CRP using time and etanercept originator (relative to biosimilar)

<50 years50–65 years>65 yearsDAS28-ESR, mean ± SDn*7771237617BL4.9 ± 1.45.3 ± 1.35.4 ± 1.3Last visit2.8 ± 1.73.1 ± 1.73.2 ± 1.7Change from BL-2.0 ± 1.7-2.2 ± 1.7-2.2 ± 1.8CDAI, mean ± SDn*7681217590BL25.7 ± 12.828.4 ± 13.328.8 ± 12.8Last visit13.3 ± 12.814.6 ± 13.214.5 ± 12.8Change from BL-12.5 ± 13.6-13.8 ± 14.0-14.3 ± 13.8

*271 patients with missing data at BL

**327 patients with missing data at BL

Conclusion:

Although elderly patients experienced a higher rate of infections, the proportion of patients withdrawing due to AE was not higher than in the other age groups. Starting with higher baseline disease activity, patients >65 years had similar benefits to disease activity and PROs when compared with younger patients. Overall, these results indicate that long-term TCZ treatment of elderly patients is effective and has an acceptable safety profile.

Disclosure of Interests:

Christof Specker Speakers bureau: AbbVie, Celgene, Chugai, Janssen-Cilag, Lilly, MSD, Novartis, Pfizer, Roche, and UCB, Consultant of: AbbVie, Boehringer Ingelheim, Chugai, Lilly, Novartis, Sobi, and UCB, Grant/research support from: Boehringer, Chugai, GSK, and Roche, Martin Aringer Speakers bureau: Roche and Chugai, Consultant of: Roche and Chugai, Grant/research support from: Roche, Gerd Rüdiger Burmester Consultant of: Lilly, Pfizer, Sanofi, and Roche, Grant/research support from: Roche, Marvin Peters Employee of: Roche Pharma AG, Michael W. Hofmann Employee of: Chugai Pharma Germany GmbH, Herbert Kellner Consultant of: Roche, Grant/research support from: Roche, Frank Moosig Grant/research support from: Roche, Hans-Peter Tony Speakers bureau: Roche, Abbvie, BMS, Chugai, Janssen, Novartis, Sanofi, and Lilly, Consultant of: Roche, Abbvie, BMS, Chugai, Janssen, Novartis, Sanofi, and Lilly, Grant/research support from: Roche, Gerhard Fliedner Grant/research support from: Roche, Chugai, Abbvie, and Lilly

Diabetes care and pregnancy outcomes for women with pregestational diabetes in Ireland

AIMS

Pre-gestational diabetes mellitus (PGDM) is associated with adverse outcomes. We aimed to examine pregnancies affected by PGDM; report on these pregnancy outcomes and compare outcomes for patients with type 1 versus type 2 diabetes mellitus; compare our findings to published Irish and United Kingdom (UK) data and identify potential areas for improvement.

METHODS

Between 2016 and 2018 information on 679 pregnancies from 415 women with type 1 Diabetes Mellitus and 244 women with type 2 diabetes was analysed. Data was collected on maternal characteristics; pregnancy preparation; glycaemic control; pregnancy related complications; foetal and maternal outcomes; unscheduled hospitalisations; congenital anomalies and perinatal deaths.

RESULTS

Only 15.9% of women were adequately prepared for pregnancy. Significant deficits were identified in availability and attendance at pre-pregnancy clinic, use of folic acid, attaining appropriate glycaemic targets and appropriate retinal screening. The majority of pregnancies (n = 567, 83.5%) resulted in a live birth but the large number of infants born large for gestational age (LGA) (n = 280, 49.4%), born prematurely <37 weeks and requiring neonatal intensive care unit (NICU) admission continue to be significant issues.

CONCLUSIONS

This retrospective cohort study identifies multiple targets for improvements in the provision of care to women with pre-gestational DM which are likely to translate into better pregnancy outcomes.

Major differences in clinical presentation, diagnosis and management of men and women with autosomal inherited bleeding disorders

BACKGROUND

In recent years, more awareness is raised about sex-specific dilemmas in inherited bleeding disorders. However, no large studies have been performed to assess differences in diagnosis, bleeding phenotype and management of men and women with bleeding disorders. Therefore, we investigated sex differences in a large cohort of well-defined patients with autosomal inherited bleeding disorders (von Willebrand disease (VWD), rare bleeding disorders (RBDs) and congenital platelet defects (CPDs)).

METHODS

We included patients from three nationwide cross-sectional studies on VWD, RBDs and CPDs in the Netherlands, respectively the WiN, RBiN and TiN study. In all studies a bleeding score (BS) was obtained, and patients filled in an extensive questionnaire on the management and burden of their disorder.

FINDINGS

We included 1092 patients (834 VWD; 196 RBD; 62 CPD), of whom 665 (60.9%) were women. Women were more often referred because of a bleeding diathesis than men (47.9% vs 36.6%, p = 0.002). Age of first bleeding was similar between men and women, respectively 8.9 ± 13.6 (mean ±sd) years and 10.6 ± 11.3 years (p = 0.075). However, the diagnostic delay, which was defined as time from first bleeding to diagnosis, was longer in women (11.6 ± 16.4 years) than men (7.7 ± 16.6 years, p = 0.002). Similar results were found when patients referred for bleeding were analyzed separately. Of women aging 12 years or older, 469 (77.1%) had received treatment because of sex-specific bleeding.

INTERPRETATION

Women with autosomal inherited bleeding disorders are more often referred for bleeding, have a longer diagnostic delay, and often require treatment because of sex-specific bleeding.

FUNDING

The WiN study was supported (in part) by research funding from the Dutch Hemophilia Foundation (Stichting Haemophilia), Shire (Takeda), and CSL Behring (unrestricted grant).

Intraprostatic Cancer Recurrence following Radical Radiotherapy on Transperineal Template Mapping Biopsy: Implications for Focal Ablative Salvage Therapy

PURPOSE

Men in whom external beam radiotherapy fails are usually placed on delayed hormone therapy. Some of these men have localized recurrence that might be suitable for further local therapy. We describe patterns of recurrence and suitability for focal ablative therapy in those undergoing transperineal template prostate mapping biopsies.

MATERIALS AND METHODS

The study included 145 consecutive patients (December 2007 to May 2014) referred with suspicion of recurrence due to rising prostate specific antigen after external beam radiotherapy or brachytherapy who underwent transperineal template prostate mapping biopsies. Suitability for focal ablative therapy required the cancer to be unifocal or unilateral, or bilateral/multifocal with 1 dominant index lesion and secondary lesions with Gleason score 3+3=6 with no more than 3 mm cancer core involvement.

RESULTS

Mean patient age was 70.7 (SD 5.8) years. Median prostate specific antigen at time of transperineal template prostate mapping biopsy was 4.5 ng/ml (IQR 2.5-7.7). Overall 75.9% (110) were suitable for a form of focal salvage treatment, 40.7% (59) were suitable for quadrant ablation, 14.5% (21) hemiablation, 14.5% (21) bilateral focal ablation and 6.2% (9) for index lesion ablation.

CONCLUSIONS

Three-quarters of patients who have localized radiorecurrent prostate cancer may be suitable for focal ablative therapy to the prostate based on transperineal template prostate mapping biopsies.

Bleeding severity in patients with rare bleeding disorders: real-life data from the RBiN study

Patients with hereditary rare bleeding disorders (RBDs) present with diverse hemorrhagic symptoms. Correlation between factor activity levels and clinical bleeding severity is poor for most RBDs. Threshold factor activity levels have been previously described in relation to bleeding severity but have not yet been validated. The Rare Bleeding Disorders in the Netherlands (RBiN) study is a nationwide cross-sectional study of patients registered in all 6 Dutch Haemophilia Treatment Centers with a known RBD and who are age 1 to 99 years. Bleeding scores were determined, and laboratory and clinical data were extracted from patient files. In all, 263 patients were included, of whom 202 (77%) attended the scheduled study visit. The median International Society of Thrombosis and Haemostasis (ISTH) bleeding assessment tool (BAT) score was 9. Correlations between baseline factor activity levels and ISTH BAT scores were strong for deficiencies in factor II (FII) (r = -0.792) and FX (r = -0.838) and were moderate for deficiencies of fibrinogen (r = -0.683), FV (r = -0.623), FVII (r = -0.516), FXIII (r = -0.516), and α2-antiplasmin (r = -0.594). There was no correlation for FXI deficiency (r = -0.218). The RBD BAT identified more women (94% vs 83%) and children (100% vs 71%) with an RBD than the ISTH BAT did. Importantly, 48% of patients had more severe bleeding than predicted for their baseline factor activity level. In addition, 34% of patients were predicted to be asymptomatic, but they actually had grade 2 (31%) or 3 (3%) bleeding. Bleeding severity in patients with RBDs is more pronounced than previously anticipated. The previously determined threshold factor activity levels to ensure no (spontaneous) bleeding in patients with an RBD are inaccurate. This trial was registered at www.clinicaltrials.gov as #NCT03347591.

Illness cognitions associated with health-related quality of life in young adult men with haemophilia

INTRODUCTION AND AIM

Knowledge on patterns of beliefs about the illness (illness cognitions) can provide insight into individual differences in adjustment to haemophilia. The current study aimed to identify (a) which sociodemographic and disease characteristics were associated with illness cognitions and (b) which illness cognitions were associated with health-related quality of life (HRQOL) in young adult men with haemophilia, besides sociodemographic and disease characteristics.

METHODS

Young adult men (18-30 years) with haemophilia in the Netherlands participated in an online multicentre cross-sectional study. Participants completed the Pediatric Quality of Life Inventory Young Adult version (PedsQL_YA). Potential sociodemographic determinants were assessed with the Course of Life Questionnaire (CoLQ) and illness cognitions with the Illness Cognition Questionnaire (ICQ). Multiple linear regression analyses were performed to assess potential determinants of illness cognitions and HRQOL.

RESULTS

Seventy young adult men with haemophilia (mean age 24.7 years, SD 3.5) participated. Born outside the Netherlands (β -0.24) and >1 bleed past 6 months (β -0.32) were associated with less acceptance of the disease. More acceptance was associated with better HRQOL in all domains: β 0.23-0.39. More helplessness was associated with worse total (β -0.30) and physical (β -0.42) HRQOL. Disease benefits, sociodemographic and disease characteristics were not associated with HRQOL.

CONCLUSION

Illness cognitions are associated with HRQOL in young adult men with haemophilia. Early recognition and identification of illness cognitions are important to facilitate support and psychosocial treatment to optimize young adults' well-being. Extra attention is needed for young adult men with frequent bleeds because they are at risk of lowered levels of acceptance of the disease.

Healthcare experiences and quality of life of adults with coeliac disease: a cross-sectional study

BACKGROUND

Coeliac disease affects many aspects of quality of life and treatment can be burdensome. Access to healthcare services is necessary for the diagnosis and management of coeliac disease. The present study aimed to investigate the healthcare experiences of adults with coeliac disease and explore the relationship between experiences and quality of life.

METHODS

A cross-sectional postal survey was sent to 800 members of Coeliac UK and contained questions about diagnosis, dietary advice, follow-up appointments, prescriptions, knowledge and information provision, and quality of life [Coeliac Disease Assessment Questionnaire (CDAQ)]. Descriptive statistics were calculated. A total problem score summarised the number of problems experienced with healthcare services. Multiple linear regression analyses were conducted to investigate experiential and demographic factors associated with quality of life.

RESULTS

An average of 5.5 problems with healthcare services was reported, with females reporting significantly more problems than males (6.5 versus 5.0, P = 0.003). The total problem score was significantly related to the CDAQ overall index score and all CDAQ dimension scores (stigma, dietary burden, symptoms, social isolation, and worries and concerns) (P < 0.001). The analyses highlighted four key areas of healthcare experiences that were significantly related to quality of life: information provision, general practioners' knowledge, communication with health professionals and access to prescriptions.

CONCLUSIONS

Poorer experiences of healthcare services in coeliac disease are related to worse quality of life. Improving services in the four key areas identified may help adults with coeliac disease to achieve a better quality of life.

Central nervous signs, blindness and cerebral vermicosis in free-ranging peregrine falcons (Falco peregrinus) associated with aberrant larval migrations

Four free-ranging peregrine falcons (Falco peregrinus) were submitted with a history of unilateral or bilateral blindness and central nervous signs to a veterinary clinic in Germany. There were no indications of trauma or ocular disease. Likewise, other differential diagnoses for CNS signs were ruled out within the diagnostic process. The clinical diagnostic panel in live falcons included general examination, radiography, endoscopy, hematology, ophthalmoscopy and parasitological examination of the feces, blood gas analysis and blood chemistry as well as computed tomography, and magnetic resonance imaging (MRI). A complete pathological and histopathological examination was performed post-mortem. The only common finding in all birds was an infection with the nematode parasite Serratospiculum tendo. The parasite was confirmed morphologically and via PCR. In two falcons intracerebral vermicoses was suspected in MRI and confirmed in subsequent histopathology, but molecular biological identification of the parasite species failed from brain tissue. Until today, S. tendo had been reported to affect the respiratory system, the liver and different parts of the gastrointestinal tract and to cause cachexia, inappetence, regurgitation, dyspnea and general signs of illness such as lethargy, poor plumage, and reduced reproduction. Our findings indicate that aberrant migration should be considered as cause for CNS signs in falcons. As S. tendo might be a possible cause for this, CNS signs might be included in the list of clinical signs of serratospiculiasis in falcons.