It May Not Be So Typical: Distinguishing Frontotemporal Dementia From Behavioral Variant Alzheimer's Disease

The Banner Alzheimer's Institute Case Conference is a weekly event in which physicians and staff discuss challenging and/or teaching cases of patients seen in clinical settings. These conferences are attended by a multidisciplinary group that includes Banner Alzheimer's Institute dementia specialists, community physicians (internal medicine, family medicine, and radiology), neuropsychologists, physician assistants, nurse practitioners, social workers, medical students, residents, and fellows. The Banner Alzheimer's Institute is located in Phoenix, Arizona, and it has an ambitious mission: to end Alzheimer's disease without losing a generation, set a new standard of care for patients and families, and forge a model of collaboration in biomedical research. The Institute provides high-level care and treatment for patients affected by Alzheimer's disease, dementia, and related disorders. In addition, the Institute offers extensive support services for families and many unique and rewarding research opportunities.

The impact of the COVID-19 pandemic on the provision & utilisation of primary health care services in Goma, Democratic Republic of the Congo, Kambia district, Sierra Leone & Masaka district, Uganda

INTRODUCTION

This study aimed to determine whether the COVID-19 pandemic had an impact on essential primary healthcare services at public primary healthcare facilities.

METHODS

The number of weekly consultations for antenatal care (ANC), outpatient (OPD), immunisations (EPI), family planning (FP) and HIV services, between January 2018 and December 2020, were collected from 25 facilities in Masaka district, Uganda, 21 in Goma, and 29 in Kambia district, Sierra Leone. Negative binomial regression models accounting for clustering and season were used to analyse changes in activity levels between 2018, 2019 and 2020.

RESULTS

In Goma, we found no change in OPD, EPI or ANC consultations, FP was 17% lower in March-July 2020 compared to 2019, but this recovered by December 2020. New diagnoses of HIV were 34% lower throughout 2020 compared to 2019. In Sierra Leone, compared to the same periods in 2019, facilities had 18-29% fewer OPD consultations throughout 2020, and 27% fewer DTP3 doses in March-July 2020. There was no evidence of differences in other services. In Uganda there were 20-35% fewer under-5 OPD consultations, 21-66% fewer MCV1 doses, and 48-51% fewer new diagnoses of HIV throughout 2020, compared to 2019. There was no difference in the number of HPV doses delivered.

CONCLUSIONS

The level of disruption varied across the different settings and qualitatively appeared to correlate with the strength of lockdown measures and reported attitudes towards the risk posed by COVID-19. Mitigation strategies such as health communications campaigns and outreach services may be important to limit the impact of lockdowns on primary healthcare services.

An exploration into early childhood physical literacy programs: A systematic literature review

This review explored the impact of physical literacy programs designed to engage two- to five-year-old preschool children. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) was used. Six EBSCO host databases were searched for the period 2011 to April 2021 using the search terms “physical literacy,” “early childhood,” and “impact.” Articles were excluded if physical literacy was not the focal intervention. The final data set consisted of seven-peer reviewed articles meeting the eligibility criteria and quality assessment for this review. Three themes were created using Braun and Clark’s (2006) approach to thematic analysis: Holistic benefits of physical literacy, Barriers to physical literacy and Education begins at home. Early childhood physical literacy programs provide holistic benefits for children; however, further research is needed in an Australian context. Families and community members working in the early childhood sector could benefit from further education and training to improve physical literacy awareness.

Optimising the use of physiotherapy resources after manipulation under anaesthetic for frozen shoulder

INTRODUCTION

Manipulation under anaesthetic (MUA) is a successful treatment for frozen shoulder (FS), and the recovery period and recurrence rates may be reduced by postoperative physiotherapy. This study evaluates two physiotherapy pathways for patients undergoing MUA for FS.

METHODS

Between 2016 and 2018, 248 age- and sex-matched patients presented to either a NHS secondary care upper limb service or the lead author's independent practice with a diagnosis of FS. The patients had differential access to postprocedure physiotherapy based on which service they presented to. In Group 1, physiotherapy advice only was given to the patient. In Group 2, supervised hydrotherapy and physiotherapy occurred postoperatively. Pre- and postprocedure Oxford Shoulder Scores (OSS) were collected for each group. Analysis of covariance (ANCOVA) was used to measure the effect of physiotherapy on postoperative OSS.

RESULTS

Group 2 showed a significantly greater improvement in postprocedure OSS when compared with Group 1 (18.2 vs 16.7) p<0.001). The estimated maximum effect of physiotherapy on postoperative OSS was an increase of 3.2.

CONCLUSION

Following MUA for FS, a statistically significant increase in OSS was detected in patients receiving postprocedure physiotherapy compared with advice alone. There was no difference in recurrence rates. The increase in OSS (3.2) is below the minimal clinically important difference, raising questions regarding the relative importance of postprocedure physiotherapy in a resource-limited environment.

Epidemiology, aetiology, interventions and genomics in children with arthrogryposis multiplex congenita: protocol for a multisite registry

INTRODUCTION

Arthrogryposis multiplex congenita (AMC) is an umbrella term including hundreds of conditions with the common clinical manifestation of multiple congenital contractures. AMC affects 1 in 3000 live births and is caused by lack of movement in utero. To understand the long-term needs of individuals diagnosed with a rare condition, it is essential to know the prevalence, aetiology and functional outcomes in a large sample. The development and implementation of a multicentre registry is critical to gather this data. This registry aims to improve health through genetic and outcomes research, and ultimately identify new therapeutic targets and diagnostics for treating children with AMC.

METHODS AND ANALYSIS

Participants for the AMC registry will be recruited from seven orthopaedic hospitals in North America. Enrollment occurs in two phases; Part 1 focuses on epidemiology, aetiology and interventions. For this part, retrospective and cross-sectional data will be collected using a combination of patient-reported outcomes and clinical measures. Part 2 focuses on core subset of the study team, including a geneticist and bioinformatician, identifying causative genes and linking the phenotype to genotype via whole genome sequencing to identify genetic variants and correlating these findings with pedigree, photographs and clinical information. Descriptive analyses on the sample of 400 participants and logistic regression models to evaluate relationships between outcomes will be conducted.

ETHICS AND DISSEMINATION

Ethical approval has been granted from corresponding governing bodies in North America. Dissemination of findings will occur via traditional platforms (conferences, manuscripts) for the scientific community. Other modalities will be employed to ensure that all stakeholders, including youth, families and patient support groups, may be provided with findings derived from the registry. Ensuring the findings are circulated to a maximum amount of interested parties will ensure that the registry can continue to serve as a platform for hypothesis-driven research and further advancement for AMC.

Abstract LB560: Engineering genetically-encoded synthetic biomarkers for breath-based cancer detection

Background: Breath analysis holds great promise for rapid and noninvasive early cancer detection. However, clinical implementation of endogenous volatile organic compound (VOC) signatures in breath is limited by low signal from nascent tumors and high background expression by nonmalignant tissues. By engineering tumors to express synthetic reporters that are not naturally produced in the human body, background signal from healthy tissues can be minimized, thereby maximizing sensitivity and specificity for tumor detection. Humans and plants share a common cholesterol biosynthesis (mevalonate) pathway, but in plants this pathway also generates volatile secondary metabolites (e.g. that attract pollinators). We therefore hypothesized that cancer cells could be coaxed to produce plant VOCs by genetically introducing the appropriate plant enzymes, and that these VOCs would be detectable in the breath as unique biomarkers of cancer.

Aims: 1) To express the citrus VOC, limonene, in a cultured human cancer cell line; 2) To determine the smallest tumor size at which exhaled limonene can be detected in mice implanted with limonene-expressing tumor cells.

Methods: HeLa cervical cancer cells were stably transfected with DNA vectors encoding limonene synthase (LS) alone or in combination with a truncated version of HMG-CoA reductase (HMGR), a key regulatory enzyme of the mevalonate pathway. Truncation of HMGR (tHMGR) by deletion of its regulatory domain renders it insensitive to feedback inhibition, augmenting flux through the mevalonate pathway and increasing limonene precursors. Cell culture headspace was analyzed using solid phase microextraction (SPME) and gas chromatography-mass spectrometry (GC-MS), confirming the presence of limonene. A xenograft murine tumor model was created by subcutaneously implanting HeLa-LS, HeLa-LS-tHMGR, or untransfected control HeLa cells in both flanks of 10-week-old athymic nude mice. For weekly VOC measurements, mice (n = 12) were placed in 1-liter chambers with continuous flow of highly pure air, and VOCs were collected using Tenax sorbent tubes, which were subsequently analyzed by GC-MS.

Results: Limonene production in HeLa-LS-tHMGR cells was double that of HeLa-LS cells (11.0 vs. 5.6 fg/cell/day) with LODs of 107,000 and 360,000 cells, respectively, and was undetectable in untransfected HeLa cells. In xenograft mice, tumor detection improved proportionally with breath sampling time: a 10-fold increase in sampling duration resulted in 9.4-fold greater limonene production (94 ng vs. 10 ng), and dynamic headspace sampling was ~100-fold more sensitive than static sampling. Importantly, limonene was a sensitive volatile reporter, permitting detection of tumors as small as 5 mm, and increased linearly with tumor size (R2 = 0.97), demonstrating strong utility for monitoring tumor progression. Pharmacokinetic modeling of tumor-derived limonene predicts detection of tumors as small as 7 mm in humans, equivalent to the detection limit of PET imaging, yet far more economical. In future work, this strategy will be incorporated into an inhalable nonviral vector formulation with a tumor-activatable promoter (e.g. survivin) for safe, non-invasive in vivo gene delivery and tumor-specific expression of limonene for breath-based early detection of non-small cell lung cancer.

Citation Format: Ophir Vermesh, Aloma D'Souza, Israt Alam, Mirwais Wardak, Theresa McLaughlin, Fadi El Rami, Ataya Sathirachinda, John Bell, Sharon Pitteri, Michelle James, Sharon Hori, Eric Gross, Sanjiv Gambhir. Engineering genetically-encoded synthetic biomarkers for breath-based cancer detection [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr LB560.

65 Therapist Confidence Utilizing Virtual Range of Motion Methods

Introduction

Since the SARS-CoV-2 virus (COVID-19) was officially declared a pandemic, there has been a marked increase in virtual clinical care. Between 2019 and 2020, telehealth (TH) visits, including tele-rehabilitation (TR), increased from 11% to 46%. While many therapy interventions can be performed with verbal guidance or demonstration, objective tool-based outcomes such as goniometrics , a valuable tool to determine burn survivor progress, have proved more challenging. The purpose of this study was to evaluate the level of confidence of therapists using three different remote methods of measuring finger range of motion (ROM).

Methods

Therapists evaluated finger ROM position of a mannequin model via a simulated TH visit using three different methods: Goniometry (GON), Visual Estimation (VE), and Electronic Protractor (EP). Pre and post-questionnaires were used to assess the participant’s experiences and comfort with each method of measurement. Descriptive statistics are used to report clinician opinions. A linear mixed effect model was used to determine the interaction of bias as a function of clinician characteristics (i.e., experience, familiarity, etc.).

Results

A total of 30 therapists and one hand surgeon participated. All reported some (30%) or a lot (70%) of familiarity with standard GON, and most reported some (30%)or a lot (40%) of familiarity with finger-specific goniometry. Post-testing, clinicians reported VE (80%) as the most difficult method and EP (73%) as the easiest. Only 7% reported feeling more confident with TR compared to in-person measurements, 27% felt equally confident, and 67% felt less confident. The average time to conduct the remote assessment measurement was 11:45 minutes using GON, 4:27 minutes using VE and 9:47 minutes using EP. There was not a significant relationship between performance bias and years of experience (p=0.587), familiarity with GON (p=0.406), familiarity with finger GON (p=0.709) or profession (p=0.281).

Conclusions

Despite the transition to virtual care, the mandate for valid and accurate documentation of functional outcome measures, including ROM, remains. Our study showed that the tools used for TR may not be the same as for in-person and clinicians need to adapt their approaches and skillsets. In addition, training with these new tools is essential for clinician confidence. In addition, there was not a relationship between experience and performance, suggesting that TR joint measurement is accessible to clinicians of all experience levels with proper training.

1266 Digital Rectal Examination: Do You Still Put Your Foot in It If You Don’t Put Your Finger in It?

Introduction

Most surgical trainees are familiar with the aphorism ‘if you don’t put your finger in it, you put your foot in it’, with regards to digital rectal examination (DRE). This commonly taught maxim, attributed to Bailey and Love in their Short Practice of Surgery, was coined to highlight the folly of neglecting DRE in patients with histories suggestive of malignant anorectal pathology. However, data are lacking on the diagnostic yield of DRE for detecting anorectal cancer in patients with lower gastrointestinal bleeding (LGIB), whilst advances in biomarker and imaging technology beg the question: is there still a role for DRE in the assessment of patients with LGIB?

Method

We designed a clinical coding search strategy to identify all adult patients with acute LGIB referred to general surgery at a UK university hospital from January to July 2020. Electronic patient records were interrogated to identify history and examination findings, diagnoses and clinical outcomes.

Results

169 patients (median age 63 (16-94) years, 54.4% male) were identified, 74.6% (126/169) with bright red bleeding, 23.7% (40/169) with altered blood and 1.8% (3/169) with melaena. DRE was performed in 91.1% (154/169) of patients, identifying blood in 42.9% (66/154) of cases and suspicious lesions, which were subsequently confirmed as anorectal malignancy, in 1.3% (2/154).

Conclusions

DRE represents a possibly stigmatising and uncomfortable examination for patients and clinicians alike. These data support the utility of DRE in patients with LGIB and may inform the discussion at the bedside to facilitate the timely diagnosis of anorectal malignancy.

1419 Targeted Use of Physiotherapy Resources in The COVID Era: How Does Face to Face Physiotherapy Compare with Simple Advice Sheets After Manipulation Under Anaesthetic for Frozen Shoulder?

Introduction

This study compares two pathways for patients undergoing MUA for FS, one where physiotherapy advice is only given to the patient (Group 1), and the other where supervised hydrotherapy and physiotherapy occur post operatively (Group 2).

Method

A descriptive analysis of pre- and post-operative Oxford Shoulder Scores and change scores were performed. Analysis of covariance (ANCOVA) was used to measure the effect of physiotherapy on post-operative OSS, with pre-operative OSS as the only covariate.

Results

The results for post-operative OSS were significantly greater for Group 2 than for Group 1 (40.7 for NHS and 44.7 for private, improvement of 17.32 for NHS and 18.23 for Private). The effect of physiotherapy was significant (p &lt; 0.001). The estimated effect of physiotherapy on postoperative OSS was an increase of 3.2 (95% confidence interval 1.5 – 4.8).

Conclusions

We detected a statistically significant increase in post-operative OSS in patients treated for frozen shoulder with MUA + physiotherapy compared with patients receiving MUA plus advice alone. These results suggest that physiotherapy does confer a real benefit, however the increased OSS is below the clinically significant level. Therefore, in a resource poor environment, such as may exist during and after COVID in many health care systems, MUA plus physio advice alone gives an excellent outcome for the treatment of FS.

Spectral characterization of flash and high flux x-ray radiographic sources with a magnetic Compton spectrometer

In this work, we present a new analysis method applied to revitalize permanent magnet Compton spectrometers used to measure photon energy spectra in the MeV range. The inversion of the measured electron distribution to determine the original photon distribution is achieved via a method of consistent coupled radiation transport and magnetic field mapping of the input photon spectra to the measured electron distribution. The method of linear least squares was used to perform the unfolding of the electron distribution to the initial photon spectra, without any assumptions made regarding the electron distribution. We present an application of this method to data from a nominal 19.4 MeV flash radiographic source (the first axis of the Dual Axis Radiographic Hydro-Test Facility) capable of generating 500 R @ 1 m in ∼60 ns and a medical therapy source (a Scanditronix M22, Microtron) capable of variable energies with nominal endpoints of 6, 10, 15, and 20 MeV and an output of ∼1000-2000 R/min @ 1 m. The results provide agreement between the modeled and unfolded experimentally measured photon spectra as quantified by statistical tests, from 1.5 to 20 MeV. Experimental results are presented as well as a discussion of the novel MCNP6-based simulations and methods for reconstruction of the spectra.

18 Manipulation Under Anaesthetic for Frozen Shoulder: Does Post-Operative Supervised Physiotherapy Affect the Outcome?

Introduction

This study compares two pathways for patients undergoing MUA for FS, one where physiotherapy advice is only given to the patient (Group 1), and the other where supervised hydrotherapy and physiotherapy occur post operatively (Group 2).

Method

A descriptive analysis of pre- and post-operative Oxford Shoulder Scores and change scores were performed.

Analysis of covariance (ANCOVA) was used to measure the effect of physiotherapy on post-operative OSS, with pre-operative OSS as the only covariate.

Results

The results for post-operative OSS were significantly greater for Group 2 than for Group 1 (40.7 for NHS and 44.7 for private, improvement of 17.32 for NHS and 18.23 for Private). The estimated effect of physiotherapy on postoperative OSS was an increase of 3.2 (95% confidence interval 1.5 – 4.8).

Conclusions

We detected a statistically significant increase in post-operative OSS in patients treated for frozen shoulder with MUA + physiotherapy compared with patients receiving MUA plus advice alone. These results suggest that physiotherapy does confer a real benefit, however the increased OSS is below the clinically significant level. Therefore, in a resource poor environment, such as may exist after COVID in many health care systems, MUA plus physio advice alone gives an excellent outcome for the treatment of FS.

Quantitative PET in the 2020s: a roadmap

Positron emission tomography (PET) plays an increasingly important role in research and clinical applications, catalysed by remarkable technical advances and a growing appreciation of the need for reliable, sensitive biomarkers of human function in health and disease. Over the last 30 years, a large amount of the physics and engineering effort in PET has been motivated by the dominant clinical application during that period, oncology. This has led to important developments such as PET/CT, whole-body PET, 3D PET, accelerated statistical image reconstruction, and time-of-flight PET. Despite impressive improvements in image quality as a result of these advances, the emphasis on static, semi-quantitative 'hot spot' imaging for oncologic applications has meant that the capability of PET to quantify biologically relevant parameters based on tracer kinetics has not been fully exploited. More recent advances, such as PET/MR and total-body PET, have opened up the ability to address a vast range of new research questions, from which a future expansion of applications and radiotracers appears highly likely. Many of these new applications and tracers will, at least initially, require quantitative analyses that more fully exploit the exquisite sensitivity of PET and the tracer principle on which it is based. It is also expected that they will require more sophisticated quantitative analysis methods than those that are currently available. At the same time, artificial intelligence is revolutionizing data analysis and impacting the relationship between the statistical quality of the acquired data and the information we can extract from the data. In this roadmap, leaders of the key sub-disciplines of the field identify the challenges and opportunities to be addressed over the next ten years that will enable PET to realise its full quantitative potential, initially in research laboratories and, ultimately, in clinical practice.

An effective digital tourniquet utilising a fenestrated limb tourniquet

We describe a safe and effective digital tourniquet utilising a fenestrated limb tourniquet which would normally be used for venepuncture.

Does Time Since Injury and Time Spent in Physical Therapy Treatment Affect Outcomes for Concussion Patients?

Purpose

To evaluate the effects of: 1) time between injury and physical therapy treatment and 2) time spent in physical therapy, on concussion symptom resolution.

Methods

Retrospective data was obtained for 202 patients who sustained a concussion and were referred for physical therapy. Subjects were assigned to groups based on type of injury (sport-related or not), time elapsed between concussion and therapy (0-14 days, 15–30, 31–60, 61–120, 121–365), and months spent in treatment (1 thru 4). Pre- and post- treatment scores were compared for the following measures: Sport Concussion Assessment Tool (SCAT), Convergence Insufficiency Symptom Survey (CISS), Dizziness Handicap Inventory (DHI), and Modified Clinical Test of Sensory Interaction on Balance (mCTSIB) using ANOVAs, with a Bonferroni-corrected p-value of p<.005.

Results

There was no significant difference in outcomes for athletes vs. non-athletes on SCAT Symptom (p=.74) or Severity Score (p=.18), CISS (p=.52), DHI (p=.05), or mCTSIB (p=.10); in outcomes for time elapsed since injury on SCAT Symptom Score (p=.80), SCAT Symptom Severity Score (p=.97), CISS (p=.61), DHI (p=.65), mCTSIB (p=.13); or in outcomes for months in treatment on SCAT Symptom Score (p=.23), SCAT Symptom Severity Score (p=.04), CISS (p=.41), DHI (p=.37), mCTSIB (p=.50).

Conclusion

Post-therapeutic improvements were noted for athletes receiving post-concussive physical therapy. Type of injury, time between injury and treatment, and time spent in treatment did not differentiate treatment outcomes for those receiving physical therapy post-concussion.

Evaluation of Aintree LOSS, a community-based, multidisciplinary weight management service: outcomes and predictors of engagement

Aintree LOSS is a community-based, multidisciplinary weight management programme for patients with severe and complex obesity, focusing on a flexible and individualized service with follow-up for up to 2 years. We evaluated all 2472 patients referred to the service between October 2009 and 2013. Demographic data were recorded at baseline, with the Index of Multiple Deprivation (IMD) used to measure socioeconomic deprivation. Weight was recorded at each visit. Mean body mass index at baseline was 45.6 (standard deviation 6.8), and 58.9% of patients lived in areas in the most deprived decile nationally. Of 2315 appropriate referrals, 1249 (55.1%) attended >2 visits; mean final weight loss was 3.50 ± 8.55 kg, and 24.1% achieved ≥5% weight loss. Of the patients, 754 (33.3%) attended for over 6 months; mean final weight loss was 4.94 ± 10 kg, and 34% achieved 5% weight loss. Multivariate logistic regression analysis showed increasing age, residence in a less deprived area and sleep apnoea to be independently associated with attendance for >6 months, and there was a linear relationship between 6-month attendance and deprivation quintile. Year-on-year analyses showed improvement in engagement over time, coinciding with efforts to improve access to the service. This work shows a multidisciplinary, community-based weight loss programme prioritizing a fully flexible and individualized approach functioning effectively in real-world practice. Maintaining engagement remains a challenge in weight loss programmes, and our results suggest younger patients living in areas with greater deprivation should be a target for efforts to improve engagement.