An investigation of the clinical impact and therapeutic relevance of a DNA damage immune response (DDIR) signature in patients with advanced gastroesophageal adenocarcinoma

BACKGROUND

An improved understanding of which gastroesophageal adenocarcinoma (GOA) patients respond to both chemotherapy and immune checkpoint inhibitors (ICI) is needed. We investigated the predictive role and underlying biology of a 44-gene DNA damage immune response (DDIR) signature in patients with advanced GOA.

MATERIALS AND METHODS

Transcriptional profiling was carried out on pretreatment tissue from 252 GOA patients treated with platinum-based chemotherapy (three dose levels) within the randomized phase III GO2 trial. Cross-validation was carried out in two independent GOA cohorts with transcriptional profiling, immune cell immunohistochemistry and epidermal growth factor receptor (EGFR) fluorescent in situ hybridization (FISH) (n = 430).

RESULTS

In the GO2 trial, DDIR-positive tumours had a greater radiological response (51.7% versus 28.5%, P = 0.022) and improved overall survival in a dose-dependent manner (P = 0.028). DDIR positivity was associated with a pretreatment inflamed tumour microenvironment (TME) and increased expression of biomarkers associated with ICI response such as CD274 (programmed death-ligand 1, PD-L1) and a microsatellite instability RNA signature. Consensus pathway analysis identified EGFR as a potential key determinant of the DDIR signature. EGFR amplification was associated with DDIR negativity and an immune cold TME.

CONCLUSIONS

Our results indicate the importance of the GOA TME in chemotherapy response, its relationship to DNA damage repair and EGFR as a targetable driver of an immune cold TME. Chemotherapy-sensitive inflamed GOAs could benefit from ICI delivered in combination with standard chemotherapy. Combining EGFR inhibitors and ICIs warrants further investigation in patients with EGFR-amplified tumours.

Fatigue in children who have recently completed treatment for acute lymphoblastic leukemia: a longitudinal study

BACKGROUND

This study examined fatigue in patients treated for childhood acute lymphoblastic leukemia (ALL) over a 2-year period (3- to 27-months post-treatment completion), from the perspective of children and parent caregivers, compared to a healthy comparison group.

METHODS

Eighty-three patients (4-16 years at enrolment) and their parents, reported on the child's fatigue using the Pediatric Quality of Life Inventory- Multidimensional Fatigue Scale (PedsQL-MFS), at 3- 15- and 27-months post-treatment completion, and 53 healthy children and their parents reported on fatigue across the same timepoints.

RESULTS

Parent proxy-reporting showed that parents of ALL patients reported more total fatigue than parents of the comparison group at all time points, with all subscales elevated (general, cognitive, and sleep/rest fatigue). In contrast, patient self-report of fatigue over this period differed from the comparison children for the general fatigue subscale only. Self-reported total fatigue was worse than the comparison group at the 27-month timepoint, with cognitive and sleep/rest fatigue symptoms contributing to this difference. Expected improvements in fatigue over time were not evident in either patient or parent report and no demographic risk factors were identified. Parents and children from both groups reported significantly more fatigue at all time points compared to commonly utilised normative population data.

CONCLUSIONS

Patients treated for childhood ALL are impacted by fatigue symptoms in the post-treatment and early survivorship period. These findings highlight that patients in the 2-years following treatment require increased symptom surveillance and may benefit particularly from interventions that target cognitive and sleep/rest fatigue.

Reduction in re-rupture rates following implementation of return-to-sport testing after anterior cruciate ligament reconstruction in 313 patients with a mean follow-up of 50 months

OBJECTIVES

The objective of this study was to assess the mid-term effectiveness of a return to sport (RTS) test in relation to preventing anterior cruciate ligament (ACL) re-rupture and contralateral ACL injury following ACL reconstruction (ACLR). Furthermore, this study aimed to assess the timing of passing a, RTS-test after surgery, and the effect age has on RTS outcomes.

METHODS

Patients undergoing ACLR between August 2014 and December 2018 took an RTS-test following rehabilitation. The RTS-test consisted of the Anterior Cruciate Ligament Return to Sport After Injury Scale, a single-leg hop, a single-leg triple hop, a single-leg triple cross-over hop, a box-drop vertical jump down, a single-leg 4-rep max-incline leg press, and a modified agility T test. RTS-passing criteria were ≥90% limb symmetry index in addition to defined takeoff and landing parameters. Mid-term review assessed sporting level, ACL re-injury, and contralateral ACL injury.

RESULTS

A total of 352 patients underwent RTS-testing, following ACLR with 313 (89%) contactable at follow-up, a mean of 50 months (standard deviation: 11.41, range: 28-76) after surgery. The re-rupture rate was 6.6% after passing the RTS-test and 10.3% following failure (p ​= ​0.24), representing a 36% reduction. Contralateral ACL injury rate after surgery was 6% and was 19% lower in those passing the RTS test. The mean age of patients passing their first RTS-test was significantly higher than that of those who failed (p ​= ​0.0027). Re-ruptures in those who passed the RTS test first time occurred late (>34 months), compared to those who failed first time, which all occurred early (<33 months) (p ​= ​0.0015). The mean age of re-rupture was significantly less than those who did not sustain a re-rupture (p ​= ​0.025).

CONCLUSION

Passing a RTS-test following ACLR reduces ACL re-rupture by 36.21% and contralateral ACL injury by 19.15% at mid-term follow-up. Younger patients are more likely to fail a RTS-test and are at higher risk of contralateral ACL rupture.

LEVEL III EVIDENCE

Are Population-Level Approaches to Dementia Risk Reduction Under-Researched? A Rapid Review of the Dementia Prevention Literature

Dementia is forecast to become increasingly prevalent, particularly in low- and middle-income countries, and is associated with high human and economic costs. Primary prevention of dementia -preventing risk factors leading to disease development - is an emerging global public health priority. Primary prevention can be achieved in two ways: individual-level or population-level. In this rapid review, we quantify the proportion of contributing interventional evidence to the dementia primary prevention literature that is concerned with either approach. We searched Medline, the National Institute for Health and Care Excellence, Cochrane, the World Health Organization, and Google to identify systematic reviews that described primary prevention interventions for dementia. We used search terms related to dementia risk reduction, intervention/policy, and review. We analysed reference lists of included dementia prevention reviews to identify contributing primary prevention evidence, and categorised these as either individual-level or population-level. Additionally, we examined search strategies to investigate the likelihood of reviews identifying available population-level interventions. We included twelve of the 527 articles retrieved. Population-level evidence was summarised by only two reviews. In these two reviews, <2.5% of the interventions described where population-level interventions. Most search strategies were weighted towards identifying individual-level evidence. Existing systematic reviews of dementia primary prevention interventions include almost no population-level evidence. Correction of this imbalance is needed to ensure that dementia prevention policies can achieve meaningful reductions in the prevalence of, and inequalities in, dementia.

What is a population-level approach to prevention, and how could we apply it to dementia risk reduction?

The World Health Organisation's 2022 'blueprint for dementia research' highlights the need for more research into population-level risk reduction. However, definitions of population-level prevention vary, and application to dementia is challenging because of its multi-factorial aetiology and a maturing prevention evidence base. This paper compares and contrasts key concepts of 'population-level prevention' from the literature, explores related theoretical models and policy frameworks, and applies this to dementia risk reduction. We reach a proposed definition of population-level risk reduction of dementia, which focusses on the need to change societal conditions such that the population is less likely to develop modifiable risk factors known to be associated with dementia, without the need for high-agency behaviour change by individuals. This definition, alongside identified policy frameworks, can inform synthesis of existing evidence and help to co-ordinate the generation of new evidence.

Multiorgan MRI findings after hospitalisation with COVID-19 in the UK (C-MORE): a prospective, multicentre, observational cohort study

INTRODUCTION

The multiorgan impact of moderate to severe coronavirus infections in the post-acute phase is still poorly understood. We aimed to evaluate the excess burden of multiorgan abnormalities after hospitalisation with COVID-19, evaluate their determinants, and explore associations with patient-related outcome measures.

METHODS

In a prospective, UK-wide, multicentre MRI follow-up study (C-MORE), adults (aged ≥18 years) discharged from hospital following COVID-19 who were included in Tier 2 of the Post-hospitalisation COVID-19 study (PHOSP-COVID) and contemporary controls with no evidence of previous COVID-19 (SARS-CoV-2 nucleocapsid antibody negative) underwent multiorgan MRI (lungs, heart, brain, liver, and kidneys) with quantitative and qualitative assessment of images and clinical adjudication when relevant. Individuals with end-stage renal failure or contraindications to MRI were excluded. Participants also underwent detailed recording of symptoms, and physiological and biochemical tests. The primary outcome was the excess burden of multiorgan abnormalities (two or more organs) relative to controls, with further adjustments for potential confounders. The C-MORE study is ongoing and is registered with ClinicalTrials.gov, NCT04510025.

FINDINGS

Of 2710 participants in Tier 2 of PHOSP-COVID, 531 were recruited across 13 UK-wide C-MORE sites. After exclusions, 259 C-MORE patients (mean age 57 years [SD 12]; 158 [61%] male and 101 [39%] female) who were discharged from hospital with PCR-confirmed or clinically diagnosed COVID-19 between March 1, 2020, and Nov 1, 2021, and 52 non-COVID-19 controls from the community (mean age 49 years [SD 14]; 30 [58%] male and 22 [42%] female) were included in the analysis. Patients were assessed at a median of 5·0 months (IQR 4·2-6·3) after hospital discharge. Compared with non-COVID-19 controls, patients were older, living with more obesity, and had more comorbidities. Multiorgan abnormalities on MRI were more frequent in patients than in controls (157 [61%] of 259 vs 14 [27%] of 52; p<0·0001) and independently associated with COVID-19 status (odds ratio [OR] 2·9 [95% CI 1·5-5·8]; padjusted=0·0023) after adjusting for relevant confounders. Compared with controls, patients were more likely to have MRI evidence of lung abnormalities (p=0·0001; parenchymal abnormalities), brain abnormalities (p<0·0001; more white matter hyperintensities and regional brain volume reduction), and kidney abnormalities (p=0·014; lower medullary T1 and loss of corticomedullary differentiation), whereas cardiac and liver MRI abnormalities were similar between patients and controls. Patients with multiorgan abnormalities were older (difference in mean age 7 years [95% CI 4-10]; mean age of 59·8 years [SD 11·7] with multiorgan abnormalities vs mean age of 52·8 years [11·9] without multiorgan abnormalities; p<0·0001), more likely to have three or more comorbidities (OR 2·47 [1·32-4·82]; padjusted=0·0059), and more likely to have a more severe acute infection (acute CRP >5mg/L, OR 3·55 [1·23-11·88]; padjusted=0·025) than those without multiorgan abnormalities. Presence of lung MRI abnormalities was associated with a two-fold higher risk of chest tightness, and multiorgan MRI abnormalities were associated with severe and very severe persistent physical and mental health impairment (PHOSP-COVID symptom clusters) after hospitalisation.

INTERPRETATION

After hospitalisation for COVID-19, people are at risk of multiorgan abnormalities in the medium term. Our findings emphasise the need for proactive multidisciplinary care pathways, with the potential for imaging to guide surveillance frequency and therapeutic stratification.

FUNDING

UK Research and Innovation and National Institute for Health Research.

A novel approach using electroacupuncture for erectile dysfunction after radical prostatectomy: A case report

INTRODUCTION

Research shows that electrical stimulation to damaged peripheral nerves has promising effects on nerve regeneration and recovery of function.

DESCRIPTION

A 71 yr. old male, who was 12 months post left intrafacial and right incremental nerve sparing robotic radical prostatectomy received 6 sessions of sacral electroacupuncture/acupuncture at weekly intervals, commencing 12 months post operatively.

METHODS

CARE guidelines informed the case study report. Positive changes in erectile function after electroacupuncture was recorded using validated scores (IIEF-5 and EHS). Qualitative information was collected via a feedback box.

DISCUSSION

Given that current treatments for post radical prostatectomy erectile dysfunction are invasive and largely unsuccessful, further investigation into electroacupuncture for this population should be pursued.

Post-acute phase and sequelae management of epidermal necrolysis: an international, multidisciplinary DELPHI-based consensus

BACKGROUND

Long-term sequelae are frequent and often disabling after epidermal necrolysis (Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN)). However, consensus on the modalities of management of these sequelae is lacking.

OBJECTIVES

We conducted an international multicentric DELPHI exercise to establish a multidisciplinary expert consensus to standardize recommendations regarding management of SJS/TEN sequelae.

METHODS

Participants were sent a survey via the online tool "Survey Monkey" consisting of 54 statements organized into 8 topics: general recommendations, professionals involved, skin, oral mucosa and teeth, eyes, genital area, mental health, and allergy workup. Participants evaluated the level of appropriateness of each statement on a scale of 1 (extremely inappropriate) to 9 (extremely appropriate). Results were analyzed according to the RAND/UCLA Appropriateness Method.

RESULTS

Fifty-two healthcare professionals participated. After the first round, a consensus was obtained for 100% of 54 initially proposed statements (disagreement index < 1). Among them, 50 statements were agreed upon as 'appropriate'; four statements were considered 'uncertain', and ultimately finally discarded.

CONCLUSIONS

Our DELPHI-based expert consensus should help guide physicians in conducting a prolonged multidisciplinary follow-up of sequelae in SJS-TEN.

89 DIAGNOSIS AND TREATMENT OF SUSPECTED OBSTRUCTIVE SLEEP APNOEA (OSA) IN OLDER PEOPLE: A RETROSPECTIVE COMPARATIVE ANALYSIS

Background

Obstructive Sleep Apnoea (OSA) is common yet often undiagnosed in older people as symptoms of fatigue and poor sleep are common and non-specific. OSA screening tools also lack validity in older patients. This study aims to review the clinical presentation, use of screening tools and treatment adherence in older people.

Methods

A retrospective cohort study of patients &gt;65 years attending a tertiary sleep clinic who underwent polysomnography for suspected OSA was performed. Electronic patient records were reviewed to obtain information on clinical presentation, screening scores, polysomnography reports and treatment initiated. Correlation between variables was performed using Pearson’s correlation co-efficient and represented using R-score. To compare CPAP usage with younger people, a cohort of controls &lt;65 years were matched in 2:1 ratio for OSA severity (mild, moderate or severe) at diagnosis. Comparison of adherence rates was performed using Mann-Whitney U-test and represented using Z-scores.

Results

A convenience sample of 100 consecutive older patients were included. Fatigue was present in 53% and witness reported snoring in 86% and apnoeas in 56%. Moderate or severe OSA was confirmed by polysomnography in 91% cases. BMI and the STOP-BANG questionnaire were positively correlated with OSA severity as measured by Apnoea Hypopnea Index, while ESS and Berlin Questionnaire were not. Positive pressure ventilation was initiated in 90% patients. CPAP was extremely effective with the median AHI falling to within normal range on follow up. CPAP usage was significantly higher in older patients compared with younger matched control (85% vs 66% p=013).

Conclusion

Older people with OSA present with classical symptoms. STOP -BANG questionnaire and BMI were positively correlated with AHI values while other screening tools lacked validity. Treatment with CPAP was highly efficacious in older people with high usage rates and should be considered as first-line treatment for moderate and severe OSA in older patients.

293 PRE-ADMISSION POTENTIALLY INAPPROPRIATE PRESCRIBING PREVALENCE ON A CARE OF THE OLDER ADULT MEDICAL WARD

Background

Potentially Inappropriate Prescribing (PIP) is a common but critical issue in care of the older adult. It is estimated that between 50 and 70% of those over 65 years are receiving at least one potentially inappropriate medication. Polypharmacy is a good indicator of PIP as it can indicate over- and inappropriate prescribing through prescribing cascade, exposing patients to risks of drug interactions and Adverse Drug Events (ADEs). 10-20% of hospital admissions of older adults are directly related to ADE of inappropriately prescribed drugs.

Methods

Point prevalence study using the ‘Screening Tool of Older Persons Prescriptions’ (STOPP) to identify PIPs on a geriatric medicine ward. Patients over 65 years of age admitted from home were included in the study. Patients’ pre-admission medications and changes made to these were assessed using STOPP.

Results

Sixteen patients out of 22 met the inclusion criteria. The average age of the patients included in the study was 82.3 years with a range from 70 to 88 years. 75% were female. 94% had polypharmacy prior to admission with an average of 2.25 PIPs (range 0 to 5). 43% (n=7) had all their PIPs addressed by a geriatrician as per STOPP, with a further 18% (n=3) having some of their PIPs altered. 25% (n=4) did not have any alterations to their PIPs.

Conclusion

Despite widely known impacts of PIPs on older adults, PIP remains highly prevalent in those admitted to hospital. PIP and polypharmacy can increase incident frailty two-fold and polypharmacy and frailty can lead to a 6-fold increase in mortality within two and a half years. We must actively educate all those involved in prescribing for this cohort of patients to reduce PIPs and their adverse effects.

250 AUDIT INTO THE USE AND COMPLICATIONS OF MAINTENANCE INHALER THERAPY IN MEDICALLY ADMITTED PATIENTS OVER THE AGE OF 65 YEARS

Background

Adequate maintenance inhaler use is associated with improved symptom control and reduced exacerbation rates, however, cognitive impairment and limitations in dexterity can be a barrier to inhaled therapy.

Methods

Between the 20th of April and 30th May 2022 patients admitted to our ward over the age of 65 years had their maintenance inhaler technique assessed using the National Asthma Council of Australia checklist. Symptom control was assessed by either the Asthma Control Test (ACT) or the Chronic Obstructive Pulmonary Disease (COPD) assessment tool (CAT). The 4 AT score was used to screen for neurocognitive impairment.

Results

20 patients were recruited to the study. 40% were male. Mean age 81.5 years +- 6.8years. The respiratory diagnosis was COPD in 70%, Asthma 20%, Interstitial Lung Disease 5% and bronchiectasis 5%. 65 % had pulmonary function testing performed. Asthma symptom control was within target in 75% of the asthma patients (ACT score &gt;20). Mean score 21 +- 2.5. COPD symptom control was within target in 31% of patients (CAT score &lt;10) . Mean CAT score of 19.3 +- 8. 4. 20% had a pre-admission diagnosis of neurocognitive impairment. The mean 4AT score of the cohort was 1.2. 35% had audible wheeze at the time of review. 80% of inhalers were prescribed for the licensed indication. 35% had potential complications of inhaler therapy – 25% pneumonia and 10% oral candidiasis. Notably all pneumonias were associated with fluticasone. Inhaler technique was associated with errors in almost a quarter of all patients (24%). Increasing 4AT score correlated with high likelihood of inhaler errors, R = 0.63.

Conclusion

Poor inhaler technique is correlated with neurocognitive impairment. Pneumonia is a potential complication of inhaler therapy and represents an opportunity for deprescribing in patients with COPD.

Search for Subsolar-Mass Binaries in the First Half of Advanced LIGO's and Advanced Virgo's Third Observing Run

We report on a search for compact binary coalescences where at least one binary component has a mass between 0.2  M_{⊙} and 1.0  M_{⊙} in Advanced LIGO and Advanced Virgo data collected between 1 April 2019 1500 UTC and 1 October 2019 1500 UTC. We extend our previous analyses in two main ways: we include data from the Virgo detector and we allow for more unequal mass systems, with mass ratio q≥0.1. We do not report any gravitational-wave candidates. The most significant trigger has a false alarm rate of 0.14  yr^{-1}. This implies an upper limit on the merger rate of subsolar binaries in the range [220-24200]  Gpc^{-3} yr^{-1}, depending on the chirp mass of the binary. We use this upper limit to derive astrophysical constraints on two phenomenological models that could produce subsolar-mass compact objects. One is an isotropic distribution of equal-mass primordial black holes. Using this model, we find that the fraction of dark matter in primordial black holes in the mass range 0.2  M_{⊙}<m_{PBH}<1.0  M_{⊙} is f_{PBH}≡Ω_{PBH}/Ω_{DM}≲6%. This improves existing constraints on primordial black hole abundance by a factor of ∼3. The other is a dissipative dark matter model, in which fermionic dark matter can collapse and form black holes. The upper limit on the fraction of dark matter black holes depends on the minimum mass of the black holes that can be formed: the most constraining result is obtained at M_{min}=1  M_{⊙}, where f_{DBH}≡Ω_{DBH}/Ω_{DM}≲0.003%. These are the first constraints placed on dissipative dark models by subsolar-mass analyses.

Clinical characteristics with inflammation profiling of long COVID and association with 1-year recovery following hospitalisation in the UK: a prospective observational study

BACKGROUND

No effective pharmacological or non-pharmacological interventions exist for patients with long COVID. We aimed to describe recovery 1 year after hospital discharge for COVID-19, identify factors associated with patient-perceived recovery, and identify potential therapeutic targets by describing the underlying inflammatory profiles of the previously described recovery clusters at 5 months after hospital discharge.

METHODS

The Post-hospitalisation COVID-19 study (PHOSP-COVID) is a prospective, longitudinal cohort study recruiting adults (aged ≥18 years) discharged from hospital with COVID-19 across the UK. Recovery was assessed using patient-reported outcome measures, physical performance, and organ function at 5 months and 1 year after hospital discharge, and stratified by both patient-perceived recovery and recovery cluster. Hierarchical logistic regression modelling was performed for patient-perceived recovery at 1 year. Cluster analysis was done using the clustering large applications k-medoids approach using clinical outcomes at 5 months. Inflammatory protein profiling was analysed from plasma at the 5-month visit. This study is registered on the ISRCTN Registry, ISRCTN10980107, and recruitment is ongoing.

FINDINGS

2320 participants discharged from hospital between March 7, 2020, and April 18, 2021, were assessed at 5 months after discharge and 807 (32·7%) participants completed both the 5-month and 1-year visits. 279 (35·6%) of these 807 patients were women and 505 (64·4%) were men, with a mean age of 58·7 (SD 12·5) years, and 224 (27·8%) had received invasive mechanical ventilation (WHO class 7-9). The proportion of patients reporting full recovery was unchanged between 5 months (501 [25·5%] of 1965) and 1 year (232 [28·9%] of 804). Factors associated with being less likely to report full recovery at 1 year were female sex (odds ratio 0·68 [95% CI 0·46-0·99]), obesity (0·50 [0·34-0·74]) and invasive mechanical ventilation (0·42 [0·23-0·76]). Cluster analysis (n=1636) corroborated the previously reported four clusters: very severe, severe, moderate with cognitive impairment, and mild, relating to the severity of physical health, mental health, and cognitive impairment at 5 months. We found increased inflammatory mediators of tissue damage and repair in both the very severe and the moderate with cognitive impairment clusters compared with the mild cluster, including IL-6 concentration, which was increased in both comparisons (n=626 participants). We found a substantial deficit in median EQ-5D-5L utility index from before COVID-19 (retrospective assessment; 0·88 [IQR 0·74-1·00]), at 5 months (0·74 [0·64-0·88]) to 1 year (0·75 [0·62-0·88]), with minimal improvements across all outcome measures at 1 year after discharge in the whole cohort and within each of the four clusters.

INTERPRETATION

The sequelae of a hospital admission with COVID-19 were substantial 1 year after discharge across a range of health domains, with the minority in our cohort feeling fully recovered. Patient-perceived health-related quality of life was reduced at 1 year compared with before hospital admission. Systematic inflammation and obesity are potential treatable traits that warrant further investigation in clinical trials.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Total neoadjuvant chemotherapy: a silver lining during the COVID pandemic for a patient with locally advanced diffuse distal gastric adenocarcinoma

Perioperative oncological therapies resulting in pathological complete response (pCR) in diffuse-type distal gastric adenocarcinoma are extremely rare. We report a case of locally advanced (cT3 N2 M0) diffuse-type distal gastric adenocarcinoma treated with 'total neoadjuvant' FLOT (eight cycles), due to the COVID-19 pandemic, and laparoscopic radical subtotal gastrectomy with D2 lymphadenectomy. The patient demonstrated a progressive radiological response on positron emission tomography with 2-deoxy-2-[fluorine-18]fluoro-d-glucose integrated with computed tomography (¹⁸F-FDG PET-CT) and pCR in the resected specimen (ypT0 N0). As far as we are aware, this is the first case of pCR in locally advanced T3 N2 diffuse distal gastric cancer to be reported in the literature. It introduces a novel approach of total neoadjuvant chemotherapy with ¹⁸F-FDG PET-CT to assess response, combined with radical minimally invasive surgical management to provide optimal care for patients with gastric cancer.

Risk factors for local atypical fibroxanthoma recurrence and progression to pleomorphic dermal sarcoma: A meta-analysis of individualized participant data

Background

Risk factors for local atypical fibroxanthoma (AFX) recurrence and progression to pleomorphic dermal sarcoma (PDS) have not previously been identified.

Objective

To identify risk factors and provide follow‐up suggestions for local AFX recurrence and progression to PDS.

Methods and Materials

A literature search was performed in the PubMed, EMBASE, and Cochrane databases. The PRISMA and MOOSE guidelines were followed. The risks of local AFX recurrence and progression to PDS were presented as Kaplan–Meier plots and risk factors were presented as hazard ratios (HRs) calculated with univariate and multivariate Cox regression.

Results

Five hundred and ninety‐eight patients with AFX from 14 studies were included. Age >74 years and male sex significantly increased the risk of local recurrence (HR: 7.31 [95% confidence interval [CI]: 1.78–30.0], p < 0.01 and HR: 2.89 [95% CI: 1.04–8.01], p < 0.05, respectively). There was no difference when comparing wide local excision and Mohs' micrographic surgery (p = 0.89). The risks of local AFX recurrence and progression to PDS after 2 years were <1%.

Conclusion

A more intensive follow‐up regimen could be considered in patients >74 years old and males due to the higher risk of local AFX recurrence.

A cross-sectional analysis of psychological distress among higher education students in Ireland

OBJECTIVES

To examine levels of psychological distress among higher education students in Ireland overall and across a range of personal, higher education, and socioeconomic characteristics, prior to the COVID-19 pandemic.

METHODS

A cross-sectional online survey of college students in Ireland was undertaken in 2018. Data on 5201 students from 13 higher education institutions (HEIs) were analyzed. Stress, anxiety, and depression symptom scores based on the Depression, Anxiety and Stress Scale (DASS-21) were calculated and reported, with statistical testing used to compare across groups.

RESULTS

Overall, 29.6% and 19.1% of respondents were classified in the mild to moderate and severe to extremely severe range for depression respectively. The corresponding proportions were 25.9% and 20.7% for anxiety, and 24.5% and 14.8% for stress. Differences across groups included higher levels of psychological distress for transgender and female students compared to males (p < 0.01), for gay/lesbian/bisexual students compared to heterosexuals (p < 0.01), for undergraduates compared to postgraduates (p < 0.01), for students from intermediate/technical/service/unskilled social classes compared to professional/self-employed social classes (p < 0.01), and for those with financial difficulties compared to those without financial difficulties (p < 0.01).

CONCLUSIONS

Rates of psychological distress were high amongst college students in Ireland prior to the COVID-19 pandemic, with substantial differences across groups. Due to study limitations, such as possible selection bias, the findings need replication. Further research is needed to determine the impact of the pandemic on the prevalence of mental illness in this population.

Demonstrating the processes and outcomes of a rural Community Mental Health Rehabilitation Service: A realist evaluation

BACKGROUND

As part of significant mental health reform, the Community Mental Health Rehabilitation Service (CMHRS) was implemented in rural South Australia. The CMHRS is a 10-bed mental health residential program offering rehabilitative mental health support to rural residents.

AIM

To analyse the CMHRS service delivery model and its impact on recovery outcomes for consumers.

METHODS

A mixed method, realist evaluation approach was utilised. A purposive sample of CMHRS staff (n = 6) and consumers (n = 8) were recruited. Consumer recovery was measured using the RAS-DS (on admission and discharge). Participants' perspectives of the service were gained via one staff focus group (n = 6) and individual semi-structured interviews (consumers n = 6; staff n = 2). Pre-post RAS-DS scores were analysed using paired t-tests/Wilcoxon paired-signed rank test, with qualitative data analysed thematically.

RESULTS

Significant positive increases in RAS-DS total scores were observed at discharge, supported by the qualitative themes of (re)building relationships and social connections and recovering health and wellbeing. Contextual factors (e.g. staffing) and program mechanisms (e.g. scheduling) impacting on service implementation were identified.

CONCLUSION

Maintaining a rehabilitation recovery-focused approach, balanced with an appropriately trained multi-disciplinary team, are vital for maximising positive consumer outcomes.

SIGNIFICANCE

This realist evaluation identifies critical factors impacting rural mental health rehabilitation service delivery.

Association between social deprivation status, age of presentation, and survival following ST-segment elevation myocardial infarction

Introduction

Many factors influence age of presentation with and survival following ST-segment myocardial infarction (STEMI). These include age, mode of, and time-delay to emergency treatment, diabetes and smoking. We sought to assess whether overall social deprivation status is associated with age of presentation and mortality following STEMI patients treated with primary PCI.

Methods

All patients treated emergently for STEMI in a large Northern Irish tertiary hospital from 2013 – 2017 were reviewed. Social deprivation is determined as a composite score relating to income, crime etc, and assigned to small geographical regions by the Northern Ireland Statistics and Research Agency. Deprivation score was assigned to patients based on their postcode. The database was ranked by social deprivation score and divided in to quintiles. The most (Grp 1) and least (Grp 5) deprived quintiles were compared. Mortality was determined from a national electronic health record.

Results

1,192 patients were included in the analysis. Mean follow up was 52.5 months (SD 15.6), minimum follow up was 35.6 months. There was no difference in gender: 70.1% male in Grp 1 vs 75.2% male in Grp 5 (p=0.68); no difference in ECG to balloon time: mean 89.9mins (95% CI 84.9–94.9) Grp 1 vs 90.5mins (95% CI 86.2–94.9) Grp 5 (p=0.86). The more deprived group was younger: mean age 60.6 (95% CI 59.5–61.6) vs 65.2 (95% CI 64.2–66.3) (p&lt;0.000). Crude survival measured by Log-rank test was the same between the groups (p=0.52). Following Cox-regression adjustment for age, survival was longer in the least deprived group (p=0.042).

Conclusion

Social deprivation is associated with both a younger age of presentation with, and a higher mortality following STEMI. This is important variable is often overlooked in medical literature and should be further studied.

Funding Acknowledgement

Type of funding sources: None.

Constraints on Cosmic Strings Using Data from the Third Advanced LIGO-Virgo Observing Run

We search for gravitational-wave signals produced by cosmic strings in the Advanced LIGO and Virgo full O3 dataset. Search results are presented for gravitational waves produced by cosmic string loop features such as cusps, kinks, and, for the first time, kink-kink collisions. A template-based search for short-duration transient signals does not yield a detection. We also use the stochastic gravitational-wave background energy density upper limits derived from the O3 data to constrain the cosmic string tension Gμ as a function of the number of kinks, or the number of cusps, for two cosmic string loop distribution models. Additionally, we develop and test a third model that interpolates between these two models. Our results improve upon the previous LIGO-Virgo constraints on Gμ by 1 to 2 orders of magnitude depending on the model that is tested. In particular, for the one-loop distribution model, we set the most competitive constraints to date: Gμ≲4×10^{-15}. In the case of cosmic strings formed at the end of inflation in the context of grand unified theories, these results challenge simple inflationary models.

Constraints on Cosmic Strings Using Data from the Third Advanced LIGO-Virgo Observing Run

We search for gravitational-wave signals produced by cosmic strings in the Advanced LIGO and Virgo full O3 dataset. Search results are presented for gravitational waves produced by cosmic string loop features such as cusps, kinks, and, for the first time, kink-kink collisions. A template-based search for short-duration transient signals does not yield a detection. We also use the stochastic gravitational-wave background energy density upper limits derived from the O3 data to constrain the cosmic string tension Gμ as a function of the number of kinks, or the number of cusps, for two cosmic string loop distribution models. Additionally, we develop and test a third model that interpolates between these two models. Our results improve upon the previous LIGO-Virgo constraints on Gμ by 1 to 2 orders of magnitude depending on the model that is tested. In particular, for the one-loop distribution model, we set the most competitive constraints to date: Gμ≲4×10^{-15}. In the case of cosmic strings formed at the end of inflation in the context of grand unified theories, these results challenge simple inflationary models.

Supportive care in the acute phase of Stevens-Johnson syndrome and toxic epidermal necrolysis: an international, multidisciplinary Delphi-based consensus

BACKGROUND

Supportive care is the cornerstone of management of adult and paediatric Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). However, consensus on the modalities of supportive care is lacking.

OBJECTIVES

Our aim in this international multicentric Delphi exercise was to establish a multidisciplinary expert consensus to standardize recommendations regarding supportive care in the acute phase of SJS/TEN.

METHODS

Participants were sent a survey via the online tool SurveyMonkey, consisting of 103 statements organized into 11 topics: multidisciplinary team composition, suspect drug management, infection prevention, fluid resuscitation and prevention of hypothermia, nutritional support, pain and psychological distress management, management of acute respiratory failure, local skincare, ophthalmological management, management of other mucosa, and additional measures. Participants evaluated the level of appropriateness of each statement on a scale of 1 (extremely inappropriate) to 9 (extremely appropriate). The results were analysed according to the RAND/UCLA Appropriateness Method.

RESULTS

Forty-five participants from 13 countries (on three continents) participated. After the first round, a consensus was obtained for 82.5% of the 103 initially proposed statements. After the second round, a final consensus was obtained for 102 statements.

CONCLUSIONS

We have reached an international Delphi-based consensus on best supportive care practice for SJS/TEN. Our expert consensus should help guide physicians in treating patients with SJS/TEN and thereby improve short-term prognosis and the risk of sequelae.

Clinical phenotypes and therapeutic responses in cutaneous-predominant sarcoidosis: 6-year experience in a tertiary referral service

BACKGROUND

There is a limited evidence base for the treatment of cutaneous sarcoidosis.

OBJECTIVE

To describe treatment modalities and responses in patients with predominantly cutaneous sarcoidosis, in addition to clinical characteristics and prevalence of systemic disease.

METHODS

Data were prospectively collected over a 6-year period. The Cutaneous Sarcoidosis Activity and Morphology Index was used to assess treatment effectiveness.

RESULTS

In total, 47 patients with biopsy-confirmed cutaneous sarcoidosis were identified. Morphologically, the most common lesions were papules (49%) and plaques (42.6%). The most commonly affected sites were the head and neck (79%); 89.4% had systemic as well as cutaneous disease; 77% received systemic corticosteroid therapy, while 87% required further steroid-sparing treatment; 40% achieved clinical remission with hydroxychloroquine (HCQ) and 88% achieved clinical remission with methotrexate (MTX). OR of achieving remission on MTX compared with HCQ was 9.8 (95% CI 2.4-40.4, P = 0.001). MTX was superior to both azathioprine (AZA) (OR = 22; 95% CI 1.7-285.9; P = 0.02) and mycophenolate mofetil (MMF) (OR = 22; 95% CI 1.7-285.9; P = 0.02) in achieving remission.

CONCLUSION

HCQ is effective and well-tolerated. MTX was associated with significantly increased probability of achieving clinical remission compared with AZA and MMF.

Cutaneous sequelae of a national health crisis: Obesity and the skin

Background

The global obesity pandemic has far‐reaching health consequences and has become a major global health challenge. The worldwide prevalence of obesity nearly doubled between 1980 and 2008 and based on the latest estimates in the European Union, obesity affects up to 30% of adults. As a consequence of this rising prevalence of obesity, there has been an increase in the frequency of certain disease of the skin.

Objectives

We review the cutaneous sequelae of obesity, firstly describing the physiological consequences of increased adiposity in the skin and secondly examining the dermatoses associated with obesity.

Cancer and breast cancer awareness interventions in an intellectual disability context: A review of the literature

BACKGROUND

Women with an intellectual disability (ID) have a similar risk of developing breast cancer as women in the general population yet present with later stage breast cancers, which have poorer outcomes.

AIM

To identify whether there is a need to develop a breast cancer awareness intervention for women with an ID.

METHODS

Interventions aimed at increasing cancer awareness and breast cancer awareness for people with an ID were identified and critically appraised.

RESULTS

Five interventions to increase cancer awareness or breast cancer awareness in people with an ID were identified.

CONCLUSION

The review highlighted the paucity of theoretically underpinned breast cancer awareness interventions specifically aimed at women with an ID. Facilitating breast cancer awareness for women with an ID could potentially lead to earlier presentation of potential symptoms of breast cancer, earlier treatment, better prognosis and ultimately, improved survival. This article establishes that there is a need for an intervention underpinned by theory to increase breast cancer awareness in women with an ID.

Comparison of provision of maxillofacial emergency service during the two COVID-19 national lockdowns in the United Kingdom

We previously published a study on the provision of emergency maxillofacial services during the first UK COVID-19 pandemic national lockdown. We repeated the study during the second lockdown and now present our findings that highlight the main differences and learning issues as the services have evolved.

Prognostic role of positron emission tomography in patients with known or suspected cardiac sarcoidosis. a systematic review and meta-analysis

Background

Sarcoidosis is a chronic inflammatory disorder of unclear etiology, characterized by the presence of non-caseating granulomas. Cardiac involvement occurs in upto 27 percent of patients, manifesting as atrioventricular blocks, ventricular arrhythmia or sudden cardiac death. Current guidelines cite insufficient evidence for the prognostic utility of positron emission tomography (PET) in patients with cardiac sarcoidosis. Thus, we performed a systematic review and meta-analysis of published studies to ascertain the prognostic significance of PET imaging in patients with suspected or diagnosed cardiac sarcoidosis.

Purpose

To review current literature and determine if PET has prognostic utility in patients with known or suspected cardiac sarcoidosis

Methods

We performed a comprehensive literature search of electronic databases (Embase, Medline and Web of Science) using MeSH terms and keywords for sarcoidosis and PET from inception through December 2019. Studies were eligible if they included patients with known and/or suspected cardiac sarcoidosis undergoing evaluation by PET with or without perfusion imaging and reported clinical events of interest. An abnormal PET study was defined as the presence of focal or focal-on-diffuse uptake of 18- fluorodeoxyglucose (18-FDG) by visual analysis. In studies with perfusion imaging, patients with only perfusion defects were excluded. The primary outcome of interest was a composite of major adverse cardiac events (MACE), including sustained ventricular tachycardia, sudden cardiac death. Secondary analysis studied association of MACE with focal right ventricular (RV) uptake in patients with an abnormal PET study. Pooled odds ratio (OR) and 95% confidence interval (CI) were calculated using a random-effects model. Heterogeneity of results among the studies was assessed using the Higgins I2 value.

Results

Out of a total of 1645 citations, 40 were selected for full-text review. Five studies were included in the final analysis with a total of 465 patients. mean follow-up was 2.3 years. Three of the five studies also reported frequency of abnormal RV uptake of 18-FDG. Patients with abnormal 18-FDG uptake on visual assessment had higher odds of MACE (OR 3.12, CI 1.9–5.01, p&lt;0.00001), compared to known or suspected cardiac sarcoid patients with normal PET studies. Heterogeneity among studies was low (I2 = 0). In patients with an abnormal PET study, abnormal focal RV uptake of 18-FDG was associated with higher odds of MACE (OR 5.24, CI 1.1–25.1, p=0.04), with moderate heterogeneity among studies (I2=41).

Conclusion

In patients undergoing PET imaging for known or suspected cardiac sarcoidosis, abnormal metabolism on visual analysis is associated with increased risk of MACE. Furthermore, focal RV uptake further increases the risk of MACE in patients with abnormal PET imaging. Thus, PET imaging can serve as a tool to risk stratify patients with known or suspected cardiac sarcoidosis.

Forrest Plots

Funding Acknowledgement

Type of funding source: None

Vulval acne: a case series describing clinical features and management

Intermittent inflammation of the vulval pilosebaceous units is common and usually self-limiting, but some patients experience recurrent and more troublesome symptoms. There is a scarcity of information on this problem. We describe the clinical and histological features in these patients and the response to treatment. A retrospective, observational study of 16 patients with this phenomenon of recurrent, protracted folliculocentric inflammation of the vulval pilosebaceous unit was performed. Details on the clinical features, histology and response to treatment were collected. Mean age at presentation was 32 years (range 21-45). All patients reported recurrent painful papules and pustules on the labia majora and labia minora. Nine patients reported a cyclical pattern to the development of lesions, with premenstrual exacerbation being most common. Histological examination of these lesions showed a folliculocentric microabscess formation surrounded by an acute and chronic inflammatory cell infiltrate, with a focal foreign-body granulomatous reaction. All our patients responded well to tetracycline, antiandrogenic or retinoid therapy. We propose the term 'vulval acne' for this condition and propose a stepwise approach to its management. We hope to highlight this as a common but underreported entity.

Pleomorphic dermal sarcoma: a clinical and histological review of 49 cases

Pleomorphic dermal sarcoma (PDS) is a rare mesenchymal neoplasm that shares histopathological features with atypical fibroxanthoma (AFX), but has additional features of deep invasion of the superficial subcutis, tumour necrosis, and vascular and perineural invasion, which confers a risk of local recurrence and metastases. To study the clinical and pathological spectrum more comprehensively, we retrieved 49 cases of pleomorphic dermal sarcoma from our departmental files. There was a strong male predominance (n=45). The mean (range) age at presentation was 80 (47-97) years. The tumours had a median (range) maximum dimension of 23.5 (5-75) mm. There was a strong predilection for the head and face (n=47), with the scalp (n=32) being the most common site. Ulceration was observed in 21 patients, tumour necrosis in seven, perineural infiltration in six, and lymphovascular invasion in two. CD10 was expressed in all cases. Smooth muscle actin was expressed in 15 and CD68 in 14. Follow up was available in 41 cases (mean (range) 22.4 (2-90) months). Six patients had local recurrences, despite all having originally undergone primary surgical resections and having reports of clear margins. Progressive metastatic disease was observed in one patient who died from their disease. Based on the Kaplan Meier method, median overall survival was 70.8 (8.4-133.1) months. Although AFX and PDS may be part of a spectrum, distinction is important to emphasise the potential for malignant behaviour in PDS.

GW190521: A Binary Black Hole Merger with a Total Mass of 150 M_{⊙}

On May 21, 2019 at 03:02:29 UTC Advanced LIGO and Advanced Virgo observed a short duration gravitational-wave signal, GW190521, with a three-detector network signal-to-noise ratio of 14.7, and an estimated false-alarm rate of 1 in 4900 yr using a search sensitive to generic transients. If GW190521 is from a quasicircular binary inspiral, then the detected signal is consistent with the merger of two black holes with masses of 85_{-14}^{+21}  M_{⊙} and 66_{-18}^{+17}  M_{⊙} (90% credible intervals). We infer that the primary black hole mass lies within the gap produced by (pulsational) pair-instability supernova processes, with only a 0.32% probability of being below 65  M_{⊙}. We calculate the mass of the remnant to be 142_{-16}^{+28}  M_{⊙}, which can be considered an intermediate mass black hole (IMBH). The luminosity distance of the source is 5.3_{-2.6}^{+2.4}  Gpc, corresponding to a redshift of 0.82_{-0.34}^{+0.28}. The inferred rate of mergers similar to GW190521 is 0.13_{-0.11}^{+0.30}  Gpc^{-3} yr^{-1}.