Twins with alveolar capillary dysplasia with misalignment of pulmonary veins: Strategies for diagnosis and management

We present a case of dichorionic-diamniotic twin females who developed hypoxemic respiratory failure. They were ultimately diagnosed by lung biopsy with alveolar capillary dysplasia with misalignment of pulmonary veins. This case highlights a practical approach to reaching a diagnosis in infants with suspected developmental lung disease.

Case report: Pneumatosis in a neonate with thrombocytopenia absent radius syndrome

BACKGROUND

Thrombocytopenia absent radius (TAR) syndrome is a rare disease with an estimated prevalence of one in 200,000 live births. TAR is associated with cardiac and renal anomalies as well as gastrointestinal problems such as CMPA. Typically neonates with CMPA present with mild intolerance, with few reports in the literature of more severe intolerance resulting in pneumatosis. We present a case of a male infant with thrombocytopenia absent radius (TAR) syndrome who developed gastric and colonic pneumatosis intestinalis.

CASE DESCRIPTION

An eight-day-old male infant born at 36 weeks gestation with a diagnosis of TAR, presented with bright red blood in his stool. At this time he was on full formula feeds. Given continued bright red blood within his stool, an abdominal radiograph was obtained which was consistent with colonic and gastric pneumatosis. A complete blood count (CBC) was notable for worsening thrombocytopenia, anemia and eosinophilia. Once enteral feeds were held there was rapid resolution of the radiographic findings and resolution of his bloody stool. He was ultimately diagnosed with a cow's milk protein allergy (CMPA).

CONCLUSION

Though there are reports of CMPA in patients with TAR, the severity of this patient's presentation with both colonic and gastric pneumatosis is unique. Without the knowledge of the association of CMPA with TAR, this case could have been misdiagnosed and led to reintroduction of cow's milk containing formula, resulting in further complications. This case highlights the importance of a timely diagnosis and severity of CMPA in this population.

114 THE EFFECTIVENESS OF A 26-WEEK CLASS AND HOME-BASED OTAGO EXERCISE PROGRAMME ON BALANCE CONFIDENCE AND PHYSICAL PERFORMANCE IN OLDER ADULTS

Background

Falls have a substantial burden on the Irish economy and on the individual. The Otago Exercise Programme (OEP) is a cost-effective falls prevention programme that can prevent 35% of falls. This study aims to evaluate the effectiveness of a 26-week modified OEP using a combined delivery approach of physiotherapists and Exercise Therapists (ET) on balance confidence and physical performance in older adults in rural Ireland.

Methods

Study-design: A prospective pre-post single arm intervention study. Older adults (≥60 years) were recruited from HSE waiting lists for the OEP which consisted of a group-class (1x/week) and a home OEP (3x/week). Participants were assessed at baseline, 6, 16 and 26 weeks. Outcome measures (OMs) were compared pre and post intervention using Paired T-Tests and Wilcoxon Signed Ranks tests. A repeated-measures ANOVA compared OMs across the time points.

Results

Improvements were detected in the CONFbal scale (diff = 2.12, 95% CI=1.353-2.803, p<0.01), 30-second sit-to-stand (diff = 3.49, CI= 2.361-4.201, p<0.01), timed-up and go (diff = 2.38, CI=8.08-12.0, p<0.01), functional reach (diff = 9.158, CI=6.758-11.294, p<0.01), 180° turn (diff = 1.04, CI=3-5, p<0.01), and the four-test balance scale (diff = 0.61, CI=1.0-3.0, p<0.01). Significant changes are noted for each measure (p<0.05) with small-moderate positive effects (ηp2=0.32-0.512). The most significant changes in the 180° turn are seen between week-0 (4.92 ±1.784) and week-6 (4.44 ±1.258) followed by a plateau in results.

Conclusion

Confidence and physical performance improved significantly pre and post intervention, suggesting the physiotherapist and ET combined delivery of the programme is effective. Static and dynamic balance improvements may plateau after 6-weeks of the OEP suggesting the participants may not have been adequately challenged. Lower limb strength and mobility continued to improve throughout suggesting the modified OEP is an effective intervention for older adults in Ireland.

64 HIGH-DOSE STEROIDS IN HAEMATOLOGICAL MALIGNANCY: A RED FLAG FOR BONE HEALTH

Background

Bone-protective treatment should always be considered when commencing glucocorticoid therapy in individuals at high risk of fracture, as outlined in recent guidelines (National Osteoporosis Guideline Group, July 2018). Despite this, many patients receive high dose glucocorticoids (>7.5mg/kg/day or equivalent for >3 months) during treatment of haematological malignancy without formal assessment of bone health.

Methods

Twenty-five patients with Non-Hodgkin’s Lymphoma (NHL) on high dose steroid chemotherapy protocols were retrospectively assessed. The inclusion criterion was defined as any patient commenced on a cyclophosphamide, doxorubicin, vincristine and prednisolone (CHOP) containing protocol from 1/8/2020 to 1/8/21. Data was collected from electronic and written patient records. Information regarding patient age, diagnosis, steroid preparation and dose, presence of risk factors for osteoporosis and calcium and vitamin D prescriptions were collected. Radiological imaging was reviewed to assess for the occurrence of fragility fractures. Each patient had a FRAX® score calculated to assess fracture risk.

Results

The mean age of patients studied was 67 years and equally distributed between males and females. All patients had NHL. 32% (n=25) of patients were identified to be at high risk for fracture (FRAX® score >20% ten-year probability of major osteoporotic fracture). 16% had already established fragility fractures prior to commencing steroid treatment. 28% of patients were females over the age of 70 years. Only 12% of patients received vitamin D and calcium supplementation. No patient commenced bone protection therapy.

Conclusion

Omission of bone health assessment prior to high dose glucocorticoid treatment is prevalent in haematological malignancy and places patients at risk of significant morbidity. Patients are not routinely considered for protective measures including calcium and vitamin D supplementation and bone protection therapy. A simple risk-assessment tool and education to staff and patients prior to glucocorticoid therapy could significantly improve practice in this area. It is now planned to introduce routine risk assessment for this cohort of patients, with re-audit following implementation.

3D printing of PEEK reactors for flow chemistry and continuous chemical processing

3D-printed parts in PEEK for flow chemistry and continuous processing produced using fused filament fabrication.

P2498Exercise capacity and all-cause mortality in remote Indigenous and non-Indigenous populations

Background

Exercise capacity is a powerful predictor of all-cause mortality. However, its association with Indigenous populations in Central Australia, who face disproportionate health burdens, is unclear. Given the isolation from tertiary centers, exercise testing could provide useful local risk-stratification.

Purpose

To characterize the association of exercise capacity with all-cause mortality in Indigenous and non-Indigenous individuals in remote Central Australia.

Methods

Demographic, medication, and all-cause mortality data were prospectively collected from patients undergoing exercise stress tests from 2007–2017.

Results

A total of 3,414 patients (34% Indigenous) were included. At 4.8±2.9 years of follow-up, 86 (2.5%) deaths had occurred. Each 1-MET increase in exercise capacity conferred a 14% lower risk for mortality among Indigenous individuals (HR 0.86, 95% CI 0.79–0.94) and 20% lower risk for mortality among non-Indigenous individuals (HR 0.80, 95% CI 0.73–0.89) after adjusting for age, comorbidities, and medications. Mortality risk reduction for each 1-MET increase in exercise capacity was similar (p=0.32) for Indigenous and non-Indigenous individuals.

Conclusions

Exercise capacity is a significant predictor of all-cause mortality in Indigenous and non-Indigenous individuals. These findings have important clinical implications towards exercise capacity for risk-stratification and preventative importance of physical activity.

Utility of state-level influenza disease burden and severity estimates to investigate an apparent increase in reported severe cases of influenza A(H1N1) pdm09 - Arizona, 2015-2016

The Arizona Department of Health Services identified unusually high levels of influenza activity and severe complications during the 2015-2016 influenza season leading to concerns about potential increased disease severity compared with prior seasons. We estimated state-level burden and severity to compare across three seasons using multiple data sources for community-level illness, hospitalisation and death. Severity ratios were calculated as the number of hospitalisations or deaths per community case. Community influenza-like illness rates, hospitalisation rates and mortality rates in 2015-2016 were higher than the previous two seasons. However, ratios of severe disease to community illness were similar. Arizona experienced overall increased disease burden in 2015-2016, but not increased severity compared with prior seasons. Timely estimates of state-specific burden and severity are potentially feasible and may provide important information during seemingly unusual influenza seasons or pandemic situations.

Quality Improvement of Clinical Handover in a Liaison Psychiatry Department: A Three-Phase Audit

Aims To audit and improve quality of clinical handover in a Liaison Psychiatry Department. Methods An 11-item Handover Checklist was used to carry out a baseline audit and immediate and delayed post-intervention re-audits. The intervention consisted of checklist posters, an electronic database and staff training. Results There was an immediate and sustained improvement in most areas, including baseline demographics and components of SBAR communication (Situation, Background, Assessment, Recommendation). The improvement between baseline and delayed re-audit was statistically significant (P=0.007). Conclusion Poor handover practices contribute to negative outcomes in healthcare but there remains a dearth of guidelines in most specialties.This audit is important as it describes an intervention which improved clinical handover at a time of significant clinical risk. This practice could be applied effectively to other services and is relevant to all specialties. Six to twelve-monthly re-audit and longitudinal assessment of clinical outcomes are recommended to maintain the practices implemented in this audit.

The basal translation rate of authentic HIV-1 RNA is regulated by 5'UTR nt-pairings at junction of R and U5

The paradigm protein synthesis rate is regulated by structural complexity of the 5′untranslated region (UTR) derives from bacterial and other riboswitches. In-solution, HIV-1 5′UTR forms two interchangeable long-range nucleotide (nt) -pairings, one sequesters the gag start codon promoting dimerization while the other sequesters the dimer initiation signal preventing dimerization. While the effect of these nt-pairings on dimerization and packaging has been documented their effect on authentic HIV translation in cellulo has remained elusive until now. HIV^NL4-3 5′UTR substitutions were designed to individually stabilize the dimer-prone or monomer-prone conformations, validated in-solution, and introduced to molecular clones. The effect of 5′UTR conformation on ribosome loading to HIV unspliced RNA and rate of Gag polypeptide synthesis was quantified in cellulo. Monomer- and dimer-prone 5′UTRs displayed equivalent, basal rate of translation. Gain-of-function substitution U103, in conjunction with previously defined nt-pairings that reorient AUG to flexible nt-pairing, significantly activated the translation rate, indicating the basal translation rate is under positive selection. The observed translation up-mutation focuses attention to nt-pairings at the junction of R and U5, a poorly characterized structure upstream of the characterized HIV riboswitch and demonstrates the basal translation rate of authentic HIV RNA is regulated independently of monomer:dimer equilibrium of the 5′UTR.

Diagnostic criteria for inclusion body myositis

Inclusion body myositis (IBM) was first identified as a specific disorder about 40 years ago and is now recognized to be the most frequently presenting primary myopathy in middle age and beyond. Initial characterization was based on the observation of specific pathological features distinguishing it from polymyositis. It was soon appreciated that there were also distinguishing clinical features. The earliest diagnostic criteria were heavily biased towards pathological features, but over time revised criteria have given increasing importance to certain clinical features. Until the specific cause of IBM is determined, and the basic pathogenetic mechanisms are better understood, there can be no diagnostic gold-standard against which to compare the sensitivity and specificity of any proposed diagnostic criteria, but such criteria are essential to ensure that patients entering clinical, epidemiological, genetic, pathological or therapeutic studies represent a homogeneous population. It is likely that any currently accepted diagnostic criteria will, once a gold-standard is eventually established, be shown to have 'missed' patients with atypical features, but that has to be accepted to make certain that current studies are not contaminated by patients who do not have IBM. In other words, in everyday clinical practice there will be the occasional patient who an experienced myologist strongly suspects has IBM, but does not meet current criteria - the criteria lack sensitivity. But if the criteria are so broad as to include all such atypical cases, they would be likely to include patients who do not in fact have IBM - they would lack specificity. The sensitivity and specificity of existing criteria have been reviewed recently, in so far as it is possible to do so, and found to have high specificity but variable sensitivity.

Northern Territory perspectives on heart failure with comorbidities – understanding trial validity and exploring collaborative opportunities to broaden the evidence base

Congestive Heart Failure (CHF) is an ambulatory care sensitive condition, associated with significant morbidity and mortality, rarely with cure. Outpatient based pharmacological management represents the main and most important aspect of care, and is usually lifelong. This narrative styled opinion review looks at the pharmacological agents recommended in the guidelines in context of the Northern Territory (NT) of Australia. We explore the concept of validity, a term used to describe the basis of standardising a particular trial or study and the population to which it is applicable. We aim to highlight the problems of the current guidelines based approach. We also present alternatives that could utilise the core principles from major trials, while incorporating regional considerations, which could benefit clients living in the NT and remote Australia.

Adverse events following trigger point dry needling: a prospective survey of chartered physiotherapists

OBJECTIVES

Trigger point dry needling (TrP-DN) is commonly used to treat persons with myofascial pain, but no studies currently exist investigating its safety. The aim of this study was to determine the incidence of Adverse Events (AEs) associated with the use of TrP-DN by a sample of physiotherapists in Ireland.

METHODS

A prospective survey was undertaken consisting of two forms recording mild and significant AEs. Physiotherapists who had completed TrP-DN training with the David G Simons Academy (DGSA) were eligible to take part in the study. Data were collected over a ten-month period.

RESULTS

In the study, 39 physiotherapists participated and 1463 (19.18%) mild AEs were reported in 7629 treatments with TrP-DN. No significant AEs were reported giving an estimated upper risk rate for significant AEs of less than or equal to (≤) 0.04%. Common AEs included bruising (7.55%), bleeding (4.65%), pain during treatment (3.01%), and pain after treatment (2.19%). Uncommon AEs were aggravation of symptoms (0.88%), drowsiness (0.26%), headache (0.14%), and nausea (0.13%). Rare AEs were fatigue (0.04%), altered emotions (0.04%), shaking, itching, claustrophobia, and numbness, all 0.01%.

DISCUSSION

While mild AEs were very commonly reported in this study of TrP-DN, no significant AEs occurred. For the physiotherapists surveyed, TrP-DN appeared to be a safe treatment.

Abstract C12: Molecular mechanisms of aggressiveness of Rb-deficient tumors

Osteosarcomas (OS) and small cell lung carcinomas (SCLC) are poorly differentiated, highly aggressive tumors, with an early proclivity to metastasize. Prognosis is poor for both, with only 10-20% of patients achieving long-term disease-free intervals. Still, OS and SCLC aggressivity remain to be molecularly explained. Interestingly, these cancer types show high rates of inactivation of the RB1 gene coding for the retinoblastoma protein (Rb), a known cell cycle repressor. This observation led us to hypothesize that in OS and SCLC, Rb loss during early tumorigenesis facilitates both increased proliferation and an early tendency for metastasis. Supporting our hypothesis, our previous studies in osteoblasts showed that Rb transcriptionally regulates a wide repertoire of cell adhesion genes, including those coding for adherens junction cadherins and integrins. We also found that adhrens junction assembly requires the Rb-dependent transcriptional repression of Pak1, a Rac1-binding kinase that destabilizes cell adhesion when up-regulated. Thus, the early proclivity for metastasis of OS and SCLC may be related to perturbations in cell adhesion due to Rb loss.

Here we present new data using the SCLC line H187 and the non-small cell lung carcinoma (NSCLC) cell lines H1975 and H520. SCLC carcinomas have high rates (> 90%) of Rb loss while NSCLC are known to be Rb wild type. Therefore, comparing H1975 and H520 vs. H187 provided us with an Rb-proficient vs. Rb-deficient system similar to the one we previously used to study Rb-engendered effects in osteoblasts. Our immunoblots and qRT-PCR showed that the Rb-null H187 cells expressed dramatically reduced levels of E-cadherin mRNA and protein relative to H1975 and H520, confirming that Rb loss impairs cell adhesion due to adherens junction loss. Interestingly, N-cadherin is up-regulated in H187 cells, suggesting that Rb loss triggers a cadherin switch similar to the one associated with epithelial-to-mesenchymal transitions. Other cell adhesion-related genes we found down-regulated in Rb-null H187 cells relative to H1975 and H520, as determined by qRT-PCR, were α-catenin, β-catenin, OB-cadherin, and the cytoskeletal adapter proteins eplin, vinculin, formin-1, and α-actinin. Our immunoblots also showed decreased levels of merlin, an adherens junction-interacting protein, in H187 cells. We also studied the expression of Rac1-binding proteins, given their involvement in cell adhesion. Our immunoblots and qRT-PCR showed reduced levels of IQGAP1 in H187 cells relative to H1975 and H520 cells. Given that IQGAP1 is a GTPase activating protein (GAP) that represses Rac1 by promoting its GDP-bound inactive state, we postulate that Rb represses Rac1 function via IQGAP1. Beta-2-chimaerin, another Rac1 GAP was also down regulated at the protein level in H187 cells. Taken together, our data in lung cell lines recapitulate most of our findings in osteoblasts, both in regards to the effect of Rb on cell adhesion and to the need for the Rb-mediated repression of Rac1 for the establishment of cell adhesion. Based on our data, we propose that Rb loss in OS and SCLC, not only leads to an increased proliferative capacity during early tumorigenesis, but also exacerbates aggressiveness of tumors at early stages by perturbing cellular adhesion, which in turn facilitates tumor cell detachment and metastasis.

Citation Format: Jonathan González-Flores, Ruth Cruz-Cosme, Yariana Rodríguez-Ortiz, Sarah Brady, Ricardo Fraticelli-Rosado, Brienne Engel, Douglas Cress, Pedro G. Santiago-Cardona. Molecular mechanisms of aggressiveness of Rb-deficient tumors. [abstract]. In: Proceedings of the Third AACR International Conference on Frontiers in Basic Cancer Research; Sep 18-22, 2013; National Harbor, MD. Philadelphia (PA): AACR; Cancer Res 2013;73(19 Suppl):Abstract nr C12.

Allosteric heat shock protein 70 inhibitors rapidly rescue synaptic plasticity deficits by reducing aberrant tau

BACKGROUND

The microtubule-associated protein tau accumulates in neurodegenerative diseases known as tauopathies, the most common being Alzheimer's disease. One way to treat these disorders may be to reduce abnormal tau levels through chaperone manipulation, thus subverting synaptic plasticity defects caused by tau's toxic accretion.

METHODS

Tauopathy models were used to study the impact of YM-01 on tau. YM-01 is an allosteric promoter of triage functions of the most abundant variant of the heat shock protein 70 (Hsp70) family in the brain, heat shock cognate 70 protein (Hsc70). The mechanisms by which YM-01 modified Hsc70 activity and tau stability were evaluated with biochemical methods, cell cultures, and primary neuronal cultures from tau transgenic mice. YM-01 was also administered to acute brain slices of tau mice; changes in tau stability and electrophysiological correlates of learning and memory were measured.

RESULTS

Tau levels were rapidly and potently reduced in vitro and ex vivo upon treatment with nanomolar concentrations of YM-01. Consistent with Hsc70 having a key role in this process, overexpression of heat shock protein 40 (DNAJB2), an Hsp70 co-chaperone, suppressed YM-01 activity. In contrast to its effects in pathogenic tauopathy models, YM-01 had little activity in ex vivo brain slices from normal, wild-type mice unless microtubules were disrupted, suggesting that Hsc70 acts preferentially on abnormal pools of free tau. Finally, treatment with YM-01 increased long-term potentiation in tau transgenic brain slices.

CONCLUSIONS

Therapeutics that exploit the ability of chaperones to selectively target abnormal tau can rapidly and potently rescue the synaptic dysfunction that occurs in Alzheimer's disease and other tauopathies.