Radiographer training for screening of patients referred for Magnetic Resonance Imaging: A scoping review

INTRODUCTION

Strict safety practices are essential to ensure the safety of patients and staff in Magnetic Resonance Imaging (MRI). Training regarding the fundamentals of MRI safety is well-established and commonly agreed upon. However, more complex aspect of screening patients, such as image review or screening of unconscious patients/patients with communication difficulties is less well discussed. The current UK and USA guidelines do not suggest the use of communication training for MRI staff nor indicate any training to encourage reviewing images in the screening process. This review aims to map the current guidance regarding safety and patient screening training for MRI diagnostic and therapeutic radiographers.

METHODS

A systematic search of PubMed, Trip Medical database and Radiography journal was conducted. Studies were chosen based on the review objectives and pre-determined inclusion/exclusion criteria using the PRISMA-ScR framework.

RESULTS

Twenty-four studies were included in the review, which identified some key concepts including MRI safety training and delivery methods, screening and communication, screening of unconscious or non-ambulatory patients and the use of imaging.

CONCLUSION

Training gaps lie within the more complex elements of screening such as the inclusiveness of question phrasing, particularly to the neurodivergent population, how we teach radiographers to screen unconscious/unresponsive patients and using imaging to detect implants.

IMPLICATIONS FOR PRACTICE

The consequences of incomplete or inaccurate pre-MRI safety screening could be the introduction of unexpected implants into the scanner or forgoing MRI for a less desirable modality. The development of enhanced training programs in implant recognition using imaging and communication could complement existing training.

Observation of Seven Astrophysical Tau Neutrino Candidates with IceCube

We report on a measurement of astrophysical tau neutrinos with 9.7 yr of IceCube data. Using convolutional neural networks trained on images derived from simulated events, seven candidate ν_{τ} events were found with visible energies ranging from roughly 20 TeV to 1 PeV and a median expected parent ν_{τ} energy of about 200 TeV. Considering backgrounds from astrophysical and atmospheric neutrinos, and muons from π^{±}/K^{±} decays in atmospheric air showers, we obtain a total estimated background of about 0.5 events, dominated by non-ν_{τ} astrophysical neutrinos. Thus, we rule out the absence of astrophysical ν_{τ} at the 5σ level. The measured astrophysical ν_{τ} flux is consistent with expectations based on previously published IceCube astrophysical neutrino flux measurements and neutrino oscillations.

Surgical outcomes of total duct excision in the diagnosis and management of nipple discharge

INTRODUCTION

Total duct excision (TDE) is performed for the diagnosis and management of nipple discharge. The Association of Breast Surgery's recent guidelines recommend considering diagnostic surgery for single-duct, blood-stained or clear nipple discharge, and for symptomatic management.

METHODS

We retrospectively reviewed the diagnostic and surgical outcomes of all cases of TDE between January 2013 and November 2019.

RESULTS

In total, 259 TDEs were carried out: 219 for nipple discharge, 29 for recurrent mastitis, 3 for screening abnormalities and 8 for breast lumps. Of the nipple discharge group, 121 had blood-stained discharge. Mean patient age was 52 years (range 19-81). Median follow-up time was 45 months (interquartile range 24-63). The following cases were identified on histopathology: 236 benign breast changes, 10 atypical ductal hyperplasia, 4 lobular carcinoma in situ, 2 low-grade ductal carcinoma in situ (DCIS), 3 intermediate-grade DCIS, 2 high-grade DCIS and 2 invasive ductal carcinomas. In total, 3.5% of patients who underwent TDE had a diagnosis of DCIS or invasive carcinoma. Blood-stained discharge was associated with a significant increase in risk of DCIS or carcinoma compared with other nipple discharge colours (p = 0.043). The most common complications of TDE were infection, poor wound healing and haematoma. Nipple discharge recurred in 14.2% of cases.

CONCLUSIONS

TDE can be considered for the diagnostics and management of nipple discharge. Blood-stained nipple discharge increases the risk of DCIS or malignancy, but the majority of the time TDE reveals benign breast pathology.

Vocal cord movement: can it be accurately graded?

INTRODUCTION

Flexible nasendoscopy (FNE) is the principal assessment method for vocal cord movement. Because the procedure is inherently subjective it may not be possible for clinicians to grade the degree of vocal cord movement reliably. The aim of this study was to assess the accuracy and consistency of grading vocal cord movement as viewed via FNE.

METHODS

Thirty FNE videos, without sound or clinical information, were assessed by six consultant head and neck surgeons. The surgeons were asked to assess and grade right and left vocal cord movement independently, based on a five-category scale. This process was repeated three times on separate occasions. Agreement and reliability were assessed.

RESULTS

Mean overall observed inter-rater agreement was 67.7% (sd 1.9) with the five-category scale, increasing to 91.4% (sd 1.9) when a three-category scale was derived. Mean overall observed intra-rater agreement was 78.3% (sd 9.7) for five categories, increasing to 93.1% (sd 3.3) for three categories. Discriminating vocal cord motion was less reliable using the five-category scale (k = 0.52) than with the three-category scale (k = 0.68).

CONCLUSIONS

This study demonstrates quantitatively that it is challenging to accurately and consistently grade subtle differences in vocal cord movement, as proven by the reduced agreement and reliability when using a five-point scale instead of a three-point scale. The study highlights the need for an objective measure to help in the assessment of vocal cord movement.

Development of a sports technology quality framework

Identifying tools and processes to effectively and efficiently evaluate technologies is an area of need for many sport stakeholders. This study aimed to develop a standardised, evidence-based framework to guide the evaluation of sports technologies. In developing the framework, a review of standards, guidelines and research into sports technology was conducted. Following this, 55 experts across the sports industry were presented with a draft framework for feedback. Following a two-round Delphi survey, the final framework consisted of 25 measurable features grouped under five quality pillars. These were 1) Quality Assurance & Measurement (Accuracy, Repeatability, Reproducibility, Specifications), 2) Established Benefit (Construct Validity, Concurrent Validity, Predictive Validity, Functionality), 3) Ethics & Security (Compliance, Privacy, Ownership, Safety, Transparency, Environmental Sustainability), 4) User Experience (Usability, Robustness, Data Representation, Customer Support & Training, Accessibility) & 5) Data Management (Data Standardisation, Interoperability, Maintainability, Scalability). The framework can be used to help design and refine sports technology in order to optimise quality and maintain industry standards, as well as guide purchasing decisions by organisations. It may also serve to create a common language for organisations, manufacturers, investors, and consumers to improve the efficiency of their decision-making relating to sports technology.

Observation of high-energy neutrinos from the Galactic plane

The origin of high-energy cosmic rays, atomic nuclei that continuously impact Earth's atmosphere, is unknown. Because of deflection by interstellar magnetic fields, cosmic rays produced within the Milky Way arrive at Earth from random directions. However, cosmic rays interact with matter near their sources and during propagation, which produces high-energy neutrinos. We searched for neutrino emission using machine learning techniques applied to 10 years of data from the IceCube Neutrino Observatory. By comparing diffuse emission models to a background-only hypothesis, we identified neutrino emission from the Galactic plane at the 4.5σ level of significance. The signal is consistent with diffuse emission of neutrinos from the Milky Way but could also arise from a population of unresolved point sources.

1156 IMPROVING RECOGNITION OF POLYPHARMACY AND ADDRESSING INAPPROPRIATE PRESCRIBING ON A CARE OF THE ELDERLY WARD

Introduction

Polypharmacy is an increasing concern in medicine which will lead to prescribing errors, serious drug interactions and potentially inappropriate prescribing.

Aim

To improve recognition of ‘Polypharmacy’, routine medication reviews during patient admissions and better communication and awareness of ‘Polypharmacy’ to General Practitioners (GP).

Methods

This audit consisted of two cycles both performed over 6 weeks.

Inclusion criteria

Patients aged 65 < and on 6 < medications, admitted to Elderly Care ward at Chelsea and Westminster hospital. Interventions after the first cycle included education such as encouragement of clear documentation in medical record and GP summary, introduction of medication reviews as part of ward round, collaborative work with pharmacists. Potentially Inappropriate Medications (PIMS) were assessed using the STOPP/START criteria approved by NICE guidelines for review of medication regimes and highlighting PIMS.

Results

First cycle - 30 patients were recruited with an average age of 79.2 (13 males and 17 females). An average number of PIMS at the time of admission was 1.3 and 0.5 on discharge. Only 1/30 (3.3%) has ‘Polypharmacy’ documented and medication reviewed; Medications Reconciliation was 29/30 (96.7%). None of the patient has documentation for Polypharmacy.

Second cycle - 29 patients were recruited with and average age of 80.1. (7 males and 22 females). PIMs on admission was 1.4 and 0.3 on discharge. 25/29 (86.2%) patients had ‘Polypharmacy being documented and Medication review for 29/29(100%). Medication Reconciliation was 29/29(100%). Most Common PIMS across both cycles were statins, antihypertensive and Proton Pump Inhibitor.

Conclusion

The interventions complete improved significantly the awareness of Polypharmacy. There is a significant increment in number of medication review of 96.7% and 82.9% on documentation for ‘Polypharmacy’, and 20% reductions in PIMS on discharge.

Pharmacy technician-led general practice support hub: a feasibility study

Introduction

Workforce pressures in general practice have led to Scottish Government initiatives to integrate pharmacy teams into general practice. The focus is completion of prescribing management-related activities releasing general practitioner time for patient-focused workload.1 Activities include medicines reconciliation from immediate discharge letters (IDL), processing outpatient prescription requests (OPL) and special request prescriptions (SR). Pharmacists effectively mobilise GP capacity completing these tasks.2 However, pharmacists may aspire to advanced practice roles including medication review case-load management. Therefore, alternative workload delivery models including centralised pharmacy technician-led general practice support hubs to complete IDL, OPL and SR tasks must be considered. National guidance outlines that pharmacy technicians may complete these tasks autonomously with minimal supervision.3 Unknowns include whether pharmacy technicians can lead this service delivery and the definition of the supervisory support required.

Aim

To evaluate the feasibility of a pharmacy technician-led hub for completion of SR, IDL and OPL.

Methods

Feasibility was studied over 4 weeks (12 April – 7 May 2021) during routine service delivery across three medical practices (approx. 23 800 patients) in NHS Greater Glasgow and Clyde. Quantitative real-time self-reported data on the volume of tasks (SR/IDL/OPL), task completion time and volume of pharmacist referrals was collected by pharmacy technicians and pharmacists and analysed in Microsoft Excel®. Qualitative data describing why pharmacy technicians referred tasks to pharmacists was collected and categorized using thematic analysis and Microsoft Excel® by the lead author. Ethical approval was not required for this service evaluation.

Results

4485 total tasks were completed: SR 87% (n=3917); IDL 7% (n=323); OPL 6% (n=245). Pharmacy technicians completed most (71%; n=3181) prescribing management-related tasks. A service delivery gap (21%; n=921 of tasks) where workload exceeded technician resource, necessitated pharmacist support. Referral rate for tasks beyond technician competence was 11% (n=383). The locally agreed 48-hour benchmark turnaround to process tasks was achieved for the majority of tasks. Breaches of the target were noted: 53 (1%) SR; 10 (3%) IDL and 5 (2%) OPL. Technicians and pharmacists completed tasks in numerically similar times. 383 tasks were referred to a pharmacist. 134 (35%) tasks could only be completed by a pharmacists due to the need for a prescribing decision or pharmacist-specific knowledge. 226 (59%) could be completed by a technician with additional knowledge or training. Examples include queries requiring interpretation of clinical parameters or blood monitoring or answering medicines information enquiries. 6% (n=23) of referrals were uncategorised due to incomplete data collection.

Discussion/Conclusion

This study provides new information describing the workload volume achieved by pharmacy technicians and characterising the supervisory role of the pharmacist. Pharmacy technicians convincingly completed most activities. Service delivery gaps need addressed including maintenance of service delivery during periods of authorised absence and professional development time. Pharmacist referral rate can be improved by upskilling pharmacy technicians. The volume of SR tasks drives the workload and could be managed more effectively by converting suitable SR tasks to controlled repeats. A Health Improvement Scotland initiative is developing this work stream. Additional projects must identify training gaps to understand technician development needs and analyse achievement of advanced pharmacist activities where technician-led hub exists.

References

1. Scottish Government. Achieving Excellence in Pharmaceutical Care: A Strategy for Scotland. Edinburgh. The Scottish Government, 2017

2. Maskrey M, Johnson CF, Cormack J et al. Releasing GP capacity with pharmacy prescribing support and New Ways of Working: a prospective observational cohort study. Brit J Gen Pract. 2018;68(675):e735-e42

3. Scottish Pharmacy Practice and Prescribing Advisers Association. National Pharmacotherapy Service Specification V4, 2021

Evidence for neutrino emission from the nearby active galaxy NGC 1068

A supermassive black hole, obscured by cosmic dust, powers the nearby active galaxy NGC 1068. Neutrinos, which rarely interact with matter, could provide information on the galaxy’s active core. We searched for neutrino emission from astrophysical objects using data recorded with the IceCube neutrino detector between 2011 and 2020. The positions of 110 known gamma-ray sources were individually searched for neutrino detections above atmospheric and cosmic backgrounds. We found that NGC 1068 has an excess of 79 − 20 + 22 neutrinos at tera–electron volt energies, with a global significance of 4.2σ, which we interpret as associated with the active galaxy. The flux of high-energy neutrinos that we measured from NGC 1068 is more than an order of magnitude higher than the upper limit on emissions of tera–electron volt gamma rays from this source.

Search for Unstable Sterile Neutrinos with the IceCube Neutrino Observatory

We present a search for an unstable sterile neutrino by looking for a resonant signal in eight years of atmospheric ν_{μ} data collected from 2011 to 2019 at the IceCube Neutrino Observatory. Both the (stable) three-neutrino and the 3+1 sterile neutrino models are disfavored relative to the unstable sterile neutrino model, though with p values of 2.8% and 0.81%, respectively, we do not observe evidence for 3+1 neutrinos with neutrino decay. The best-fit parameters for the sterile neutrino with decay model from this study are Δm_{41}^{2}=6.7_{-2.5}^{+3.9}  eV^{2}, sin^{2}2θ_{24}=0.33_{-0.17}^{+0.20}, and g^{2}=2.5π±1.5π, where g is the decay-mediating coupling. The preferred regions of the 3+1+decay model from short-baseline oscillation searches are excluded at 90% C.L.

Strong Constraints on Neutrino Nonstandard Interactions from TeV-Scale ν_{μ} Disappearance at IceCube

We report a search for nonstandard neutrino interactions (NSI) using eight years of TeV-scale atmospheric muon neutrino data from the IceCube Neutrino Observatory. By reconstructing incident energies and zenith angles for atmospheric neutrino events, this analysis presents unified confidence intervals for the NSI parameter ε_{μτ}. The best-fit value is consistent with no NSI at a p value of 25.2%. With a 90% confidence interval of -0.0041≤ε_{μτ}≤0.0031 along the real axis and similar strength in the complex plane, this result is the strongest constraint on any NSI parameter from any oscillation channel to date.

Multiplex imaging to reveal the dynamics of MAVS-mediated control of Ebola virus replication in tissues

The RIG-I like receptor pathway that signals through the mitochondrial antiviral signaling protein (MAVS) is important in sensing RNA viruses, driving production of interferons, and inhibiting viral spread. How this signaling coordinates immune responses in tissues is incompletely understood. To understand the mechanisms of MAVS-mediated control, we examined the spatial relationship between EBOV antigen and cells in livers. C57BL/6J (B6) or MAVS−/− mice were inoculated intraperitoneally with 100 FFU of either wild-type (WT-EBOV) or mouse-adapted EBOV (MA-EBOV) with samples collected at 3 and 5 days post infection (dpi). This resulted in a spectrum of disease outcomes: complete survival (B6 WT-EBOV), weight loss and survival (B6 MA-EBOV and MAVS−/− WTEBOV) and 100% lethality (MAVS−/− MA-EBOV). Macrophage (MF), dendritic cell (DC) and T-Cell (TC) responses were examined by Opal-Plex, a multiplex staining method developed in house, combined with quantitative image analysis through object-based segmentation and spatial statistics. In B6 mice at 3 dpi, there was an increase in cellular recruitment of monocytes and CD8+ T-cells. An association between EBOV nucleoprotein (NP) and F4/80+ cells was observed in the survival phenotype and was especially prominent at 3 dpi. Further development of LysMCre MAVSfl/fl mice will determine if MAVS signaling in the macrophages is required for viral control to the macrophage compartment or if the phenotypes observed could have resulted from a bystander effect. This work will help to define dynamics of host control of viral dissemination and further define the relationship between tissue architecture and disease outcome.

All studies were done with approval from the ICUC of the NIH/NIAID.

Supported by The Intramural Program of the NIH/NIAID

Using single cell spatial and transcriptional analysis to understand early host response to RNA virus infections

The RIG-I like receptor pathway, which signals through the mitochondrial anti-viral signaling (MAVS) protein, initiates the type I interferon (IFN) response to RNA viruses such as vesicular stomatitis virus (VSV) and Ebola Virus (EBOV). To investigate the mechanism of MAVS-mediated control of VSV and EBOV infections in vivo, we utilized single cell RNA sequencing and multiplex immunohistochemistry (mIHC) in C57Bl/6J and MAVS−/− animals to understand the cellular response spatially and transcriptomically in the draining lymph nodes (dLN). Identification of virally infected cells through scRNA-Seq allowed contrast of infected cells and bystander cells. Viral quantification of EBOV and VSV samples showed an increased viral load in MAVS−/− conditions and distinct patterns of dissemination through the LN. The relationship between viral load and IFN signaling revealed a negative correlation in EBOV infected cells with no relationship in VSV infected cells highlighting the importance of viral inhibition of the IFN response in EBOV infections. To assess these patterns spatially, mIHC antibody panels have been implemented on control and experimental tissue. An in-house algorithm for cell segmentation called RAPID was applied to a controlled experiment and revealed extensive batch effects from the staining process. Current work to perform batch normalization is being carried out to better assess changes in protein marker expression. Combining information gained from the sequencing analysis with the observed spatial organization through mIHC, we aim to develop a model illustrating the role of the MAVS-dependent pathway in controlling early virus replication.

Supported by Intramural research program of the NIH

Search for Relativistic Magnetic Monopoles with Eight Years of IceCube Data

We present an all-sky 90% confidence level upper limit on the cosmic flux of relativistic magnetic monopoles using 2886 days of IceCube data. The analysis was optimized for monopole speeds between 0.750c and 0.995c, without any explicit restriction on the monopole mass. We constrain the flux of relativistic cosmic magnetic monopoles to a level below 2.0×10^{-19}  cm^{-2} s^{-1} sr^{-1} over the majority of the targeted speed range. This result constitutes the most strict upper limit to date for magnetic monopoles with β≳0.8 and up to β∼0.995 and fills the gap between existing limits on the cosmic flux of nonrelativistic and ultrarelativistic magnetic monopoles.

Histomorphometric and microarchitectural analysis of bone in metastatic breast cancer patients

BACKGROUND

Despite widespread use of repeated doses of potent bone-targeting agents (BTA) in oncology patients, relatively little is known about their in vivo effects on bone homeostasis, bone quality, and bone architecture. Traditionally bone quality has been assessed using a trans-iliac bone biopsy with a 7 mm "Bordier" core needle. We examined the feasibility of using a 2 mm "Jamshidi™" core needle as a more practical and less invasive technique.

METHODS

Patients with metastatic breast cancer on BTAs were divided according to the extent of bone metastases. They were given 2 courses of tetracycline labeling and then underwent a posterior trans-iliac trephine biopsy and bone marrow aspirate. Samples were analyzed for the extent of tumor invasion and parameters of bone turnover and bone formation by histomorphometry.

RESULTS

Twelve patients were accrued, 1 had no bone metastases, 3 had limited bone metastases (LSM) (<3 lesions) and 7 had extensive bone metastases (ESM) (>3 lesions). Most of the primary tumors were estrogen receptor (ER)/progesterone receptor (PR) positive. The procedure was well tolerated. The sample quality was sufficient to analyze bone trabecular structure and bone turnover by histomorphometry in 11 out of 12 patients. There was a good correlation between imaging data and morphometric analysis of tumor invasion. Patients with no evidence or minimal bone metastases had no evidence of tumor invasion. Most had suppressed bone turnover and no detectable bone formation when treated with BTA. In contrast, 6 out of 7 patients with extensive bone invasion by imaging and evidence of tumor cells in the marrow had intense osteoclastic activity as measured by the number of osteoclasts. Of these 7 patients with ESM, 6 were treated with BTA with 5 showing resistance to BTA as demonstrated by the high number of osteoclasts present. 3 of these 6 patients had active bone formation. Based on osteoblast activity and bone formation, 3 out of 6 patients with ESM responded to BTA compared to all 3 with LSM. Compared to untreated patients, all patients treated with BTA showed a trend towards suppression of bone formation, as measured by tetracycline labelling. There was also a trend towards a significant difference between ESM and LSM treated with BTA, highly suggestive of resistance although limited by the small sample size.

DISCUSSION

Our results indicate that trans-iliac bone biopsy using a 2 mm trephine shows excellent correlation between imaging assessment of tumor invasion and tumor burden by morphometric analysis of bone tissues. In addition, our approach provides additional mechanistic information on therapeutic response to BTA supporting the current clinical understanding that the majority of patients with extensive bone involvement eventually fail to suppress bone turnover (Petrut B, et al. 2008). This suggests that antiresorptive therapies become less effective as disease progresses.

798 A Rare Complication and Unexpected Pathology Following an Anterior Exenteration – A Case Report

We present a case report of an unexpected pathology in addition to a rare complication in a 62-year-old female following an anterior exenteration and an abdominal wall reconstruction. Initial biopsies characterised the malignancy as a potential urachal adenocarcinoma, but the final pathology revealed a solitary endometrial adenocarcinoma metastasis from endometrial cancer 6 years previously.

Due to the nature of the tumour, an abdominal wall resection was required, and reconstruction involved a pedicled thigh flap. Post-operatively the small bowel herniated under the flap and this resulted in true mechanical small bowel obstruction. The loop of herniated bowel is visible on CT imaging in the area of the proximal thigh. The patient returned to theatre for an emergency laparotomy and the abdominal wall defect was closed instead with a surgical implant derived from animal tissue. The patient made an excellent recovery, was discharged home, and continues to do well. This patient is an example of excelling in adversity.

Using single cell spatial and transcriptional analysis to understand early host response to RNA viral infections

The innate immune system serves as the first line of defense against pathogens. One innate defense mechanism is the RIG-I like receptor pathway (RLR) which signals through the mitochondrial anti-viral signaling protein (MAVS) which plays a role in initiating the interferon (IFN) response to RNA viruses such as vesicular stomatitis virus (VSV). To investigate the mechanisms the MAVS-dependent pathway has on early viral control following VSV infection in vivo, we used a combination of two approaches: single cell RNA sequencing and multiplex imaging. These two techniques allow us to assess the individual cellular response to VSV in whole lymph node tissue. After intradermal inoculation, skin draining lymph nodes were assessed using single cell sequencing. Macrophages and plasmacytoid dendritic cells (pDCs) showed significantly elevated IFN stimulated gene (ISG) detection in C57Bl/6J (B6) mice compared to the MAVS−/− animals at 8 hours post infection (hpi), yet there was no detectable viral reads. This early initiation of ISG expression played a role in detection of viral RNA at 24 hpi which saw significantly elevated viral RNA in the MAVS−/− animals compared to the B6 animals. Interestingly, the virus replication in both conditions was contained to the macrophage populations suggesting that without the MAVS pathway active, the virus was still contained. Combining this information along with the observed spatial organization through multiplex tissue imaging, we aim to develop a model illustrating the role of the MAVS-dependent pathway in controlling early virus replication.

Animal experiments were done in accordance with the guidelines of the NIAID/NIH Institutional ACUC. This research was supported by the IRP of NIH/NIAID.

An exploratory study to investigate animal health and reproductive wastage among Australian meat goat producers

The Australian goat meat industry has grown significantly in the last decade, with the value of exports nearly tripling. However, because carcase weight has remained constant over this time, the drivers of industry growth are price and supply. Animal health and reproduction are key factors contributing to supply and productivity, yet limitations to production management are poorly understood, hampering advice for effective intervention. This exploratory study aims to provide insights into the animal health and reproductive management practices and perceptions among meat goat producers in Australia. To achieve this aim, 20 producers, located in New South Wales, Queensland, Western Australia and Victoria, operating under different production systems were interviewed. The results of this study suggest that animal health management could be improved and that producers perceive a lack of relevant and species-specific information available to help them make informed decisions. Reproductive management and records varied greatly across producers interviewed. Kid loss was identified as an issue, with a 28% estimated average (6%-47% range) of losses from kidding until weaning. Producers identified predation, doe nutrition and mismothering as the biggest contributors to kid loss, with the majority of losses occurring within a week of birth. All producers believed management could minimise kid loss. This study highlights the importance of improving reproductive rates among goat enterprises and provides new information on the current practices within the Australian meat goat industry. This may assist the development of appropriate strategies for improving health and reproductive management and delivery of advice to producers.

eV-Scale Sterile Neutrino Search Using Eight Years of Atmospheric Muon Neutrino Data from the IceCube Neutrino Observatory

The results of a 3+1 sterile neutrino search using eight years of data from the IceCube Neutrino Observatory are presented. A total of 305 735 muon neutrino events are analyzed in reconstructed energy-zenith space to test for signatures of a matter-enhanced oscillation that would occur given a sterile neutrino state with a mass-squared differences between 0.01 and 100  eV^{2}. The best-fit point is found to be at sin^{2}(2θ_{24})=0.10 and Δm_{41}^{2}=4.5  eV^{2}, which is consistent with the no sterile neutrino hypothesis with a p value of 8.0%.

Characteristics of the Diffuse Astrophysical Electron and Tau Neutrino Flux with Six Years of IceCube High Energy Cascade Data

We report on the first measurement of the astrophysical neutrino flux using particle showers (cascades) in IceCube data from 2010-2015. Assuming standard oscillations, the astrophysical neutrinos in this dedicated cascade sample are dominated (∼90%) by electron and tau flavors. The flux, observed in the sensitive energy range from 16 TeV to 2.6 PeV, is consistent with a single power-law model as expected from Fermi-type acceleration of high energy particles at astrophysical sources. We find the flux spectral index to be γ=2.53±0.07 and a flux normalization for each neutrino flavor of ϕ_{astro}=1.66_{-0.27}^{+0.25} at E_{0}=100  TeV, in agreement with IceCube's complementary muon neutrino results and with all-neutrino flavor fit results. In the measured energy range we reject spectral indices γ≤2.28 at ≥3σ significance level. Because of high neutrino energy resolution and low atmospheric neutrino backgrounds, this analysis provides the most detailed characterization of the neutrino flux at energies below ∼100  TeV compared to previous IceCube results. Results from fits assuming more complex neutrino flux models suggest a flux softening at high energies and a flux hardening at low energies (p value ≥0.06). The sizable and smooth flux measured below ∼100  TeV remains a puzzle. In order to not violate the isotropic diffuse gamma-ray background as measured by the Fermi Large Area Telescope, it suggests the existence of astrophysical neutrino sources characterized by dense environments which are opaque to gamma rays.

FRI0326 PREVALENCE AND IMPACT OF COMORBIDITIES IN AXIAL SPONDYLOARTHRITIS: SYSTEMATIC REVIEW AND META-ANALYSIS

Background:

Comorbidities are common among patients with axial spondyloarthritis (axSpA). The majority of axSpA patients have at least one comorbid medical condition in addition to any extra-articular manifestations [1]. Comorbidity ‘burden’ is associate with poorer function, quality of life and work-related outcomes [2]. They also influence treatment decisions and are key drivers of mortality.

Objectives:

We performed a systematic review and meta-analysis to 1) describe the prevalence of commonly reported comorbidities, 2) compare the prevalence of comorbidities between axSpA and control populations.

Methods:

A systematic review was performed in September 2019 using Medline, PubMed, Scopus and Web of Science, in accordance with PRISMA guidelines. Studies were included if they reported the prevalence of comorbidities on disease outcomes, and excluded if they focused on a single comorbidity or closely related diseases in one organ system. Two independent reviewers screened titles and abstracts, assessed full-texts for eligibility and extracted data from qualifying studies. Where possible, we performed meta-analyses for comorbidities reported by at least 3 studies using random-effects models. Pooled prevalence estimates were reported as percentages (95% confidence interval, I2statistic for heterogeneity).

Results:

36 studies reported prevalence of of individual comorbidities, amounting to a combined sample size of 119,427 patients. The most prevalent individual comorbidities were hypertension (pooled prevalence 22%), hyperlipidaemia (17%) and obesity (14%) (Figure 1). Eleven studies consistently showed higher prevalence of comorbidities in axSpA than controls (Table 1); odds ratios (OR) were particularly large for depression (pooled OR 1.80) and congestive cardiac failure (OR 1.84). There was significant heterogeneity for the majority of meta-analysis estimates.

Table 1.

Meta-analysis estimates for odds ratios (OR) of comorbidities compared between axSpA and control groups.

Number of studiesPooled OR95% confidence intervalI2, %Hypertension91.581.29 to 1.9298Any cardiovascular disease31.420.999 to 2.0399Any ischaemic heart disease71.511.21 to 1.8787Congestive cardiac failure41.841.25 to 2.7389Stroke61.301.04 to 1.6281Peripheral vascular disease51.471.10 to 1.9683Diabetes81.141.001 to 1.3083Hyperlipidaemia51.181.01 to 1.3994Cancer51.221.01 to 1.4793Depression41.801.45 to 2.2392Figure 1.

Pooled prevalence of individual comorbidities.

Conclusion:

Comorbidities are common in axSpA. Almost all comorbidities examined were more prevalent in axSpA patients than age and sex matched controls, with ≥80% higher odds for congestive cardiac failure and depression. Systematic and repeated assessments should therefore be integrated into routine clinical practice to ensure holistic patient-centred management. Additional studies are needed to validate comorbidities indices for axSpA research.

References:

[1]Zhao SS, Radner H, Siebert S, et al. Comorbidity burden in axial spondyloarthritis: a cluster analysis. Rheumatology. 2019 Oct 1;58(10):1746–54.

[2]Nikiphorou E, Ramiro S, van der Heijde D, et al. Association of Comorbidities in Spondyloarthritis With Poor Function, Work Disability, and Quality of Life: Results From the Assessment of SpondyloArthritis International Society Comorbidities in Spondyloarthritis Study. Arthritis Care Res. 2018 Aug;70(8):1257–62.

Disclosure of Interests:

None declared

Orthorexic tendencies are linked with difficulties with emotion identification and regulation

BACKGROUND

Orthorexia nervosa (ON) is characterised by an unhealthy obsession with healthy eating and while it is not recognised as an eating disorder (or any disorder), current research is exploring similarities and differences with such disorders. The literature has shown that individuals with eating disorders have difficulties identifying and describing emotions (known as alexithymia) as well as regulating them. However no research to date has looked at whether people with orthorexic tendencies also suffer from difficulties with emotions. In this paper, we refer to people with orthorexic tendencies but do not assume that their healthy eating is at a pathological level needing clinical attention.

METHODS

The current study examined this by asking 196 healthy adults with an interest in healthy eating to complete four questionnaires to measure ON (ORTO-15 - reduced to ORTO-7CS), eating psychopathology (EAT-26), alexithymia (TAS-20) and emotion dysregulation (DERS-16).

RESULTS

We found that difficulties identifying and regulating emotions was associated with symptoms of ON, similar to what is found in other eating disorders. We suggest that ON behaviours may be used as a coping strategy in order to feel in control in these participants who have poor emotion regulation abilities.

CONCLUSIONS

Our results show that individuals with ON tendencies may share similar difficulties with emotions compared to other eating disorders. While important, our results are limited by the way we measured ON behaviours and we recommend that further research replicate our findings once a better and more specific tool is developed and validated to screen for ON characteristics more accurately.

Ice therapy: cool, current and complicated

This is the fourth Capsule review article provided by the WSAVA Global Pain Council and which discusses the use of ice or cold therapy as a non-pharmacologic modality for pain control in small animal practice. The physiological effects of cold therapy on tissues, receptors and ion channels are discussed; as well as indications, recommendations for, and limitations of use.

Acceptability of the copper intrauterine device as a form of emergency contraception in New South Wales, Australia

Background: The copper-intrauterine device (Cu-IUD) is the most effective emergency contraception (EC), and the only method providing ongoing contraception; however, it is underutilised in Australia.Methods: An online cross-sectional survey of clients and clinicians at a family planning service was undertaken. Clients aged 16-55 and identifying as female or transgender male were eligible. The survey explored previous experience with and knowledge of the Cu-IUD as EC among clients, current EC practices among clinicians, and barriers and enablers among clients and clinicians.Results: Of 470 clients, 64.5% had previously used EC. Only 12.7% knew the Cu-IUD was a form of EC and 2% had used it. When given information on effectiveness, side-effects and costs, 46.8% reported they would consider the Cu-IUD for EC. However, 40% viewed cost and possible side-effects as barriers. Of the 58 clinicians surveyed, 55% reported discussing Cu-IUD as EC with clients versus 94% discussing oral EC, with time pressures reported as the main barrier.Conclusion: Low awareness among clients, and limited discussion by clinicians, highlights a need for increased education and promotion strategies for the Cu-IUD as EC. With greater knowledge, demand for this option may increase. This will require processes to ensure timely access to insertions.

Time-Integrated Neutrino Source Searches with 10 Years of IceCube Data

This Letter presents the results from pointlike neutrino source searches using ten years of IceCube data collected between April 6, 2008 and July 10, 2018. We evaluate the significance of an astrophysical signal from a pointlike source looking for an excess of clustered neutrino events with energies typically above ∼1  TeV among the background of atmospheric muons and neutrinos. We perform a full-sky scan, a search within a selected source catalog, a catalog population study, and three stacked Galactic catalog searches. The most significant point in the northern hemisphere from scanning the sky is coincident with the Seyfert II galaxy NGC 1068, which was included in the source catalog search. The excess at the coordinates of NGC 1068 is inconsistent with background expectations at the level of 2.9σ after accounting for statistical trials from the entire catalog. The combination of this result along with excesses observed at the coordinates of three other sources, including TXS 0506+056, suggests that, collectively, correlations with sources in the northern catalog are inconsistent with background at 3.3σ significance. The southern catalog is consistent with background. These results, all based on searches for a cumulative neutrino signal integrated over the 10 years of available data, motivate further study of these and similar sources, including time-dependent analyses, multimessenger correlations, and the possibility of stronger evidence with coming upgrades to the detector.

Comparing proxy rated quality of life of people living with dementia in care homes

BACKGROUND

Improving quality of life (QOL) for people with dementia is a priority. In care homes, we often rely on proxy ratings from staff and family but we do not know if, or how, they differ in care homes.

METHODS

We compared 1056 pairs of staff and family DEMQOL-Proxy ratings from 86 care homes across England. We explored factors associated with ratings quantitatively using multilevel modelling and, qualitatively, through thematic analysis of 12 staff and 12 relative interviews.

RESULTS

Staff and family ratings were weakly correlated (ρs = 0.35). Median staff scores were higher than family's (104 v. 101; p < 0.001). Family were more likely than staff to rate resident QOL as 'Poor' (χ2 = 55.91, p < 0.001). Staff and family rated QOL higher when residents had fewer neuropsychiatric symptoms and severe dementia. Staff rated QOL higher in homes with lower staff:resident ratios and when staff were native English speakers. Family rated QOL higher when the resident had spent longer living in the care home and was a native English. Spouses rated residents' QOL higher than other relatives. Qualitative results suggest differences arise because staff felt good care provided high QOL but families compared the present to the past. Family judgements centre on loss and are complicated by decisions about care home placement and their understandings of dementia.

CONCLUSION

Proxy reports differ systematically between staff and family. Reports are influenced by the rater:staff and family may conceptualise QOL differently.

Intraperitoneal and incisional analgesia in small animals: simple, cost-effective techniques

The World Small Animal Veterinary Association Global Pain Council (WSAVA-GPC) has recently published its first "capsule review" by Monteiro et al. These are short articles that present a brief assessment of the scientific evidence and practical recommendations on important, and sometimes controversial, subjects in pain management. The capsules will be published regularly in the Journal of Small Animal Practice, the official journal of the WSAVA. This second article discusses the use of intraperitoneal and incisional analgesia in small animal practice, including their limitations and recommendations by the authors.

Long-term use of non-steroidal anti-inflammatory drugs in cats with chronic kidney disease: from controversy to optimism

This is the first of a series of capsule reviews published by the World Small Animal Veterinary Association - Global Pain Council (WSAVA-GPC). Each of these short articles provides a brisk assessment of the scientific evidence in specific aspects of pain management, including analgesic techniques, recommendations and controversies surrounding their use. In this first capsule review, the scientific evidence available on the long-term use of non-steroidal anti-inflammatory drugs in cats with concomitant chronic pain and chronic kidney disease is discussed.

Constraints on Minute-Scale Transient Astrophysical Neutrino Sources

High-energy neutrino emission has been predicted for several short-lived astrophysical transients including gamma-ray bursts (GRBs), core-collapse supernovae with choked jets, and neutron star mergers. IceCube's optical and x-ray follow-up program searches for such transient sources by looking for two or more muon neutrino candidates in directional coincidence and arriving within 100 s. The measured rate of neutrino alerts is consistent with the expected rate of chance coincidences of atmospheric background events and no likely electromagnetic counterparts have been identified in Swift follow-up observations. Here, we calculate generic bounds on the neutrino flux of short-lived transient sources. Assuming an E^{-2.5} neutrino spectrum, we find that the neutrino flux of rare sources, like long gamma-ray bursts, is constrained to <5% of the detected astrophysical flux and the energy released in neutrinos (100 GeV to 10 PeV) by a median bright GRB-like source is <10^{52.5}  erg. For a harder E^{-2.13} neutrino spectrum up to 30% of the flux could be produced by GRBs and the allowed median source energy is <10^{52}  erg. A hypothetical population of transient sources has to be more common than 10^{-5}  Mpc^{-3}  yr^{-1} (5×10^{-8}  Mpc^{-3}  yr^{-1} for the E^{-2.13} spectrum) to account for the complete astrophysical neutrino flux.

Search for neutrinos from decaying dark matter with IceCube: IceCube Collaboration

With the observation of high-energy astrophysical neutrinos by the IceCube Neutrino Observatory, interest has risen in models of PeV-mass decaying dark matter particles to explain the observed flux. We present two dedicated experimental analyses to test this hypothesis. One analysis uses 6 years of IceCube data focusing on muon neutrino 'track' events from the Northern Hemisphere, while the second analysis uses 2 years of 'cascade' events from the full sky. Known background components and the hypothetical flux from unstable dark matter are fitted to the experimental data. Since no significant excess is observed in either analysis, lower limits on the lifetime of dark matter particles are derived: we obtain the strongest constraint to date, excluding lifetimes shorter than10 28 s at 90% CL for dark matter masses above 10 TeV .

Nucleocapsid protein-based vaccine provides protection in mice against lethal Crimean-Congo hemorrhagic fever virus challenge

Crimean-Congo hemorrhagic fever (CCHF) is an acute, often fatal viral disease characterized by rapid onset of febrile symptoms followed by hemorrhagic manifestations. The etiologic agent, CCHF orthonairovirus (CCHFV), can infect several mammals in nature but only seems to cause clinical disease in humans. Over the past two decades there has been an increase in total number of CCHF case reports, including imported CCHF patients, and an expansion of CCHF endemic areas. Despite its increased public health burden there are currently no licensed vaccines or treatments to prevent CCHF. We here report the development and assessment of the protective efficacy of an adenovirus (Ad)-based vaccine expressing the nucleocapsid protein (N) of CCHFV (Ad-N) in a lethal immunocompromised mouse model of CCHF. The results show that Ad-N can protect mice from CCHF mortality and that this platform should be considered for future CCHFV vaccine strategies.

Crimean-Congo hemorrhagic fever (CCHF) is a tick-borne disease that can manifest as a viral hemorrhagic fever syndrome. The CCHF virus is widely spread throughout the African continent, the Balkans, the Middle East, Southern Russia and Western Asia where it remains a serious public health concern. Currently, there are no licensed treatments or vaccines available, and medical countermeasures are urgently needed. We developed an adenovirus vector vaccine based on the conserved structural nucleoprotein (N) as the antigen. A prime-boost approach showed promising efficacy in the most widely used immunocompromised mouse model. This vaccine approach demonstrates a role for N in protection and suggests its consideration for future CCHFV vaccine strategies.

Relationship between speaking English as a second language and agitation in people with dementia living in care homes: Results from the MARQUE (Managing Agitation and Raising Quality of life) English national care home survey

OBJECTIVE

As not speaking English as a first language may lead to increased difficulties in communication with staff and other residents, we (1) tested our primary hypotheses that care home residents with dementia speaking English as a second language experience more agitation and overall neuropsychiatric symptoms, and (2) explored qualitatively how staff consider that residents' language, ethnicity, and culture might impact on how they manage agitation.

METHODS

We interviewed staff, residents with dementia, and their family carers from 86 care homes (2014-2015) about resident's neuropsychiatric symptoms, agitation, life quality, and dementia severity. We qualitatively interviewed 25 staff.

RESULTS

Seventy-one out of 1420 (5%) of care home residents with dementia interviewed spoke English as a second language. After controlling for dementia severity, age, and sex, and accounting for care home and staff proxy clustering, speaking English as a second language compared with as a first language was associated with significantly higher Cohen-Mansfield Agitation Inventory (adjusted difference in means 8.3, 95% confidence interval 4.1 to 12.5) and Neuropsychiatric inventory scores (4.1, 0.65 to 7.5). Staff narratives described how linguistic and culturally isolating being in a care home where no residents or staff share your culture or language could be for people with dementia, and how this sometimes caused or worsened agitation.

CONCLUSIONS

Considering a person with dementia's need to be understood when selecting a care home and developing technology resources to enable dementia-friendly translation services could be important strategies for reducing distress of people with dementia from minority ethnic groups who live in care homes.

Abstract P2-03-07: Digital image analysis of Ki67 in hot spots is superior to alternative proliferation associated markers in breast cancer

INTRODUCTION

Proliferative activity is one of the most important prognostic parameters in cancer. During the pathological examination of breast tumors, it is routinely evaluated by a count of the number of mitoses. Adding immunohistochemical stains of the nuclear protein Ki67 provides extra prognostic and predictive information. However, the currently used methods for both of these evaluations battle imperfections, primarily in reproducibility. In this study, we make an equally broad and detailed evaluation of mitoses, Ki67 and the more recently described Phosphohistone H3 (PHH3) in primary breast cancer using digital image analysis (DIA). Furthermore, we aim to investigate the prognostic and predictive value of proliferation-associated biomarkers in breast cancer stromal cells in relation to patient outcome.

MATERIALS AND METHODS

Two cohorts of primary breast cancer specimens (total n=297) with clinicopathological data including &gt;10 years survival data, were sectioned and stained for Ki67, PHH3 and pancytokeratin (CKMNF116) and all glass slides were digitally scanned at x20. The DIA software used was the Visiopharm Integrator System (VIS) by Visiopharm A/S, Hoersholm, Denmark. VIS operates by a 'digital fusion' method that automatically excludes non-epithelial tissue restricting the analysis of the biomarkers (Ki67 and PHH3) to CKMNF116 positive cells. Both manual and DIA scores were compared for sensitivity and specificity for the gene expression based Luminal B versus A subtype, for high versus low transcriptomic grade as well as for their prognostic value in terms of Cox regression hazard ratios and breast cancer specific and overall survival. Further, we investigated whether the expression of Ki67 in the tumors' hot spots, invasive edges or as an average across all regions should be assessed for maximum power in relation to these outcomes. In addition, by inverting the DIA algorithm run by the VIS on the same cohorts, the expression of Ki67 and PHH3 was evaluated in the tumor stromal compartment.

RESULTS

Regardless of tumor region, DIA of Ki67 outperformed the other markers in sensitivity and specificity for gene expression subtypes and transcriptomic grade. In contrast to mitotic counts, tumors with high expression of Ki67 as defined by DIA, had significantly increased hazard ratio for all-cause mortality within 10 years from diagnosis. DIA of Ki67 was superior to manual Ki67 and PHH3 evaluations as well as to mitotic counts in terms of separation of patients with poor versus relatively good survival. Finally, we replaced the manual mitotic counts with DIA of Ki67 in hot spots as the marker for proliferation when determining histological grade. This increased the differences in estimated mean overall survival between the highest and lowest grades and added significantly more prognostic information to the classic Nottingham histological grade.

CONCLUSIONS

We conclude that digital image analysis of Ki67 in hot spots should be suggested as the marker of choice for proliferative activity in breast cancer.

Citation Format: Robertson S, Stålhammar G, Wedlund L, Gholizadeh S, Lippert M, Rantaleinen M, Bergh J, Hartman J. Digital image analysis of Ki67 in hot spots is superior to alternative proliferation associated markers in breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P2-03-07.

Collection and determinants of patient reported outcome measures in haemodialysis patients in Scotland

BACKGROUND/INTRODUCTION

Patient reported outcome measures (PROMs) can evaluate the quality of health in patients with established renal failure. There is limited experience of their use within national renal registries.

AIM

To describe the Scottish Renal Registry's (SRR) experience of collecting PROMS in the haemodialysis population and correlate PROMS to demographic and clinical parameters.

DESIGN

Retrospective observational cross-sectional study.

METHODS

Haemodialysis patients in Scotland were invited to complete the KDQOL™-36 questionnaire on the day of the annual SRR census in 2015 and 2016. Questionnaires were linked to census demographic and clinical variables.

RESULTS

In 2016, 738 questionnaires were linked to census data (39% of prevalent haemodialysis population). Response rates differed with age (≥ 65 years 42%, < 65 years 36%) [χ2P = 0.006]; duration of renal replacement therapy (<1 year 46%, ≥1 < 5 years 38%, ≥ 5 years 33%) [χ2P = 0.002] and social class (Scottish Index of Multiple Deprivation (SIMD) Class 1 32%, Class 2 41%, Class 3 40%, Class 4 48%, Class 5 40%) [χ2P < 0.001]. There were significant differences in PROMs with age, SIMD quintile and primary renal diagnosis. Achieving a urea reduction ratio of >65% and dialysing through arteriovenous access were associated with significantly higher PROMs. PROMs were not affected by haemoglobin or phosphate concentration.

DISCUSSION/CONCLUSIONS

Routine collection of PROMs is feasible and can identify potentially under-recognized and treatable determinants to quality of life. The association between attaining recommended standards of care and improved PROMs is striking. Individual and population-wide strategies are required to improve PROMs.