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Recent Submissions

  • Case report of spuriously low sodium and calcium in a 36-year-old male in primary care.

    Costelloe, Seán J; McCarthy, Kelly; O'Connell, Marguerite; Butler, Mark (2020-04-15)
    An unseparated serum specimen for a 36-year-old male was received from primary care. The specimen arrived in the laboratory at Cork University Hospital one day after collection, as documented on the paper request card, and was promptly centrifuged. Analysis was delayed for three days due to operational constraints and serum indices were run at the same time as the biochemical analyses. Results showed a moderately haemolysed specimen with remarkably low concentrations of both sodium (119 mmol/L) and total calcium (1.15 mmol/L), with all other parameters within their appropriate reference intervals (RIs). The complete report was released electronically and both sodium and calcium results were phoned to, and acknowledged by, the requesting general practitioner (GP). Discussion between the medical scientists and clinical biochemist on duty raised the possibility that the specimen was significantly older than initially thought. Further discussion of results with the GP clarified that the documented time of collection corresponded with specimen receipt by the courier, rather than the time of phlebotomy. Thus, the specimen was 7 days old when received in the laboratory and 10 days old when analysed. This case illustrates the dangers of multiple convergent preanalytical errors. Laboratories should be mindful of the stability of analytes in unseparated blood and unusual patterns of results which might suggest a specimen is "old", and that this may coexist with erroneous request information. Any potential adverse effects on patient care were prevented in this case by laboratory vigilance.
  • COVID-19 pandemic and the risk of infection in multiple sclerosis patients on disease modifying therapies: "what the bleep do we know?"

    Mansoor, Salman; Kelly, Siobhan; Murphy, Kevin; Waters, Aine; Siddiqui, Nauman Saleem (2020-05-01)
    The novel coronavirus which emerged in Wuhan province of China has taken world by surprise. Since been diagnosed in December 2019, it has been termed a "Pandemic" and there is a growing concern in physicians across the globe. As new evidence is emerging, there are various preventative strategies which are being deployed. Multiple sclerosis patients who are on disease modifying therapies (DMTs) might be at a higher risk of acquiring or a poorer outcome due to their immune status. This review looks at the available evidence in managing this global crisis.
  • ERS International Congress, Madrid, 2019: highlights from the Basic and Translational Science Assembly.

    Ubags, Niki D; Baker, Jonathan; Boots, Agnes; Costa, Rita; El-Merhie, Natalia; Fabre, Aurélie; Faiz, Alen; Heijink, Irene H; Hiemstra, Pieter S; Lehmann, Mareike; et al. (2020-03-02)
    In this review, the Basic and Translational Sciences Assembly of the European Respiratory Society (ERS) provides an overview of the 2019 ERS International Congress highlights. In particular, we discuss how the novel and very promising technology of single cell sequencing has led to the development of a comprehensive map of the human lung, the lung cell atlas, including the discovery of novel cell types and new insights into cellular trajectories in lung health and disease. Further, we summarise recent insights in the field of respiratory infections, which can aid in a better understanding of the molecular mechanisms underlying these infections in order to develop novel vaccines and improved treatment options. Novel concepts delineating the early origins of lung disease are focused on the effects of pre- and post-natal exposures on neonatal lung development and long-term lung health. Moreover, we discuss how these early life exposures can affect the lung microbiome and respiratory infections. In addition, the importance of metabolomics and mitochondrial function analysis to subphenotype chronic lung disease patients according to their metabolic program is described. Finally, basic and translational respiratory science is rapidly moving forward and this will be beneficial for an advanced molecular understanding of the mechanisms underlying a variety of lung diseases. In the long-term this will aid in the development of novel therapeutic targeting strategies in the field of respiratory medicine.
  • Lysosomal Acid Lipase Deficiency: Therapeutic Options.

    Pastores, Gregory M; Hughes, Derralynn A (2020-02-11)
    Lysosomal acid lipase (LAL) deficiency is a metabolic (storage) disorder, encompassing a severe (Wolman disease) and attenuated (Cholesterol ester storage disease) subtype; both inherited as autosomal recessive traits. Cardinal clinical features include the combination of hepatic dysfunction and dyslipidemia, as a consequence of cholesteryl esters and triglyceride accumulation, predominately in the liver and vascular and reticuloendothelial system. Significant morbidity can arise, due to liver failure and/or atherosclerosis; in part related to the severity of the underlying gene defect and corresponding enzyme deficiency. Diagnosis is based on demonstration of decreased LAL enzyme activity, complemented by analysis of the cognate gene defects. Therapeutic options include dietary manipulation and the use of lipid-lowering drugs. Sebelipase alfa, a recombinant enzyme replacement therapy, has garnered regulatory approval, following demonstration of improvements in disease-relevant markers and clinical benefit in clinical trials, which included increased survival in the most severe cases.
  • Investigation of the long-term yield of auditing for conformity with the ISO 15189:2012 quality standard in a hospital pathology laboratory.

    Green, Alastair David; Kavanagh-Wright, Lucille; Lee, Graham Robert (2020-03-04)
    Introduction: Pathology laboratories are increasingly seeking accreditation to quality standards to assure Quality of Service (QoS). However, there is little data available regarding the value of this in laboratories with well-established Quality Management Systems (QMS). Moreover, critics of accreditation claim it redirects resources toward trivial issues. Our objective was to investigate the value of auditing for conformity with the ISO 15189:2012 standard in such laboratories. Design: and Methods: In total, 483 Audit-Identified Non-Conformities (AINCs) were documented within our department since transitioning to an ISO 15189:2012 compliant QMS. The potential consequences of these were assessed by three clinical laboratorians who assigned them into categories based on their likely impact. These were: Unlikely (no clear consequences); Possible (potential for poor QoS/harm); and Probable (Likely to cause poor QoS/harm). Additionally, total numbers/severity of Real-Time Non-Conformities (RTNCs) detected outside of auditing were examined to provide additional insight into the effects of accreditation on QoS. Results: According to majority decision: 395 (81.8%) of AINCs were classified Unlikely, 88 (18.2%) were Possible, and none were Probable. The relative proportion of Unlikely AINCs also rose over time. Total numbers and severity of RTNCs dropped in the short-term following transition to an ISO 15189:2012 QMS, but steadily rose thereafter. Conclusions: Our data suggest auditing for conformity with ISO 15189:2012 standards may be effective in attaining accreditation, but may have diminishing returns in the long-term once the QMS is established, unless there is continual improvement in the audit process to promote better use of resources.
  • Towards European harmonisation of healthcare for patients with rare immune disorders: outcome from the ERN RITA registries survey.

    Papa, Riccardo; Cant, Andrew; Klein, Christoph; Little, Mark A; Wulffraat, Nico M; Gattorno, Marco; Ruperto, Nicolino (2020-01-30)
    The Rare Immunodeficiency, AutoInflammatory and AutoImmune Disease (RITA) network is a European Research Network (ERN) that brings together the leading centres for rare immune disorders. On April 2018 an online survey was sent to all RITA members in order to facilitate the harmonization of data collection in rare immune disorders registries. Currently, as many as 52 different registries collect data on rare immune disorders, of whom 30 (58%) are dedicated primarily to autoimmune diseases, 15 (29%) to primary immunodeficiencies and 12 (23%) to autoinflammatory disorders. Improving data on patient safety, outcome, and quality of life measures is warranted to unfold the full potential of RITA registries.
  • Antimicrobial De-Escalation in the ICU: From Recommendations to Level of Evidence.

    Lakbar, Ines; De Waele, Jan J; Tabah, Alexis; Einav, Sharon; Martin-Loeches, Ignacio; Leone, Marc (2020-05-27)
    Antimicrobial de-escalation (ADE) is a component of antimicrobial stewardship (AMS) aimed to reduce exposure to broad-spectrum antimicrobials. In the intensive care unit, ADE is a strong recommendation that is moderately applied in clinical practice. Following a systematic review of the literature, we assessed the studies identified on the topic which included one randomized controlled trial and 20 observational studies. The literature shows a low level of evidence, although observational studies suggested that this procedure is safe. The effects of ADE on the level of resistance of ecological systems and especially on the microbiota are unclear. The reviewers recommend de-escalating antimicrobial treatment in patients requiring long-term antibiotic therapy and considering de-escalation in short-term treatments.
  • Routine neck ultrasound by respiratory physicians in the diagnosis and staging of patients with lung cancer and mediastinal lymphadenopathy: a prospective pilot study.

    Ahmed, Mohammed; Daneshvar, Cyrus; Breen, David (2020-02-10)
    Introduction: Cervical lymphadenopathy in lung cancer indicates advanced disease. The presence of mediastinal lymphadenopathy is commonly associated with involvement of neck lymph nodes and some studies suggest routine neck ultrasound (NUS) in this group of patients. We conducted a two-phase study looking at training a respiratory physician to perform ultrasound-guided neck lymph node aspiration in patients with suspected lung cancer. Methods: In the first phase of the study, one of the authors underwent training in NUS according to predetermined criteria. The adequacy of sampling was prospectively recorded. In the second phase, consecutive patients with suspected lung cancer and mediastinal lymphadenopathy underwent NUS and sampling of abnormal lymph nodes. The outcomes were the adequacy of samples for pathological analysis and molecular analysis, prevalence of cervical lymphadenopathy, and change in stage. Results: Following the period of training, 35 patients underwent neck node sampling with an overall adequacy of 88.6% (95% CI 78.1-99.1%). Cervical lymph node involvement was confirmed in 13 out of 30 patients with lung cancer (43.3%, 95% CI 25.5-62.6%). Further immunohistochemistry and molecular studies were possible in all patients when it was required (nine cases). NUS led to nodal upstaging in four out of 30 (13.3%) cases. Conclusion: Training a respiratory physician to perform NUS and needle sampling to an acceptable level is feasible. Benefits of embedding this procedure in lung cancer diagnosis and pathway staging need to be explored in further studies.
  • Comparison of long-term clinical outcomes in multivessel coronary artery disease patients treated either with bioresoarbable polymer sirolimus-eluting stent or permanent polymer everolimus-eluting stent: 5-year results of the CENTURY II randomized clinical trial.

    Iñiguez, Andrés; Chevalier, Bernard; Richardt, Gert; Neylon, Antoinette; Jiménez, Victor A; Kornowski, Ran; Carrie, Didier; Moreno, Raul; Barbato, Emanuele; Serra-Peñaranda, Antoni; et al. (2019-04-29)
    Objectives: To assess the long-term safety and efficacy of a sirolimus-eluting stent with bioresorbable polymer (BP-SES; Ultimaster), in comparison to a benchmark everolimus-eluting, permanent polymer stent (PP-EES; Xience), in a prespecified subgroup of patients with multivessel coronary artery disease (MVD) enrolled in the CENTURY II trial. Background: The use of coronary stenting in high-risk subgroups, like MVD patients, is rising. The clinical evidence, including long-term comparative analysis of the efficacy and safety benefits of different new-generation drug eluting stents, however, remains insufficient. Methods: Among 1,119 patients (intention-to-treat) enrolled in the CENTURY II prospective, randomized, single-blind, multicenter trial, a prespecified subgroup of 456 MVD patients were allocated by stratified randomization to treatment with BP-SES (n = 225) or PP-EES (n = 231). The previously reported primary endpoint of this study was freedom from target lesion failure (TLF: a composite of cardiac death, target vessel-related myocardial infarction [MI] and clinically-indicated target lesion revascularization) at 9 months. Results: In this MVD substudy, baseline patient, lesion and procedure characteristics were similar between the treatment arms. At 1 and 5 years, both BP-SES and PP-EES displayed low and comparable rates of TLF (5.3 vs. 7.8%; p = .29 and 10.2 vs. 13.4%; p = .29), and definite or probable stent thrombosis (0.4 vs. 1.3%; p = .33 and 0.9 vs. 1.7%; p = .43), respectively. Composite endpoint of cardiac death and MI, and patient-oriented composite endpoint of any death, MI, and coronary revascularizations were also similar. Conclusions: These results confirm good long-term safety and efficacy of the studied bioresorbable polymer stent in this high-risk patient population.
  • Inflammatory marker alteration in response to systemic therapies in psoriasis.

    Grechin, Cristina; Gheucă Solovăstru, Laura; Vâță, Dan; Ionela Pătrașcu, Adriana; Ioana Grăjdeanu, Alina; Porumb-Andrese, Elena (2020-02-18)
    Substantial research has focused on the presence of biomarkers involved in both the pathogenesis of psoriasis and its comorbidities. The identification of these biomarkers has a crucial role in establishing the diagnosis and prognosis, in understanding the physiopathological mechanism and in determining the therapeutic response. The aim of this study was to emphasize the alteration in inflammatory markers in response to systemic therapies in psoriasis. Evolution of inflammatory marker alteration was studied in 194 patients with psoriasis, aged between 7 and 87 years. Two groups were set up: the first comprised of patients treated with methotrexate (n=51), while the second comprised patients treated with biological therapy (n=143). Each group was evaluated for blood values of C-reactive protein (CRP), erythrocyte sedimentation rate (ESR) and fibrinogen before and after treatment, the fluctuation of these values according to the treatment, the interrelation between inflammatory markers and inflammatory activity of the disease and the evolution of the disease after treatment. In group I, 46 out of 51 patients had elevated levels of acute phase reactants before treatment. After treatment with methotrexate 7.5 mg/week, 12 out of 46 patients had elevated blood levels of ESR and 18 out of 46 patients of CRP and fibrinogen. Before treatment with biological therapy, 138 patients out of 143 presented abnormal high range for acute phase reactants. After treatment with biological therapy, 18 patients out of 138 had elevated blood levels of ESR and 37 patients out of 138 had elevated CRP and fibrinogen. A favorable evolution was noted in 98 patients out of 138. It was concluded that the systemic treatment with both methotrexate and biological therapy showed a marked decline in the patients with abnormal values of CRP, ESR and fibrinogen, indirectly showing a decline in the inflammatory activity of psoriasis.
  • Developing a lung nodule management protocol specifically for cardiac CT: Methodology in the DISCHARGE trial.

    Haase, Robert; Dodd, Jonathan D; Kauczor, Hans-Ulrich; Kazerooni, Ella A; Dewey, Marc (2020-06-25)
    Purpose: In this methodology paper we describe the development of a lung nodule management algorithm specifically for patients undergoing cardiac CT. Methods: We modified the Lung-RADS algorithm specifically to manage lung nodules incidentally detected on cardiac CT (Lung-RADS for cardiac CT). We will evaluate the modified algorithm as part of the DISCHARGE trial (www.dischargetrial.eu) in which patients with suspected coronary artery disease are randomly assigned to cardiac CT or invasive coronary angiography across Europe at 16 sites involving 3546 patients. Patients will be followed for up to four years. Results: The major adjustments to Lung-RADS specifically for cardiac CT relate to 1) incomplete coverage of the lungs by cardiac CT compared with chest CT, and when to order a completion chest CT versus a follow up chest CT, 2) cardiac CT findings will not trigger annual lung-cancer screening, and 3) a lower threshold of at least 10 mm for classifying new ground glass nodules as probably benign (category 3). Conclusions: The DISCHARGE trial will assess a lung nodule management algorithm designed specifically for cardiac CT in patients with stable chest pain across Europe.
  • PIM kinase inhibition: co-targeted therapeutic approaches in prostate cancer.

    Luszczak, Sabina; Kumar, Christopher; Sathyadevan, Vignesh Krishna; Simpson, Benjamin S; Gately, Kathy A; Whitaker, Hayley C; Heavey, Susan (2020-01-31)
    PIM kinases have been shown to play a role in prostate cancer development and progression, as well as in some of the hallmarks of cancer, especially proliferation and apoptosis. Their upregulation in prostate cancer has been correlated with decreased patient overall survival and therapy resistance. Initial efforts to inhibit PIM with monotherapies have been hampered by compensatory upregulation of other pathways and drug toxicity, and as such, it has been suggested that co-targeting PIM with other treatment approaches may permit lower doses and be a more viable option in the clinic. Here, we present the rationale and basis for co-targeting PIM with inhibitors of PI3K/mTOR/AKT, JAK/STAT, MYC, stemness, and RNA Polymerase I transcription, along with other therapies, including androgen deprivation, radiotherapy, chemotherapy, and immunotherapy. Such combined approaches could potentially be used as neoadjuvant therapies, limiting the development of resistance to treatments or sensitizing cells to other therapeutics. To determine which drugs should be combined with PIM inhibitors for each patient, it will be key to develop companion diagnostics that predict response to each co-targeted option, hopefully providing a personalized medicine pathway for subsets of prostate cancer patients in the future.
  • Survey on ART and IUI: legislation, regulation, funding and registries in European countries: The European IVF-monitoring Consortium (EIM) for the European Society of Human Reproduction and Embryology (ESHRE).

    Calhaz-Jorge, C; De Geyter, C H; Kupka, M S; Wyns, C; Mocanu, E; Motrenko, T; Scaravelli, G; Smeenk, J; Vidakovic, S; Goossens, V (2020-02-06)
    Study question: How are ART and IUI regulated, funded and registered in European countries? Summary answer: Of the 43 countries performing ART and IUI in Europe, and participating in the survey, specific legislation exists in only 39 countries, public funding (also available in the 39 countries) varies across and sometimes within countries and national registries are in place in 31 countries. What is known already: Some information devoted to particular aspects of accessibility to ART and IUI is available, but most is fragmentary or out-dated. Annual reports from the European IVF-Monitoring (EIM) Consortium for ESHRE clearly mirror different approaches in European countries regarding accessibility to and efficacy of those techniques. Study design size duration: A survey was designed using the online SurveyMonkey tool consisting of 55 questions concerning three domains-legal, funding and registry. Answers refer to the countries' situation on 31 December 2018. Participants/materials settings methods: All members of EIM plus representatives of countries not yet members of the Consortium were invited to participate. Answers received were checked, and initial responders were asked to address unclear answers and to provide any additional information they considered important. Tables of individual countries resulting from the consolidated data were then sent to members of the Committee of National Representatives of ESHRE, asking for a second check. Conflicting information was clarified by direct contact. Main results and the role of chance: Information was received from 43 out of the 44 European countries where ART and IUI are performed. Thirty-nine countries reported specific legislation on ART, and artificial insemination was considered an ART technique in 35 of them. Accessibility is limited to infertile couples in 11 of the 43 countries. A total of 30 countries offer treatments to single women and 18 to female couples. In five countries ART and IUI are permitted for treatment of all patient groups, being infertile couples, single women and same sex couples, male and female. Use of donated sperm is allowed in 41 countries, egg donation in 38, the simultaneous donation of sperm and egg in 32 and embryo donation in 29. Preimplantation genetic testing (PGT) for monogenic disorders or structural rearrangements is not allowed in two countries, and PGT for aneuploidy is not allowed in 11; surrogacy is accepted in 16 countries. With the exception of marital/sexual situation, female age is the most frequently reported limiting criteria for legal access to ART-minimal age is usually set at. 18 years and maximum ranging from 45 to 51 years with some countries not using numeric definition. Male maximum age is set in very few countries. Where permitted, age is frequently a limiting criterion for third-party donors (male maximum age 35 to 55 years; female maximum age 34 to 38 years). Other legal constraints in third-party donation are the number of children born from the same donor (in some countries, number of families with children from the same donor) and, in 10 countries, a maximum number of egg donations. How countries deal with the anonymity is diverse-strict anonymity, anonymity just for the recipients (not for children when reaching legal adulthood age), mixed system (anonymous and non-anonymous donations) and strict non-anonymity.Public funding systems are extremely variable. Four countries provide no financial assistance to patients. Limits to the provision of funding are defined in all the others i.e. age (female maximum age is the most used), existence of previous children, maximum number of treatments publicly supported and techniques not entitled for funding. In a few countries, reimbursement is linked to a clinical policy. The definition of the type of expenses covered within an IVF/ICSI cycle, up to what limit and the proportion of out-of-pocket costs for patients is also extremely dissimilar.National registries of ART and IUI are in place in 31 out of the 43 countries contributing to the survey, and a registry of donors exists in 18 of them. Limitations reasons for caution: The responses were provided by well-informed and committed individuals and submitted to double checking. Since no formal validation was in place, possible inaccuracies cannot be excluded. Also, results are a cross section in time and ART and IUI legislations within European countries undergo continuous evolution. Finally, several domains of ART activity were deliberately left out of the scope of this ESHRE survey. Wider implications of the findings: Results of this survey offer a detailed view of the ART and IUI situation in European countries. It provides updated and extensive answers to many relevant questions related to ART usage at national level and could be used by institutions and policymakers in planning services at both national and European levels. Study funding/competing interests: The study has no external funding, and all costs were covered by ESHRE. There were no competing interests.ESHRE Pages are not externally peer reviewed. This article has been approved by the Executive Committee of ESHRE.
  • Correction to: Core Rehabilitation Outcome Set for Single Sided Deafness (CROSSSD) study: protocol for an international consensus on outcome measures for single sided deafness interventions using a modified Delphi survey.

    Katiri, Roulla; Hall, Deborah A; Buggy, Nora; Hogan, Nicholas; Horobin, Adele; van de Heyning, Paul; Firszt, Jill B; Bruce, Iain A; Kitterick, Pádraig T (2020-03-17)
    Following the publication of our article [1], the authors have notified us of a typo in the third bullet point of the Consensus Criteria section.
  • Health Care Professionals' Perspectives on Life-Course Immunization: A Qualitative Survey from a European Conference.

    Philip, Roy K; Di Pasquale, Alberta (2020-04-14)
    Today, fewer children die each year from vaccine-preventable diseases than older adults. Health systems need new immunization strategies to tackle the burden of vaccine-preventable disease in an aging society. A life-course immunization (LCI) approach-which entails vaccination throughout an individual's lifespan-enables adults to age with reduced risk to disease, thereby enabling healthy, active and productive aging. We conducted an audience response system (ARS)-based survey to investigate HCP perspectives on LCI in an opportunistic sample of 222 health care professionals (HCPs) from around the world who attended a European infectious diseases conference. Survey results show that LCI is a priority for HCPs (77.4%-88.6%), with most of them stating the need to frame it as a part of a healthy lifestyle (91.0%-100.0%). Insufficient LCI recommendations by vaccine providers (12.9%-33.3%) and governments (15.2%-41.9%) and insufficient targeted budget allocation (6.1%-21.7%) were indicated as the main barriers to implement LCI, ahead of vaccine hesitancy (9.7%-15.2%). HCPs were willing to make LCI a gateway to healthy aging but need support to work together with other stakeholders involved in the vaccination journey. This could be a step towards equitable health care for all of society.
  • Heart University: a new online educational forum in paediatric and adult congenital cardiac care. The future of virtual learning in a post-pandemic world?

    Tretter, Justin T; Windram, Jonathan; Faulkner, Theresa; Hudgens, Michelle; Sendzikaite, Skaiste; Blom, Nico A; Hanseus, Katarina; Loomba, Rohit S; McMahon, Colin J; Zheleva, Bistra; et al. (2020-04-13)
    Online learning has become an increasingly expected and popular component for education of the modern-day adult learner, including the medical provider. In light of the recent coronavirus pandemic, there has never been more urgency to establish opportunities for supplemental online learning. Heart University aims to be "the go-to online resource" for e-learning in CHD and paediatric-acquired heart disease. It is a carefully curated open access library of paedagogical material for all providers of care to children and adults with CHD or children with acquired heart disease, whether a trainee or a practising provider. In this manuscript, we review the aims, development, current offerings and standing, and future goals of Heart University.
  • Taking guidance from parents involved in a longitudinal birth cohort - the ROLO family advisory committee.

    Walsh, N M; O'Brien, E C; Geraghty, A A; Byrne, D F; Whelan, A; Reilly, S; Murray, S; Reilly, C; Adams, E; Farnan, P M; et al. (2020-04-28)
    Background: The ROLO Study (Randomised cOntrol trial of a Low glycaemic index diet in pregnancy to prevent macrosomia) was a randomised control trial conducted between 2007 and 2011 to examine if a low glycaemic index (GI) diet could reduce the incidence of macrosomia. The ROLO Family Advisory Committee is a self-selected group of parents who are involved in the longitudinal follow-up of the ROLO Study. The committee was established in 2017 and the goal is to achieve a partnership between ROLO families and researchers, leading to improved research quality, relevance, and outcomes. This research method is termed "Public and patient involvement (PPI)" and describes how researchers collaborate and engage with the public in order to make research more relevant to them. Methods: The ROLO study mothers and children have been prospectively followed-up at multiple time points post-pregnancy. In October 2017, all women were invited to join the ROLO Family Advisory Committee via email or via advertisement on the ROLO Study Facebook page. Fathers and other guardians of the study children were also invited to join. Two annual meetings with the research team and parents were held in 2018 and 2019. The meetings were recorded, transcribed verbatim by researchers, and thematically analysed. Results: Parents provided opinions on the areas they felt should be explored within the ROLO study using information that was collected up to the current follow-up point. They also shared views on research interests which were of importance to them. These topics included; child mental health, fussy eating in childhood and healthy eating policies in schools. Mothers were much more concerned about factors which influenced their child's health rather than their own. Incorporating an element of PPI to this study was found to be a positive learning experience for participants and researchers. Conclusion: The involvement of parents has enriched the research agenda at the UCD Perinatal Research Centre. We will continue to engage with the parents of the ROLO Study and plan to involve the children to explore their opinions at the next opportunity.
  • Difficult Airway Society guidelines for awake tracheal intubation (ATI) in adults.

    Ahmad, I; El-Boghdadly, K; Bhagrath, R; Hodzovic, I; McNarry, A F; Mir, F; O'Sullivan, E P; Patel, A; Stacey, M; Vaughan, D (2019-11-14)
    Awake tracheal intubation has a high success rate and a favourable safety profile but is underused in cases of anticipated difficult airway management. These guidelines are a comprehensive document to support decision making, preparation and practical performance of awake tracheal intubation. We performed a systematic review of the literature seeking all of the available evidence for each element of awake tracheal intubation in order to make recommendations. In the absence of high-quality evidence, expert consensus and a Delphi study were used to formulate recommendations. We highlight key areas of awake tracheal intubation in which specific recommendations were made, which included: indications; procedural setup; checklists; oxygenation; airway topicalisation; sedation; verification of tracheal tube position; complications; management of unsuccessful awake tracheal intubation; post-tracheal intubation management; consent; and training. We recognise that there are a range of techniques and regimens that may be effective and one such example technique is included. Breaking down the key practical elements of awake tracheal intubation into sedation, topicalisation, oxygenation and performance might help practitioners to plan, perform and address complications. These guidelines aim to support clinical practice and help lower the threshold for performing awake tracheal intubation when indicated.
  • Speech Sound Disorders in Children: An Articulatory Phonology Perspective.

    Namasivayam, Aravind Kumar; Coleman, Deirdre; O'Dwyer, Aisling; van Lieshout, Pascal (2020-01-28)
    Speech Sound Disorders (SSDs) is a generic term used to describe a range of difficulties producing speech sounds in children (McLeod and Baker, 2017). The foundations of clinical assessment, classification and intervention for children with SSD have been heavily influenced by psycholinguistic theory and procedures, which largely posit a firm boundary between phonological processes and phonetics/articulation (Shriberg, 2010). Thus, in many current SSD classification systems the complex relationships between the etiology (distal), processing deficits (proximal) and the behavioral levels (speech symptoms) is under-specified (Terband et al., 2019a). It is critical to understand the complex interactions between these levels as they have implications for differential diagnosis and treatment planning (Terband et al., 2019a). There have been some theoretical attempts made towards understanding these interactions (e.g., McAllister Byun and Tessier, 2016) and characterizing speech patterns in children either solely as the product of speech motor performance limitations or purely as a consequence of phonological/grammatical competence has been challenged (Inkelas and Rose, 2007; McAllister Byun, 2012). In the present paper, we intend to reconcile the phonetic-phonology dichotomy and discuss the interconnectedness between these levels and the nature of SSDs using an alternative perspective based on the notion of an articulatory "gesture" within the broader concepts of the Articulatory Phonology model (AP; Browman and Goldstein, 1992). The articulatory "gesture" serves as a unit of phonological contrast and characterization of the resulting articulatory movements (Browman and Goldstein, 1992; van Lieshout and Goldstein, 2008). We present evidence supporting the notion of articulatory gestures at the level of speech production and as reflected in control processes in the brain and discuss how an articulatory "gesture"-based approach can account for articulatory behaviors in typical and disordered speech production (van Lieshout, 2004; Pouplier and van Lieshout, 2016). Specifically, we discuss how the AP model can provide an explanatory framework for understanding SSDs in children. Although other theories may be able to provide alternate explanations for some of the issues we will discuss, the AP framework in our view generates a unique scope that covers linguistic (phonology) and motor processes in a unified manner.
  • Medical Management of Patients After Atypical Femur Fractures: a Systematic Review and Recommendations From the European Calcified Tissue Society.

    van de Laarschot, Denise M; McKenna, Malachi J; Abrahamsen, Bo; Langdahl, Bente; Cohen-Solal, Martine; Guañabens, Núria; Eastell, Richard; Ralston, Stuart H; Zillikens, M Carola
    Context: Atypical femur fractures (AFFs) are serious adverse events associated with bisphosphonates and often show poor healing. Evidence acquisition: We performed a systematic review to evaluate effects of teriparatide, raloxifene, and denosumab on healing and occurrence of AFF. Evidence synthesis: We retrieved 910 references and reviewed 67 papers, including 31 case reports, 9 retrospective and 3 prospective studies on teriparatide. There were no RCTs. We pooled data on fracture union (n = 98 AFFs on teriparatide) and found that radiological healing occurred within 6 months of teriparatide in 13 of 30 (43%) conservatively managed incomplete AFFs, 9 of 10 (90%) incomplete AFFs with surgical intervention, and 44 of 58 (75%) complete AFFs. In 9 of 30 (30%) nonoperated incomplete AFFs, no union was achieved after 12 months and 4 (13%) fractures became complete on teriparatide. Eight patients had new AFFs during or after teriparatide. AFF on denosumab was reported in 22 patients, including 11 patients treated for bone metastases and 8 without bisphosphonate exposure. Denosumab after AFF was associated with recurrent incomplete AFFs in 1 patient and 2 patients of contralateral complete AFF. Eight patients had used raloxifene before AFF occurred, including 1 bisphosphonate-naïve patient. Conclusions: There is no evidence-based indication in patients with AFF for teriparatide apart from reducing the risk of typical fragility fractures, although observational data suggest that teriparatide might result in faster healing of surgically treated AFFs. Awaiting further evidence, we formulate recommendations for treatment after an AFF based on expert opinion.

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