bluuebunny/crossref_metadata_2025 huggingface dataset:
1455 A 10-year review of insulin-related enquiries to the UK National Poisons Information Service (NPIS)
Authors: Moyns Emma , Ferner Robin , Euan Sandilands , Gray Laurence , Thanacoody Ruben , Bradberry Sally
Published: December 2022

Aims, Objectives and Background

More than 4.9 million people in the UK have diabetes, and sufferers are at increased risk of depression.1We reviewed enquiries to the NPIS about insulin overdose.

Method and Design

Retrospective analysis of enquiries between 1 November 2011 and 31 October 2021.

Results and Conclusion

We received 1195 enquiries involving insulin. Further analysis was limited to the 169 enquiries involving insulin only (90.5% via injection).

Most enquiries (88%) concerned adults ≥ 18 years. There were 34 non-diabetic and 98 diabetic patients: 32 Type 1, 10 Type 2, and 56 type undocumented. Exposures were intentional (n=114, 68%), from therapeutic error (n=28), accidental (n=16) or circumstances unknown (n=11).

Long-acting insulins were involved in 71 cases, and the highest dose was 20000 units (table 1). The lowest recorded blood glucose concentration (mmol/L) at the time of the enquiry was in the range 0–0.9 (n=7), 1.0–1.9 (n=29), 2.0–2.9 (n=25), 3.0–3.9 (n=12), >4.0 (n=14). Hypokalaemia (defined as K+<3.5 mmol/L) was noted in 26 (n=15%) enquiries. The maximum Poisoning Severity2(n=162) was graded: none (n=55), minor (n=29), moderate (n=44), and severe (n=34).

Treatments given prior to contacting the NPIS were IV glucose (n=91, 54%), IV/IM glucagon (n=26, 15%), IV octreotide (n=6, 4%) and IV corticosteroids (n=2, 1%). No patient underwent surgical excision of the injection site. Long-acting insulins accounted for 5/6 cases where octreotide was given.

Abstract 1455 Table 1

Details of dose, insulin type, nadir blood glucose concentration, and Poisoning Severity Score in 169 cases of insulin poisoning reported to the UK National Poisons Information Service in the ten years to 31st October 2021. Ø = unrecordable

Insulin type*Median dose Units (range)Lowestblood glucoseconcnmmol/L (mg/dL)Known diabeticpatientsMaximum poisoning severityModeraten% of all moderateSeveren% of all severeLong acting (N=71)600 (10–20000)Ø492352%1441%Medium acting (N=24)900 (60–4500)0.6 (11)11818%721%Short acting (N=14)75 (28–2000)1.6 (29)737%13%Ultrashort acting (N=35)180 (1.5–4800)1 (18)231023%515%Unknown (N=18)188 (45–400)Ø800%721%Canine (N=7)20 (7–1600)4.2 (76)000%00%

*Where two or more insulin types or mixtures were involved (n=55, 32.5%), the longest-acting component was counted.

Conclusions

Hypoglycaemia following insulin overdose was mostly managed satisfactorily by intravenous glucose infusion, with glucagon used occasionally. The role of octreotide and corticosteroids was unclear. Approximately 20% of cases were severe, especially following overdose of medium- and long-acting insulins; we recorded no fatalities.

References

https://www.diabetes.org.uk/professionals/position-statements-reports/statistics. Accessed February 2022.

Persson HE, Sjöberg GK, Haines JA, De Garbino JP. Poisoning severity score. Grading of acute poisoning.J Toxicol Clin Toxicol1998;36: 205–213.
1632 Clinical predictors of fracture in patients with shoulder dislocation: systematic review of diagnostic test accuracy studies
Authors: Oldrini Ilaria , Coventry Laura , Novak Alex , Gwilym Steve , Metcalfe David
Published: December 2022

Aims, Objectives and Background

Pre-reduction radiographs are conventionally used to exclude important fracture before attempts to reduce a dislocated shoulder in the Emergency Department. However, this step increases cost, exposes patients to ionising radiation, and might delay closed reduction. Some studies have suggested that pre-reduction imaging may be omitted for a sub-group of patients with shoulder dislocations.

The objective was to determine whether clinical predictors can identify patients that might safely undergo closed reduction of a dislocated shoulder without pre-reduction radiographs.

Method and Design

A systematic review and meta-analysis of diagnostic test accuracy studies that have evaluated the ability of clinical features to identify concomitant fractures in patients with shoulder dislocation. All fractures were included except for Hill-Sachs lesions. Quality assessment was undertaken using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. Data were pooled and meta-analysed by fitting univariate random effects and multi-level mixed effects logistic regression models.

Results and Conclusion

Eight studies reported data on 2,087 shoulder dislocations and 343 concomitant fractures. The prevalence of concomitant fracture was 17.5%. The most accurate clinical predictors were age >40 (LR+ 1.8 [95% CI 1.5–2.1]; LR- 0.4 [0.2–0.6]), female sex (LR+ 2.0 [1.6–2.4], LR- 0.7 [0.6–0.8]), first time dislocation (LR+ 1.7 [1.4–2.0]; LR-0.2 [0.1–0.5]), and presence of humeral ecchymosis (LR+ 3.0–5.7; LR- 0.8–1.1). The most important mechanisms of injury were: high-energy mechanism fall (LR+ 2.0–9.8), fall >1 flight of stairs (LR+ 3.8 [95% CI 0.6–13.1]; LR- 1.0 [95% CI 0.9–1.0]), and motor vehicle collision (LR+ 2.3 [0.5–4.0]; LR- 0.9 [0.9–1.0]). The Quebec Rule had a sensitivity of 92.2% (95% CI 54.6–99.2%) and specificity (33.3%, 23.1–45.3%) but the Fresno-Quebec rule maintained 100% sensitivity across three studies that included 564 shoulder dislocations and 98 fractures.

In conclusion, the Fresno-Quebec Rule has undergone both internal and external validation and may now have a role in clinical practice.
1412 Cervical spine immobilisation in ambulatory patients
Authors: Phillips Hannah , Savadia Krishna , Johnson Graham
Published: December 2022

Aims, Objectives and Background

Approximately 2500 people suffer a traumatic cervical spinal fracture per year in the UK, of which 10–14% have an associated spinal cord injury. Emergency department practice was changed after Sundstrom et al (2014) found existing evidence for cervical spine collars to be weak. From April 2015 a new guideline was implemented in the Royal Derby Hospital removing the routine use of cervical collars for certain groups. This allowed patients who self-presented to the ED who met the Canadian C-spine criteria for radiographic imaging to remain free from immobilisation devices and undergo standing plain films or self-position for CT imaging.

Method and Design

A retrospective case note review was carried out from April 2009 to September 2021. Patients with a confirmed diagnosis of cervical spine fracture were identified and those who did not arrive by ambulance were selected for analysis. Their case notes were reviewed for fracture site, time since injury, neurological symptoms and clinical management.

Results and Conclusion

Cervical spine fracture was diagnosed in 30 patients each year on average over the study period. Fifteen per cent were not conveyed by ambulance. Over 70% of patients presented more than 4 hours after their injury. The most common site of injury was C6/7 (50%) followed by C2 (30%). Those patients who self-presented to the emergency department and were subsequently diagnosed with a cervical spine fracture suffered no adverse outcomes. Self-presentation to the emergency
1692 A multi-centre prospective observational study to evaluate healthcare impacts of e-scooters on emergency departments
Authors: Roberts Tom ,   Trainee Emergency Research Network Collaborators (TERN)
Published: December 2022

Aims, Objectives and Background

This study aims to report the prevalence of E-scooter related injuries, delineate the impact of rental schemes on Emergency Departments (ED) and report associated ED resource use and cost.

E-scooters have risen in popularity since the expansion of rental schemes and there is rising concern over the healthcare impact of faster illegal private E-scooters. Current literature is limited on the healthcare related impact of E-scooters by retrospective design and focus on specific injury patterns (e.g. orthopaedic or maxillofacial).

This study presents prospective data on E-scooter related injury presenting to the ED, comparing sites with and without rental schemes.

Method and Design

A prospective observational study for four weeks of recruitment across twenty EDs across the United Kingdom (12 with rental schemes and 8 without). All patients presenting to ED with an E-scooter associated injury were identified.

A prospective observational design was chosen to more accurately collect data on E-scooter injury patterns and behaviours. Sites with and without rental schemes were chosen to compare the impact of rental schemes.

Abstract 1692 Figure 1

Results and Conclusion

E-scooter related injury was found in 250 ED patients. Fractures were diagnosed in 30.4% of patients and 19.4% sustained a head injury (4.2% classified as severe traumatic brain injury). Only 6.4% of riders were helmeted and 19.8% were intoxicated with alcohol. Mean unadjusted ED costs per patient were £297.31. The mean Injury Severity Score (ISS) was 2.8 in rental E-scooter incidents and 3.0 in private E-scooter incidents. From multiple linear regression modelling, helmet use, alcohol use and private or rental E-scooters were not predictive of ISS.

In conclusion, E-scooter riders are vulnerable to injuries of varying severity. Low rates of helmet use and high prevalence of alcohol intoxication suggest a need for targeted public health interventions, but improved data collection is required. Health service costs should be considered when reviewing the suitability of rental schemes.
1674 The KnifeSavers bleeding control campaign: an evaluation of the public education programme
Authors: Russell Nicole , Tattam Kristian , Callon Josh , Jackson Robert , Misra Nikhil
Published: December 2022

Aims, Objectives and Background

Penetrating trauma remains a leading cause of mortality in the United Kingdom with major haemorrhage a potentially preventable cause of death.

KnifeSavers, a not-for-profit healthcare professional led organisation based at a regional major trauma centre, launched in 2019 to educate and empower the public how to manage a bleeding wound. There are three pillars of the campaign; an education programme, distribution of bleeding control packs and a public awareness campaign all focused on stopping major bleeding at scene.

The aim of this review is to evaluate the response to the education programme and improvement in confidence and ability of the attendees to control major bleeding.

Method and Design

Adult public members attending KnifeSavers education sessions between July 2021 and March 2022 were recruited to partake in pre and post event surveys.

Utilising a 5-point Likert scale participants willingness and preparedness to manage bleeding knife related wounds were assessed.

The data was comparatively measured, without accounting for attrition, to evaluate a change in response.

Abstract 1674 Figure 1

Comparison of pre and post survey 5-point Likert scale data

Results and Conclusion

There were 137 responses to the pre survey and 74% retention rate for the post session survey (n=101).

Despite a consistently high willingness in participants to intervene (93% pre session and 96% post), only 28% felt prepared to manage a bleeding wound prior to the education session, and 27% felt prepared to use a bleeding control kit.

Following the session an increase to 98% of participants were prepared to deal with a bleeding wound, and 96% prepared use a bleeding control kit.

Of note 97% of attendees stated it was important that training was delivered by health care professionals.

This data suggests that the KnifeSavers education programme is an effective strategy in increasing public preparedness to manage life-threatening bleeding wounds and supports further expansion of the programme.

A further mixed methods qualitative assessment including paired t-test statistical analysis is underway.
1673 Environmental leadership and the ‘green’ ED
Authors: Steley Zoe , Robertson Sandy , Farley Martin
Published: December 2022

Aims, Objectives and Background

The climate crisis is the biggest health threat facing humanity and healthcare accounts for approximately 5% of the UK’s carbon footprint. To address this, the NHS has set the ambitious target of achieving net-zero emissions by 2040. This raises the question as to how emergency departments – sites of resource-intensive clinical activity – can be engaged appropriately on environmental sustainability. Can a standardised approach be developed to hasten and consolidate efforts? To test this, we developed the GreenED framework. The aim was to trial a set of actionable criteria that could be implemented by any ED seeking to measure and reduce impacts, and increase staff engagement. It is designed to be easy to implement in the context of the emergency care crisis, and administered by RCEM. To our knowledge, this is the first framework in the world specifically designed for use in EDs.

Method and Design

The framework is modelled on UCL’s successful LEAF programme for sustainable laboratories. Criteria were drafted based on a review of literature in healthcare sustainability relevant to emergency care, and structured into bronze, silver and gold levels based on anticipated feasibility. ED staff in 8 departments across England were then recruited to pilot bronze level. Following an induction session, participants were engaged via monthly meetings, providing updates on progress and sharing approaches and challenges. Verbal feedback and written submissions were collected.

Results and Conclusion

Sites attempted as many actions as possible; most achieved at least 3 criteria. Identified obstacles were lack of senior support, guidance on how to implement changes, and time for sustainability work. Through both measurable impacts and qualitative feedback, this pilot has shown a clear demand for reducing environmental impacts, but significant challenges impeding progress. To continue leading in this we need to ensure senior buy-in and dedicate resources towards improving the sustainability of everyday departmental practices.
1435 Anaphylaxis case note review – a retrospective observational study
Authors: Tilbury Nicholas , Tabner Andrew , Johnson Graham
Published: December 2022

Aims, Objectives and Background

Anaphylaxis is seen relatively frequently in the emergency department, and if not managed promptly and appropriately, is associated with significant morbidity and mortality. Often patients are admitted for extended periods of observation due to fears that they may develop a biphasic reaction. NICE has recently updated its guidelines on this but acknowledges the sparsity of research investigating the appropriate length of the observation period. The purpose of this study was to identify the frequency of biphasic reactions and what period of observation would be sufficient for patients following attendance with anaphylaxis.

Method and Design

This was a retrospective observational study which looked at the presentation, treatment and outcomes of patients presenting to Royal Derby Hospital emergency department with anaphylaxis over the last 10 years. The patients were identified from clinical coding completed at the time of discharge and the information was attained from a combination of electronic and paper notes. We defined a biphasic reaction as a recurrence of anaphylaxis without re-exposure to an allergen following a complete resolution of symptoms and normalisation of observations.

Results and Conclusion

A total of 377 patients were identified as presenting with anaphylaxis from the discharge coding. After case note review, 346 of these were concluded to have been true anaphylaxis (examples of those excluded were hereditary angioedema and ACE-inhibitor related angioedema). 321 (93%) were given intra-muscular adrenaline at some point and 244 (70%) were admitted to hospital for further treatment or observation. Of the 346 cases included in the study only 5 (1.4%) met the criteria for a biphasic reaction. Interestingly, 1 patient was responsible for 3 of those 5 attendances. The results of our study strongly suggest that the risk of a biphasic reaction is significantly less than previously thought and that admission for prolonged observation may be unnecessary in the majority of cases.
1357 Patient-reported outcome measure for older people living with frailty receiving acute care (PROM-OPAC): a programme of development and field-testing
Authors: Oppen James van , Coats Timothy , Conroy Simon , Valderas Jose M , Mackintosh Nicola
Published: December 2022

Aims, Objectives and Background

Acute healthcare outcomes for older people living with frailty are not meaningfully measured using only service delivery metrics (time targets) or broad outcomes (mortality). This programme developed and field-tested a novel Patient Reported Outcome Measure (PROM).

Method and Design

1: To define important healthcare goals, interviews were conducted with older people living with frailty during acute care.

2: A systematic review searched for measures previously used for older people with frailty in acute settings. These measures were appraised for content validity with lay collaborators and patient participants.

3: Some areas identified in [1] had no existing measures, so novel questions were devised, improved, and reduced using co-creation and cognitive interviews with lay collaborators and patient participants.

4: The resulting questions were field-tested for feasibility and psychometric performance with a multi-site cohort of patients.

Results and Conclusion

1: Acute healthcare outcome goals were classified under Autonomy (information, security, control) and Function (physical, psychosocial, symptom relief).

2: Four existing sets of questions measuring Function were identified. EQ-5D provided the best compromise between reliability and burden.

3: There were no existing measures of Autonomy, so seven novel questions were developed and scaled.

4: When Function and Autonomy questions were tested in 128 patients, median completion time was 12 minutes and most participants required researcher assistance. Mean inter-item correlation for novel items was 0.28 with adequate response distribution. Exploratory factor analysis (Table 1) indicated a three-factor structure (RMSEA, 0.043) with good internal consistency (Cronbach’s alpha, 0.73. Range for subscales, 0.62–0.77). 35% returned a post-discharge retest.

Abstract 1357 Table 1

PROM-OPAC items and structure of factors. Responses used a five-level scale (agree strongly, agree, neither agree nor disagree, disagree, disagree strongly)

From patient interviews, the PROM-OPAC was developed to measure Autonomy (seven novel questions) and Function (EQ5D). In-hospital and follow-up collection appeared feasible, although users required support to overcome accessibility barriers. Validation in multi-site cohorts is ongoing. Potential future applications include system-level metrics, service-level quality improvement, and patient-level shared decision-making.
1502 Geospatial visualisation of emergency department attendance rates and their associations with deprivation and non-urgent attendances
Authors: Sutton-Klein Joanna , Lewis Jen , Shephard Neil , Campbell Ric , Stone Tony , O’Keeffe Colin , Mason Suzanne
Published: December 2022

Aims, Objectives and Background

Attendances at emergency departments in England continue to increase above the capacity of the urgent and emergency care system. There is significant variability in the rates of attendance at emergency departments across different localities. The aim of this study is to model the association of deprivation and non-urgent attendances with locality-based emergency department attendance rates. The secondary aim is to create an interactive data visualisation tool to engage stakeholders, clinicians, and the public with the research.

Method and Design

We undertook a retrospective, observational study using routinely collected emergency department attendance data from Yorkshire and the Humber (population 5.4 million) between January 2013 and March 2017. We calculated average annual age and sex standardised attendance rates at emergency departments for small localities known as lower layer super output areas.

The association between emergency department attendance rates, deprivation and non-urgent attendances was examined using multivariable linear and logistic regression models, which were adjusted for travel time to the nearest emergency department.

The data was visualised to create an interactive choropleth map using R.

Abstract 1502 Figure 1

Screenshot of interactive data visualisation tool showing age and sex standardised annual emergency department attendance rates in Yorkshire and the Humber

Results and Conclusion

The analytical sample included 6,389,383 attendances across 2,880 localities, with a median age and sex standardised annual emergency department attendance rate of 308 per 1000 population (interquartile range 130).

The fully adjusted linear regression model was significant (Adjusted R2 = 0.648, F (7, 2872)=757, p<0.001 ). Higher locality-based emergency department attendance rates were significantly predicted by each increasing decile of deprivation (β =14.8, p=0.002), each minute less of travel time to the emergency department (β = 7.86, p<0.001) and each percent greater proportion of low acuity attendances (β = 8.61, p<0.001).

A large proportion of the variability in emergency department attendance rates in different geographical areas can be explained by deprivation levels and proportion of non-urgent attendances. This provides an opportunity for targeted interventions to reduce emergency department attendances.
1358 The association between major trauma centre care and outcomes of adult patients injured by low falls in England and Wales
Authors: Tonkins Michael , Bouamra Omar , Lecky Fiona
Published: December 2022

Aims, Objectives and Background

Disability and death due to low falls is increasing worldwide and disproportionately affects older adults. Current trauma systems were not designed to suit the needs of these patients. This study assessed the effectiveness of major trauma centre care in adult patients injured by low falls.

Method and Design

Data were obtained from the Trauma Audit and Research Network on adult (age >16 years) patients injured by falls from <2 metres between 2017–2019 in England and Wales. Binary logistic regression and Cox Regression were used to control for casemix. 30-day survival, length of hospital stay and discharge destination were compared between major trauma centres (MTCs) and trauma units or local emergency hospitals (TU/LEHs).

Results and Conclusion

127,334 patients were included of whom 27.6% attended an MTC. The median age was 79.4 years (IQR 64.5–87.2 years), and 74.2% of patients were aged >65 years. MTC care was not associated with improved 30-day survival (adjusted odds ratio [AOR] 0.91, 95% CI 0.87–0.96). Transferred patients had a significant impact upon the results. After excluding transferred patients, the AOR for survival in MTCs was 1.056 (95% CI 1.001–1.113). The association between improved survival and MTC care was greatest in patients who suffered major trauma (AOR 1.126, 95% CI 1.044–1.215) and was absent in patients aged >65 (AOR 1.038, 95% CI 0.982–1.097).

TU/LEH care is at least as effective as MTC care due to the facility for secondary transfer from TU/LEHs to MTCs. In patients who are not transferred, MTCs are associated with greater odds of 30-day survival in the whole cohort and in the most severely injured patients. Future research must determine the optimum means of identifying patients in need of higher-level care, the components of care which improve patient outcomes, and develop patient-focused outcomes which reflect the characteristics and priorities of contemporary trauma patients.
1338 The babies kept coming and coming – Emergency department infant attendances from 2019–2021. A nation-wide electronic health records study
Authors: Aldridge Patrick , Wyatt Steve , Ross Samantha , Narayanan Sankara , Zuccolo Luisa
Published: December 2022

Aims, Objectives and Background

In 2020 limited evidence suggested increased emergency department (ED) attendances for infants in England, associated with feeding problems. We examined the frequency and distribution of infant feeding-related attendances (IFA) at EDs before and during the SARS-CoV2 pandemic.

Method and Design

All attendances at 48 major EDs (England) in two 50-week periods before and during the COVID-19 pandemic: period 1, 2 April 2019 to 10 March 2020 and period 2, 1 April 2020 to 10 March 2021. Anonymised datasets were obtained from the National Commissioning Data Repository across all age groups, with an infant defined as <1year.

We estimated the change in frequency of ED presentations by age group and diagnosis before and after the SARS-CoV2 pandemic began in England. We compared changes in the frequency of attendances of IFP by infant age, sex, ethnicity, deprivation, rurality, arrival mode, arrival time, acuity, mother’s age, gravidity and mental health, birth length of stay, attendance duration and disposal (admission or discharge). IFA was classified as feeding problems, neonatal jaundice and gastro-oesophageal reflux.

Abstract 1338 Figure 1

Results and Conclusion

Whilst total ED attendances fell by 16.7% (95% CI -16.8% to -16.6%), infant attendances increased for feeding problems (+7.5% 95% CI 2.3% to 13.0%), neonatal jaundice (+12.8%, 95% CI 3.3% to 23.3%) and gastro-oesophageal reflux (+9.7%, 95% CI 4.4% to 15.2%). These increases were more pronounced amongst first babies (+22.4%, 95% CI 13.1% to 32.5%) and brief hospital stay after birth (0–1 days, +20.1%, 95% CI 14.8% to 25.7%). Our analysis suggests many of these attendances were low acuity. Taken together, IFA presentations (figure 1) increased by 8.9% (95% CI 5.4% to 12.5%) in 2020–21.

ED attendances reduced dramatically and systematically with the COVID-19 pandemic, but infant feeding-related attendances increased. This implies growth in the unmet needs of infants and identifies future target groups for health policy.
1396 Prednisolone for Bell’s Palsy in children: A randomised, double-blind, placebo-controlled, Multicentre Trial
Authors: Babl Franz , Herd David , Borland Meredith , Kochar Amit , Lawton Ben , Hort Jason , West Adam , George Shane , Zhang Michael , Velusamy Karthik , Dalziel Stuart
Published: December 2022

Aims, Objectives and Background

Corticosteroids can be used to treat idiopathic facial paralysis (Bell’s palsy) in children, but their effectiveness is uncertain.

Aims

To determine if prednisolone improves recovery of children with Bell’s palsy at one month.

Method and Design

Double-blind, placebo-controlled, randomised, trial of prednisolone in children presenting to ED with Bell’s palsy.1Patients 6 months to <18 years, recruited <72 hours after symptom onset, were randomly assigned to receive 10 days of treatment with oral prednisolone (1 mg/kg) or placebo. The primary outcome: complete recovery of facial function at 1 month on the House-Brackmann scale.2Secondary outcomes: facial function, adverse events and pain to 6 months.

Results and Conclusion

Between October 2015 to August 2020, 187 children were randomised (94 to prednisolone and 93 to placebo) and included in the intention-to-treat analysis. At 1 month, the proportions of patients who had recovered facial function were 49% (n=43/87) in the prednisolone group compared with 57% (n=50/87) in the placebo group (risk difference -8.1%, 95% CI -22.8 to 6.7; adjusted odds ratio [aOR] 0.7, 95% CI 0.4 to 1.3). At 6 months these proportion were 99% (n=77/78) for prednisolone and 93% (n=76/82) for placebo respectively (risk difference 6.0%, 95% CI -0.1 to 12.2; aOR 3.0 95% CI 0.5 to 17.7) (figure 1). There were no serious adverse events and little evidence for group differences in secondary outcomes.

Abstract 1396 Figure 1

In children with Bell’s palsy the vast majority recover without treatment. The study does not provide evidence that early treatment with prednisolone improves complete recovery.

References

Sullivan F, Swan I, Donna P, Morrison J, Smith B, McKinstry B,et al. Early treatment with prednisolone or acyclovir in bell’s palsy.N Eng J Med2007;357(16):1598–607.

House JW, Brackmann DE. Facial nerve grading system.Otolaryngol Head Neck Surg. 1985;93(2):146–7.
Few-Shot Learning-Based Network Intrusion Detection through an Enhanced Parallelized Triplet Network
Authors: Tian Ji-Yu , Wang Zu-Min , Fang Hui , Chen Li-Ming , Qin Jing , Chen Jie , Wang Zhi-He
Published: December 2022

Network intrusion detection is one of the critical techniques to enhance cybersecurity. Several few-shot learning-based methods have recently been proposed to alleviate the dependence on large training samples in many supervised learning methods. However, it is still a challenge to achieve real-time higher-accuracy intrusion detection which is an essential requirement for high-speed network security. In this study, we propose a novel few-shot learning-based network intrusion detection method to address this challenge. Specifically, we improve the detection accuracy and real-time processing speed simultaneously in the metric procedure via two mechanisms: (i) we utilize a hard sample selection scheme as a refining stage of our triplet network model training to increase the detection accuracy; and (ii) we design a lightweight embedding network and parallelize the metric feature extraction process to achieve real-time analysis speed. To evaluate the proposed method, we construct few-shot learning-based datasets by using two real and heterogeneous network traffic intrusion detection data sources. Extensive results demonstrate that our method outperforms the state-of-the-art methods in terms of real-time performance and high detection accuracy of malicious samples.
Facing Our Ancestors
Authors: Hochadel Oliver
Published: December 2022

Paleoartists reconstruct hominids for museums, popular science magazines and other media as three-dimensional sculptures or two-dimensional images. This paper describes the practices and the self-understanding of half a dozen paleoartists, in part based on interviews. It will ask the following questions: How does one become a paleoartist, what skills and what knowledge are required? How are reconstructions of Australopithecines and Neanderthals actually manufactured? How do paleoartists deal with the notorious gaps in the fossil record? The claim for scientific rigor, the artist’s quest for creativity and the market forces, demanding visually attractive representations of early humans, are in constant tension. The paper analyses how paleoartists, paleoanthropologists (advisors) and museum curators (sponsors) interact and negotiate contested issues. It will argue that these reconstructions of hominids shape not only the perception of our ancestors of the general public but also influence the knowledge production of the human origin researchers themselves.
Iron Induces Resistance Against the Rice Blast Fungus Magnaporthe oryzae Through Potentiation of Immune Responses
Authors: Sánchez-Sanuy Ferran , Mateluna-Cuadra Roberto , Tomita Keisuke , Okada Kazunori , Sacchi Gian Attilio , Campo Sonia , San Segundo Blanca
Published: December 2022

Iron is an essential nutrient required for plant growth and development. The availability of iron might also influence disease resistance in plants. However, the molecular mechanisms involved in the plant response to iron availability and immunity have been investigated separately from each other. In this work, we found that exposure of rice plants to high iron enhances resistance to infection by the fungal pathogenMagnaporthe oryzae, the causal agent of blast disease. RNA-Seq analysis revealed that blast resistance in iron-treated rice plants was associated with superinduction of defense-related genes during pathogen infection, includingPathogenesis-Relatedgenes. The expression level of genes involved in the biosynthesis of phytoalexins, both diterpene phytoalexins and the flavonoid phytoalexin sakuranetin, was also higher in iron-treated plants compared with control plants, which correlated well with increased levels of phytoalexins in these plants duringM. oryzaeinfection. Upon pathogen infection, lipid peroxidation was also higher in iron-treated plants compared with non-treated plants. We also show thatM. oryzaeinfection modulates the expression of genes that play a pivotal role in the maintenance of iron homeostasis. Histochemical analysis ofM. oryzae-infected leaves revealed colocalization of iron and reactive oxygen species in cells located in the vicinity of fungal penetration sites (e.g. appressoria) in rice plants that have been exposed to iron. Together these findings support that ferroptosis plays a role in the response of iron-treated rice plants to infection by virulentM. oryzae.Understanding interconnected regulations between iron signaling and immune signaling in rice holds great potential for developing novel strategies to improve blast resistance in rice.
Lateral dorsal infundibular approach: an alternative option for the safe completion of difficult laparoscopic cholecystectomy
Authors: Song Juxian , Chen Jian , Zheng Shuguo
Published: December 2022

Background

Difficult laparoscopic cholecystectomy (LC) due to acute cholecystitis (AC) increases the risk of bile duct injuries and postoperative complications. Here, we added the lateral dorsal infundibular approach as an initial surgical maneuver during LC to improve outcomes.

Methods

We describe the detailed technical procedure of the lateral dorsal infundibular approach in patients with AC resulting in difficult LC. This technique was developed after nearly 10 years of experience in laparoscopic surgery, and has been routinely used in the past 5 years. We also retrospectively analyzed the perioperative data for 469 patients with difficult LC.

Results

A total of 469 patients with AC received difficult LC between July 2016 and June 2021, of which 438 (93.4%) performed a lateral dorsal infundibular approach. Sixty-four patients (13.6%) had variations of the hepatic bile duct and cystic duct according to preoperative magnetic resonance cholangiopancreatography, 438 patients (93.4%) received elective surgery, 31 (6.6%) received emergency surgery, and 10 (2.1%) underwent conversion. There was no postoperative bile leaks and no bile duct injuries in the described technique.

Conclusion

During difficult LC, the critical view of safety can be gradually achieved by changing the surgical approach to achieve cholecystectomy.
Novel compound heterozygous mutations of MTHFR Gene in a Chinese family with homocystinuria due to MTHFR deficiency
Authors: Lu Yitong , Zhao Shaozhi , He Xiaohui , Yang Hua , Wang Xiaolei , Miao Chen , Liu Hongwei , Zhang Xinwen
Published: December 2022

Background

Homocystinuria due to methylenetetrahydrofolate reductase (MTHFR) deficiency is a rare autosomal recessive disorder. The purpose of this study is to expand the mutation site of the MTHFR gene and provide genetic counseling for this family.

Methods

A couple came to our hospital for pre-pregnancy genetic counseling. We collected the family history and detailed clinical information, then performed whole-exome sequencing, and analyzed the pathogenicity of the candidate mutations.

Results

We found that the father of the proband had homocystinuria, the proband and his brother had low blood methionine levels at birth, and the brain MRI showed brain dysplasia. The third fetus was found to have a broadened triangle of the bilateral ventricle at 19 weeks of pregnancy. The compound heterozygous variants of c.602 A > C (p.His201Pro) and c.1316T > C (p.Leu439Pro) of the MTHFR gene in the first three fetuses were found by whole-exome sequencing. The heterozygous c.602 A > C variant of the MTHFR gene is a novel missense variant that has been submitted to the ClinVar with Variation ID 992,662.

Conclusion

In consideration of the clinical phenotype, family history, and result of genetic testing, we speculated that both patients may have homocystinuria due to MTHFR deficiency. Homocystinuria due to MTHFR deficiency caused by compound heterozygous mutations composed of the MTHFR gene in this family may be associated with cerebral atrophy and cerebral dysplasia. The novel compound heterozygous mutations broaden the mutation spectrum of the MTHFR gene and enhance the application of genetic counseling and carrier screening in rare diseases.
Construction and function analysis of the LncRNA-miRNA-mRNA competing endogenous RNA network in autoimmune hepatitis
Authors: Li Zhencheng , Liu Ying , Hou Yiwen , Li Zhurong , Chen Chen , Hao Huiqin , Liu Yang
Published: December 2022

Aims

To construct the lncRNA-miRNA-mRNA competing endogenous RNA (ceRNA) network based on our microarray chip data for providing new insights into the pathogenesis of autoimmune hepatitis.

Methods

The ceRNA pairs were obtained by calculating the co-expression relationships among the differentially expressed lncRNAs (DELs), differentially expressed microRNAs (DEMis), and differentially expressed mRNAs (DEMs) with Pearson correlation analysis and hypergeometric distribution. The data of the differentially expressed genes were obtained from our previous studies in the concanavalin A-induced AIH mouse model. The biological functions of the ceRNA network were revealed by carrying out the GO and KEGG enrichment analysis. The expression of some differentially expressed genes constructed in the ceRNA pair was validated, and the correlation to liver injury was analyzed.

Results

The mRNAs constructed in the ceRNA network were most significantly annotated in the GO terms of “inflammatory response” and enriched in “Cytokine-cytokine receptor interaction” and “MAPK signaling pathway”. The differences in the expression of Gm38975, mmu-miR-125a-3p, and Map3k13 between the model group and control group were significant, and the expression of these genes at a transcriptional level was positively or negatively correlated to the activity of ALT and AST as well as the amount of MDA and NO.

Conclusion

Our work is the first in its kind to predict and illustrate the comprehensive lncRNA-miRNA-mRNA ceRNA network associated with the etiopathogenesis of AIH. This study indicates to lay the foundation for revealing the potential roles of ceRNAs in the occurrence of AIH and provide novel treatment targets for this disease.
Pre-neuromusculoskeletal injury Risk factor Evaluation and Post-neuromusculoskeletal injury Assessment for Return-to-duty/activity Enhancement (PREPARE) in military service members: a prospective, observational study protocol
Authors: Butowicz Courtney M. , Hendershot Brad D. , Watson Nora L. , Brooks Daniel I. , Goss Donald L. , Whitehurst Robert A. , Harvey Alisha D. , Helton Matthew S. , Kardouni Joseph R. , Garber Matthew B. , Mauntel Timothy C.
Published: December 2022

Background

Non-battle related musculoskeletal injuries (MSKI) are one of the primary medical issues diminishing Service member medical readiness. The MSKI problem is challenging because it is difficult to assess all of the factors that increase MSKI risk and influence post-MSKI outcomes. Currently, there are no high-throughput, clinically-feasible, and comprehensive assessments to generate patient-centric data for informing pre- and post-MSKI risk assessment and mitigation strategies. The objective of the “Pre-neuromusculoskeletal injury Risk factor Evaluation and Post-neuromusculoskeletal injury Assessment for Return-to-duty/activity Enhancement (PREPARE)” study is to develop a comprehensive suite of clinical assessments to identify the patient-specific factors contributing to MSKI risks and undesired post-MSKI outcomes.

Methods

This is a phased approach, multi-center prospective, observational study (ClinicalTrials.gov number: NCT05111925) to identify physical and psychosocial factors contributing to greater MSKI risk and undesired post-MSKI outcomes, and to identify and validate a minimal set of assessments to personalize risk mitigation and rehabilitation strategies. In Phase I, one cohort (n = 560) will identify the physical and psychosocial factors contributing to greater MSKI risks (single assessment), while a second cohort (n = 780) will identify the post-MSKI physical and psychosocial factors contributing to undesired post-MSKI outcomes (serial assessments at enrollment, 4 weeks post-enrollment, 12 weeks post-enrollment). All participants will complete comprehensive movement assessments captured via a semi-automated markerless motion capture system and instrumented walkway, joint range of motion assessments, psychosocial measures, and self-reported physical fitness performance and MSKI history. We will follow participants for 6 months. We will identify the minimum set of clinical assessments that provide requisite data to personalize MSKI risk mitigation and rehabilitation strategies, and in Phase II validate our optimized assessments in new cohorts.

Discussion

The results of this investigation will provide clinically relevant data to efficiently inform MSKI risk mitigation and rehabilitation programs, thereby helping to advance medical care and retain Service members on active duty status.

Trial Registration: PREPARE was prospectively registered on ClinicalTrials.gov (NCT05111925) on 5 NOV 2021, prior to study commencement.
Pre-operative kidney biomarkers and risks for death, cardiovascular and chronic kidney disease events after cardiac surgery: the TRIBE-AKI study
Authors: Vasquez-Rios George , Moledina Dennis G. , Jia Yaqi , McArthur Eric , Mansour Sherry G. , Thiessen-Philbrook Heather , Shlipak Michael G. , Koyner Jay L. , Garg Amit X. , Parikh Chirag R. , Coca Steven G. ,   for the TRIBE-AKI Consortium
Published: December 2022

Background

Soluble tumor necrosis factor receptor (sTNFR)1, sTNFR2, and plasma kidney injury molecule-1 (KIM-1) are associated with kidney events in patients with and without diabetes. However, their associations with clinical outcomes when obtained pre-operatively have not been explored.

Methods

The TRIBE-AKI cohort study is a prospective, multicenter, cohort study of high-risk adults undergoing cardiac surgery. We assessed the associations between pre-operative concentrations of plasma sTNFR1, sTNFR2, and KIM-1 and post-operative long-term outcomes including mortality, cardiovascular events, and chronic kidney disease (CKD) incidence or progression after discharge.

Results

Among 1378 participants included in the analysis with a median follow-up period of 6.7 (IQR 4.0–7.9) years, 434 (31%) patients died, 256 (19%) experienced cardiovascular events and out of 837 with available long-term kidney function data, 30% developed CKD. After adjustment for clinical covariates, each log increase in biomarker concentration was independently associated with mortality with 95% CI adjusted hazard ratios (aHRs) of 3.0 (2.3–4.0), 2.3 (1.8–2.9), and 2.0 (1.6–2.4) for sTNFR1, sTNFR2, and KIM-1, respectively. For cardiovascular events, the 95% CI aHRs were 2.1 (1.5–3.1), 1.9 (1.4–2.6) and 1.6 (1.2–2.1) for sTNFR1, sTNFR2 and KIM-1, respectively. For CKD events, the aHRs were 2.2 (1.5–3.1) for sTNFR1, 1.9 (1.3–2.7) for sTNFR2, and 1.7 (1.3–2.3) for KIM-1. Despite the associations, each of the biomarkers alone or in combination failed to result in robust discrimination on an absolute basis or compared to a clinical model.

Conclusion

sTNFR1, sTNFR2, and KIM-1 were independently associated with longitudinal outcomes after discharge from a cardiac surgery hospitalization including death, cardiovascular, and CKD events when obtained pre-operatively in high-risk individuals. Pre-operative plasma biomarkers could serve to assist during the evaluation of patients in whom cardiac surgery is planned.
Short and long-term outcomes after off-pump coronary endarterectomy stratified by different target vessels
Authors: Fang Ying , Wei Hua , Wu Zhen , Song Wei , Liu Changcheng , Li Haiyang , Gu Chengxiong
Published: December 2022

Background

The efficacy of off-pump coronary endarterectomy (CE) has been proven in patients with diffuse coronary artery disease (DCAD). However, the clinical benefits of of-pump CE stratified by different target vessels remain controversial. This retrospective study assessed the effect of the territory and number of CE on short- and long-term outcomes of DCAD.

Methods

From January 2012 to December 2014, 246 patients undergoing off-pump coronary artery bypass grafting (OPCABG) + CE were included. The patients were grouped by the territory and number of CE. The primary endpoints were postoperative acute myocardial infarction (PMI) and long-term major adverse cardiovascular and cerebrovascular events (MACCE).

Results

Sixty-five patients (26.42%) were in the left anterior descending branch (LAD) group (CE on LAD), 134(54.47%) in the right coronary artery (RCA) group (CE on RCA), and 47(19.10%) in the multi-vessels group. PMI in the LAD group, RCA group, and multi-vessels group were 3.08%, 6.72%, and 14.89%, respectively (P = 0.08). Multi-vessels CE (OR = 9.042, 95%CI 2.198–37.193, P = 0.002), CE-plaque length ≥ 3 cm (OR = 6.247, 95%CI 2.162–18.052, P < 0.001), and type 2 diabetes mellitus (2DM) (OR = 4.072, 95%CI 1.598–10.374, P = 0.003) were independent risk factors of PMI. The long-term (mean 76 months) MACCE in the LAD group, RCA group, and multi-vessels group were 13.85%, 17.91%, and 10.64%, respectively (P = 0.552). Cox analysis indicated that PMI (HR = 7.113, 95%CI 3.129–16.171, P < 0.001) and Age ≥ 65 years (HR = 2.488, 95%CI 1.214–5.099, P = 0.013) increased the risk of long-term MACCE.

Conclusions

Multi-vessel CE and CE-plaque length ≥ 3 cm significantly increased risk of PMI after OPCABG + CE, but the territory and number of CE did not affect long-term MACCE.
Evaluation of engineered low-lignin poplar for conversion into advanced bioproducts
Authors: Lin Chien-Yuan , Geiselman Gina M. , Liu Di , Magurudeniya Harsha D. , Rodriguez Alberto , Chen Yi-Chun , Pidatala Venkataramana , Unda Faride , Amer Bashar , Baidoo Edward E. K. , Mansfield Shawn D. , Simmons Blake A. , Singh Seema , Scheller Henrik V. , Gladden John M. , Eudes Aymerick
Published: December 2022

Background

Lignocellulosic resources are promising feedstocks for the manufacture of bio-based products and bioenergy. However, the inherent recalcitrance of biomass to conversion into simple sugars currently hinders the deployment of advanced bioproducts at large scale. Lignin is a primary contributor to biomass recalcitrance as it protects cell wall polysaccharides from degradation and can inhibit hydrolytic enzymes via non-productive adsorption. Several engineering strategies have been designed to reduce lignin or modify its monomeric composition. For example, expression of bacterial 3-dehydroshikimate dehydratase (QsuB) in poplar trees resulted in a reduction in lignin due to redirection of metabolic flux toward 3,4-dihydroxybenzoate at the expense of lignin. This reduction was accompanied with remarkable changes in the pools of aromatic compounds that accumulate in the biomass.

Results

The impact of these modifications on downstream biomass deconstruction and conversion into advanced bioproducts was evaluated in the current study. Using ionic liquid pretreatment followed by enzymatic saccharification, biomass from engineered trees released more glucose and xylose compared to wild-type control trees under optimum conditions. Fermentation of the resulting hydrolysates using Rhodosporidium toruloides strains engineered to produce α-bisabolene, epi-isozizaene, and fatty alcohols showed no negative impact on cell growth and yielded higher titers of bioproducts (as much as + 58%) in the case of QsuB transgenics trees.

Conclusion

Our data show that low-recalcitrant poplar biomass obtained with the QsuB technology has the potential to improve the production of advanced bioproducts.