Future Cases Research Articles

BN SO54 - Complex Management of a Gastrocutaneous Fistula Following Pancreatic Necrosectomy: A Case Report

Abstract Background Gastrocutaneous fistulas are rare but serious complications that can arise following the surgical treatment of necrotizing pancreatitis. This post-operatory complication can be refractory to conservative management and may be further aggravated by severe skin injuries and malnutrition. This case report describes the comprehensive and multidisciplinary approach of a challenging case of gastrocutaneous fistula, ultimately requiring re-intervention. Method A 78-year-old female with a history of severe necrotizing pancreatitis underwent pancreatic necrosectomy by laparotomy. Postoperatively, she developed a gastric fistula, initially repaired with a double-layered suture. Recurrence led to a gastrocutaneous fistula with continuous gastric drainage and chemical burn of the surrounding skin. Initial conservative management included insertion of a nasogastric tube for gastric decompression, followed by placement of a PEG tube to redirect the drainage and prevent further skin damage and an esophagojejunal feeding tube to bypass the fistula and maintain nutrition. Nevertheless, the fistula persisted, resulting in significant skin erosion and deterioration of the patient’s condition. Results Given the failure of conservative measures and a concurrent diagnosis of a pancreatic fistula, a surgical approach was deemed necessary. The patient was transferred to a specialized hospital center, where she underwent fistulectomy with partial gastrectomy and wound closure. Negative pressure wound therapy (NPWT) was applied to the ulcerated skin to promote healing. This approach led to the successful closure of the gastrocutaneous fistula and healing of the skin wound. The patient showed marked clinical recovery, with no signs of infection or fistula recurrence and the nutritional status was successfully managed through enteral feeding leading to a notable functional recovery. Conclusion This case underlines the complexity of managing gastrocutaneous fistulas, demonstrating the efficacy of combining surgical and supportive therapies, serving as a reference for similar future cases and emphasizing the need for comprehensive management strategies for complex postoperative complications.

Gabapentinoids and Risk of Hip Fracture

ImportanceThe increased use of gabapentinoids has been most pronounced in older people who are also susceptible to hip fractures.ObjectiveTo investigate the overall association between gabapentinoids and the risk of hip fractures and the stratified association across age groups, frailty status, and history of chronic kidney disease.Design, Setting, and ParticipantsThis was a case-case-time-control study in patients hospitalized for hip fracture in Victoria, Australia, between March 1, 2013, and June 30, 2018, with at least 1 prescription for a gabapentinoid before fracture. Conditional logistic regression was used to estimate the odds ratio (OR) and 95% CI for gabapentinoid dispensing in the index (1-60 days prefracture) compared with the reference (121-180 days prefracture) period. To adjust for the underlying time trend in gabapentinoid use, each index case was matched with up to 5 controls, selected from future cases of the same age and sex. Subgroup analyses were conducted in subgroups with or without chronic kidney disease (CKD), frailty scores less than 5, and frailty scores 5 and above. Frailty was computed using the Hospital Frailty Risk Score (HFRS). Data were analyzed from November 2023 to April 2024.ExposureGabapentinoids (pregabalin or gabapentin).Main Outcome and MeasureHip fracture.ResultsOf 28 293 patients hospitalized for hip fractures, 2946 (1752 [59.5%] aged ≥80 years; 2099 [71.2%] female) were dispensed a gabapentinoid before hip fracture. Gabapentinoid dispensing was associated with increased odds of hip fractures (OR, 1.96; 95% CI, 1.66-2.32). After adjusting for the exposure-time trend and concomitant use of other central nervous system medications, the odds of hip fractures remained elevated (OR, 1.30; 95% CI, 1.07-1.57). The association between gabapentinoid dispensing and hip fracture was higher in patients with HFRS 5 and above (OR, 1.75; 95% CI, 1.31-2.33) and CKD (OR, 2.41; 95% CI, 1.65-3.52).Conclusions and relevanceIn this case-case-time-control study of Australian residents hospitalized for hip fracture, gabapentinoid use was associated with an increased risk of hip fractures, especially in patients who were frail or had chronic kidney disease. In addition to the known risk associated with kidney impairment, frailty status may be an important risk factor when considering use of gabapentinoids.

Evapotranspiration Estimation with the Budyko Framework for Canadian Watersheds

Actual evapotranspiration (AET) estimation plays a crucial role in watershed management. Hydrological models are commonly used to simulate watershed responses and estimate AET. However, their calibration heavily depends on station-based data, which is often limited in availability and frequently inaccessible, making the process challenging and time-consuming. In this study, the Budyko model framework, which effectively utilizes remote sensing data for hydrological modeling and requires the calibration of only one parameter, is adopted for AET estimation across Ontario, Canada. Four different parameter estimation methods were developed and compared, and an attribution analysis was also conducted to investigate the impacts of climate and vegetation factors on AET changes. Results show that the developed Budyko models performed well, with the best model achieving a Nash-Sutcliffe Efficiency (NSE) value of 0.74 and a Root Mean Square Error (RMSE) value of 55.5 mm/year. The attribution analysis reveals that climate factors have a greater influence on AET changes compared to vegetation factors. This study presents the first Budyko modeling attempt for Canadian watersheds. It demonstrates the applicability and potential of the Budyko framework for future case studies in Canada and other cold regions, providing a new, straightforward, and efficient alternative for AET estimation and hydrological modeling.

Ask Me

In this poster, we share ongoing research into the use of realistic AI-generated avatars for education in a large Australian business school. These highly realistic avatars have been used as educational presenters to provoke critical discussions on ethical AI by immersing students in text-to-video technology (Vallis et al., 2024). From this initial study, an emergent typology for avatars in educational media has been developed, to help educators design for teaching and learning based on learning purposes and modes of delivery Britton & Vallis, 2023; Vallis & Britton, 2024). Such practical, theoretical guidance in designing, developing, and deploying AI in education is much needed (Dawson et al., 2023). Drawing upon learnings to date, we further explore synthetic media designs for effective and ethical use in education. The poster presents three use cases of synthetic media with QR codes to demonstrate their application and to facilitate discussion at the conference. An additional fourth QR code will be added to gather participant feedback on which use case they found most compelling and educational, as well as their reasons for their preferences. The first use case explores short video presentations, where synthetic media offers students a choice of accents, voices, and faces to present educational content (Dao et al., 2021). This approach aims to free teacher time for more learner guidance and communication, potentially enhancing learning outcomes. Video-based learning can enhance student engagement and understanding by providing flexible, interactive, and visually stimulating experiences (Sabli? et al., 2021). The second use case is ‘Ask me’, a trial of a realistic avatar that answers frequently asked questions. Multimodal AI, like GPT-4o, with integrated voice, video, and audio capabilities, can simulate real-world scenarios for educational scenarios with engaging and realistic experiences (Mollick & Mollick, 2023). Future use cases may include specific learning activities such as role-play and rehearsal. Multimodal feedback on student progress is presented in the third use case. A lifelike digital representation of a teacher has been designed to closely mimic a real human teacher’s appearance and expressions. Simple video feedback, generated based on student interactions with university systems and combined with a teacher’s text, is sent via email to enhance engagement. This trial is designed to augment feedback, rather than replace interaction between students and teachers (Bozkurt & Sharma, 2023). By presenting these use cases, we aim to provide practical insights and stimulate discussions on the ethical and effective use of synthetic media in education. Our preliminary findings indicate benefits to using AI-generated avatars, if the ethical implications and the quality of human-AI interactions are carefully considered in the learning design (Vallis et al., 2024).

Dementia risk reduction in the African context: Multi-national implementation of multimodal strategies to promote healthy brain aging in Africa (the Africa-FINGERS project).

Dementia prevention in Africa is critically underexplored, despite the continent's high prevalence of modifiable risk factors. With a predominantly young and middle-aged population, Africa presents a prime opportunity to implement evidence-based strategies that could significantly reduce future dementia cases and mitigate its economic impact. The multinational Africa-FINGERS program offers an innovative solution, pioneering culturally sensitive, multidomain interventions tailored to the unique challenges of the region. Leveraging insights from landmark global studies such as Worldwide-FINGERS and Alzheimer's Disease Neuroimaging Initiative, the program employs a multideterminant precision prevention framework, grounded in community based systems dynamics. Africa-FINGERS further integrates cutting-edge state-of-the-art multimodal biomarker evaluations tailored to regional contexts, with the goal of advancing brain health and establishing a global standard for dementia prevention. This groundbreaking initiative highlights the potential for scalableand sustainable interventions, thus is poised to transform dementia risk reduction efforts across the continent. HIGHLIGHTS: Dementia rates are escalating in Africa, largely due to longer life spans and increased prevalence of modifiable risk factors. Yet, few regional interventions have directly targeted lifestyle factors to reduce dementia risk. The multinational Africa-FINGERS study will address this gap by adapting the successful FINGERS lifestyle intervention to African populations. Africa-FINGERS will pioneer a culturally informed, multidomain dementia risk reduction intervention in the African region through feasibility dementia prevention trials in rural and urban sites across Kenya and Nigeria in the first instance, enrolling 600 at-risk adults (≥ 50 years). The program adoptsparticipatory research methods to develop culturally appropriate interventions and build infrastructure to evaluate dementia biomarkers from ante and post mortem samples. A cost-effectiveness analysis will be conducted to guide the strategic implementation of Africa-FINGERS into regional health systems. The Africa-FINGERS strategy aligns with the Worldwide-FINGERS framework and integrates the global Alzheimer's Disease Neuroimaging Initiative approach, emphasizing multimodal analysis.

The Energy Charter Treaty: Letting the sun set on sunset clauses

AbstractThis article focuses on the sunset clause of the Energy Charter Treaty (ECT). The ECT is a multilateral investor‐state arbitration treaty which allows for the use of investor‐state dispute settlement (ISDS) tribunals to arbitrate challenges arising from shifts in energy policy that lead to a loss in profits for relevant energy companies. The treaty has become controversial as climate activists have alleged it is slowing down efforts to transition away from fossil fuels. Withdrawal from the ECT does not necessarily solve the alleged issues as the treaty contains a sunset clause, allowing for the provisions of the ECT to remain in force for 20 years post withdrawal. This article seeks to analyse various mechanisms and strategies for neutralising the sunset clause as part of a wider effort to ensure the ECT does not interfere with the phasing out of fossil fuels. It will be argued that such neutralisation should be possible through the use of Article 62 of the Vienna Convention on the Law of Treaties (VCLT), on the basis that there has been a fundamental change in circumstances since the inception of the treaty. This use of the rebus sic stantibus doctrine can be justified on the basis that a swift and substantial transition away from fossil fuels is now required to ensure states can meet their obligations under the Paris Agreement. This article will also explore alternatives to an Article 62 VCLT argument (i.e. a fundamental change in circumstances) that could nonetheless achieve the primary goal of ensuring that states are not bound to a pro fossil‐fuel treaty. Examples of alternatives include the insertion of a climate carve‐out to remove protections from investments that hinder climate action or the use of the defence of necessity in future ECT arbitration cases to argue that the state should not remain bound to the sunset clause. Regardless of whichever scenario is pursued by states, the article seeks to highlight that any and all efforts must be made to neutralise the sunset clause to ensure there is no interference with necessary efforts to pursue climate action.

Identification and differentiation of somapacitan, a long-acting growth hormone derivative, and recombinant human growth hormone in equine plasma by LC-HRMS for doping control purpose

Somapacitan, a long-acting growth hormone derivative, and recombinant human growth hormone (rhGH) are protein-based drugs generally used to treat growth disorders and GH deficiency in humans. Due to their potential to enhance the horse performance, the use of these drugs is prohibited at-all-times by the International Federation of Horseracing Authorities for horseracing and the Fédération Equestre Internationale for equestrian sports. In this study, we developed a test method for the identification and differentiation of somapacitan and rhGH in equine plasma by using liquid chromatography high-resolution mass spectrometry (LC–HRMS). The method involved C4 solid-phase extraction after ammonium sulfate precipitation, followed by chloroform/methanol precipitation, trypsin digestion, and analysis by LC-HRMS. The discriminative identification of somapacitan and rhGH was successfully achieved through the detection of their respective unique T10 peptide fragments. Noteworthy, the T10 peptide fragment of somapacitan was detected with its side chain structure remaining intact. The limit of identification (confirmation) (LOI) was determined to be 5 ng/mL for somapacitan and 2 ng/mL for rhGH in equine plasma, while the limit of detection (LOD) was 5 ng/mL for somapacitan and 1 ng/mL for rhGH. Furthermore, using the peptide fragments T1, T8, and T9 (which are shared between somapacitan and rhGH), the presence of somapacitan in equine plasma could be confirmed with higher sensitivity, achieving down to LOIs of 2 ng/mL and LODs of 1 ng/mL. The method was validated with respect to specificity, identification capability, robustness, precision, and reproducibility, paving the way for the analysis of post-administration samples from our already planned administration trials and future potential positive cases.

New ways of collecting urban freight traffic data and applications for urban freight policies and research

The current quality of data on urban logistics traffic patterns is poor. Data are scarce, heterogeneous, often old and expensive to collect. This research looks at new ways to collect urban freight data and make that data available to both policy-makers and academia. Three case studies are examined: Rotterdam, the Netherlands; Brussels, Belgium; and Barcelona, Spain. They help identify new sources of data from traffic and parking policies: automated number plate recognition cameras, an on-street delivery smartphone app, and a truck pricing scheme. Both the context in which new data sources of interest to urban logistics are produced, and the level of appropriation of these data by local stakeholders and the research community are examined. We then construct an analysis grid to evaluate the diversity of systems (technical and socio-technical) producing data relevant to urban logistics. This analysis framework can be used to facilitate comparisons between data sources and thus help future case studies. In the three cases, we found that local governments use the data more than researchers do. The issue of data dissemination raises questions about costs (who is to bear the cost of storing, maintaining and extracting data sets?) as well as regulatory questions. We conclude that local administrations should be encouraged to work towards harmonizing data collection methods and data sharing conditions in order to improve the quality and comparability of the data. Cities in countries with little access to new sources of data, such as France for regulatory reasons, should try to find ways to create data source opportunities. In all countries, urban freight research communities should be encouraged to use the now increasingly available data.

A conceptual framework for digital health marketing strategies to enhance public health outcomes in underserved communities

This paper proposes a conceptual framework for integrating digital health marketing strategies with public health initiatives to enhance healthcare access and outcomes in underserved communities. The framework focuses on leveraging digital marketing tools such as social media, mobile applications, email campaigns, and search engine optimization to disseminate critical health information, promote preventive measures, and engage communities in healthier behaviors. It addresses the persistent challenges faced by underserved populations, including limited healthcare access, low health literacy, and cultural barriers, by utilizing the accessibility and broad reach of digital channels. The proposed framework incorporates three core components: (1) Health Information Dissemination, which explores the use of targeted digital campaigns to provide culturally relevant and accessible health education; (2) Community Engagement, which leverages interactive platforms such as social media and mobile apps to foster participation in preventive healthcare initiatives and healthy lifestyle practices; and (3) Behavioral Change Promotion, which emphasizes using digital tools to influence health behaviors through personalized messaging, reminders, and virtual support groups. By integrating digital marketing strategies into public health programs, the framework aims to improve healthcare outcomes by increasing awareness of preventive measures, enhancing early diagnosis, and promoting disease management. It also underscores the role of data analytics in refining outreach efforts by identifying specific health needs, tracking engagement, and measuring the effectiveness of interventions. This conceptual framework holds promise for healthcare providers, policymakers, and digital marketers seeking to enhance public health outcomes in underserved communities. It provides a structured approach to combining the strengths of digital marketing with public health goals, creating more inclusive, accessible, and effective health interventions. Future research and case studies can build on this model to refine digital health marketing strategies and assess their long-term impact on public health in underserved populations.

10.F. Skills building seminar: How public health professionals can use the right to health to advance climate action and justice

Abstract The climate crisis is the single biggest threat to global health, peace and security, a crisis multiplier, and a significant driver of health inequalities. In many areas of public health policy, legal action and litigation have delivered significant and long-lasting impacts. In April 2024, the European Court of Human Rights concluded that Switzerland had violated the right to health of older women in Switzerland by failing to meet its past greenhouse gas (GHG) emissions reduction targets and set future GHG targets. State-of-the-art public health evidence provided by the Intergovernmental Panel on Climate Change and Lancet Countdown on Health and Climate Change were vital to the Court’s decision, which has implications for all Council of Europe member states, and globally. Rigorous scientific evidence of health harms, including but not limited to heat stress, can inform other climate litigation grounded in the right to health. Public health researchers and practitioners are essential to this litigation. In recognition of this emerging role, in November 2023 the Faculty of Public Health (UK) and the Aletta Jacobs School of Public Health launched ‘From analysis to action: climate change litigation. A guide for public health professionals’ at the 16th European Public Health Conference. The guide was also endorsed by ASPHER, ASPPH, EUPHA, Global Consortium on Climate and Health Education, Global Network for Academic Public Health, Lancet Countdown, Public Health Ethics and Law Global Network, and WFPHA. This workshop will familiarise participants with recent rights-based climate litigation and explore the role of public health professionals in identifying, collecting, storing, assessing and presenting this evidence in a form that is accessible to court officials without medical training. First, there will be short presentations on 1) the role of the law in climate action and the role of scientific evidence of health harms in human rights litigation, and 2) How to collect and use scientific evidence of health harms in climate litigation (15 minutes). Small group discussions will follow, addressing questions such as: The health harm of climate change-related heat stress was a major factor in the 2024 decision of the European Court of Human Rights in KlimaSeniorinnen v. Switzerland: What other health harms could support future cases? In what population groups? What opportunities do you see today for public health researchers and practitioners to compile such evidence to make the most compelling case? How can public health researchers and practitioners work more closely with legal experts and affected communities to bring this evidence to court? (20 minutes) The workshop will conclude with a plenary discussion of these questions and the small group responses. (25 minutes) As a result of the workshop, participants will be better prepared to identify opportunities to contribute compelling evidence of health harms in climate litigation. Key messages • Rigorous scientific evidence of climate change-related health harms is proving central to success in rights-based climate litigation. • Public health professionals have a key role in identifying and presenting compelling evidence of health harms in climate litigation. Speakers/Panelists David Patterson University of Groningen, Groningen, Netherlands Farhang Tahzib Faculty of Public Health, Haywards Heath, UK

Systematic review of thyroid function in NKX2-1-related disorders: Treatment and follow-up.

NKX2-1, a crucial transcription factor in thyroid, lung, and brain development, is associated with rare disorders featuring thyroid dysfunction, neurological abnormalities, and respiratory symptoms. The primary challenge in managing NKX2-1-related disorders (NKX2-1-RD) is early diagnosis of the genetic defect and treating specific endocrine disorders. Levothyroxine (LT4) serves as the standard hypothyroidism treatment, with required dosages influenced by the severity of the individual's disorder, which varies widely among affected individuals. This systematic review aims to assess the effectiveness of LT4 treatment in NKX2-1-RD and explore optimal dosing strategies. The primary focus is on the challenges associated with the prompt diagnosis of genetic defects, rather than the established treatment protocols for individual endocrine failures. Adhering to PRISMA guidelines, the review includes 42 studies involving 110 genetically confirmed NKX2-1-RD patients with hypothyroidism. The study investigates congenital hypothyroidism as the most prevalent endocrine alteration, along with gestational and overt hypothyroidism. The administration of LT4 treatment, dosages, and patient responses are analyzed. Among the findings, congenital hypothyroidism emerges as the predominant endocrine alteration in 41% of patients. Notably, LT4 treatment is administered in only 10% of cases, with a mean dose of 52 μg/day. The variability in initiation and dosage is likely influenced by the age at diagnosis. Positive responses, characterized by TSH adjustments within normal ranges, are observed in 11 monitored patients. Early detection of congenital hypothyroidism is emphasized for timely LT4 initiation. Challenges in standardization are highlighted due to the variability in clinical manifestations and diagnostic procedures across NKX2-1-RD cases. While this review provides valuable insights into thyroid and pituitary disease treatment, limited details on LT4 treatment represent a significant study limitation. Key reporting points for future case studies are proposed to enhance the understanding and management of NKX2-1-RD hypothyroidism.

From Gross Disproportionality to Human Dignity: Redefining Section 12 in the Context of Mandatory Minimum Sentences

In this short paper, we contend that human dignity must remain at the heart of the section 12 analysis, and should be strengthened in future cases that will be tackling the remaining mandatory minimums. In so doing, we critically examine the Supreme Court’s recent development of the section 12 framework, particularly in light of the 2023 mandatory minimum jurisprudence, with a specific emphasis on the concept of human dignity. The analysis centers on the role of reasonable hypotheticals in advancing the primary objective of section 12 — safeguarding human dignity — by scrutinizing the three pivotal components of the gross disproportionality analysis. We suggest that the section 12 analysis focuses on proportionality and human dignity rather than the current “gross disproportionality” standard in assessing what constitutes cruel and unusual punishment. These suggestions are underpinned by an approach that considers proportionality a principle rooted in human dignity. Nevertheless, proportionality has its limits and therefore section 12 should be complemented by an approach that takes into account prison conditions and the effects of imprisonment on marginalized groups, which are rooted in inequalities. Finally, the analysis questions the third component of the gross disproportionality analysis, which calls for deference to the legislature in order to prioritize objectives that instrumentalize the individual and are contrary to human dignity. These objectives are problematic, we suggest, and best addressed within section 1 of the Charter.

Subcutaneous panniculitis-like T-cell lymphoma (SPTCL) in a 15-Year-old male presenting with orofacial Swelling

BackgroundSubcutaneous panniculitis-like T-cell lymphoma (SPTCL) is a rare form of non-Hodgkin lymphoma that primarily affects subcutaneous tissues. Its occurrence in the orofacial region is exceptionally uncommon, presenting diagnostic challenges due to symptom overlap with more prevalent orofacial condition.Case presentationThis report details the case of a 15-year-old male who presented with persistent left-sided facial swelling, initially misdiagnosed as facial cellulitis. Diagnostic complexity arose from the similarity of symptoms to common orofacial diseases. Comprehensive diagnostic approaches, including liquid-based thin-layer cytometry, immunohistochemistry, and advanced imaging, were pivotal in identifying SPTCL. The recurrence of symptoms following the cessation of dexamethasone treatment indicated hormone dependency. Surgical intervention and subsequent histopathological analysis confirmed SPTCL, with immunohistochemical profiling playing a critical role in the definitive diagnosis. The patient’s management involved a multidisciplinary approach, leading to a referral to a hematology specialist and subsequent favorable outcomes.ConclusionsThis case underscores the diagnostic challenges of orofacial lymphomas such as SPTCL and highlights the necessity for early, accurate pathological diagnosis. It emphasizes the role of advanced diagnostic techniques and the importance of a comprehensive, multidisciplinary approach in the management of such rare cases. This report contributes to the limited but growing body of literature on SPTCL in the orofacial region, providing insights for clinicians in similar future cases.

The road (not) taken: implications of health-focused arguments for rights-based climate change litigation in Europe

ABSTRACT Rights-based climate change litigation has become central to advancing mitigation ambition across the globe. This article analyses trends in legal argumentation in such litigation at the supranational level and identifies two principal arguments commonly employed by litigants: the adverse effects of climate change on human health or culture. The study reveals that claims based on the European Convention on Human Rights (ECHR) almost exclusively engage with health-based arguments, while culture-based arguments are more prevalent in cases brought under the International Covenant on Civil and Political Rights and the American Convention on Human Rights. Various factors are explored to elucidate the reason for this distinction, including the types of applicants, the absence of an explicit right to culture in the ECHR, the European Court of Human Rights’ earlier environmental jurisprudence, and perceptions of justiciability. In doing so, the analysis sheds light on the potential implications of the differing approaches to rights-based climate change litigation before the European Court of Human Rights. This includes the Court’s landmark judgment in Verein KlimaSeniorinnen and others v Switzerland as well as implications for future cases. This research offers critical insights on the strategic direction of rights-based climate change litigation, including its possible limitations.

Environmental Conditions Associated with Four Index Cases of Pacific Oyster Mortality Syndrome (POMS) in Crassostrea gigas in Australia Between 2010 and 2024: Emergence or Introduction of Ostreid herpesvirus-1?

Warm water temperature is a risk factor for recurrent mass mortality in farmed Pacific oysters Crassostrea gigas caused by Ostreid herpesvirus-1, but there is little information on environmental conditions when the disease first appears in a region—the index case. Environmental conditions between four index cases in Australia (2010, 2013, 2016 and 2024) were compared to provide insight into possible origins of the virus. Each index case was preceded by unusually low rainfall and higher rates of temperature change that could increase oyster susceptibility through thermal flux stress. Water temperature alone did not explain the index cases, there being no consistency in sea surface, estuary or air temperatures between them. Tidal cycles and chlorophyll-a levels were unremarkable, harmful algae were present in all index cases and anthropogenic environmental contamination was unlikely. The lack of an interpretable change in the estuarine environment suggests the recent introduction of OsHV-1; however, viral emergence from a local reservoir cannot be excluded. Future events will be difficult to predict. Temperature flux and rainfall are likely important, but they are proxies for a range of undetermined factors and to identify these, it will be necessary to develop comprehensive protocols for data acquisition during future index cases.

Sputum and tongue swab molecular testing for the in-home diagnosis of tuberculosis in unselected household contacts: a cost and cost-effectiveness analysis.

Delayed and missed diagnosis are a persistent barrier to tuberculosis control, partly driven by limitations associated with sputum collection and an unmet need for decentralized testing. Household contact investigation with point-of-care testing of non-invasive specimens like tongue swabs are hitherto undescribed and may be a cost-effective solution to enable community-based active case finding. In-home, molecular point-of-care testing was conducted using sputum and tongue specimens collected from all household contacts of confirmed tuberculosis cases. A health economic assessment was executed to estimate and compare the cost and cost-effectiveness of different in-home, point-of-care testing strategies. Incremental cost effectiveness ratios of strategies utilizing different combination testing algorithms using sputum and/or tongue swab specimens were compared. The total implementation cost of delivering the standard of care for a 2-year period was $84 962. Strategies integrating in-home point-of-care testing ranged between $87 844 - $93 969. The cost-per-test for in-home, POC testing of sputum was the highest at $20·08 per test. Two strategies, Point-of-Care Sputum Testing and Point-of-Care Combined Sputum and Individual Tongue Swab Testing were the most cost-effective with ICERs of $543·74 and $547·29 respectively, both below a $2,760 willingness-to-pay threshold. An in-home, point-of-care molecular testing strategy utilizing combination testing of tongue swabs and sputum specimens would incur an additional 10.6% program cost, compared to SOC, over a 2-year period. The increased sample yield from tongue swabs combined with immediate result notification following, in-home POC testing would increase the number of new TB cases detected and linked to care by more than 800%. Evidence before this study: We searched PubMed for original research published between January 1, 1950 and June 30, 2024 that evaluated the cost-effectiveness of in-home POC molecular testing, as part of HCI strategies for tuberculosis. PubMed search terms used included ["household contact investigation" OR "household contact tracing"] AND "tuberculosis" AND "cost-effectiveness". The search revealed 8 studies, of which one was removed as HCIs were leveraged for the provision of short course preventative therapy and not tuberculosis testing. None of the studies were conducted in South Africa. All seven remaining studies relied on a hub-and-spoke model of sputum collection and transportation with sputum tested at a centralized laboratory facility. Although active case finding strategies like HCIs are endorsed by the WHO to improve early case detection and treatment initiation, limited research has been done to assess its cost-effectiveness in low- and middle-income countries.Added value of this study: To our knowledge, this is the first example of in-home molecular point-of-care (POC) testing as part of HCI. The use of primary data to estimate and compare the incremental cost effectiveness of different combination, in-home testing strategies utilizing alternative sample types equips policy makers with a selection of strategy options to choose from. The tradeoff between sample types with high collection yield and those with increased accuracy becomes evident in the economic analysis, highlighting the need to consider both yield and accuracy in effective clinical decision making and use-case development. The success of in-home, POC tongue swab testing of all contacts, irrespective of symptom presentation shows great promise for universal testing programs.Implications of all available evidence: Results from our economic modeling provide evidence in support for the integration of in-home, POC tuberculosis (TB) testing during HCI. The use of less invasive tongue swab samples to increase sample yield in the absence of sputum expectoration highlights the value of combination testing strategies. Immediate result notification resulting from rapid, in-home POC testing shows great promise for increasing early case detection and improving treatment uptake. In-home, POC testing strategies, when incorporated into HCI could curb ongoing community transmission and reduce the overall burden of TB. Considerations for adopting novel POC testing strategies in future active case finding programs like HCI should strongly be considered. We evaluated the cost-effectiveness of in-home, point-of-care TB testing of household contacts. The findings indicate that combined testing strategies using tongue swab and sputum specimens could significantly increase TB case detection, with modest additional program costs.

ALK1-negative Epithelioid Histiocytoma

Abstract Introduction/Objective We present a case of epithelioid histiocytoma (EH). The epithelioid nature of this lesion imitates the appearance of neoplastic lesions such as melanocytic, dermatofibroma/histiocytoma, non-Langerhans histiocytosis such as reticulohistiocytoma, atypical fibroxanthoma, and rhabdomyosarcoma. Methods/Case Report Due to the unusual morphology and aberrant immunohistochemical staining pattern of this specific case, the sample was analyzed through Next Generation Sequencing (NGS), which showed the presence of a fusion of genes Sequestosome 1 (SQSTM1) and Anaplastic lymphoma kinas (ALK). SQSTM1 gene produces proteins involved in signal transduction pathways as well as autophagy, while ALK mainly serves the role of cellular communication and development. The most well-known ALK fusion partners include SQSTM and Vinculin (VCL), while there are other fusion partners that were more recently discovered such as Dynactin Subunit 1 (DCTN1) and ETS variant transcription factor 6 (ETV6). The spectrum of neoplasms produced through these fusions is wide as seen in lung adenocarcinoma and renal cell carcinoma (EML4-ALK), epithelioid histiocytoma (SQSTM1-ALK and VCL- ALK), pediatric renal cell carcinoma (VCL-ALK) among others. Results (if a Case Study enter NA) NA Conclusion We hope this case is a helpful addition to the literature to further aid diagnoses of future ALK fusion cases.

UNDERSTANDING THE MANAGEMENT OF MALIGNANT GLIOMAS DURING COVID-19 PANDEMIC IN A HIGH VOLUME TERTIARY GOVERNMENT HOSPITAL IN THE PHILIPPINES

Abstract AIMS Malignant glioma is a common primary brain tumor with a great burden of disease. When COVID-19 set in, it became a challenge to manage an already difficult treatment process in low-resource-setting centers. Despite this, conventional recommendations and standard treatment protocols are followed. However, outcomes were perceived to deviate from the convention, hence the reason for this study which is to understand the nature of outcomes in the management of malignant gliomas during the COVID-19 pandemic in Southern Philippines Medical Center (SPMC), the largest government tertiary hospital in the Philippines. METHOD A retrospective chart review of nine clinically and histologically diagnosed cases of malignant gliomas admitted in SPMC between April 2020 to September 2021 was performed. The clinical presentations, image correlation, and outcomes were listed. Then, classified as desirable, undesirable but acceptable, or unacceptable based on factors identified. Qualitative analysis by deduction including outcomes determining possible modifications in treatment of future cases was done. RESULTS Of the nine cases, one was listed as desirable, one with unacceptable outcome due to management complications, and the rest were labeled as undesirable but acceptable either because of advanced disease or poor KPS score. Three major factors were determined: the roles of pre-hospital and initial treatment delays, the decision for surgical treatment, and the COVID-19 pandemic. CONCLUSION The shift in the outcomes of malignant gliomas during COVID-19 shows the management challenge in low resource centers. There is an increase in highly malignant cases with guarded prognosis due to lack of education, support, and resources in terms of early diagnosis, treatment, and post-surgical care. This was aggravated by the restrictions imposed by the pandemic and financial crisis, especially for patients below the poverty line. Delays in management show a significant influence on prognosis regardless of treatment. As such, possible modifications in the current treatment algorithm are hereby recommended.

“Sweet” detectives: children crack the case for a healthy future

To coincide with British Science Week, we ran an outreach activity in March 2024 with several year 5 and 6 (ages 9–11) classes at Whitehall Park School in Islington, London. Cases of type 2 diabetes are on the increase in children, so we wanted to raise awareness of diabetes and discuss the importance of healthy living as prevention. We also wanted to promote the work of scientists and show the diversity of those working in science, technology, engineering and mathematics disciplines. We did this through a range of accessible, fun hands-on interactive activities such as getting children to play the role of scientists to test the sugar content of popular soft drinks. Through these activities and by collecting feedback, we learnt how much children already knew about healthy living and diabetes and recorded how much they learnt from doing our activity. Children said they enjoyed the activity, and we received positive feedback from teachers. This feedback will help inform our future diabetes research and improve our communications with the public and local communities. Due to the success of these activities, we plan to take them to more schools across London in the near future.

Cervical osteomyelitis in the setting of multiple comorbidities: a complex anatomical approach. Illustrative case.

Vertebral osteomyelitis (VO), also known as spinal osteomyelitis or spondylodiscitis, is a rather rare yet serious disease comprising 3%-5% of all osteomyelitis cases, with only 3%-6% of this subset affecting the cervical spine. Risk factors include an advanced age, diabetes, immunosuppression, and intravenous (IV) drug use. The incidence of VO has increased over recent decades, with high-risk patients experiencing higher mortality rates. Treatment guidelines for VO are not standardized and rely on physician preference, often starting with IV antibiotics and progressing to surgery, if necessary. A 54-year-old female with tracheostomy-dependent obesity hypoventilation syndrome, hypertension, and morbid obesity presented with upper back pain after a fall. Imaging revealed early C6-7 discitis osteomyelitis, which was initially managed conservatively with IV antibiotics. Her condition worsened, leading to anterior corpectomy of C6-7, followed by posterior cervical fusion from C5 to T2 in the sitting position. This approach was chosen due to the patient's complex anatomy and tracheostomy. This case underscores the need for unique surgical approaches in high-risk patients with complex anatomy. It highlights the importance of interdisciplinary care when managing VO, especially in patients with multiple comorbidities. Given the increasing rates of morbid obesity, this case provides valuable insights for neurosurgical decision-making in similar future cases. https://thejns.org/doi/10.3171/CASE24448.