Review of a paediatric inflammatory bowel disease service during the pandemic and the impact of the CNS role.

BACKGROUND: Inflammatory bowel disease (IBD) is a chronic relapsing and remitting condition. The COVID-19 pandemic has severely disrupted provision of medical care across the world. IBD clinical nurse specialists (CNSs) played a pivotal role in the care of children with IBD during the pandemic national lockdown and in the recovery phase. This article aims to look at the impact of COVID-19 on the paediatric IBD service in one children's hospital and the effect on the IBD CNSs' workload. METHOD: A retrospective review of clinical notes and the service's IBD database from January 2019 to September 2020. RESULTS: There was a significant increase in the number of email and telephone contacts to the IBD CNS team during lockdown. There was an increase in virtual clinics, and an increase in new IBD patients coming to the service, but a reduction in the number of face-to-face consultant clinics. CONCLUSION: COVID-19 has disrupted medical services to children with IBD and led to a reduction in face-to-face activities but has also led to a significant increase in virtual activities. CNSs have taken up a wider role to cover patient care during a time of both medical and nursing redeployment.

Palliative care teaching in the new internal medicine curriculum: Project ECHO-an innovative approach to postgraduate education.

BACKGROUND: The Internal Medicine Training (IMT) Programme is an evolution of Core Medical Training introduced in 2019. The IMT curriculum places an increased emphasis on palliative care; however, access to palliative care training is variable. Project ECHO (Extension of Community Healthcare Outcomes) develops communities of practice and is a valuable tool for medical education. We report on an evaluation of Project ECHO to deliver palliative medicine training across a geographically large deanery in the North of England. METHODS: The Project ECHO training programme involved multipoint video technology, telementoring, expert talks and case-based discussions over six sessions, and was fully mapped to the palliative care component of the IMT curriculum. We collected data particularly around attendance and self-reported confidence and knowledge. RESULTS: By creating a community of practice, we provided virtual placements and over 9 hours of virtual direct contact with palliative medicine consultants; and in total, 921 individual attendances occurred, with 62% attending all six sessions. The course was associated with an increase in self-reported confidence and high satisfaction. DISCUSSION: Project ECHO is an effective method of delivering teaching to trainees across a large geographical area. Course evaluation shows outstanding results in trainee satisfaction, confidence, knowledge, patient care, clinical skills and reduction in fear when managing death and dying.

Variation in access and prescription of vedolizumab and ustekinumab in paediatric patients with inflammatory bowel disease: a UK-wide study.

BACKGROUND: Therapeutic options for paediatric inflammatory bowel disease (IBD) are limited, especially for younger children. Unlike in adults, vedolizumab and ustekinumab are not licensed for paediatric use in the UK. We aimed to understand the real-world access to, and use of, these therapies in the paediatric population. METHODS: We surveyed UK IBD centres to assess the incident use of vedolizumab and ustekinumab from 1 January 2021 to 31 December 2021. We collected information on funding, dose escalations and therapeutic drug monitoring. RESULTS: 18 of 21 centres responded, covering an estimated 5260 patients. One hundred and thirteen were started on vedolizumab, prescription incidence 2.2%, median prescriptions per centre was 4 (range 1-20). Considering ustekinumab, 73 patients were commenced, prescription incidence 1.4%. Median prescription per centre was 3.5 (range 1-13). Prescription rates at each centre were not predicted by patient number cared for at that centre (p=0.2). Dose escalation was common in vedolizumab (66.7% centres) and ustekinumab (55.5%).Funding strategies varied substantially, and multiple funding sources were used; 12 of 18 centres (66.7%) reported funding through routine National Health Service (NHS) England/Scottish arrangements. There was local NHS trust funding in 8 of 18 centres (44.4%). Individual funding requests (IFRs) were used in 5 of 18 (27.8%), although IFRs are reserved for patients with unique additional characteristics. Four centres were unable to achieve funding in pre-pubescent children. CONCLUSIONS: There is widespread use of vedolizumab and ustekinumab across the UK, although practice is highly variable. Access to therapy appeared to differ substantially. There is a growing disparity between international guidelines and real-world practice. Establishing early and effective therapy in all patients remains a priority.

Nicorandil and ranolazine overdose management.

A man in his 60s was admitted to the emergency department with chest pain following an intentional overdose of nicorandil and ranolazine. He was known to have an extensive cardiac history and had taken his prescribed medication with suicidal ideation. On presentation, he was hypotensive with a blood pressure of 70/50 mm Hg despite fluid resuscitation. He was commenced on vasopressor support and transferred to the intensive care unit. Despite an adequate blood pressure on vasopressors, he suffered a ventricular fibrillation cardiac arrest. Return of spontaneous circulation with a Glasgow Coma Score of 15 was achieved following cardiopulmonary resuscitation and three direct current shocks. Following subsequent continuous overnight significant vasopressor dependence, a dose of glucagon was given, and within 2 hours, his vasopressor requirement ceased, maintaining an unsupported normal blood pressure. He remained stable and was subsequently discharged to the coronary care unit for monitoring.

Genetic and demographic implications of the Bantu expansion: insights from human paternal lineages.

The expansion of Bantu languages, which started around 5,000 years before present in west/central Africa and spread all throughout sub-Saharan Africa, may represent one of the major and most rapid demographic movements in the history of the human species. Although the genetic footprints of this expansion have been unmasked through the analyses of the maternally inherited mitochondrial DNA lineages, information on the genetic impact of this massive movement and on the genetic composition of pre-Bantu populations is still scarce. Here, we analyze an extensive collection of Y-chromosome markers--41 single nucleotide polymorphisms and 18 short tandem repeats--in 883 individuals from 22 Bantu-speaking agriculturalist populations and 3 Pygmy hunter-gatherer populations from Gabon and Cameroon. Our data reveal a recent origin for most paternal lineages in west Central African populations most likely resulting from the expansion of Bantu-speaking farmers that erased the more ancient Y-chromosome diversity found in this area. However, some traces of ancient paternal lineages are observed in these populations, mainly among hunter-gatherers. These results are at odds with those obtained from mtDNA analyses, where high frequencies of ancient maternal lineages are observed, and substantial maternal gene flow from hunter-gatherers to Bantu farmers has been suggested. These differences are most likely explained by sociocultural factors such as patrilocality. We also find the intriguing presence of paternal lineages belonging to Eurasian haplogroup R1b1*, which might represent footprints of demographic expansions in central Africa not directly related to the Bantu expansion.

Genetic origin, admixture, and asymmetry in maternal and paternal human lineages in Cuba.

BACKGROUND: Before the arrival of Europeans to Cuba, the island was inhabited by two Native American groups, the Tainos and the Ciboneys. Most of the present archaeological, linguistic and ancient DNA evidence indicates a South American origin for these populations. In colonial times, Cuban Native American people were replaced by European settlers and slaves from Africa. It is still unknown however, to what extent their genetic pool intermingled with and was 'diluted' by the arrival of newcomers. In order to investigate the demographic processes that gave rise to the current Cuban population, we analyzed the hypervariable region I (HVS-I) and five single nucleotide polymorphisms (SNPs) in the mitochondrial DNA (mtDNA) coding region in 245 individuals, and 40 Y-chromosome SNPs in 132 male individuals. RESULTS: The Native American contribution to present-day Cubans accounted for 33% of the maternal lineages, whereas Africa and Eurasia contributed 45% and 22% of the lineages, respectively. This Native American substrate in Cuba cannot be traced back to a single origin within the American continent, as previously suggested by ancient DNA analyses. Strikingly, no Native American lineages were found for the Y-chromosome, for which the Eurasian and African contributions were around 80% and 20%, respectively. CONCLUSION: While the ancestral Native American substrate is still appreciable in the maternal lineages, the extensive process of population admixture in Cuba has left no trace of the paternal Native American lineages, mirroring the strong sexual bias in the admixture processes taking place during colonial times.

Admixture and sexual bias in the population settlement of La Réunion Island (Indian Ocean).

La Réunion, one of the three Mascarene islands located in the Indian Ocean, remained devoid of inhabitants until it was first colonized by the French in the middle of the 17th century. The continuous flow of foreign-born slaves and immigrant workers from Africa, India, Southeast Asia, and China to work on coffee and sugar cane plantations led to the island becoming a melting pot of people of multiple ethnic origins. To establish the impact of the different incoming ethnic groups on the present Reunionese gene pool, we have sequenced both hypervariable regions I and II of the mitochondrial DNA molecule, the 9 bp COII/tRNA(Lys) deletion, and four SNPs located in the coding region in a total of 41 samples of the general population, and a further 18 STRs and 35 SNPs on the Y chromosome in 26 of these samples. Our results show that there was a strong sexual bias (asymmetrical gene flow) in the peopling of La Réunion, where admixture events were mainly between male settlers and females from the incoming slave groups. Most of the Y-chromosome gene pool is of European/Middle Eastern ancestry (85%), whereas the mtDNA gene pool is mainly of Indian and East Asian ancestry (70%). The absence of genetic diversity within these two major components of the mtDNA gene pool suggests these populations may have witnessed strong founder effects during the colonization process.

Results of the 2003-2004 GEP-ISFG collaborative study on mitochondrial DNA: focus on the mtDNA profile of a mixed semen-saliva stain.

We report here a review of the seventh mitochondrial DNA (mtDNA) exercise undertaken by the Spanish and Portuguese working group (GEP) of the International Society for Forensic Genetics (ISFG) corresponding to the period 2003-2004. Five reference bloodstains from five donors (M1-M5), a mixed stain of saliva and semen (M6), and a hair sample (M7) were submitted to each participating laboratory for nuclear DNA (nDNA; autosomal STR and Y-STR) and mtDNA analysis. Laboratories were asked to investigate the contributors of samples M6 and M7 among the reference donors (M1-M5). A total of 34 laboratories reported total or partial mtDNA sequence data from both, the reference bloodstains (M1-M5) and the hair sample (M7) concluding a match between mtDNA profiles of M5 and M7. Autosomal STR and Y-STR profiling was the preferred strategy to investigate the contributors of the semen/saliva mixture (M6). Nuclear DNA profiles were consistent with a mixture of saliva from the donor (female) of M4 and semen from donor M5, being the semen (XY) profile the dominant component of the mixture. Strikingly, and in contradiction to the nuclear DNA analysis, mtDNA sequencing results yield a more simple result: only the saliva contribution (M4) was detected, either after preferential lysis or after complete DNA digestion. Some labs provided with several explanations for this finding and carried out additional experiments to explain this apparent contradictory result. The results pointed to the existence of different relative amounts of nuclear and mtDNAs in saliva and semen. We conclude that this circumstance could strongly influence the interpretation of the mtDNA evidence in unbalanced mixtures and in consequence lead to false exclusions. During the GEP-ISFG annual conference a validation study was planned to progress in the interpretation of mtDNA from different mixtures.

SNPlexing the human Y-chromosome: a single-assay system for major haplogroup screening.

SNPs are one of the main sources of DNA variation among humans. Their unique properties make them useful polymorphic markers for a wide range of fields, such as medicine, forensics, and population genetics. Although several high-throughput techniques have been (and are being) developed for the vast typing of SNPs in the medical context, population genetic studies involve the typing of few and select SNPs for targeted research. This results in SNPs having to be typed in multiple reactions, consuming large amounts of time and of DNA. In order to improve the current situation in the area of human Y-chromosome diversity studies, we decided to employ a system based on a multiplex oligo ligation assay/PCR (OLA/PCR) followed by CE to create a Y multiplex capable of distinguishing, in a single reaction, all the major haplogroups and as many subhaplogroups on the Y-chromosome phylogeny as possible. Our efforts resulted in the creation of a robust and accurate 35plex (35 SNPs in a single reaction) that when tested on 165 human DNA samples from different geographic areas, proved capable of assigning samples to their corresponding haplogroup.