Prevalence and impact of X-ray screening for atlantoaxial instability in children with Down syndrome

Introduction: Atlantoaxial instability (AAI) is defined as excessive movement between the first and second cervical vertebra. This can lead to spinal cord compression, resulting in myelopathic and radicular symptoms. These symptoms occur in 1-2% of the down syndrome (DS) population. DS athletes are often required to undergo pre-participation X-ray screening for AAI to help identify those at risk. However, the evidence for plain cervical spine X-ray as a form of screening is poor. Aim: This project aims to explore the use, sensitivity and specificity of X-ray screening for AAI in the Irish DS population, to investigate the prevalence of symptomatic AAI, to identify the rate of sport exclusion based on an abnormal X-ray and to investigate whether neuromuscular conditions, type of schooling or activity level are significantly correlated to an abnormal Xray. Method: This is a nation-wide cross-sectional online survey. It was rolled out via email by Down Syndrome Ireland to 1511 registered families. The survey asked parents if their child has had to undergo x-ray screening, the result of the x-ray, the impact of the result and if they developed symptoms. The survey also assessed parental knowledge of symptoms of AAI. Results: Out of 240 responders, 7 responders had symptomatic AAI and 5 of these had normal X-rays (29% sensitivity). Chi-Squared testing showed no variables significantly correlated with having an abnormal X-ray. Of the total group of 146 who underwent X-ray pre-participation screening, 20 had abnormal results and were excluded from playing their desired sports (specificity 86.7 %). Conclusion: X-ray screening for AAI in Ireland is very common and can result in the exclusion of many from participating in sports. Plain X-ray has low sensitivity. Therefore, it is not an optimal screening tool for AAI in asymptomatic children. More should be done to improve parental knowledge of this condition

Percutaneous retrieval of the locked helex septal occluder

The HELEX device is approved for percutaneous closure of an atrial septal defect (ASD). It is also often used off-label to close patent foramen ovale (PFO). The device is well tolerated because it is very flexible, but this characteristic increases the likelihood of embolization of locked implants. While the company provides a mechanism to retrieve devices that do not lock correctly, retrieval of locked and released devices is much more difficult. A case of percutaneous retrieval of an embolized, locked HELEX device is reported. This device was successfully retrieved from the aorta by snaring the left atrial eyelet and unlocking the device. A variety of potential techniques for retrieval of these devices was explored on the bench top. Strategies which can be used to successfully retrieve embolized HELEX devices are described

Characterizing the use of virtual care in primary care settings during the COVID-19 pandemic: a retrospective cohort study

Background In March 2020, Canada implemented restrictions to curb viral transmission of COVID-19, which resulted in abrupt disruptions to conventional (in-person) clinical care. To retain continuity of care the delivery of primary care services shifted to virtual care. This study examined the nature of virtual visits, characterizing the use and users of virtual care in primary care settings from March 14/20 to June 30/20 of the COVID-19 pandemic.  Methods Retrospective cohort study of primary care providers in Manitoba, Canada that participate in the Manitoba Primary Care Research Network (MaPCReN) and offered ≥ 1 virtual care visit between 03/14/20 and 06/30/20 representing 142,616 patients. Tariff codes from billing records determined the visit type (clinic visit, virtual care). Between 03/14/20, and 06/30/20, we assessed each visit for a follow-up visit between the same patient and provider for the same diagnosis code. Patient (sex, age, comorbidities, visit frequency, prescriptions) and provider (sex, age, clinic location, provider type, remuneration, country of graduation, return visit rate) characteristics describe the study population by visit type. Generalized estimating equation models describe factors associated with virtual care.  Results There were 146,372 visits provided by 154 primary care providers between 03/14/20 and 06/30/20, of which 33.6% were virtual care. Female patients (OR 1.16, CI 1.09–1.22), patients with ≥ 3 comorbidities (OR 1.71, CI 1.44–2.02), and patients with ≥ 10 prescriptions (OR 2.71, 2.2–1.53) had higher odds of receiving at least one virtual care visit compared to male patients, patients with no comorbidities and patients with no prescriptions. There was no significant difference between the number of follow-up visits that were provided as a clinic visit compared to a virtual care visit (8.7% vs. 5.8%) (p = 0.6496). Conclusion Early in the pandemic restrictions, approximately one-third of visits were virtual. Virtual care was utilized by patients with more comorbidities and prescriptions, suggesting that patients with chronic disease requiring ongoing care utilized virtual care. Virtual care as a primary care visit type continues to evolve. Ongoing provision of virtual care can enhance quality, patient-centered care moving forward.Applied Science, Faculty ofMedicine, Faculty ofNon UBCAllergy and Immunology, Division ofMedicine, Department ofNursing, School ofPediatrics, Department ofReviewedFacultyResearche

PPAR agonists as effective adjuvants for COVID-19 vaccines, by modifying immunogenetics: a review of literature

Abstract Background Several coronavirus vaccine have been fast-tracked to halt the pandemic, the usage of immune adjuvants that can boost immunological memory has come up to the surface. This is particularly of importance in view of the rates of failure of seroconversion and re-infection after COVID-19 infection, which could make the vaccine role and response debatable. Peroxisome proliferator-activated receptors (PPARs) have an established immune-modulatory role, but their effects as adjuvants to vaccination have not been explored to date. Main body of the abstract It is increasingly recognized that PPAR agonists can upregulate the levels of anti-apoptotic factors such as MCL-1. Such effect can improve the results of vaccination by enhancing the longevity of long-lived plasma cells (LLPCs). The interaction between PPAR agonists and the immune system does not halt here, as T cell memory is also stimulated through enhanced T regulatory cells, antagonizing PD-L1 and switching the metabolism of T cells to fatty acid oxidation, which has a remarkable effect on the persistence of T memory cells. What is even of a more significant value is the effect of PPAR gamma on ensuring a profound secretion of antibodies upon re-exposure to the offending antigen through upregulating lipoxin B4, therefore potentially assisting the vaccine response and deterring re-infection. Short conclusion In view of the above, we suggest the use of PPAR as adjuvants to vaccines in general especially the emerging COVID-19 vaccine due to their role in enhancing immunologic memory through DNA-dependent mechanisms