Abstracts from the 4th Annual Student Medical Summit

s from the 4th Annual Student Medical Summit Virtual. 6 February 2021 Published: 11 May 2021 Abstracts – BMC Proceedingss – BMC Proceedings A01: An audit of frequent attenders in Cork university hospital emergency department Emer Dight, Conor Deasy School of Medicine, University College Cork, Co. Cork, Ireland; Emergency department, Cork University Hospital, Co. Cork, Ireland Correspondence: Emer Dight BMC Proceedings 2021, 15(Suppl 4):A01: Background In recent decades overcrowding of hospitals has become a major issue in Ireland. The emergency department, by nature of its walk-in attendees, has been put under increasing pressure. Frequent attenders (FA) have been shown to have increased mortality rates compared to non-frequent attenders (NFA) [1]. The primary aim of this audit was to profile Cork University Hospital’s (CUH) emergency department (ED) FAs and to describe their prevalence. FA were also then compared to NFA where possible. An FA is defined as any patient that attends five or more times per annum. Materials and Methods A retrospective audit of CUH’s 358 FAs from 1 January to 31 December 2019 was completed. NFA were also analysed for comparative purposes. All data was recorded on Microsoft Excel. The data collected included: arrival date, age, time spent in department, discharge destination and preliminary diagnosis. Results Approximately 01.1% of patients accounted for 5.7% of attendances in 2019. 358 patients presented a total of 2,565 times to the emergency department. The number of visits per patients ranged from 5 to 68. The average number of visits per patient was seven. The mean age was 56 years. 47% of FA were female and 53% were male. 40% of FA visits were by ambulance compared with 30% by NFAs. FAs were discharged to a ward to receive further care in 43% of cases where NFA went to a ward 29%. FA’s top presenting complaint was ‘unwell adult’ and 4.7% of FA attendances were due to mental illness compared to 0.75% of NFA. Conclusion This audit was the first of its kind to be done analysing CUH’s FA. Further studies are required to examine measures to reduce FA attendance if appropriate and to reduce the risk of adverse outcomes for this vulnerable group.


A02:
A survey of compliance with the HSE paediatric anaesthesia model of care in Irish hospitals and a local audit of paediatric anaesthesia outcomes Ciara Walsh 1 , John Chandler 2 1 School of Medicine, University College Cork, Cork, Ireland; 2  In 2015, the HSE released the Paediatric Anaesthesia Model of Care (PAMoC). It provides a framework for the governance of paediatric anaesthesia in Ireland. The document outlines recommendations pertaining to facilities, training, and structure of the paediatric anaesthesia service. It aims to improve patient outcomes such as postoperative nausea and vomiting, unplanned admissions and fasting times [1]. Thus far, there has been no research investigating the implementation of the PAMoC. This study sought to document the uptake of the PAMoC in non-specialist Irish public hospitals and to assess anaesthesiologists' attitudes towards this model of care.

Materials and methods
All public hospitals in the Republic of Ireland providing a paediatric anaesthesia service, excluding specialist centres operated by Children's Health Ireland, were invited to participate in this study. An anonymous survey requesting information regarding facilities, training and structure of their paediatric anaesthesia service was sent via email, to assess their compliance with the model of care.

Background
Cartilage is a tough and flexible connective tissue made up of chondrocytes, which synthesize and turn over the components of the extracellular matrix [1]. It has a role of weight bearing, and act as a cushion and a shock absorber between the bones [2]. Today, 25 million people worldwide suffer from cartilage defect [3]. Once damaged, the cartilage is very unlikely to self-heal due to its avascular nature and the passive diffusion of cells through the matrix [2]. The actual treatments for cartilage damage, including medication, physiotherapy and surgery, do not allow for a complete cure of the tissue and are often seen as both clinically and cost expensive for the patient. There is therefore a need for new treatments which could promote the regeneration of cartilage to a healthy state instead of solely focusing on relieving the symptoms. Tissue engineering appears like a promising option and uses functional scaffolds to recruit endogenous chondrocytes in vivo, at the site of injury [4].

Materials and methods
In this study, a new functionalized peptide hydrogel named RA-GF was designed by enriching the bio scaffold PuraMatrix (RADA16) with platelet derived growth factor (PDGF). We hypothesized that RA-GF would better promote the proliferation and cell viability of chondrocytes compared to RADA16 alone. The chondrocytes were isolated and cultured from femoral condyle of bovine knee joints [5,6]. Proliferation tests were performed using RADA16 as control and measurements were taken at day 1,3 and 7. The results were analysed with an ANOVA test to determine any difference between RA-GF and RADA16. Finally, a cytotoxicity test was completed using three different dyes, namely Calcein Acetoxymethyl (Calcein AM), Propidium Iodide (IP) and NucBlue [7]. The number of cells was counted manually based on images obtained from fluorescence microscopy for calculation of percent viability. Results PDGF significantly increased the proliferation of chondrocytes in vitro (Figure 1). The increase in proliferation and the cell viability seen with RA-GF was not statistically significant compared to RADA16 alone ( Figure 2 and 3). Conclusions RA-GF shows potential as a bio scaffold, however in-depth research over longer periods of time is required to properly evaluate the benefits of this hydrogel in articular cartilage regeneration. Future work should include the effect of RA-GF on chondrocytes migration, differentiation and expression of chondrogenic related genes in vitro, as well as the in vivo regenerative capacity of RA-GF in induced cartilage defect.

Background
Gaps in addiction medicine training are a reason for poor substance use care in North America [1]. Hospital addiction medicine consult services (AMCS) provide critical medical services, including screening and treatment of substance use disorders (SUD) [2]. While these programs often feature an educational component for medical learners, the impact of AMCS teaching on objective knowledge and career aspirations in addiction medicine has not been well described.

Materials and Methods
We report findings from two sequential studies conducted at a large academic hospital in Vancouver, Canada. The first study assessed the impact of an AMCS clinical rotation on medical trainee addiction medicine objective knowledge using an online survey of six true/false questions before and after the rotation. The second study examined the impact of an AMCS rotation on career aspirations using four seven-point Likert-type questions. One-sample t-tests on mean differences (MD) with Benjamini-Hochberg adjustment for multiple comparisons were employed for statistical analyses. Conclusion AMCS rotations appear to improve addiction medicine knowledge and aspirations to pursue addiction medicine as a career among medical trainees. Larger-scale evaluations and outcomes research on integrating SUD teaching in these settings will help move the discipline forward.  Background Breast cancer is the most common cancer in women with a very high incidence and mortality rate in the UK and Ireland. Breast conserving surgery (BCS) is the most frequently performed procedure for treating women with early stage breast cancer. With a burden of establishing a positive margin in real time, there is an emphasizes on the need of an accurate IMA tool like the iKnife. In order to establish the burden of positive margins a systematic review have been carried out. The systematic review evaluated the effect of DCIS on positive margin. This systematic literature review identified articles evaluating the positive margin and/or re-operation rate associated with BCS [1]. Inclusion and exclusion criteria are as seen in Figure1.

Materials and methods
To start, an electronic search was performed on MEDLINE and EMBASE using specific search criteria. Using Covidence, two review authors, independently screened by title and abstract the studies we had identified through the search strategy. Studies were screened and included based on criteria as seen in Figure 1., only clinical studies with data on BCS associated with positive DCIS margins leading to re-excision were incorporated. The remaining papers which were included were then subjected to further screening based on the final full text review. Papers for the full text review were acquired using multiple sources with most papers being obtained from the Endnote software whilst the rest are still being sourced from reaching out to local libraries and journal editors. Alongside this we are finalising a data extraction spreadsheet. Once the full text review is complete, data can then be extracted from each study and incorporated into the spreadsheet. The spreadsheet is being drafted by using different past meta-analysis, similar in nature to our study. We searched for papers from high impact factor publications to ensure the quality and standard of our data extraction. The next step for us is to discuss and finalise the spreadsheet with the final extraction factors which are deemed relevant. To further ensure the quality of the appraisal we are currently searching for different quality scoring systems [2]. Once that is successfully completed, the final step would be to run a meta-analysis to combine the high-quality data extracted. Results A total of 2,714 studies were imported for screening where 577 duplicates were removed leaving 2,137 studies to be screened. Using Covidence, the studies were filtered, and 1,876 studies were found irrelevant not satisfying the set criteria. The remaining 261 papers are subject to full text screening next before data extraction and metaanalysis can be carried out. Conflicts were discussed and resolved between the review authors. The PRISMA model which is an evidence based minimum set of items for reporting was used as seen in Figure  2. We believe that adhering to the PRIMSA guidelines would reduce potential bias and may improve review quality [3].

Conclusions
Currently we are working on the final results of this systematic review. As of now we could only comment on the prevalence of DCIS found at the positive margin and the impact it has on re-excision [4,5]. We hope to gain fruitful insights once the systematic review is completed.

Background
Nipple discharge is the 3rd most frequent complaint of women attending rapid diagnostic breast clinics. Nipple smear cytology remains the single most utilised diagnostic modality for investigation of fluid content, although its diagnostic accuracy remains uncertain. The objective of this paper is to conduct a systematic review and meta-analysis of the diagnostic accuracy of nipple discharge fluid assessment.

Materials and methods
This systematic review incorporated Medline, Embase and Scopus databases searches, for studies interrogating the diagnostic data of nipple discharge fluid cytology compared to histopathology gold standard. Data from studies published from 1956-2019 were analysed. The analysis included 8,648 cytology samples from 59, 991 women. Hierarchical and bivariate models for diagnostic meta-analysis were utilised to attain overall pooled sensitivity and specificity. Sub-group analysis of the diagnostic potential of blood in discharge fluid, as well as imaging modalities was conducted.

Results
Of 837 studies retrieved, forty-five studies fulfilled the criteria for review and meta-analysis. Analysis included 8, 648 cytology samples. The diagnostic accuracy meta-analysis of nipple discharge fluid illustrated a sensitivity of 75%

Conclusions
Pooled data from all studies encompassing nipple discharge fluid assessment suggests that nipple smear cytology is of limited diagnostic accuracy. Moreover, in patients with only nipple discharge as the presenting symptom, no individual imaging modality has a high enough diagnostic accuracy to exclude carcinoma. Our recommendation is that a tailored approach to diagnosis is required, given variable sensitivities of current available tests.

A07:
Differentiation lineage alters the cytoskeletal and epigenetic response of mesenchymal stem cells to tensile strain Chris Glynn 1 , Stephen D. Thorpe  Background Mesenchymal stem cells (MSCs) are widely used for connective tissue regenerative therapies. The application of external mechanical forces to MSCs can initiate and drive fibro-chondrogenic differentiation and is associated with epigenetic modification histone 3 lysine 27 trimethylation (H3K27me3) affiliated with heterochromatin formation [1,2]. The aim of this study is to investigate differentiation-dependent changes in cytoskeletal organisation and nuclear shape in response to 2-D dynamic uniaxial tensile strain.

Materials and methods
MSCs were subjected to uniaxial tensile strain of 3% at 1 Hz for 6 hours per day, repeated daily for 3 days in media to encourage osteogenic (OM), adipogenic (AM) or fibro-chondrogenic differentiation alongside control basal media (BM). To explore the role of transforming growth factor-β3 Beta (TGF-β3) in mechanically driven fibro-chondrogenic differentiation, media with (CM+) and without (CM-) TGF-β3 was used. Fluorescently labelled cell images ( Figure 1) were processed using a custom MATLAB script to assess filamentous (F-)actin orientation and alignment, nucleus shape and orientation, and H3K27me3 and F-actin intensity pixel intensities within the nucleus.

Results
Uniaxial dynamic tensile strain led to alignment of F-actin and nuclei in the direction perpendicular to the direction of stretch in basal, osteogenic and chondrogenic media with TGF-β3 but does not occur in adipogenic or chondrogenic media without TGF-β3. The correlation between actin fibre and nuclei orientation increased with strain application in basal media but dropped with strain in chondrogenic media with or without TGF-β. This indicates a potential disconnect between the nucleus and cytoskeleton in strained chondrogenic MSCs (Figure 2). A lack of realignment in chondrogenic media without TGF-β (compared to media with TGF-β) was observed, along with no significant increase in F-actin intensity and a significant reduction in H3K27me3 intensity with stretch. This suggests that TGF-β is necessary for a functional response to stretch.
The combination of strain and differentiation induction led to a reduction in H3K27me3 intensity in all conditions (p < 0.05). Conclusion Differentiation alters the response of strain. In studying trilineage differentiation of mesenchymal stem cells we see the high dependence of strain response on lineage, suggesting an interplay between biochemical signalling and mechanical signalling. Future work will investigate the changing nature of cytoskeletalnucleus connectivity in chondrogenic differentiation as this provides a potential active mechanism whereby the cell regulates strain transfer to the nucleus.

Background
The incidence of melanoma is increasing in the elderly population [1], in whom prevalent comorbidities must be considered perioperatively. Despite significant developments in the adjuvant therapy space, surgery, in the form of wide local excision (WLE) +/-sentinel lymph node biopsy (SLNB), remains the cornerstone of treatment of primary melanoma. This study aims to determine how age and associated comorbid factors influence surgical decision-making and subsequent outcomes for melanoma patients over the age of 70 years.

Materials and methods
Data was collected retrospectively for all melanoma patients over the age of 70 treated at a single tertiary referral centre over 10 years. Demographics, comorbidities, diagnosis, surgical management details, disease-free (DFS) and overall survival (OS) were tabulated. The impact of age and comorbidities were analysed. Results A total of 107 patients met inclusion criteria. The median age was 79.33 (range 70-96) years, and median Breslow Thickness was 1.45mm (range 0.02-22 ). Excisional biopsy only was performed in 15% (n=16), with 85% (n=91) progressing to WLE. Patients who underwent WLE displayed increased DFS (p=0.003), with no impact on OS (p=0.716), and were significantly younger than those who only had excisional biopsy (p=0.003). Of those eligible for SLNB (n=41), 53.7% (n=22) underwent the procedure. Of note, SLNB had no significant impact on DFS (p=0.633) or OS (p=0.222).

Conclusions
In the elderly melanoma patient cohort, WLE resulted in improved DFS, but had no effect on OS. If these elderly melanoma patients are suitable surgical candidates, WLE should be offered where possible, in an effort to reduce morbidity from recurrent disease.

Background
Trisomy 21 (T21) or Down syndrome is the most common chromosomal abnormality reported worldwide. The rate of T21 in Ireland is 1 in 411-546 live births, the highest in Europe. [1] Infantile spasms (IS) occur in 0.6-13% of T21 infants and is associated with poorer neurodevelopmental outcomes, increased risk of epilepsy and autism spectrum disorders [2], [3], [4]. The purpose of this review is to identify effective treatment options to assist in management of IS in T21 infants.

Conclusion
This review has the largest cohort of T21 patients with IS (n=54) reported to date. Spasm cessation can be achieved in 44% (n=24) after treatment with first medication. Monotherapy prednisolone was the most frequently prescribed first line medication (n=20) achieving spasm cessation in 60% (12/20). Most medications were well tolerated with Vigabatrin accounting for the majority of side effects experienced (46%). Despite high rate of spasm cessation, developmental concerns (83%) and ongoing seizures (24%) were common.

Background
Non-Valvular Atrial Fibrillation (NVAF) is the most common cardiac arrhythmia and can result in ischaemic stroke [1]. Compared to the general population, patients with kidney failure receiving haemodialysis have a higher incidence of NVAF and stroke, but also of major bleeding [2]. Studies examining the risk-to-benefit ratio of oral anticoagulation (OAC) for NVAF in patients receiving haemodialysis have produced inconclusive findings [3]. We investigated patient and physician perspectives with respect to the risks and benefits of OAC for NVAF in patients receiving maintenance haemodialysis.

Materials and Methods
We screened all patients scheduled to attend any of two hospitalbased and one community-based dialysis clinic in the month of October 2019 for a diagnosis of NVAF. We collected demographic, comorbidity, dialysis prescription, and medication data for all identified cases. Patients were interviewed regarding their understanding of NVAF and associated stroke and bleeding risks. Separately, physician members of the Irish Nephrology Society were surveyed regarding their perspectives on NVAF management in haemodialysis patients and perceived risk-benefit of OAC in six hypothetical cases. T-test and Chi-square tests were used for univariate analyses. Two-way repeated measures ANOVA was used to examine variation within and across case vignettes with respect to perceived risk-benefit of OAC.

Results
We identified 41 patients (17% of those screened) with NVAF. 18 (44%) of these patients were prescribed OAC (11 warfarin, 7 apixiban). OAC use was positively associated with heart failure (p=0.01), higher BMI (p=0.01) and CHA 2 DS 2 -VASc scores ≥ 3 (p<0.05). Otherwise, there were no meanginful clinical differences, and no statistically significant differences, in the characteristics of those receiving vs. not receiving OAC. 27% of surveyed patients reported awareness of stroke risk in NVAF and 61% of those prescribed OAC were aware of the bleeding risk. 21 physicians responded to the survey, a response rate of 17.8%. Uncertainty regarding NVAF management existed, with 90% asserting clinical equipoise surrounding OAC therapy. Varying the stroke, bleeding, and falls risk in the 6 hypothetical cases did significantly influence risk-benefit perceptions and likelihood to prescribe OAC (p< 0.01). However, irrespective of baseline risk-benefit perception, physicians were positively biased towards initiating OAC, and further biased towards continuing OAC (if already prescribed) (p<0.01). Conclusions A paucity of evidence regarding the relative risks and benefits of OAC for NVAF in patients on dialysis has led to inconsistent and uncertain physician practice patterns. There is urgent need for randomized controlled trials of OAC for NVAF in patients on dialysis. Background On March 12 th , 2020, the Irish government implemented disease containment measures due to the COVID-19 pandemic leading to widespread social isolation, school closures and changes in daily routine [1]. While older individuals are considered most at risk physically, evidence from the H1N1 and SARS epidemics showed that approximately 33.0% of quarantined children availed of mental health services due to anxiety and adjustment disorders highlighting the potential impact of a pandemic on paediatric mental health [2]. A prospective study was conducted exploring the impact of COVID-19 and the first national lockdown on paediatric mental health presentations to the Emergency Department (ED) at Temple Street Children's University Hospital (TSCUH). Materials and methods ED mental health presentations from March-April 2019 (n=79) and 2020 (n=60) were reviewed. Multiple variables, including reason for presentation, diagnosis and presence of self-harm (SH) and suicidal intent, were prospectively gathered for 2020 cases and compared to 2019 presentations. Descriptive analyses of clinical findings using T tests, chi-square tests and one-way ANOVA tests were performed as appropriate and statistical significance was considered with p < 0.05. Ethical exemption was granted by the chair of the local ethics committee.

Conclusions
Our findings show fewer ED presentations during lockdown. Those who present are often high risk and known to services. Further research is needed to explore reasons for this in order to proactively manage vulnerable individuals in the community through effective service planning. Authors equally contributed to the work; i.e., the first 6 authors are co-first authors who contributed to this research equally with regards to time and effort dedicated. Background This study seeks to identify settings that are more prone to the transmission of COVID-19, which can provide insight regarding the opening and closure of such settings as well as monitoring and testing. As a result, this study can assist governments in prioritizing control measures when tackling possible future waves of the pandemic and future pandemics of a similar nature.

Materials and methods
Following a comprehensive review of the relevant literature and media articles, extraction of the cluster data of eight countries was performed by way of hand searching of reputable databases. The following data was extracted and arranged in an accessible online sheet: The total number of clusters and cases for each cluster type, the total number of cases in the country, date and source of the data collection. The cluster types were divided into 10 main types, with subcategories for specified types. Each country had 2 members assigned for data validation and review.

Results
Among the eight included countries, we have found 3905 clusters and a total number of 1907974 patients. Indoor settings (mass accommodation and residential facilities) comprised the highest number of both number of clusters (3313/3905) and infected patients (1836870/1907974), while the outdoor ones comprised 592 clusters and 71104 patients. Mass accommodation was associated with the highest number of cases in 5 of the 8 countries. Social events and residential settings were responsible for the highest number of cases in South Korea and Malaysia, respectively. In the USA, workplace facilities have reported 165 clusters of infection including 122 food production facilities.

Conclusions
As lockdowns pose a dilemma to governments worldwide due to the widespread effects of these measures, obtaining appropriate information concerning the transmissibility and the behavior of the disease is crucial in order to guide the removal of lockdowns across different fields and regions. Background As the COVID-19 pandemic continues to dominate the globe and cause substantial mortality and morbidity, new research has put the spotlight on the T-cell response to SARS-cov-2. With particular scrutiny and import being placed on the suggested cross-reactivity of memory T-cells specific to a common-cold coronavirus having heterologous immunity to SARS-cov-2.

Materials and Methods
Using an epitope prediction software, NetMHCpan, a list of the likely MHCII epitopes for CD4 T-cells, representing the 8 most common alleles, was generated for the SARS-cov-2 spike protein. Following the methods of Mateus et al, NetMHCpan was configured to predict 15mer epitopes, where only a core 9 amino acids had to be conserved (Table 1) [1]. Additionally, a sequence alignment of the spike protein genome for these viruses was performed using Jalview to manually assess for conservation and a literature review of relevant papers on T-cell cross-reactivity were performed ( Figure 1).

Results
Out of 92 SARS-cov-2 epitope predictions, 2 epitopes were conserved across the board with SARS and the four common-cold coronaviruses, and 8 epitopes had varying degrees of conservation with different computations of the 6 coronaviruses.

Conclusions
These conserved epitopes across the human coronavirus family are significant in that they contribute to the growing body of evidence of human coronavirus memory T-cells displaying heterologous immunity to SARS-cov-2. The results underscore the need for further research, but also these results and how they fit in with the previous literature, informs understanding of the immune response to COVID-19 and future therapeutic designs, and offers an explanation for the variability of symptoms of COVID-19 symptoms [1,2]. Background Parkinson's disease (PD) is the second most common neurodegenerative disease after Alzheimer's disease, but the exact etiology of PD remains unclear [1]. Recent studies have shown that GI symptoms serve as a prodrome to PD and this suggests that Helicobacter pylori may play a role in infection among PD patients, but detection and eradication of H. pylori are not part of current PD management. Methods Articles were selected from MEDLINE and EMBASE databases according to inclusion and exclusion criteria for this meta-analysis. The prevalence of H. pylori infection in PD, its relationship with unified Parkinson's disease rating scale (UPDRS) scores and gut SNCA gene expression in cases and controls were analyzed using odds ratios (OR) and standardized mean differences (SMD) with 95% confidence intervals (CI). Fixed and random-effects models were applied. All statistical analyses were performed with the Review Manager (RevMan) Version 5.4 software suite.

Results
Eleven studies were included in the first meta-analysis (5039 PD cases, 23194 controls) where H. pylori infection was more prevalent in PD patients [OR (95% CI): 1.46 (1.26, 1.68), Pz < 0.00001]. Five studies which included UPDRS scores showed a significant association between H. pylori infection and mean UPDRS scores [SMD (95% CI): 0.27 (0.02, 0.52), Pz = 0.03]. SNCA gene expression was also significantly higher among H. pylori patients [SMD (95% CI): 0.89(0.09, 1.69), Pz = 0.03]. Conclusion A higher prevalence of H. pylori was found among PD patients with a consistently lower UPDRS score among the healthy controls shows not only the increased risk among the infected cohort but how it worsens motor function. Furthermore, the significance of SNCA expression in gut biopsies of H. pylori infected patients suggests its importance in the management of PD and potentially as a screening tool. Background Clinical tools based on artificial intelligence have shown a lot of potential for heart disease treatment, diagnosis and monitoring. Artificial intelligence (AI) is defined as "the concept that machines can be improved to assume some capabilities normally thought to be like human intelligence such as learning, adapting, self-correction, etc." [1]. In this review, we explore how AI is currently being utilised for the purpose of cardiac rehabilitation.

Materials and methods
The libraries PubMed, Medline, Embase, Cochrane, and Scopus were searched for suitable papers using search terms for heart disease, artificial intelligence and rehabilitation. Table 1 contains a summary of major inclusion and exclusion criteria.

Results
The search returned 156 studies. After screening according to our inclusion criteria, 8 studies were included in our review.

Smart Watches
Mobile devices like the Apple Watch or Fitbit Charge HR 2 have demonstrated their potential for health monitoring and making earlier diagnosis. This enables the prevention of major adverse cardiac events and therefore, a reduction in hospitalization rates.

Home-Based Rehabilitation and Monitoring
Home-based interventions consist of home-based exercise protocols in combination with a digital health system used for delivering the protocol and for patients to report their progress. The use of such tools can help patients lose weight and improves body composition, acting as a form of secondary prevention [2]. In addition, homebased cardiac rehabilitation programs can greatly improve accessibility for patients. Decision Making Support AI-based technologies also have the potential to be an aid to the physician. For patients with ambiguous or unclear symptoms, the use of a neuro-fuzzy model can offer doctors decision-making support when it comes to prescribing different therapies [3]. Such models Background Melanoma, a potentially deadly skin cancer is increasing incidence worldwide. It develops from melanocytes located preferentially in the pigmented epidermis rather than the pigmented hair follicle(HF) epithelium [1]. In greying HFs the aging follicular melanin unit has been associated with increased melanocyte death by apoptosis perhaps triggered by uncontrolled oxidative stress(OS). Ataxia Telangiectasia Mutated(ATM) is a protein kinase that can sense DNA damage and OS, however its activation mechanisms in skin are little understood [2]. We aimed to investigate the relationship of melanocyte death (in greying HFs) and ATM sensing of OS.

Materials and methods
Human haired scalp tissue (n=7,all male[25-73yrs,mean=46,4>40yrs]) was ethically obtained from The Charles Institute via Hair Restoration Blackrock. Tissue sections (5-10μm) were cut and a double immunohistochemistry assay was performed using a melanocyte lineage marker (Nkibeteb) and antibodies to ATM and phospho-ATM. Images were prepared using CellSense and ImageJ.

Results
Melanocyte number decreased in greying HFs as pigmentation decreased ( Figure 1). Nuclear ATM was expressed in the HF bulbar melanocytes and in some fibroblast cells of the dermal papilla of the HF bulb, but not in melanocytes of the more superficial and UV exposed epidermis (Figure 2,3). By contrast, phospho-ATM was expressed cytoplasmically in the keratinocytes of the epidermis and of the upper HF ( Figure 3).

Conclusions
Results confirmed melanocyte depletion in human canities-affected HF and also suggested a protective role of ATM to OS in HF bulbs that retained pigmented melanocytes even at significant age. A potential melanoma intervention strategy may be to modulate ATM kinase expression in melanoma cells to make these cells more susceptible to a canities-like deletion [1,2]. Background Cancer cachexia is a severe muscle wasting condition, affecting up to 50% of cancer patients [1]. It is linked to reduced treatment tolerance and response, and increased morbidity and mortality [2]. As the exact mechanism of cancer cachexia is not understood, further investigations are crucial to finding an effective therapy. Mitochondria are greatly affected in catabolic conditions of muscle loss [3] and dysfunctional mitochondria can trigger catabolic signalling pathways causing muscle atrophy [3]. This project aims to determine changes in muscle in a mouse model of breast cancer and investigate potential associated mechanisms.

Materials and Methods:
The gastrocnemius and tibialis anterior were isolated from 3 control mice and 3 tumour-bearing mice. The muscles were cryosectioned at 8μm and fluorescently imaged at 20x magnification (Fig 1). RNA was isolated and used for quantitative polymerase chain reaction to establish changes in the expression of mitochondrial and atrophyrelated genes.

Results:
No significant difference was found between muscle fibre sizes in control mice and mice with cancer (Fig 2). Significant decrease in the relative expression of the mitochondrial genes Tomm20 and MT-ND1 was observed in tibialis anterior samples from tumour-bearing mice. Significant decrease in the relative expression of the mitochondrial genes COXIV and OPA1 was also observed in gastrocnemius samples from tumour-bearing mice.

Conclusion
The weight of tibialis anterior, but not gastrocnemius muscles, was significantly reduced in tumour-bearing mice compared to control mice. However despite this and contrary to findings from human studies [2], muscle fibre diameter and distribution did not show a significant difference between tumour-bearing mice and control mice, potentially due to detection challenges of the atrophic muscle fibres. Further investigations using larger sample sizes and different time points from tumour induction are necessary. Expression of Tomm20 and MT-ND1 was reduced in the tibialis anterior muscle of tumour-bearing mice, while the expression of COXIV and OPA1 was reduced in the gastrocnemius muscle of tumour-bearing mice. These changes may indicate cancer cachexia's effect on biogenesis of mitochondria (Tomm20), the oxidative phosphorylation process (COXIV and MT-ND1), cellular atrophy and mitochondrial stability (OPA1) within skeletal muscle and may be linked to fibre type-specific changes in these processes.

A19:
Investigating macrophage activation in response to damageassociated molecular patterns in multiple sclerosis

Materials and methods
We measured the hallmarks of macrophage activation; NO (Greiss assay), IL-6, TNFα and IL-1β (ELISA), and miR-155 (RT-PCR). Raw 264.7 and bone marrow-derived macrophages were stimulated in a dose and timedependent manner with HMGB1 and Toll-like receptor agonist, LPS as a positive control. All experiments were performed in triplicate, 4 independent times. Results At 4, 6, 24 and 48 hrs, LPS (1 mg/ml) induced activation markers (NO, IL-6, TNFα and IL-1β) in a time-dependent manner in both cell lines as expected. This was greatest with LPS at 48 hrs. HMGB1 alone (5, 10 and 50 ng/ml) did not have any impact on any of the activation parameters. However, when stimulated with both LPS and HMGB1, for 48 hrs, a statistically significant synergistic effect in NO, IL-6, TNFα and IL-1β production by Raw264.7 was seen.

Conclusions
Our investigations imply that HMGB1 can synergistically enhance an inflammatory response in LPS stimulated macrophages. The impact of HMGB1 at later time points suggests it may worsen chronic inflammation, which may be relevant in MS patients who have increased HMGB1 and suffer chronic inflammation. Further characterisation will explore the different domains of the HMGB1 molecule on macrophage activation, as well as the mechanism of enhanced macrophage activation markers.  Background In cases where a brain tumour is seen on neuroimaging brain biopsies are the gold standard method for confirming the diagnosis. Brain biopsies have a less predictable role in the investigation of patients with a neurologic syndrome of unknown aetiology in whom a neoplastic process is not suspected and are not frequently performed in this setting. Brain biopsy tend to be the last diagnostic resource in these disorders and the value of this procedure on diagnosis as well as outcome/management is less well-defined. The aim of this study was to evaluate the diagnostic yield and safety of brain biopsies performed in a single Neurosciences centre for clinically non-neoplastic brain diseases; to compare the pathologic evaluation with pre-biopsy diagnosis; and to analyse if biopsy results significantly altered patient management.

Materials and methods
This is a retrospective study of brain biopsies for non-neoplastic brain diseases performed at a single Neurosciences centre over a period of 10 years. Cases were identified using neuropathology reports and cases were excluded if the pre-operative diagnosis was clearly malignancy. The relationship between preoperative presenting complaint, laboratory testing, neuroimaging and management were examined and compared with post-biopsy clinical outcome as well as management changes.

Results
Twenty cases were identified from pathology reports. Sixteen of the twenty biopsies (80%) were pathologically diagnostic. Amyloid angiopathy was the most common diagnosis (41.7%) while demyelinating disorder and vasculopathy each accounted for 16.7% of the diagnoses made. Following biopsy results, clinical management altered in 80% of patients with the introduction of immunosuppressive agents being the most common change (occurring in 43.8%). 15.4% of patients with clinical outcome recorded returned to pre-disease baseline and a further 46.2% of patients with a recorded clinical outcome improved without returning to pre-disease baseline. Complications were rare but did not impact overall outcome.

Conclusions
This study shows that brain biopsies, when appropriately performed, are useful and have a high diagnostic yield even independently of other investigative modalities. Clinical outcome was, for the majority, positive with a large proportion of the patients improving clinically. Complications were rare and did not impact the patients overall outcome. This shows that brain biopsies are useful and safe as part of the diagnostic algorithm for non-neoplastic neurological conditions of uncertain or ambiguous aetiology and impact significantly on patient management.

Background
Currently, there is limited date on the effects of COVID-19 on pregnancy and neonatal outcome. This literature review aims to investigate the possibility of fetal vertical transmission in COVID-19 positive pregnant mothers by diagnosing through placental swabs.

Materials and methods
The search terms 'pregnant COVID-19 positive mothers', 'fetal vertical transmission' and 'placental swabs' were used. 11 papers were selected for this review.

Results
This literature review comprises 45 COVID-19 positive pregnant women whose placentas and neonates were also analysed by RT-PCR for the presence of SARS-CoV-2. 43 neonates were successfully delivered primarily via caesarean section out of 45 expectant mothers (96%). 2 mothers did not deliver due to severe preeclampsia and a miscarriage both occurring in the second trimester. 3 neonates tested positive for SARS-CoV-2 (7%). We report no neonatal mortality after birth and no maternal mortality. 8 female's placentas tested positive for SARS-CoV-2 out of a total of 45 tested (18%). Of these 8, 2 cases of SARS-CoV-2 were identified in the maternal, neonatal and placental tissue.

Conclusions
After reviewing multiple studies and investigating the nature of placental physiology in SARS-CoV-2 positive mothers we conclude that there is no concrete evidence of vertical transmission occurring between mother and infant. However, there are inconsistencies across the different papers used for this review and further research investigating the effects of COVID-19 on pregnant women by using RT-PCR to test the mother, placenta, vaginal fluid, breast milk and infant for SARS-CoV-2 at various stages of transmission is urgently needed.

A23:
Pain detectives: Optimizing the management of pain and irritability in children with severe neurological impairment Ketchum K 1,11 , Hermansen AM 1 , Andrews G 1 , Pawliuk C 1 , Dewan T 9 , Gnanakumar V 10 , Orkin J 4,5 , Richardson A 1 Vadeboncoeur C 6,7,8  Background Children with severe neurological impairment (SNI) are amongst the most vulnerable patients seen by clinicians. Children with SNI are typically non-verbal, non-mobile and cognitively impaired [1]. Many of these children experience pain or demonstrate irritability on a daily basis [2]. The source of this discomfort is difficult to identify when these children are unable to communicate. Due to the complex nature of these sensations, we use the term Pain and Irritability of Unknown Origin (PIUO) to describe them. We believe that lack of a standardized approach to investigating and managing PIUO may be contributing to pain persistence and suffering in this population.
To address this, our team developed a systematic approach for the assessment of pain in patients with SNI. The PIUO Pathway, as we have termed it, incorporates structured history-taking, physical examination, screening investigations for known and occult sources of pain, and pharmacological interventions. The goal is to efficiently assess treatable causes of nociceptive-inflammatory pain.

Methods
We used a waitlist-controlled randomized trial to test the efficacy of the PIUO Pathway. Participants were randomized to PIUO Pathway or waitlist (standard care) arms. The Pathway was deemed a success if the source of nociceptive-inflammatory pain was identified or if a participant was pain-free/had low pain on two consecutive visits. Secondary outcomes to be studied included decreased pain severity, improved family quality of life and ease of implementation of the PIUO Pathway for clinicians.

Results
This trial is ongoing. Preliminary results show that 23 children have completed the PIUO Pathway. Four participants have had their source of pain identified, and treatment strategies for these children are currently being investigated. Seven other participants have had their PIUO identified and resolved. Recruiting will continue across our four Canadian research sites until 120 participants have completed the Pathway. Results for secondary outcomes will be assessed upon trial completion. Children in whom a source of pain remains unidentified or who continue to have pain after completion of the PIUO Pathway will be eligible to participate in our next trial, which is a prospective N-of-1 randomized controlled trial which will investigate the efficacy of gabapentin in relieving PIUO in children with SNI. Background Type 1 myotonic dystrophy (DM1) is a multi-system neuromuscular disease caused by a trinucleotide expansion of the DMPK gene, which results in toxic gain-of-function activity of RNA, leading to a myriad of downstream splice variants and aberrant proteins. This research will explore if the splice variants share any common functionalities or pathway interactions.

Materials and methods
From existing published literature, experimentally validated and predicted splice variants in DM1 were analyzed using pathway analysis to determine if they contribute to common biological pathways. In total, 83 predicted and 55 experimentally validated splice variants in DM1 were examined using KEGG mapper and Reactome databases, with statistics computed using Reactome over-representation analysis. MicroRNA predicted to regulate misspliced genes were gathered using TargetScan:Human, and their pathway analysis was also conducted in order to search for common functionality between the two datasets.

Results
Predicted misspliced DM1 genes revealed strong pathway interactions in responses of the innate and adaptive immune system: antigen processing/presentation (p<1.11E-16), endosome and phagosome pathways (p<1.11E-16), and cytokine signalling (p<2.74E-14). Experimentally validated misspliced DM1 genes showed significant pathway interactions involving: MECP2 regulation of gene transcription (p<1.7E-7), cardiac conduction (p<1.57E-4), RTK signal transduction (p<2.26E-3), platelet homeostasis (p<2.53E-3), ion channel transport (p<2.79E-3) and integrin signalling (p<3.99E-3). Both gene sets implicated pathways involved in muscle contraction (p< 5.05E-4) and myogenesis (p<0.0341). MicroRNA analyses revealed significant pathway interactions in the immune system, platelet homeostasis, myogenesis and muscle contraction, axon guidance, and intracellular signal transduction. Conclusions Pathway analysis of DM1 variant genes and their regulatory micro-RNA shows common functionality pathways prominently in immune system operations (e.g. interleukin and interferon signalling, and lymphocyte activity). These are especially present in the predicted misspliced gene set which has yet to be experimentally explored. Future studies should confirm which of these common pathways could be viable mechanisms for intervention or biomarkers of prognosis/ disease severity. Background Globally, congenital uterine anomalies have a strong association with an increased risk of adverse pregnancy outcomes including miscarriage (43%) [1], pre-term birth (>20%) [2] and caesarean delivery (>34%) [2]. The objective of this study is to examine the obstetric outcomes for women with significant uterine anomalies in the National Maternity Hospital, Ireland (NMH).

Material and methods
This is a retrospective cohort study of all cases of uterine anomalies in pregnancy in the NMH over a 10 year period (2011-Present). Cases were identified by reviewing the database of the NMH's Preterm Birth Clinic, where all women with known uterine anomalies are referred for their antenatal care. Within this time frame, there have been 33 such pregnancies amongst 19 women. A significant uterine anomaly was defined as Unicornuate, Bicornuate, Didelphys and Septate Uterus requiring resection, with or without a Vaginal Septum.

Conclusions
Our study found a notably lower preterm birth rate (3.1%) amongst this cohort of women relative to the findings of International studies where rates as high as 39.7% were recorded. Our miscarriage rate (13.5%) was also lower than comparable studies (42.9%). The caesarean delivery rate was higher amongst this cohort relative to the background population and international findings. However, this was largely attributed to elective sections due to increased maternal age and patient demand. Insights gained from this data will help us to focus counselling in our own specific population regarding the pregnancy outcomes of women with uterine anomalies. Our findings suggest that this area warrants further national investigation. We recommend a similar audit be carried out in the remaining Irish Maternity Hospitals using the same methodology. This could prove invaluable if nationwide results differ significantly from ours in which case key differentiating factors may be identified.

Background
The geriatric population is defined as those over the age of 65 years [1]. This patient population comprises >14.15% of Ireland's total population and 53% of inpatient hospital care [2,3]. Thus, it is important for health care professionals (HCP) to identify those that are frail and in need of comprehensive geriatric care. This audit sought to examine Portiuncula University Hospital's (PUH) compliance with the Health Service Executive (HSE) guidelines which states that all older adult patients identified as being frail or at risk of frailty should have a comprehensive geriatric assessment (CGA) [1].

Materials and Methods
To assess the congruence of PUH and the HSE guidelines, a questionnaire was distributed to 131 PUH HCP evaluating the level of awareness of frailty and confidence in managing frail patients. Additionally, 59 geriatric surgical patient charts were reviewed to assess PUH adherence with the use of standardized frailty tools and appropriate referrals for geriatric surgical patients admitted to hospital. The next steps will include educating HCP and re-auditing 3 months after.

Results
Results from the questionnaire showed discrepancy between confidence reported (32%) and factual knowledge (68%) of frailty assessment amongst PUH HCP (Figure 1 and Figure 2). Results also showed that all hospital departments would benefit from formal education. Lastly, based on the guidelines PUH is underutilizing frailty assessment tools and referrals for CGA's with only 17% of all geriatric surgical inpatients being appropriately referred, 2% having a Rockwood score and 4% having a 4AT score completed.

Conclusion
The results of this audit will help target future research and tailor educational interventions. It is evident from the results that education is needed for all HCP at PUH in order to maximize utilization of standardized frailty assessments. Future goals are to establish a database on geriatric care in PUH for research purposes and expand the database to include other departments.

Background
Atrial fibrillation (AF) is the most common clinical arrhythmia, carrying an approximate lifetime risk of one in four after age 40 years [1]. Only anticoagulation has been proven to reduce AF-related mortality [2]. Inappropriate NOAC doses lead to less favourable outcomes in relation to thromboembolic events and death [3]. This project aims to determine the degree of compliance with Non-Vitamin K Antagonist Oral Anticoagulant (NOAC) dosing standards and to implement a computerised NOAC dosing aid to reduce the occurrence of inappropriate NOAC dosing in non-valvular atrial fibrillation (NVAF) patients.  function and bodyweight testing reminders for NVAF patients (Figures 3, 4).

Conclusion
Inappropriate NOAC dosing is prevalent in general practice and detrimental to patient health. Compliance with NOAC dosing standards in AF patients can be optimised by utilising a computerised dosing aid and formal reminder systems.

A28:
Designing an e-health portal for the patient voice in cancer research to promote public and patient involvement in research across academic and patient

Background
The Patient Voice in Cancer Research (PVCR) grew from an "unmet need" to involve the voices of cancer patients and their families with the scientific research process. To bring the PVCR in line with Public Patient Involvement (PPI) initiatives internationally, a dedicated, engaging website was drafted as a vital communication tool.

Materials and methods
A literature review of international PPI websites (Canada, Europe, UK) and attendance at the annual PPI Summer School (University of Limerick) were undertaken. A consent form and interview questions for PVCR Committee Members were designed and interviews conducted with cancer patients (6) and researchers (5) to develop 11 informative / reflective profiles. The National Adult Literacy Agency guidance was sought concerning requirements for obtaining a Plain English Mark, in line with international standards.

Results
The profiles and transcripts have been reviewed, and permission granted for use in the PVCR website, social media and a manuscript for peer review entitled 'Could You Give Us An Idea On What We Are All Doing Here?'. This paper documents the PVCR journey from initiation to involvement nationally. and is being prepared for the journal, Research Involvement and Engagement.

Conclusions
The PVCR are paving a new path in PPI in cancer research in Ireland. This research included assimilating (i) a reflective insight into the motivation and impact of PVCR membership since its initiation in 2016 and (ii) the vision of patients and researchers for PPI and its importance in advancing cancer research; crucial aspects for the PVCR website.

Background
Oesophageal adenocarcinoma (OAC) is an aggressive cancer with worse prognosis in the advanced stage of disease [1]. Standard treatment for locally advanced oesophageal cancer is neoadjuvant chemoradiation followed by surgery (trimodal regimen) [2]. The role of postoperative treatment is unclear [2]. Our study aims to review the benefits of adjuvant therapy in the postoperative period.

Methods
We carried out a review of 8 papers using the following databases: PubMed, Embase, clinical trials.gov, Cochrane. We set out to determine the hazard ratio, average 3-year and 5-year overall survival percentages of patients who underwent both neoadjuvant and adjuvant therapy.

Results
We identified a total of 16,299 patients. Of this cohort, 1712 underwent adjuvant therapy (experimental arm) and the remaining 14,587 were treated in the control arm. There was a 15% reduction in death

Conclusion
Although a considerable benefit is seen with the inclusion of this therapy to the trimodal regimen, its use across a range of disease presentations did not present any statistically significant benefit in context of both 3 and 5-year overall survival rates. Nevertheless, a promising finding of reduced risk of death (statistically significant) was observed in the residual nodal disease cohort. This trial dispenses a great opportunity for considerable research to be conducted in this area to definitively conclude if it should be incorporated into the typical treatment regime and thus combat the high mortality rate associated with this disease.

Methods
Retrospective review of healthcare records in a Tertiary Rehabilitation Hospital. All patients discharged from the in-patient rehabilitation service with an ICD 10 coded diagnosis of Transport accidents (V00 -V89.9) (Transport accident-related injury) from 2014-2018 were included. Results 338 cases were identified. 179 did not meet the inclusion criteria due to record duplication and miscoding. The total number of healthcare records analysed systematically using a standardised proforma was 159. 109 (68%) were male and 50 32%) were female. 115 (72%) were under 40 years of age. 122 (77%) had traumatic brain injuries, 32 (20%) had traumatic spinal cord injuries and 4 (2.5%) had traumatic amputation. There were no combined injuries. There was an overall reduction in RTC related injuries over the 4 years studied but the numbers varied over each year, so an overall trend was not apparent.

Conclusion
The number of admissions to a National Rehabilitation Hospital with Road traffic collision related injury reduced over the course of the 5 years of review but remains elevated. Linking data between MTA and NRH admission information may be an effective way to better understand the impact of RSA strategy and policy.

A31:
In Background Dexamethasone is a potent broad-spectrum corticosteroid that decreases the transcription of pro-inflammatory cytokines, whilst simultaneously increasing the transcription of anti-inflammatory cytokines. The cytokine storm that is central to the pathogenesis of Acute Respiratory Distress Syndrome (ARDS) and multi-organ failure is seen in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) related deaths. The objective of this study is to appraise the current evidence for the use of dexamethasone in the treatment of patients admitted to the intensive care unit (ICU) with SARS-COV2 infection.

Materials and methods
We conducted searches of two databases, EMBASE and PubMed, using the terms "COVID-19", "Dexamethasone", and "ICU". The search was limited to English language publications only, and human clinical trials only. A PRISMA flow chart was used to guide our search methodology.

Results
The database search identified 59 articles. Of these, two duplicates were discarded, and 57 citations were screened. 54 of these publications were deemed irrelevant based on the inclusion and exclusion criteria. Three were forwarded for full text review and met inclusion and exclusion criteria on full-text review. All three were deemed eligible. The selected studies consisted of two Randomised Clinical Trials (RCTs), and one Case Series Report. The results from the three papers were unanimous in their conclusion that dexamethasone was superior to standard care in the treatment of patients admitted to ICU with SARS-COV2. There was also a shorter duration of hospitalisation seen in the patient group treated with dexamethasone.

Conclusions
Our systematic review found that dexamethasone was superior to standard care alone in patients admitted to the ICU with SARS-COV2 infection. However, administration of dexamethasone to patients not on respiratory support resulted in a higher incidence of death, compared to standard care alone. Background Astrocytes are non-neuronal supportive cells which play a number of diverse roles in the healthy central nervous system (CNS). Following spinal cord injury, astrocytes become reactive (characterized by altered gene expression and morphology [1]) and form a glial scar around the lesion [2]. This glial scar contributes to tissue softening and altered extracellular matrix (ECM) deposition in the CNS. Interestingly, both stiffness and ECM composition have been shown to affect astrocyte reactivity [3]. However, the effect of substrate stiffness on astrocytes is not yet well understood. The increasing use of biotherapeutic implantable devices has led to heightened interest in the reaction of cells to implant properties such as stiffness. Therefore, characterization of the reaction of astrocytes to substrates of varying stiffness is a critical factor to consider in the design of implantable therapeutic devices for use in the CNS.

Methods
We aimed to create a 3D hyaluronic acid (HyA) scaffold with tuneable stiffness. However, HyA requires trophic ECM proteins to support cell attachment. We first cultured astrocytes on coverslips with various ECM components to assess their effects on astrocyte physiology via immunocytochemistry, fluorescence microscopy and ImageJ software. We then manufactured HyA scaffolds using 3 concentrations; 3, 5 & 10mg/mL. Stiffness was assessed by mechanical testing, while pore size was characterized by Toluidine blue staining and microscopy. We then cultured astrocytes on scaffolds of varying stiffness and assessed their metabolic activity (via Alamar blue assays) and expression of reactivity associated proteins (via ELISA) across multiple timepoints.

Results
Astrocyte metabolic activity was not significantly altered by the assessed ECM components. However, actin outgrowth and cell area were significantly increased in astrocytes cultured on ECM1 and ECM1+2, while nuclear:cytoplasm area and GFAP intensity (basic metrics of astrocyte reactivity) were not significantly altered in any group. The manufacture of scaffolds with tuneable stiffness was successful; the 3mg/mL scaffolds were significantly softer than the 10mg/mL scaffolds. Pore size was significantly higher in the 3 and 5mg/mL scaffolds compared to the 10mg/mL scaffolds. The metabolic activity of astrocytes cultured on the scaffolds initially decreased (D1-D4), but remained consistent at later timepoints (D4-D21); the 3mg/mL scaffold displayed the greatest activity at D21. Secretion of IL-6 from the astrocytes significantly decreased in all groups from D1 onwards, with no detectable levels at D21. Quantification of actin and GFAP coverage revealed that softer scaffolds had significantly greater coverage of both actin and GFAP.

Conclusions
The substrate stiffness of HyA scaffolds has significant effects on astrocyte physiology and has significant implications for scaffold design.

A33:
Prolonged response to metastatic pancreatic cancer treated with pembrolizumab based on mismatch repair status characterized from next generation sequencing Lan D. Vaccination was first discovered in 1796 by Edward Jenner in an effort to prevent the spread of smallpox disease [1,2]. The smallpox vaccine, described as the most successful vaccination effort in human history, was administered for over 150 years until the World Health Organization (WHO) declared the disease eradicated in 1980 [3,4,5].
In 1998, a study by Wakefield et al. reported a possible causal relationship between measles-mumps-rubella vaccination and autism in 12 children in the UK, resulting in the anti-immunization lobby receiving considerable media attention [6,7]. Although the publication was retracted in 2010, the controversy surrounding vaccination has had a lasting impact [8]. With COVID-19 cases still increasing throughout Ireland and the rest of the world, and COVID-19 vaccination options on the horizon, we find ourselves at an important moment in time to take a closer look at vaccination and the antiimmunization lobby.

Materials and methods
We performed a literature search with regards to the COVID-19 vaccination options, and have explored current vaccine trials and data. We then compared our findings with the framework for vaccine allocation and prioritization as outlined by the WHO. Additionally, we also explored the ethical question of who should receive access to vaccines first.

Results
After extensive review of the literature, we gathered information regarding the importance of vaccinations, herd immunity, and the strategic ways to immunize large populations. By highlighting the statistically significant results of several vaccine candidates, we illustrated the importance of the vaccination process as a safe and effective way to combat a virus in the midst of a pandemic affecting nearly every nation worldwide. Through careful research and analysis, our study aims to not only reduce skepticism of these vaccines, but to also emphasize the statistics that highlight their benefits.

Conclusion
Skepticism of a vaccine for a virus reaching all ends of the globe is a profound issue seen in countless nations. With growing concerns about safety and efficacy, it is important to delineate data emphasizing the benefits of multiple tested therapeutics in order to effectively combat the pandemic.

Background
Experimental HIV-1 vaccines frequently elicit antibodies against HIV-1 which may react with commonly used HIV diagnostic tests, a phenomenon known as vaccine-induced seropositivity/seroreactivity (VISP/VISR). We sought to determine under clinic conditions if the OraQuick ADVANCE Rapid HIV-1/2 Antibody Test could detect HIV-1 vaccine-induced antibodies.

Materials and methods
Plasma assessment of HIV-1 cross-reactivity was examined in end-ofstudy samples from 57 healthy, HIV-uninfected participants who received a candidate vaccine which has entered Phase 2B and 3 testing. We also screened 120 healthy, HIV-uninfected, unblinded HIV-1 vaccine participants with VISP/VISR for an assessment using saliva. These participants came from 21 different parent vaccine protocols representing 17 different vaccine regimens, all of which contained an HIV-1 envelope immunogen. OraQuick ADVANCE was compared to results from concurrent blood samples using a series of commercial HIV screening immunoassays.

Results
Fifty-seven unique plasma samples from vaccine recipients were assayed in vitro and only one (1.8%) was reactive by OraQuick ADVA NCE ( Conflict of Interest: The authors declare no conflict of interest.

Background:
The SARS-CoV-2 pandemic has had profound implications on healthcare institutions. The aim of this study is to assess and compare referral patterns during Covid-19 to corresponding dates for the preceding three years (2017-2019), in order to pre-emptively coordinate the logistics of the surgical unit for similar future experiences.

Methods:
A retrospective review was carried out at our institution, a national tertiary referral centre for spine pathology. Two distinct time-points were chosen to represent the varied levels of social restriction during the current pandemic; (i) Study period 1 (SP1) from 11/03/20-08/06/

Background
Idiopathic intracranial hypertension (IIH) is defined as elevated intracranial pressure in the absence of an identifiable cause. The relationship between IIH and anemia remains controversial. The goal of this study was to report on consecutive cases of IIH with a fulminant course and severe anemia (hemoglobin <80g/L) to provide additional evidence to this topic. This study also aimed to examine the causal relationship between anemia and IIH.

Materials and Methods
The retrospective case series of four patients with IIH and severe anemia, was diagnosed after neurologic imaging, lumbar puncture and an extensive workup to exclude secondary causes. MEDLINE, Embase, Cochrane Library, and grey literature were searched to September 2020. Primary studies on patients with diagnoses of anemia of any kind and IIH were included. Primary outcomes included the total number of cases of anemia and IIH. A meta-analysis on the prevalence of anemia in IIH compared to control patients was conducted.

Results
Four patients (all female) were included in the series with an average age of 28 years, and mean body mass index of 32.2kg/m 2 . Visual acuity ranged from 20/20 to 20/50 and the average Humphrey mean deviation was -7.30dB. The average hemoglobin at presentation was 71g/L and MCV 72.0. Correction of the anemia required aggressive treatment with intravenous iron in two patients and oral iron in the remaining cases. All patients were also treated with acetazolamide and optic nerve sheath fenestration for one patient. All patients had resolution of the papilledema and symptoms within 3 months as their hemoglobin increased to normal levels at that time. Often such patients present in an acute crisis triggered by a life changing event necessitating a multidisciplinary input which causes their management plan to be complex and slow. Determining a medical illness as the cause of a patient's acute psychiatric symptoms is not always straightforward and limited de-escalation facilities in the ED can lead to further inefficiencies in patient care. Despite this, there is currently limited literature on the flow of patients in the ED with psychiatric presentations. This pilot project aims to analyse the current practice of medical assessments in the ED of such patients and their effects on patient flow.

Methods
Patients were registered, triaged, and clinical notes documented on SVUH ED IT system: IMS MAXIMS. Data was gathered for 156 ED attendances over a 10-week consecutive period on investigations performed (including bloods, ECG, CT-Brain, Urine Toxicology, Urine Dipstick, and X-ray), total ED visit duration (Figure 1), and significant testing performed. Results 119 patients (76.3% of total) had some form of investigations performed including bloods, ECG, X-rays, CT-brain, urine toxicology, and urine dipstick. The percentage of abnormal test results from total amount tested for urine dipstick and urine toxicology tests was 46.5% and 66.7% respectively. In contrast, X-rays, CT-brain, and ECGs there was a low percentage of abnormal test results -12.5%, 7.69%, and 2.6% respectively. We compared the mean ED duration to each of the tests done and noticed, when using the Kruskal-Wallis test, that there is a significant difference in the mean ED duration when urine toxicology (p=0.005), CT-brain (p=0.002), and ECGs (p=0.011) were performed but no significance for urine dipstick testing (p= 0.122). However, when we compared the mean ED duration with "abnormal" results and "not done" urine dipstick tests using Mann-Whittney U test we obtained a p value of 0.04 which is significant.

Conclusions
We observed a high rate of investigations being performed for patients presenting with psychiatric complaints, with a high rate of normal results for most tests. We also observed a significantly longer duration of ED stay for patients when X-rays, ECGs, and CT-brain were performed. Strategies focused on rationalising the use of investigations in the ED will optimise flow for this patient cohort.

A39:
A retrospective study of body mass index and weight loss in Irish adults admitted to an acute hospital following infection with SARS-CoV-

Background
The rapid spread of the virus SARS-CoV-2, hereafter COVID-19, resulted in a global pandemic in March 2020. As with most infections, various complications and lengthy hospital stays have been noted in patients contracting COVID-19. Weight loss and malnutrition may be predictors for complications during the recovery from infection and have also been predictive of an increased length of hospital stay [1]. The aim of the current study was to investigate the potential associations between body mass index (BMI) and percentage weight loss with length of stay (LOS) and complications experienced as an inpatient with COVID-19.

Materials and Methods
This was a single centre cohort study involving adult patients diagnosed with COVID-19 and admitted to an acute general hospital in Ireland between the 1 st of March 2020 and the 31 st of May 2020. Data were extracted from relevant patient charts using a standardised reporting form and were analysed using SPSS (IBM SPSS version 26.0)

Results
Of the 30 patients included in the study, 29 were discharged following recovery from COVID-19 and there was one fatality. During the hospital stay, 37% (n=11) of patients suffered severe weight loss, 10% (n=3) suffered moderate weight loss, 13% (n=4) sustained mild weight loss and 40% (n=12) had no weight loss. The mean percentage weight lost was 2.91% (median, interquartile range =1.43%, 0-16.6) There was no significant relationship between percentage weight loss and LOS overall. However, in patients with a noncomplex discharge (n= 20) a significant positive linear correlation (r= 0.516, p= 0.02) was found. A significant positive correlation between percentage weight loss and number of complications during recovery was also observed overall (r= 0.423, p= 0.02).

Conclusion
There were significant findings for both the number of complications experienced and LOS based on the percentage weight loss suffered by patients. The current study found that the larger the deficit between a patient's weight at admission and at discharge, the greater the potential for complications and lengthier hospital stays. Therefore, the results of the current study highlight the need for appropriate multidisciplinary management of patients with COVID-19, including targeted nutritional management during a hospital stay and following discharge.
In conclusion, preventing weight loss and malnutrition is imperative in patients who are hospitalised with SARS-CoV-2 to minimise the risk of complications. Reporting of thyroid incidentalomas (TI) on imaging preformed for other indications has led to a clinical dilemma. The majority of thyroid nodules are benign, however; current guidelines suggest that a TI should be worked up to rule out malignancy. This study aims to determine the incidence of TIs and the likelihood that they reveal a sinister pathology in the largest Irish cohort studied to date.

Materials & Methods
A retrospective observational chart review was conducted using imaging studies obtained in Cork University Hospital from July 2018 to December 2018. The PACS database was searched using the defined inclusion and exclusion criteria. The body and summary of 500 carotid dopplers and 500 computed tomography (CT) thorax were manually screened for phrases such as "thyroid mass" or "thyroid nodule". Once all the patients with TIs were identified, electronic records and their medical charts were used to track the follow ups and final outcome of the identified nodules.

Results
Out of 1,000 scans, 14 (1.4%) thyroid incidentalomas were discovered. The average age for TIs according to this study was 68 and an equal distribution was seen amongst the genders. The occurrence of TIs by imaging was 2/500 (0.4%) for carotid doppler and 12/500 (2.4%) for CT thorax. Three (21.4%) TIs were further evaluated with a subsequent ultrasound. All three TIs were found to be ≥ 1.0cm and underwent investigation by fine needle aspiration. Using cytology, these TIs were given a Thy 2 grading (non-neoplastic).

Conclusion
This study found no clinical benefit to reporting the presence of TIs discovered incidentally. The three TIs that were evaluated were found to be benign, suggesting that TIs are unlikely to have a sinister pathology. A higher number of TIs were discovered on CT in comparison to US. This can be explained by a lack of formal guidelines for reporting thyroids on CTs. The concern remains that~98 TIs are expected to be found on these modalities in a year, this number may be enough to cause strain on the healthcare system. In addition, further work-up of these TIs burden patients with invasive investigations and cause them unnecessary anxiety about their health. Background Depression in the elderly can be challenging to treat but is known to respond well to pharmacotherapy. Selective Serotonin Reuptake Inhibitors or SSRIs are the most prescribed antidepressants because of their efficacy and low side effect profile. Little is known about direct comparisons between different SSRIs and their efficacy level. The primary outcome of this literature review is to assess the data on escitalopram, citalopram, fluoxetine, and sertraline to determine which one is the most efficacious regarding treatment of late-life depression Materials and methods The literature search was conducted using MEDLINE with full text, APAPsycArticles, and APAPsycINFO along with keywords "escitalopram", "citalopram", "sertraline", "fluoxetine", "depression", "elderly"", and "geriatric". This review includes studies that looked at the efficacy of SSRIs in treatment of depression in the elderly where the term "elderly" was defined as anyone aged over 60. Exclusion criteria includes studies that did not mention efficacy or look at patients under the age of 60. Studies with missing data were also excluded. Efficacy was identified using standardized depression scales such as the Hamilton Depression Scale (HAMD) [1], Geriatric Depression Scale (GDS) [2], or Montgomery-Asberg-Depression Scale (MADRS) [3]. Relevant literature was screened based on abstracts and titles. The articles were then read thoroughly, and their references were also searched to find eligibility. The results of the literature search are summarised in Figure 1.

Results
The use of citalopram in elderly patients with depression was assessed in 496 patients. The results are summarised in Table 1.
Citalopram was associated with a greater proportion of remission with greater daily dose and HAMD scores from baseline significantly improved [4]. Escitalopram was associated with a less positive response in elderly patients with major depression. Sertraline favored poorly when compared with other antidepressants like fluvoxamine. Fluoxetine had improved efficacy compared with placebo but similar efficacy when compared with amitriptyline Conclusion Citalopram consistently showed improvement in scores of efficacy in the studies that were reviewed. There is, however, more data required in direct comparisons between SSRIs and treatment of depression in the elderly before a more concrete conclusion can be drawn.  Lavretsky et al. [4] Double-blind, placebo-controlled Improved HAMD from baseline Greater dose led to greater remission Kyle et al. [5] Double-blind, double-dummy, parallel-group Improved mood and better tolerance Compared citalopram with amitriptyline Navarro et al. [6] Single-blind Improved mood and better tolerance Compared citalopram to nortriptyline Allard et al. [7] Double-blind, parallel Improvement in MADRS compared to baseline Venlafaxine as efficacious as citalopram Klysner et al. [8] Open followed by double-blind

Improvement in MADRS
Citalopram associated with lower rates of recurrence