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Extracorporeal membrane oxygenation (ECMO) support has a high incidence of both bleeding and thrombotic complications. Despite clear differences in patient characteristics and pathologies between veno-venous (VV) and veno-arterial (VA) ECMO support, anticoagulation practices are often the same across modalities. Moreover, there is very little data on their respective coagulation profiles and comparisons of thrombin generation in these patients. This study compares the coagulation profile and thrombin generation between patients supported with either VV and VA ECMO. A prospective cohort study of patients undergoing VA and VV ECMO at an Intensive care department of a university hospital and ECMO referral centre. In addition to routine coagulation testing and heparin monitoring per unit protocol, thromboelastography (TEG), multiplate aggregometry (MEA), calibrated automated thrombinography (CAT) and von-Willebrand’s activity (antigen and activity ratio) were sampled second-daily for 1 week, then weekly thereafter. VA patients had significantly lower platelets counts, fibrinogen, anti-thrombin and clot strength with higher d-dimer levels than VV patients, consistent with a more pronounced consumptive coagulopathy. Thrombin generation was higher in VA than VV patients, and the heparin dose required to suppress thrombin generation was lower in VA patients. There were no significant differences in total bleeding or thrombotic event rates between VV and VA patients when adjusted for days on extracorporeal support. VA patients received a lower median daily heparin dose 8500 IU [IQR 2500–24000] versus VV 28,800 IU [IQR 17,300–40,800.00]; < 0.001. Twenty-eight patients (72%) survived to hospital discharge; comprising 53% of VA patients and 77% of VV patients. Significant differences between the coagulation profiles of VA and VV patients exist, and anticoagulation strategies for patients of these modalities should be different. Further research into the development of tailored anticoagulation strategies that include the mode of ECMO support need to be completed.

Methane (CH 4 ) emission by carbon-rich cryosols at the high latitudes in Northern Hemisphere has been studied extensively. In contrast, data on the CH 4 emission potential of carbon-poor cryosols is limited, despite their spatial predominance. This work employs CH 4 flux measurements in the field and under laboratory conditions to show that the mineral cryosols at Axel Heiberg Island in the Canadian high Arctic consistently consume atmospheric CH 4 . Omics analyses present the first molecular evidence of active atmospheric CH 4 -oxidizing bacteria (atmMOB) in permafrost-affected cryosols, with the prevalent atmMOB genotype in our acidic mineral cryosols being closely related to Upland Soil Cluster α. The atmospheric (atm) CH 4 uptake at the study site increases with ground temperature between 0 °C and 18 °C. Consequently, the atm CH 4 sink strength is predicted to increase by a factor of 5–30 as the Arctic warms by 5–15 °C over a century. We demonstrate that acidic mineral cryosols are a previously unrecognized potential of CH 4 sink that requires further investigation to determine its potential impact on larger scales. This study also calls attention to the poleward distribution of atmMOB, as well as to the potential influence of microbial atm CH 4 oxidation, in the context of regional CH 4 flux models and global warming.

Climate warming and subsequent permafrost thaw may result in organic carbon and nutrient stores being metabolized by microbial communities, resulting in a positive feedback loop of greenhouse gas (GHG) soil emissions. As the third most important GHG, understanding nitrous oxide (N₂O) flux in Arctic mineral ice-wedge polygon cryosols and its relationship to the active microbial community is potentially a key parameter for understanding future GHG emissions and climatic warming potential. In the present study, metatranscriptomic analyses of active layer Arctic cryosols, at a representative ice-wedge polygon site, identified active nitrogen-fixing and denitrifying bacteria that included members of Rhizobiaceae, Nostocaceae, Cyanothecaceae, Rhodobacteraceae, Burkholderiaceae, Chloroflexaceae, Azotobacteraceae and Ectothiorhodospiraceae. Unique microbial assemblages with higher proportion of Rhodobacteriales and Rhocyclales were identified by targeted functional gene sequencing at locations with higher (P = 0.053) N₂O emissions in the wetter trough soils compared with the dryer polygon interior soils. This coincided with a higher relative abundance of the denitrification nirS gene and higher nitrate/nitrite concentrations in trough soils. The elevated N₂O flux observed from wetter trough soils compared with drier polygon interior soils is concerning from a climate warming perspective, since the Arctic is predicted to become warmer and wetter.

We describe an unusual presentation of a suspected pediatric foreign body (FB) aspiration which was found to be an occlusive inflammatory myofibroblastic tumor (IMT) of the distal trachea. These are rarely reported entities, with the potential for significant airway bleeds. Multidisciplinary discussion and involvement allowed for a safe patient outcome. Pediatric foreign body aspirations are common presentations to emergency departments. However, while rare, tumors or other masses may have a similar presentation and should be considered on the differential.

BackgroundThe most common cancer diagnosed in germline TP53 pathogenic variant (PV) carriers is premenopausal breast cancer. An increased rate of breast tumour HER2 positivity has been reported in this group. Screening for breast/other cancers is recommended in PV carriers.Objectives1. To assess the frequency of germline TP53 PVs reported diagnostically in women with breast cancer at <30 years of age.2. To evaluate the impact of personal/family history and HER2 status on the likelihood of germline TP53 pathogenic/likely pathogenic variant (PV/LPV) identification.MethodsGenetic test results from patients undergoing diagnostic germline TP53 tests between 2012 and 2017 in the four London Regional Clinical Genetics Services were reviewed. Clinical/pathology data and family history were extracted from genetics files for women diagnosed with breast cancer at <30 years.ResultsThe overall germline TP53 PV/LPV variant detection rate was 9/270=3.3% in all women diagnosed with breast cancer at <30 years and 2/171=1.2% in those with no second/subsequent cancer diagnosis or family history of TP53-spectrum cancers. Breast cancers were significantly more likely to be HER2-positive in TP53 PV/LPV carriers than in non-carriers (p=0.00006).ConclusionsGermline TP53 PVs/LPVs are uncommon among women diagnosed with breast cancer aged <30 years without other relevant personal or family cancer history but have an important clinical impact when identified.

Severe headaches associated with hypertension developed in a 36-year-old woman 10 days after delivery of twins by cesarean section; initial brain magnetic resonance imaging (MRI) and computed tomographic examinations were normal. Headaches persisted despite antihypertensive medications; a seizure and an episode of aphasia and hemiparesis occurred. Repeated MRI and magnetic resonance angiography showed posterior white-matter changes on T 2 -weighted sequences and multifocal narrowing and dilatation of intracranial arteries. A diagnostic procedure was performed. Severe headaches associated with hypertension developed in a 36-year-old woman 10 days after delivery of twins. Headaches persisted despite antihypertensive medications; a seizure and an episode of aphasia and hemiparesis occurred. MRI and magnetic resonance angiography showed posterior white-matter changes and multifocal narrowing and dilatation of intracranial arteries. Presentation of Case Dr. W. Taylor Kimberly: A 36-year-old woman was admitted to the hospital because of headaches, hypertension, and seizures. Nineteen days before the current admission, she delivered healthy twins at 35.6 weeks of gestation by cesarean section (for breech presentation) at another hospital. She was discharged on the fifth day. Nine days before the current admission, she began to have intermittent, throbbing, bifrontal headaches, and 2 days later she saw her gynecologist. She rated the pain as 8 (on a scale of 0 to 10, with 10 being the most severe pain). The blood pressure was 150/72 mm . . .

Introduction Delivering 24/7 specialist palliative care is a national priority. A previous study looking at the urgent requests to the hospice, over 3 months, showed that over ¾ of appropriate admissions were admitted within 24 hours. Aim To describe the characteristics of patients who were admitted following a request for emergency admission over a 3 month period. Methodology This was a retrospective case note review of data for the 12 months prior to emergency admission, describing the events leading up to and the outcome of the admission. Results Twenty-nine patients were included in the analysis. Of the 29 patients included, 34% were from the most deprived quintile. Ninety percent of emergency referrals and 100% of admissions had a malignant diagnosis. Forty-one percent of emergency admissions were for end-of-life care (EOLC). Sixty-six percent had a DNACPR before admission and 90% had an electronic key information summary. Seventy-five percent had at least 1 hospital admission in the previous year but only 1 patient was admitted from hospital. Patients being admitted for EOLC or by their GP had a shorter length of admission. Seventy-two percent died during the admission and 28% were discharged home and later died at home or in the hospice. No patients died in hospital. Conclusion The emergency admissions to the hospice over these 3 months were genuine emergencies. Most of the patients were living in deprivation, meaning they are more likely to have multiple co-morbidities and social complexities. These emergency admissions to the hospice prevented admission to hospital and furthermore any of these patients dying in hospital. Anticipatory care planning was evident but further work needs done to explore the impact of deprivation, the reasons behind the lack of emergency requests for patients with non-malignant conditions and pathways for direct hospice transfer of acute front door hospital admissions where appropriate.