Sheffield Yorks, United Kingdom

Adult SMA Research and Clinical Hub

Spinal muscular atrophy (SMA) is a genetic motor neuron disease with a broad spectrum of severity, affecting both infants and adults. Advances in treatment, including Nusinersen (Spinraza), onasemnogene abeparvovec (Zolgensma), and Risdiplam (Evrysdi), have significantly improved patient outcomes, highlighting the need for stronger clinical networks to monitor the long-term effects of these therapies. The Adult SMA REACH Study builds upon the success of SMA REACH UK, which has been instrumental in collecting natural history and treatment data for paediatric SMA patients. The study benefits from collaboration with TREAT-NMD, the UK SMA Patient Registry, and iSMAC, aligning with international efforts to harmonise SMA data collection. By leveraging Newcastle University's experience in global SMA initiatives, Adult SMA REACH aims to enhance patient care, inform clinical decision-making, and contribute to future SMA research.

Multi-omics Study in Citrin Deficiency

Citrin deficiency (CD) is an inherited autosomal recessive metabolic condition that is also a secondary urea cycle disorder caused by mutations in the SLC25A13 gene, which encodes for the mitochondrial transporter, citrin. Citrin is a key component of the mitochondrial malate-aspartate shuttle (MAS) and is responsible for moving Nicotinamide Adenine Dinucleotide (NADH) from the cytosol into the mitochondria via reducing equivalents such as malate, which drives mitochondrial respiration to produce energy in the form of adenosine triphosphate (ATP). The MAS is also critical in regulating Nicotinamide Adenine Dinucleotide (NAD+/NADH) redox balance to maintain cytosolic redox-dependent metabolic pathways such as glycolysis, gluconeogenesis, amino acid metabolism, and lipid metabolism. Citrin is also required to supply cytosolic aspartate, which is the substrate of one of the urea cycle enzymes, namely argininosuccinate synthetase 1, and thus important for the proper functioning of the urea cycle. The clinical presentations of citrin deficiency often vary widely between patients but can generally be distinguished by distinct clinical phenotypes, which are neonatal intrahepatic cholestasis caused by citrin deficiency (NICCD) that affects infants, the "failure to thrive and dyslipidemia" form of CD (FTTDCD) in childhood, the adaptation or silent period, and citrullinemia type II (CTLN2), which represents the most severe form of the condition. While only a small percentage of CD patients develop CTLN2, the prognosis for these patients is typically poor. It is notable that all CD patients above 1 year old (post-NICCD) naturally develop a characteristic food preference that favors a diet rich in protein and fat while being low in carbohydrates. Other clinical findings observed in some CD patients include fatty liver, fatigue, hypoglycemia, and failure to thrive. There is currently no effective cure for CD. Before the onset of CTLN2, patients are primarily managed by diet control with a low carbohydrate, high protein and high-fat diet, as well as medium chain triglyceride (MCT) supplementation. CTLN2 patients have been treated with sodium pyruvate, arginine, and MCT with limited success, with severe cases requiring liver transplantation as the only solution. There are currently no specific biomarkers that effectively track the disease progression, making it challenging to monitor how well patients are actually doing or to measure the effectiveness of therapies. Without proper management or timely medical interventions, patients may develop CTLN2. Given the urgent and unmet need for biomarkers specific to CD, the main goal of this study is to uncover disease-specific biomarkers by analyzing blood samples collected from CD patients using both targeted and untargeted metabolomics, proteomics, lipidomics, and transcriptomics. Targeted omics will involve the analysis of cellular pathways associated with the condition, such as the MAS pathway, glycolysis, protein metabolism, de novo lipogenesis, lipolysis, gluconeogenesis, NAD+ metabolism, ureagenesis, and the glutamine synthetase pathway. Identification of such biomarkers will allow a deeper understanding of the disease pathogenesis. Importantly, these biomarkers may enable better tracking of disease progression and may help to prevent the onset of CTLN2. Finally, these biomarkers will also greatly benefit the development of effective therapeutic options for CD in clinical trials by serving as measurable endpoints. Obtaining the necessary material from patients consists of a minimally invasive venous blood sampling taken during a regular outpatient visit and after the informed consent of the patients or caretakers.

Open Label Trial Studying the Safety and Effectiveness of ILUVIEN® (190μg) in Children and Adolescents, Who Have Recurrent Non-infectious Uveitis Affecting the Posterior Segment of the Eye.

Polycystic Kidney Disease 1 (PKD1) Gene Variant Groups in Autosomal Dominant Polycystic Kidney Disease

Neurological Responses in Patients with Dentine Hypersensitivity

Dentine hypersensitivity (DH) is a common dental condition that has been defined as a 'short, sharp pain arising from exposed dentine in response to stimuli typically thermal, evaporative, tactile, osmotic or chemical and which cannot be ascribed to any other form of dental defect or pathology'. Many DH interventions have been investigated over the last 60 years, but a lack of standardisation of pain measurement and objectivity of measures are major limitations for assessing the efficacy of products (or understanding why products fail). A potential solution to this problem is greater understanding of the pain propagation mechanism from controlled stimulus to objective, measurable markers of pain severity. EEG (electroencephalography) is a non-invasive technique that measures the electrical activity of the brain using the electrodes placed on the scalp. EEG provides information about the brain's electrical activity over time, helping diagnose and understand certain neurological conditions. The investigators have carried out a number of studies using human dental pulp and other human tissue to further understand the mechanisms of pain including pulpal pain. Evoked potentials are EEG responses to specific stimuli, such as light, sound or heat. Pain-evoked potentials from tooth pulp are evoked potentials specifically related to pain originating from the pulp of a tooth. This type of measurement records the brain's electrical response to a stimulus applied to a tooth, such as thermal stimuli. The resulting EEG recording can provide information about how the central nervous system processes painful stimuli, including the speed and magnitude of the response. It was hypothesised that EEG pain-evoked potentials, if generated and measured in a controlled and repeatable way, can potentially be used (in conjunction with other diagnostic methods) to objectively evaluate the severity of dentine sensitivity and compare the efficacy of different treatment options.

The Effect of Mobile Devices on the Development and Health of Young Children

Quality assurance Researchers undertaking the measurements are highly experienced in the procedures and analysis. The investigators are utilising only validated tools that are well-established in the literature. The exposure and use of interactive electronic devices (e.g., tablets and smartphones) will be measured by an app that will access information directly from the participant's devices (Android or iOS) using mobile sensing software to capture screen time and app usage (Lind et al. 2023). The app has been successfully used to measure smartphone use in children (Bagot et al., 2022; Wade et al., 2021). The measurement of emerging abilities, our primary outcome measure, has been validated and widely used in the literature (Howard et al. 2017). The investigators will use an administration fidelity checklist to assess practice across researchers before the start of data collection. A range of secondary outcomes will be recorded (i.e. BMI (calibrated scales and repeated measures), movement behaviour (accelerometry Cliff et al. 2024), motor development (NIH toolbox, Reuben et al., 2013), parent and child interaction (StimQ2, Cates et al. 2023). These measurements have been used in the SUNRISE study, which is collecting data on children at this age in 63 countries around the world (https://sunrise-study.com/) and published in a protocol (Okely et al., 2021). Training videos and support have been provided by the SUNRISE team and have been used to inform our study protocol. Since child development is influenced by a number of covariates, the investigators have selected the most commonly reported in the literature and suggested by our PPI group (i.e. sex, age, ethnicity, maternal education, parenting style (PSDQ- SV. Robinson et al. 2001), attendance to childcare, parental addiction to smartphones (SAS-SV, Kwon et al., 2013) and screen viewing policy. Data processing Data capture forms have been created for applicable measures to standardise data input and aid with data entry. In terms of data processing and analysis. The investigators will conduct preliminary data cleaning, exploring whether values of continuous variables are within range, plausibility of means and standard deviations, and validity of coded categories. The investigators will assess data distributions and identify any univariate outliers from graphical methods and from cases with very large, standardised scores disconnected from other scores and multivariate outliers by graphical methods and inspection of leverage/Mahalanobis distances, discrepancy and influence statistics. Any possible errors will be investigated on an individual basis. The investigators will also investigate the extent, pattern and nature of missing data. If the proportion of missing data is small (below 5%), they will consider complete case analyses. If the amount or pattern of missing data precludes complete case analysis, the investigators will consider data imputation. Multiple imputations will be used due to their robustness to the type of data missingness. If imputation is conducted, sensitivity studies will be conducted by comparing results derived from data with and without imputation. Data analysis Descriptive analysis The sample will be summarised descriptively. The investigators will report the number of children in each educational unit and primary and secondary outcomes by time point (baseline and follow-up). For continuous outcomes, summary information will be presented as means (standard deviations (SD); ranges). For categorical outcomes, summary information will be presented as frequencies (percentages). The need for variable transformations to stabilise variance or achieve Normality will be assessed. Inferential analysis The following test variables will be considered for the analysis: 1) IED duration; 2a) IED mode educational; 2b) IED mode age-appropriate. 1. Multilevel regression modelling of primary outcome The investigators conceptualised a 2-level random intercepts multilevel model, with children clustered within educational units. This model will consider EA at the follow-up to be the outcome measure designed to answer the primary research questions: How is IED duration (hours per day) and mode (educational vs. non-educational; age-appropriate vs. non-age-appropriate) at baseline, controlling for child-level covariates (including EA baseline scores) and educational unit-level covariates, associated with EA at follow-up in a multilevel model in which children are clustered within educational units? The variance partition coefficient (VPC; the proportion of residual variance associated with each level of the model) will be assessed via a null model before proceeding to a covariate model. The investigators will consider merging the levels in the model if VPC statistics reveal negligible clustering effects (negligible residual variance at the level of the educational unit). A non-linear multiple regression modelling will be conducted if there is evidence for a non-linear relationship between the level of IED usage at baseline and EA at follow-up, allowing for a single maximum (corresponding to optimum levels of baseline IED usage) or plateau; otherwise, linear regression models will be conducted. If data indicates an optimum IED level of usage associated with a specific maximum value of EA score at follow-up, alternative non-linear functional forms will be considered with maxima or plateauing features, including polynomial (e.g. quadratic) and logarithmic forms, and piecewise functions. The investigators will compare the fit of multiple distributions in the vicinity of any turning point and select the best-fitting model in this region to maximise the accuracy with which the maximum value of EA may be obtained. Confidence intervals will be fitted around the function to derive a range of values for the maximum value. The investigators will conduct both non-fully adjusted and adjusted models, with adjusted models adjusted for all covariates at each level of the model. Non-adjusted models will include (i) the single determinant of the level of IED usage (duration) at baseline, (ii) the determinants of IED predominant mode at baseline (as defined above), and (iii) determinants of IED duration and mode. These determinants will all be added in at the child level of the model. First-order interactions will be included within unadjusted models to capture any differential effects in assessing levels of IED usage with differing predominant modes of use. Any interaction revealed to be of substantive importance will be retained in a re-cast model alongside all main effects. Adjusted models will be based on the included variables of both IED duration and IED predominant mode, any interactions of substantive importance and all controlling covariates at the appropriate level of the model. The investigators will not use automated modelling strategies for variable selection and will retain all main effects in the adjusted model. However, collinearity will be assessed in adjusted models and consider deletion of controlling covariates if excessive collinearity is apparent (variance inflation factor >=5 for any variable). 2. Multilevel regression modelling of secondary outcomes The investigators will conduct multiple linear regression modelling on all numerical secondary outcomes and multiple logistic regression modelling for the binary secondary outcome measure, using the same model structure as for the main analysis of the primary outcome. If any evidence is revealed for non-linearity between the level of IED duration and the secondary outcomes, The investigators will consider non-linear modelling for the analysis of the primary outcome; else, they will consider linear modelling. In both cases, the same set of covariates and interactions defined for the primary outcome will be adjusted. No adjustment for multiple analyses will be made; hover, all analyses will be planned a priori and reported in full. 3. Multilevel regression modelling: subsidiary analysis To explore the socio-ecological correlates of IED duration at the individual (gender, age and ethnicity), interpersonal (maternal education, parenting style and smartphone addiction), and organisational (childcare policy and attendance) levels, will be conducted as a subsidiary analysis, considering the above set of variables as determinants of IED using the variables that are reported as controlling variables. Random intercepts and multiple linear regression modelling on the outcome of IED duration will be conducted at baseline. A 2-level hierarchical structure will be used, with variables designated as Individual or Interpersonal attached at the lower (child) level and variables designated as Organisational attached at the upper (educational unit) level. Any relationships revealed during this process will be used in future modelling to generate hypotheses within a wider structural equation modelling framework. 4. Sensitivity analysis and data reporting For the primary outcome, the plan is to conduct sensitivity analyses to assess the sensitivity of the model to certain assumptions, as mentioned above. The investigators will compare parameter estimates of tested variables in unadjusted and adjusted models. For the multilevel modelling of the relationship between IED duration and EA, both random slopes and random intercepts models will be used to assess variation in slopes between higher-level units. If data imputation is viable, models will be run with and without imputed data (see 'Data cleaning and assessment of missing data'). For linear and non-linear regression models of continuous numerical outcomes, in the main and subsidiary analyses, the investigators will report all unstandardised parameter estimates with associated 95% confidence intervals and p-values. For logistic regression models, all odds ratios with associated 95% confidence intervals and p-values will be reported. If evidence is revealed for a non-linear trend, the investigators will report the functional form of the best-fitting curve and identify the location of any maximum or commencement of plateauing effects. All regression modelling assumptions will be checked, including homogeneity of variance and normality of outcome variables for each value of an independent variable, using residual analysis. Statistical analyses will be conducted using MLwiN version 3.06 (Charlton et al., 2022) and Stata version 17 (Stata Corp 2021).

A Study to Investigate the Safety and Efficacy of mRNA-1403 in Participants ≥18 Years of Age for the Prevention of Acute Gastroenteritis

Myocardial Injury After Radical Nephrectomy

Patients undergoing nephrectomy have a greater risk of cardiac events requiring admission compared to the general population. For example, registry data report 21% of patients over 65 undergoing nephrectomy have at least one cardiovascular event after surgery. Myocardial injury after non-cardiac surgery (MINS) is a condition which is associated with increased mortality and a higher rate of major adverse cardiac events (MACE), in both the immediate perioperative period and within 1-year post-surgery. Diagnosis is via the presence of elevated troponin levels in the first 3 days post-surgery, in the absence of ischaemic symptoms and ECG changes. The occurrence of MINS following nephrectomy for renal cell carcinoma has not yet been explored. Risk factors for MINS include increasing age and post-operative acute kidney injury. Results from the British Association of Urological Surgeons (BAUS) Nephrectomy audit demonstrate that most patients undergoing nephrectomy are over 60 and that increasing age is associated with lower eGFR pre-operatively. The accepted further reduction in post-operative GFR with nephrectomy makes these patients at high risk of MINS. The BAUS Nephrectomy audit also demonstrates that elderly patients undergoing nephrectomy are likely to be anaemic preoperatively. In at-risk patients, any intraoperative haemodynamic instability may progress to myocardial injury and cardiac related complications due to a change in myocardial oxygen demand. Most radical nephrectomies are now performed using robotic or laparoscopic approaches. Current evidence from retrospective studies and a small prospective study suggests that there is no difference in perioperative nor oncological outcomes between laparoscopic and robotic radical nephrectomy, including blood loss. However, no studies to date have looked at MINS and large-scale prospective studies comparing the haemodynamic effects of laparoscopic vs robotic nephrectomy are needed. Understanding the spectrum of MINS and its potential impact on patients undergoing nephrectomy is pivotal. This could lead to better patient selection and stratified care to improve outcomes. Advances in systemic therapy for metastatic disease mean nephrectomy may become more prevalent in persons on multiple therapies. As patients undergoing nephrectomy are at high risk of MINS, it is vital to have a greater understanding of this potential complication. This aligns with the James Lind Alliance Priority Setting Partnership in perioperative care which highlights the importance of research into post-operative complications. Furthermore, this group also underlines the importance of adequate preoperative discussions with patients, which would include the risk of postoperative complications such as MINS. Eligible patients who have consented to the study will have their troponin levels measured on the day of the surgery and at day 1 post-op to diagnose MINS. A baseline quality of life assessment will also be made by asking patients to complete an EQ-5D-5L questionnaire. Any blood transfusions during the admission period will also be recorded. At day 90 post-op, the occurrence of MACE events and days out of hospital (DAOH90) will be checked, and the patient will be contacted to complete the quality-of-life questionnaire again. Baseline assessments: The following demographic information will be prospectively collected by reviewing the patient's medical notes: - Age, sex, and ethnicity - Previous history of ischaemic heart disease, congestive cardiac failure, cerebrovascular disease (stroke or TIA), diabetes - Tumour characteristics (radiological T stage, laterality) Pre-op renal function and baseline troponin will be measured on the day of surgery. Primary outcome measure: The primary outcome measure is the proportion of patients undergoing laparoscopic or robotic radical nephrectomy with evidence of myocardial injury (MINS). This will be defined as a raised troponin level >99th percentile upper reference limit on any sample taken within 72 hours following the operation. Patients will have troponin levels measured on the morning of surgery and at day 1 post-op. If applicable, this can be retrieved as an 'add on' test on routine samples, without the requirement for an additional "blood draw" to avoid extra burden to patients. Sites will be expected to manage patients post-operatively as per Trust guidelines - this may or may not include troponin monitoring. The European Society for Cardiology advocates testing of troponins but does not make treatment recommendations. If troponin monitoring is not part of usual care, the troponin samples will not be available to the clinical team to avoid any inadvertent additional investigations which may add to patient burden. Instead, we would arrange the troponin results to be processed after surgery. However, the clinical team can request troponin tests for clinical information, for example in the assessment of chest pain. In this situation, the troponin sample would be processed immediately and be available for the clinical team to view. The clinical team will be expected to follow local guidelines regarding the clinical management. If the clinical team requests a troponin level for clinical assessment, we will also note this in the research record. Secondary outcome measures: Perioperative assessments: ● Any blood transfusions during the intraoperative and/or postoperative period will be recorded. This will allow assessment of potential cardiovascular instability compared between the groups (laparoscopic vs robot-assisted) and how this translates to rates of MINS and MACE post-op. 90 days (+/- 7 days) post-procedure: Patients will be contacted by the research team via telephone to assess the following: - The occurrence of any major adverse cardiovascular event (myocardial infarction, stroke, arrhythmia, cardiac arrest, and cardiac related death) during admission will be recorded. This will be obtained as part of patient follow up at 90 days post-op. - Days out of hospital at 90 days (DAOH90). This will be recorded following discussion with the patient and review of local hospital data - Impact on quality of life will be assessed using the EQ-5D-5L via a telephone interview by the research team.

The Use of DXA in Scoliosis

This pilot study is an interventional study where patients having routine standing or sitting spinal x-rays for scoliosis monitoring or as part of a treatment protocol will be approached to see if they would have an additional supine AP DXA image. Participants will only have one additional DXA image during the pilot study. The consent will be obtained by one of the spinal surgeons or a specialist spinal nurse. The DXA scan will be performed by one of the radiographers. This study may be performed by a medical student or junior doctor (either would be part of the care team) and supervised by the PI. The pilot study is expected to last 9 months and consist of 25 patients. The DXA images will be reviewed by 2 consultant spinal surgeons and a consultant radiologist who will make a collective decision every month as to whether the study, or that part of the study, should continue. Two scoliosis patients have read the study protocol and given their input. The Sheffield Children's Hospital Scoliosis PPI group will feedback on key aspects during the study and help define future studies suggested by this study.

Erdafitinib Monotherapy or in Combination With Cetrelimab in Muscle-invasive Bladder Cancer Patients With Fibroblast Growth Factor Receptor (FGFR ) Gene Alterations

The aim of the study is to assess the antitumor activity measured as ypT0 rate, defined as no evidence of residual disease based on pathological review of the surgical specimen (pCR) and tumour downstaging (<ypT2). Patients must have a MIBC (cT2-T4a N0/N1 M0) who harbour selected FGFR alterations stated in the protocol and are either ineligible for or refuse cisplatin-based neoadjuvant chemotherapy, as defined by consensus criteria (see 6.1 Inclusion criteria). Once it is confirmed that the subjects fulfil the eligibility criteria and have signed the informed consent form, they will receive erdafitinib alone (cohort 1) or erdafitinib in combination with cetrelimab (cohort 2). Patients will receive neoadjuvant treatment with erdafitinib alone (cohort 1) or erdafitinib plus cetrelimab (cohort 2) before proceeding to Radical Cystectomy (RC) (to be performed within 2 - 6 weeks after the last study drug treatment) Cohort 1: patients will receive erdafitinib Cohort 2: patients will receive erdafitinib in combination with cetrelimab intravenously (IV) Radiological assessment: A Computed Tomography /Magnetic Resonance Imaging and/or Positron Emission Tomography (per standard local imaging practices) will be scheduled as follow: - Basal assessment: during screening period (no more than 28 days before Cycle1, Day 1(C1D1) - Response assessment: At the end of treatment period allowing time for imaging review in advance of Radical cystectomy (RC). - Follow-up assessment: an image evaluation must be done at first follow-up visit and thereafter, it will be schedule according to local standards and as clinically indicated. A local pathological assessment will be done on specimens obtained during RC (for co-primary endpoints). Thereafter, during the follow-up period, pathological assessments will be scheduled according to local standards and as clinically indicated. Patients with disease progression during the treatment phase will be discontinued from the study and will receive their treatment according to the investigator's judgment and monitored to evaluate Overal Survival .