Safety and efficacy of tenecteplase in patients with wake-up stroke assessed by non-contrast CT (TWIST): a multicentre, open-label, randomised controlled trial

BACKGROUND

Current evidence supports the use of intravenous thrombolysis with alteplase in patients with wake-up stroke selected with MRI or perfusion imaging and is recommended in clinical guidelines. However, access to advanced imaging techniques is often scarce. We aimed to determine whether thrombolytic treatment with intravenous tenecteplase given within 4·5 h of awakening improves functional outcome in patients with ischaemic wake-up stroke selected using non-contrast CT.

METHODS

TWIST was an investigator-initiated, multicentre, open-label, randomised controlled trial with blinded endpoint assessment, conducted at 77 hospitals in ten countries. We included patients aged 18 years or older with acute ischaemic stroke symptoms upon awakening, limb weakness, a National Institutes of Health Stroke Scale (NIHSS) score of 3 or higher or aphasia, a non-contrast CT examination of the head, and the ability to receive tenecteplase within 4·5 h of awakening. Patients were randomly assigned (1:1) to either a single intravenous bolus of tenecteplase 0·25 mg per kg of bodyweight (maximum 25 mg) or control (no thrombolysis) using a central, web-based, computer-generated randomisation schedule. Trained research personnel, who conducted telephone interviews at 90 days (follow-up), were masked to treatment allocation. Clinical assessments were performed on day 1 (at baseline) and day 7 of hospital admission (or at discharge, whichever occurred first). The primary outcome was functional outcome assessed by the modified Rankin Scale (mRS) at 90 days and analysed using ordinal logistic regression in the intention-to-treat population. This trial is registered with EudraCT (2014-000096-80), ClinicalTrials.gov (NCT03181360), and ISRCTN (10601890).

FINDINGS

From June 12, 2017, to Sept 30, 2021, 578 of the required 600 patients were enrolled (288 randomly assigned to the tenecteplase group and 290 to the control group [intention-to-treat population]). The median age of participants was 73·7 years (IQR 65·9-81·1). 332 (57%) of 578 participants were male and 246 (43%) were female. Treatment with tenecteplase was not associated with better functional outcome, according to mRS score at 90 days (adjusted OR 1·18, 95% CI 0·88-1·58; p=0·27). Mortality at 90 days did not significantly differ between treatment groups (28 [10%] patients in the tenecteplase group and 23 [8%] in the control group; adjusted HR 1·29, 95% CI 0·74-2·26; p=0·37). Symptomatic intracranial haemorrhage occurred in six (2%) patients in the tenecteplase group versus three (1%) in the control group (adjusted OR 2·17, 95% CI 0·53-8·87; p=0·28), whereas any intracranial haemorrhage occurred in 33 (11%) versus 30 (10%) patients (adjusted OR 1·14, 0·67-1·94; p=0·64).

INTERPRETATION

In patients with wake-up stroke selected with non-contrast CT, treatment with tenecteplase was not associated with better functional outcome at 90 days. The number of symptomatic haemorrhages and any intracranial haemorrhages in both treatment groups was similar to findings from previous trials of wake-up stroke patients selected using advanced imaging. Current evidence does not support treatment with tenecteplase in patients selected with non-contrast CT.

FUNDING

Norwegian Clinical Research Therapy in the Specialist Health Services Programme, the Swiss Heart Foundation, the British Heart Foundation, and the Norwegian National Association for Public Health.

Diagnostic yield from cardiac gene panel testing for inherited cardiac conditions in a large Irish cohort

Background

Inherited cardiomyopathies (hypertrophic, dilated and arrhythmogenic) and cardiac ion channelopathies (long QT, Brugada and CPVT) predispose to sudden cardiac death/sudden arrhythmic death syndrome. Given their genetically heterogenous nature, multi-gene DNA sequencing panels are useful to aid genetic diagnosis.

Purpose

Investigate the diagnostic yield from cardiac gene panel testing undertaken in patients (including molecular autopsy in deceased patients) referred to four clinical services from 2002 to 2020.

Methods

Data was collected by interrogation of departmental databases, family charts, and review of molecular genetic diagnostic reports.

Results

We evaluated molecular genetic diagnostic results from 835 individuals (461 males, 374 females) from 824 families, including 58 deceased patients who underwent molecular autopsy. The median age of the cohort was 44 years (range 0.1–86 years).

Testing for hypertrophic cardiomyopathy (HCM) and long QT syndrome (LQT) genes represented 36% and 32% of the cohort, respectively, with the remaining 32% accounting for other cardiomyopathies, arrhythmia syndromes or metabolic/syndromic diseases. The overall variant detection rate was 50% across all panel types. Three hundred and fifty patients (42%) carried a single variant, 68 patients (8%) carried multiple variants (up to a maximum of four), including two individuals who carried two actionable (pathogenic/likely pathogenic) variants each and 30 individuals (5%) with one actionable variant plus a variant of uncertain significance (VUS).

The overall diagnostic yield of at least one actionable variant was 28%. At least one VUS was detected in 27% of the cohort. Molecular autopsy yielded an actionable variant in 10% of patients, while 30% of the subcohort carried at least one VUS (up to maximum of two).

We found a positive association between female sex and the likelihood of detecting an actionable variant. By decade of age, detection of actionable variants ranged from 19% (60–69 years) to 41% (0–9 years). By panel type, actionable variants ranged from 14% (Brugada) to 35% (cardiomyopathy). The burden of VUS ranged from 22% (LQT) to 46% (dilated cardiomyopathy).

Altogether 234 actionable variants were detected in 26 genes, including seven metabolic or syndromic disease genes. From those with non-metabolic/syndromic forms of disease, 84% of actionable variants were detected in well established ICC genes. Analysis of gene-disease associations for VUS detected from HCM and LQT panels revealed that 10–25% were detected in genes now deemed to have only moderate or limited evidence of disease causation.

Conclusion

Most actionable variants in this cohort were detected in well-established ICC genes, suggesting that large gene panels offer little extra sensitivity compared to historic smaller gene panels. Despite recent gene curation efforts, the high burden of VUS remains a considerable challenge in ICC management.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): National Children's Research Centre

The role of ILR monitoring in patients with a family history of SADS, a view from real clinical practice

Background/Introduction

Implantable Loop Recorder (ILR) device monitoring is an established method for long term heart rhythm monitoring in patients with inherited cardiac conditions. Many present with a family history of Sudden Arrhythmic Death Syndrome (SADS). The value of ILR findings in the investigation of SADS relatives has not been well documented.

Purpose

We aimed to evaluate the impact of ILR monitoring on the management plans of patients with a family history of SADS.

Methods

We performed a retrospective analysis of the ILR reports and electronic patient records of all patients at the inherited cardiac disease clinic with a family history of SADS and an ILR implanted. Patient demographics, ILR implant indication and specific changes to management plans were recorded and analysed using descriptive statistics.

Results

All 135 patients with ILR monitoring at the inherited cardiac disease clinic were screened and 87 patients (57.6% female, 41.7±14.0 years) with SADS relatives were included in the study. The mean follow up period was 657.9±392.3 days from ILR implant. Indications for ILR implantation included syncope (n=31, 15.7%), presyncope (45, 22.7%), palpitations (44, 22.2%), chest pain (9, 4.5%), short term heart rhythm monitor findings (6, 3.0%), ECG findings (6, 3.0%), asymptomatic indications (10, (5.1%) including patients with more than one relative with SADS, a family history of conduction disease or family history of long QT syndrome), and atypical symptoms (2 (1%) including seizures and sleep paralysis). Some patients had more than one indication for ILR at the time of implant. As a direct result of ILR monitoring, 43 (49.4%) patients had a change to their management plan. 6 specific definitions for management changes were used: Permanent pacemaker implantation (2, 2.3%), subsequent electrophysiology study (3, 3.5%), medication change (7, 8.1%), arrhythmia excluded as a cause for patient symptoms (26, 29.9%), prompted ILR implant in first degree relative (11, 12.6%) and ILR re-implant for further monitoring for premature conduction disease (1, 1.2%). Patients whose indication for ILR implant was palpitations had the highest likelihood for change of management with 27 changes associated with this indication, of which exclusion of arrhythmia as a cause for symptoms (15) was the most frequent outcome. The indications, syncope and presyncope both yield 21 management changes each.

Conclusion

The use of ILR devices in family relatives of patients with SADS provides information that may directly impact on patient management, with syncope providing the highest yield and reassurance the most common outcome in our cohort. ILR monitoring helped guide a wide range of other management strategies which included changes to medications and the need for further cardiac procedures. This data represented clinical practice in a niche patient cohort who are at risk for inherited cardiac conditions and associated arrhythmias.

Funding Acknowledgement

Type of funding sources: None. Indication for ILR vs management changeIndications for ILR implant

Gender bias in ACS management

Background

Cardiovascular disease is implicated in approximately 1 in every 3 deaths occurring in both women and men worldwide. Numerically, it is responsible for more female than male deaths each year, due largely to longer life expectancy amongst women. Consequently, guidelines from the major international bodies recommend against the use of sex as a discriminating factor in the evaluation of chest pain. Still there remains a public perception of excess cardiovascular risk in men, contributing to a delay in the seeking of medical attention by women with symptoms of acute coronary syndrome (ACS). We hypothesise the attendant concern that unconscious gender bias amongst clinicians influences the management of patients presenting with ACS from triage to invasive assessment and treatment.

Aim

To examine the relationship between patient gender and clinical management of ACS.

Methods

We conducted a retrospective cross sectional study of all patients in whom ACS was suspected during a year long period using the laboratory database of a tertiary cardiac referral centre in Ireland. In all patients for whom high sensitivity cardiac troponin T assay was ordered during the full calendar year 2019, age, sex and troponin level were recorded. We determined the likelihood of invasive angiography for male versus female patients after adjustment for age and troponin result.

Results

A total of 30,560 requests for high sensitivity cardiac troponin T (troponin) were made to the laboratory in the year ending December 2019. Excluding 464 for technical and sampling issues, 30,096 assays were included in the analysis. 43.84% (N=13,194) of samples were female and 56.16% (N=16,902) male. These samples were collected from 10,807 patients (5,294 female and 5,513 male). Median age was 58 for females and 57 for males. The upper limit of normal in our institution for serum troponin is <14ng/L and there is no adjustment for sex. 22.01% (N=1,165) of females and 33.39% (N=1,841) of males had at least one troponin level reported above the normal range. Of female patients with at least one troponin above the normal limit, 10.21% (N=119) underwent invasive coronary angiography compared to 18.52% (N=341) of males. Of females in whom all troponin results were normal, 5.84% (N=241) proceeded to invasive angiography versus 9.18% (N=337) of males.

Conclusion

Notwithstanding the limitations of lack of adjustment for risk profile, the results of this analysis demonstrate a higher rate of invasive angiography in males compared with females independently of troponin level. This is in keeping with previous research suggesting a gender gap in the approach of clinicians to ACS, and suggests an unconscious sex-based discrimination when making decisions around diagnosis and treatment. Education regarding the prevalence of coronary atherosclerosis, and interventions to alter the attitudes of clinicians, are some of the interventions suggested to close this gap.

Funding Acknowledgement

Type of funding sources: None.

The utility of the implantable loop recorder in patients with a diagnosis or family history of long QT syndrome

Background

There is limited published data on the use of implantable loop recorders (ILRs) in patients with long QT syndrome (LQTS).

Purpose

We sought to evaluate the utility of the ILR in patients who had a diagnosis of LQTS or who had a family history of LQTS.

Methods

We carried out a retrospective analysis of patients attending an Inherited Cardiac Conditions Clinic who had an active ILR and who had a diagnosis or family history of LQTS. Patient demographics, indications for ILR implantation and clinical outcomes were compiled.

Results

Nine patients with a diagnosis of LQTS and an active ILR were identified with an average age of 37 years. Genetic results were available for seven patients. Four patients had a confirmed pathogenic mutation (one KCNQ1 and three KCNH2), one patient had a variant of uncertain significance in SCN5A and two patients had negative genetic testing. Indications for implantation were syncope (n=4), recurrent altered consciousness episodes (n=1), assessment of occult arrhythmia or beta blocker complications (n=2), palpitations and dizziness (n=1) and nocturnal dyspnoea and palpitations (n=1). Mean follow-up was 706 days and average age at ILR implant was 35 years. The ILR for three patients was a second device, implanted after end of battery life of the initial ILR. ILR recordings led to a change in management in three patients: finding of paroxysmal atrial fibrillation (n=1), finding of nocturnal QTc of 511ms with a change in medications (n=1) and a pause leading to cessation of beta blocker (n=1).

Eleven patients with a family history of LQTS and active ILR were identified. Nine patients were female, and the average age was 44.4 years. Genetic test results were available for five patients. Three patients had a pathogenic mutation in SCN5A, and two patients had negative genetic testing for common LQTS genes. Indications for implantation included syncope (n=5), lightheaded episodes (n=3) and risk assessment in gene carriers (n=3). The mean duration of ILR follow-up was 680 days and average age at ILR implant was 42.5 years. Five patients had no arrhythmia detected during ILR recording, two patients had supraventricular tachycardia identified, in two patients ILR data outruled a sinister cause for a symptomatic episode, one patient had documentation of SVT and brief NSVT which led to referral for electrophysiology study and one patient had no recurrence of symptoms and a second ILR was implanted.

Conclusion

ILRs were inserted in selected patients with a diagnosis of LQTS or in patients with a family history of LQTS or who were gene carriers. Rationale for ILR implantation included risk stratification, monitoring for occult arrhythmia and rhythm-symptom correlation in symptomatic patients. The ILR impacted management in almost 50% of patients and is considered an important tool in selected patients attending Inherited Cardiac Condition Clinics.

Funding Acknowledgement

Type of funding sources: None. Table 1

Sexual risk and HIV testing disconnect in men who have sex with men (MSM) recruited to an online HIV self-testing trial

OBJECTIVES

We report the frequency of previous HIV testing at baseline in men who have sex with men (MSM) who enrolled in an HIV self-testing (HIVST) randomized controlled trial [an HIV self-testing public health intervention (SELPHI)].

METHODS

Criteria for enrolment were age ≥ 16 years, being a man (including trans men) who ever had anal intercourse (AI) with a man, not being known to be HIV positive and having consented to national HIV database linkage. Using online survey baseline data (2017-2018), we assessed associations with never having tested for HIV and not testing in the previous 6 months, among men who reported at least two recent condomless AI (CAI) partners.

RESULTS

A total of 10 111 men were randomized; the median age was 33 years [interquartile range (IQR) 26-44 years], 89% were white, 20% were born outside the UK, 0.8% were trans men, 47% were degree educated, and 8% and 4% had ever used and were currently using pre-exposure prophylaxis (PrEP), respectively. In the previous 3 months, 89% reported AI and 72% reported CAI with at least one male partner. Overall, 17%, 33%, 54%, and 72% had tested for HIV in the last 3 months, 6 months, 12 months and 2 years, respectively; 13% had tested more than 2 years ago and 15% had never tested. Among 3972 men reporting at least two recent CAI partners, only 22% had tested in the previous 3 months. Region of residence and education level were independently associated with recent HIV testing. Among current PrEP users, 15% had not tested in the previous 6 months.

CONCLUSIONS

Most men in SELPHI, particularly those reporting at least two CAI partners and current PrEP users, were not testing in line with current UK recommendations. The results of the trial will inform whether online promotion of HIVST addresses ongoing testing barriers.

Visual Immunoprecipitate Assay (VIP) for Listeria monocytogenes and Related Listeria Species Detection in Selected Foods: Collaborative Study

Six foods representing a variety of food products were analyzed by the Assurance Listeria polyclonal enzyme immunoassay (EIA) and by either the Bacteriological Analytical Manual or the U.S. Department of Agriculture culture method for detecting Listeria monocytogenes and related Listeria species. Samples of each food type, at each inoculation level, were analyzed simultaneously by both methods. A total of 19 laboratories representing federal government agencies and private industry in the United States and Canada participated. Food types were inoculated with Listeria species including L. monocytogenes, with the exception of 3 lots of green beans, which were naturally contaminated. During this study, 1764 samples and controls were analyzed and confirmed, of which 492 were positive and 947 were negative by both methods. There were 159 samples that were positive by culture method but negative by the EIA and 188 that were negative by culture method but positive by EIA. Twenty-two samples were negative by EIA and by culture method but confirmed positive when Assurance selective enrichment broths were subcultured to selective agar. The Assurance polyclonal EIA for detecting L. monocytogenes and related Listeria species in foods has been adopted first action by AOAC INTERNATIONAL.

Assurance Polyclonal Enzyme Immunoassay for Detection of Listeria monocytogenes and Related Listeria Species in Selected Foods: Collaborative Study

Six foods representing a variety of food products were analyzed by the Assurance Listeria polyclonal enzyme immunoassay (EIA) and by either the Bacteriological Analytical Manual or the U.S. Department of Agriculture culture method for detecting Listeria monocytogenes and related Listeria species. Samples of each food type, at each inoculation level, were analyzed simultaneously by both methods. A total of 19 laboratories representing federal government agencies and private industry in the United States and Canada participated. Food types were inoculated with Listeria species including L. monocytogenes, with the exception of 3 lots of green beans, which were naturally contaminated. During this study, 1764 samples and controls were analyzed and confirmed, of which 492 were positive and 947 were negative by both methods. There were 159 samples that were positive by culture method but negative by the EIA and 188 that were negative by culture method but positive by EIA. Twenty-two samples were negative by EIA and by culture method but confirmed positive when Assurance selective enrichment broths were subcultured to selective agar. The Assurance polyclonal EIA for detecting L. monocytogenes and related Listeria species in foods has been adopted first action by AOAC INTERNATIONAL.

Week 48 Resistance Analyses of the Once-Daily, Single-Tablet Regimen Darunavir/Cobicistat/Emtricitabine/Tenofovir Alafenamide (D/C/F/TAF) in Adults Living with HIV-1 from the Phase III Randomized AMBER and EMERALD Trials

Darunavir/cobicistat/emtricitabine/tenofovir alafenamide (D/C/F/TAF) 800/150/200/10 mg is being investigated in two Phase III trials, AMBER (NCT02431247; treatment-naive adults) and EMERALD (NCT02269917; treatment-experienced, virologically suppressed adults). Week 48 AMBER and EMERALD resistance analyses are presented. Postbaseline samples for genotyping/phenotyping were analyzed from protocol-defined virologic failures (PDVFs) with viral load (VL) ≥400 copies/mL at failure/later time points. Post hoc analyses were deep sequencing in AMBER, and HIV-1 proviral DNA from baseline samples (VL <50 copies/mL) in EMERALD. Through week 48 across both studies, no darunavir, primary PI, or tenofovir resistance-associated mutations (RAMs) were observed in HIV-1 viruses of 1,125 participants receiving D/C/F/TAF or 629 receiving boosted darunavir plus emtricitabine/tenofovir-disoproxil-fumarate. In AMBER, the nucleos(t)ide analog reverse transcriptase inhibitor (N(t)RTI) RAM M184I/V was identified in HIV-1 of one participant during D/C/F/TAF treatment. M184V was detected pretreatment as a minority variant (9%). In EMERALD, in participants with prior VF and genoarchive data (N = 140; 98 D/C/F/TAF and 42 control), 4% had viruses with darunavir RAMs, 38% with emtricitabine RAMs, mainly at position 184 (41% not fully susceptible to emtricitabine), 4% with tenofovir RAMs, and 21% ≥ 3 thymidine analog-associated mutations (24% not fully susceptible to tenofovir) detected at screening. All achieved VL <50 copies/mL at week 48 or prior discontinuation. D/C/F/TAF has a high genetic barrier to resistance; no darunavir, primary PI, or tenofovir RAMs were observed through 48 weeks in AMBER and EMERALD. Only one postbaseline M184I/V RAM was observed in HIV-1 of an AMBER participant. In EMERALD, baseline archived RAMs to darunavir, emtricitabine, and tenofovir in participants with prior VF did not preclude virologic response.

HIV self-testing intervention experiences and kit usability: results from a qualitative study among men who have sex with men in the SELPHI (Self-Testing Public Health Intervention) randomized controlled trial in England and Wales

Objectives

SELPHI (HIV Self‐Testing Public Health Intervention) is the largest randomized controlled trial (RCT) of HIV self‐testing (HIVST) in a high‐income setting to date, and has recruited 10 000 men who have sex with men (cis‐ and transgender) and transgender women who have sex with men. This qualitative substudy aimed to explore how those utilizing self‐tests experience HIVST and the implications for further intervention development and scale‐up. This is the first qualitative study in Europe investigating experiences of HIVST among intervention users, and the first globally examining the experience of using blood‐based HIVST.

Methods

Thirty‐seven cisgender MSM SELPHI participants from across England and Wales were purposively recruited to the substudy, in which semi‐structured interviews were used to explore testing history, HIVST experiences and intervention preferences. Interviews were audio‐recorded, transcribed and analysed through a framework analysis.

Results

Men accessed the intervention because HIVST reduced barriers related to convenience, stigma and privacy concerns. Emotional responses had direct links to acceptability. Supportive intervention components increased engagement with testing and addressed supportive concerns. HIVST facilitated more frequent testing, with the potential to reduce sexually transmitted infection (STI) screening frequency. Substudy participants with an HIV‐positive result (n = 2) linked to care promptly and reported very high acceptability. Minor adverse outcomes (n = 2; relationship discord and fainting) did not reduce acceptability. Ease of use difficulties were with the lancet and the test processing stage.

Conclusions

Intervention components shaped acceptability, particularly in relation to overcoming a perceived lack of support. The intervention was broadly acceptable and usable; participants expressed an unexpected degree of enthusiasm for HIVST, including those with HIV‐positive results and individuals with minor adverse outcomes.

The CORE Group Polio Project: An Overview of Its History and Its Contributions to the Global Polio Eradication Initiative

The CORE Group Polio Project (CGPP) has contributed to polio eradication by successfully engaging civil society, particularly the non-governmental organization (NGO) community. This engagement, which began with a grant from the U.S. Agency for International Development in 1999, has contributed to improvements in routine immunization programs, polio campaign quality, and surveillance for acute flaccid paralysis in many challenging geographic areas. The CGPP has worked closely with polio eradication partners in a collaborative and supportive role. The CGPP has focused largely on high-risk areas with marginalized or hard-to-reach populations where health systems and immunization programs have also been weak and where transmission of poliovirus had not been stopped. The CGPP has engaged local civic leaders and communities in ways to complement top-down vertical efforts of ministries of health and other partners in the Global Polio Eradication Initiative. The CGPP has developed innovative strategies to detect cases using community-based surveillance, promoted independent campaign monitoring, established cross-border initiatives, and developed a strong and creative cadre of community mobilizers to track missed children and deliver behavior change education. Many of the innovations and approaches that the CGPP helped to develop are now being replicated by governments and international agencies to tackle other public health priorities in underserved and marginalized communities around the world. This article is the first in a series of articles describing the work of the CGPP. Because the article describes the work of more than 40 NGOs in 11 countries over 20 years, it provides only an overview, leaving many important details and variations of the CGPP's work to be described elsewhere, including in other articles included in this series.

The effect of time to surgery on outcomes and complication rates following total hip arthroplasty for fractured neck of femur

INTRODUCTION

Total hip arthroplasty is recommended for elderly patients with fractured neck of femur who are independently mobile, have few co-morbidities and are not cognitively impaired. Providing a daily total hip arthroplasty service is challenging for some units in the UK and considering that these patients may be physiologically distinct from the average hip fracture patient, loss of the best practice tariff as a result of surgical delay may be unjustified. The aim of this study was to determine whether time to surgical intervention for patients eligible for total hip arthroplasty had a negative impact on patient complications, length of stay and functional outcomes.

METHODS

All patients undergoing total hip arthroplasty for fractured neck of femur at our institution over a ten-year period were identified. Complications and functional outcomes were compared between patients receiving total hip arthroplasty before and after 36 hours.

RESULTS

Of 112 consecutive patients undergoing total hip arthroplasty, 70 responded to a questionnaire or telephone consultation. Four patients were excluded owing to delayed presentation, the presence of advanced rheumatoid arthritis or a pathological fracture. Two-thirds (64%) of the remaining 66 patients underwent surgery within 36 hours of presentation. There were no significant differences between the groups of patients receiving surgery before or after 36 hours with regard to postoperative length of stay, complications, Oxford hip scores or visual analogue scale scores for state of health.

CONCLUSIONS

Delaying surgery for patients eligible for total hip arthroplasty as per the National Institute for Health and Care Excellence guidelines is justified and should not incur loss of the best practice tariff.

Historical collections as a tool for assessing the global pollination crisis

There is increasing concern about the decline of pollinators worldwide. However, despite reports that pollinator declines are widespread, data are scarce and often geographically and taxonomically biased. These biases limit robust inference about any potential pollinator crisis. Non-structured and opportunistic historical specimen collection data provide the only source of historical information which can serve as a baseline for identifying pollinator declines. Specimens historically collected and preserved in museums not only provide information on where and when species were collected, but also contain other ecological information such as species interactions and morphological traits. Here, we provide a synthesis of how researchers have used historical data to identify long-term changes in biodiversity, species abundances, morphology and pollination services. Despite recent advances, we show that information on the status and trends of most pollinators is absent. We highlight opportunities and limitations to progress the assessment of pollinator declines globally. Finally, we demonstrate different approaches to analysing museum collection data using two contrasting case studies from distinct geographical regions (New Zealand and Spain) for which long-term pollinator declines have never been assessed. There is immense potential for museum specimens to play a central role in assessing the extent of the global pollination crisis.This article is part of the theme issue 'Biological collections for understanding biodiversity in the Anthropocene'.

Advancing Cancer Health Equity in Pacific Islanders: A 15-Year Investment in Cancer Research, Training and Outreach in Guam, Hawaii and the U.S. Associated Pacific Islands

Background: Pacific Islanders (PI) in Guam (GU), Hawaii (HI), and the U.S. associated Pacific Islands (USAPI) experience greater cancer health disparities compared with majority populations in GU, HI, and the U.S. continent. Social determinants including geographic, socio-cultural, and economic factors are barriers to health and health care, leading to late stage diagnosis and poor survival outcomes. PIs are also highly underrepresented among cancer researchers. Aim: The University of Guam (UOG)/University of Hawaii Cancer Center (UHCC) partnership aims to grow cancer research capacity at UOG, develop cancer health disparities research at UHCC focusing on Pacific Islanders (PI), raise awareness of cancer and cancer prevention in GU, HI and the USAPI, and increase the number of cancer and biomedical scientists of PI ancestry in the U.S. Methods: An infrastructure comprised of five principal investigators and approximately 30 participating faculty, administrative staff, and community and scientific advisory members, supported by funds from the National Cancer Institute and the partnering institutions, has provided 15 years of support for cancer research, training, and outreach designed to reduce cancer health disparities and advance health equity among Pacific Islanders in GU, HI and the USAPI. Results: Fifteen collaborative research projects have been funded through the partnership. Many of these projects have focused on the prevention of unhealthy lifestyle behaviors that lead to increased cancer risk. Prepilot, pilot and full research projects address cancer health disparities of regional relevance and global importance, notably breast, cervical and oral cancers as well as tobacco and betel nut use. A betel nut cessation intervention, the first of its kind, shows promising quit rates. This research has resulted in over 80 publications, 100+ abstracts, and 9 grant awards. The partnership has recruited and trained 26 underrepresented graduate scholars in cancer health disparities, including two scholars who have since joined UOG's faculty and are now independently conducting research, participating in the partnership as investigators, and mentoring tomorrow's scientists. UOG faculty and early stage investigators continue to receive mentorship and career development support. Outreach activities have contributed to the introduction and passage of significant cancer prevention and control legislation in Guam and Saipan. Outcomes are communicated through the partnership's Website, social media, and community reports and seminars. Conclusion: The partnership has significantly increased research capacity at UOG and cultivated interest in cancer research among underrepresented minority students at the partnering institutions. A regional research infrastructure has been established, and research findings are informing public health policy and planning. Resources have been leveraged to address PI cancer health disparities in GU, HI, and the USAPI.

Clinical efficacy of a next-generation sequencing gene panel for primary immunodeficiency diagnostics

Primary immunodeficiencies (PIDs) are rare monogenic inborn errors of immunity that result in impairment of functions of the human immune system. PIDs have a broad phenotype with increased morbidity and mortality, and treatment choices are often complex. With increased accessibility of next-generation sequencing (NGS), the rate of discovery of genetic causes for PID has increased exponentially. Identification of an underlying monogenic diagnosis provides important clinical benefits for patients with the potential to alter treatments, facilitate genetic counselling, and pre-implantation diagnostics. We investigated a NGS PID panel of 242 genes within clinical care across a range of PID phenotypes. We also evaluated Phenomizer to predict causal genes from human phenotype ontology (HPO) terms. Twenty-seven participants were recruited, and a total of 15 reportable variants were identified in 48% (13/27) of the participants. The panel results had implications for treatment in 37% (10/27) of participants. Phenomizer identified the genes harbouring variants from HPO terms in 33% (9/27) of participants. This study shows the clinical efficacy that genetic testing has in the care of PID. However, it also highlights some of the disadvantages of gene panels in the rapidly moving field of PID genomics and current challenges in HPO term assignment for PID.

Together Eating & Activity Matters (TEAM): results of a pilot randomized-clinical trial of a spousal support weight loss intervention for Black men

Objectives

The objective of this study is to evaluate the feasibility, participation, preliminary efficacy and retention in a couples-based weight loss intervention among Black men.

Design setting participants

Two-arm pilot randomized clinical trial in an academic clinical setting. Forty self-identified Black men and their female cohabitating partners (n = 80) aged 18 to 65 years with body mass index from 25 to 45 kg/m2 were randomized using computer generated tables to allocate treatments.

Intervention

Participants were randomized to a standard behavioural weight loss (Standard) programme or the Standard programme plus partner involvement (Enhanced). Both interventions focused on calorie reduction, physical activity and self-monitoring to facilitate weight loss. Enhanced included couples skills training and couple's communication components.

Main outcome and measures

Changes in weight from baseline to 3 months among men. Partner weight loss (secondary).

Results

Forty Black couples (men mean [SD] age, 47.4[11] years; body mass index, 35.0[6.1]), were recruited. Retention was 100% of the men and 98% of female partners. Attendance at group sessions was 63-73%. Between groups, mean (SD) weight changes among men were -3.4[.04] and -4.7[5.9] kg (p = 0.57) and among women -0.23[4.46] and -2.47[3.62] kg (p = 0.09), in the standard and enhanced groups.

Conclusions

Weight losses from an intervention enhanced by partner involvement and an intervention with no partner involvement were not different. Treatment choice can be based on preference rather than outcome as both treatments are effective in producing clinically significant percent weight loss.Trial registration Clinical Trials NCT02458053.