A quality appraisal of economic evaluations of community water fluoridation: A systematic review

OBJECTIVES

To critically appraise the methodological conduct and reporting quality of economic evaluations (EE) of community water fluoridation (CWF).

METHODS

A systematic literature search was conducted in general databases and specialist directories of the economic literature. The Consensus on Health Economic Criteria list (CHEC) appraised the methodological quality while the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) assessed the reporting quality of included studies.

RESULTS

A total of 1,138 records were identified, of which 18 met the inclusion criteria. Cost analysis emerged as the most prevalent type of EE, though a growing trend towards conducting full EEs is observed. CHEC revealed the items most frequently unfulfilled were the study design, measurement and valuation of costs and outcomes, while CHEERS also identified reporting deficiencies in these aspects. Furthermore, the review highlights subtleties in methodological aspects that may not be discerned by CHEC, such as the estimation of the impact of fluoridation and the inclusion of treatment savings within cost estimates.

CONCLUSIONS

While numerous studies were conducted before publication of these assessment instruments, this review reveals that a noteworthy subset of studies exhibited good methodological conduct and reporting quality. There has been a steady improvement in the methodological and reporting quality over time, with recently published EEs largely adhering to best practice guidelines. The evidence presented will assist policymakers in leveraging the available evidence effectively to inform resource allocation decisions. It may also serve as a resource for researchers to enhance the methodological and reporting standards of future EEs of CWF.

Inhomogeneous Photosusceptibility of VO_{2} Films at the Nanoscale

Pump-probe nano-optical experiments were used to study the light-induced insulator to metal transition (IMT) in thin films of vanadium dioxide (VO_{2}), a prototypical correlated electron system. We show that inhomogeneous optical contrast is prompted by spatially uniform photoexcitation, indicating an inhomogeneous photosusceptibility of VO_{2}. We locally characterize temperature and time dependent variations of the photoexcitation threshold necessary to induce the IMT on picosecond timescales with hundred nanometer spatial resolution. We separately measure the critical temperature T_{L}, where the IMT onsets and the local transient electronic nano-optical contrast at the nanoscale. Our data reveal variations in the photosusceptibility of VO_{2} within nanoscopic regions characterized by the same critical temperature T_{L} where metallic domains can first nucleate.

"I want to see them thrive!": exploring health service research priorities for young Aboriginal children growing up in Alice Springs - a qualitative study

To better understand the specific influences of early life on the long-term health and well-being of local Aboriginal children in Alice Springs, high-quality local longitudinal data is required. The Central Australian Aboriginal Congress and the Murdoch Children's Research Institute are exploring the feasibility of establishing a cohort study to fill this gap. A nested qualitative study was conducted to identify priority issues that can be translated into research questions answerable through the proposed cohort study. Semi-structured interviews and focus group discussions (FGDs) were conducted with a range of key community stakeholders, parents and caregivers of young Aboriginal children from Alice Springs in the Northern Territory between 2020 and 2021. Two Aboriginal and two non-Aboriginal researchers conducted 27 interviews and 3 FGDs with 42 participants. Three broad themes were constructed through reflexive thematic analysis representing the areas of focus community stakeholders and parents want future research to prioritise: (1) social determinants of health (2) building positive connections, and (3) making sure kids grow up strong and healthy. Priority setting for future research should be driven by Aboriginal and Torres Strait Islander peoples in order to be of practical benefit to their community. This qualitative study found that housing, transport and positive connections through nurturing and engaged parents were some of the most important issues raised. Participants also wanted future research to focus on issues specific to children such as nutrition, hearing loss, language development and capacity to learn. These findings will guide future work led by local Aboriginal researchers to co-design the proposed cohort study.

The effects of short-term, progressive exercise training on disease activity in smouldering multiple myeloma and monoclonal gammopathy of undetermined significance: a single-arm pilot study

BACKGROUND

High levels of physical activity are associated with reduced risk of the blood cancer multiple myeloma (MM). MM is preceded by the asymptomatic stages of monoclonal gammopathy of undetermined significance (MGUS) and smouldering multiple myeloma (SMM) which are clinically managed by watchful waiting. A case study (N = 1) of a former elite athlete aged 44 years previously indicated that a multi-modal exercise programme reversed SMM disease activity. To build from this prior case study, the present pilot study firstly examined if short-term exercise training was feasible and safe for a group of MGUS and SMM patients, and secondly investigated the effects on MGUS/SMM disease activity.

METHODS

In this single-arm pilot study, N = 20 participants diagnosed with MGUS or SMM were allocated to receive a 16-week progressive exercise programme. Primary outcome measures were feasibility and safety. Secondary outcomes were pre- to post-exercise training changes to blood biomarkers of MGUS and SMM disease activity- monoclonal (M)-protein and free light chains (FLC)- plus cardiorespiratory and functional fitness, body composition, quality of life, blood immunophenotype, and blood biomarkers of inflammation.

RESULTS

Fifteen (3 MGUS and 12 SMM) participants completed the exercise programme. Adherence was 91 ± 11%. Compliance was 75 ± 25% overall, with a notable decline in compliance at intensities > 70% V̇O2PEAK. There were no serious adverse events. There were no changes to M-protein (0.0 ± 1.0 g/L, P =.903), involved FLC (+ 1.8 ± 16.8 mg/L, P =.839), or FLC difference (+ 0.2 ± 15.6 mg/L, P =.946) from pre- to post-exercise training. There were pre- to post-exercise training improvements to diastolic blood pressure (- 3 ± 5 mmHg, P =.033), sit-to-stand test performance (+ 5 ± 5 repetitions, P =.002), and energy/fatigue scores (+ 10 ± 15%, P =.026). Other secondary outcomes were unchanged.

CONCLUSIONS

A 16-week progressive exercise programme was feasible and safe, but did not reverse MGUS/SMM disease activity, contrasting a prior case study showing that five years of exercise training reversed SMM in a 44-year-old former athlete. Longer exercise interventions should be explored in a group of MGUS/SMM patients, with measurements of disease biomarkers, along with rates of disease progression (i.e., MGUS/SMM to MM).

REGISTRATION

https://www.isrctn.com/ISRCTN65527208 (14/05/2018).

The effect of progesterone concentrations during superovulation of Holstein heifers in a randomized trial

The aim of this study was to evaluate the effect of different progesterone (P4) concentrations during the follicular growth on the intensity of estrous expression, ovarian response to the superovulatory treatment, and embryo production and quality in superovulated heifers. A total of 63 Holstein heifers were randomly assigned into 2 experimental groups: Low P4 (n = 31) and High P4 (n = 32). Animals received a pre-synchronization protocol followed by a protocol of superovulation that included the allocated P4 treatment. Activity was monitored continuously by an automated activity monitor, and estrus characteristics (maximum intensity and duration) were recorded. Embryo collection was performed 7 d post artificial insemination (AI). Embryos were counted and graded from good or excellent (1) to degenerated (4). The outcomes of interest were: number and diameter of follicles at the time of AI, ovulation success (confirmed 7 d post-AI), time to estrus event, maximum intensity and duration of estrus, number and quality of embryos. Data were analyzed according to the type of outcome variable using logistic, linear, or Poisson regression models. A total of 105 embryos (High P4: n = 42; Low P4: n = 63) were graded for quality. Different P4 levels did not affect the maximum intensity (High P4 = 497.8 ± 23.9%; Low P4 = 542.2 ± 23.5%) or the duration (High P4 = 13.5 ± 1.5 h; Low P4 = 14.3 ± 1.4 h) of estrus. Heifers in the High P4 treatment had greater number of follicles at time of AI (High P4 = 16.6 ± 1.6 follicles; Low P4 = 13.9 ± 1.2 follicles), but with smaller diameter (High P4 = 11.3 ± 0.1 mm; Low P4 = 12.0 ± 0.1 mm) compared with Low P4. High P4 heifers tended to have better embryo quality compared with Low P4 heifers (odds ratio = 1.98; 95% CI = 0.90-4.35). High P4 heifers had less embryos than Low P4 heifers, but this was modified by the CIDR (intravaginal implant of P4) removal to estrus interval (interval 0-21 h: mean ratio = 1.15, 95% CI = 0.42-1.87; interval 22-46 h: mean ratio = 0.58, 95% CI = 0.27-0.96). Although estrous expression was not associated with embryo quality, as the duration and the maximum intensity of estrous expression increased, the number of embryos recovered 7 d post-AI increased (duration: mean ratio = 1.04; 95% CI = 1.03-1.05; maximum intensity: mean ratio = 1.50; 95% CI = 1.42-1.58). In conclusion, P4 during the follicular growth, and intensity of estrus, are playing a role in regulating the quality and the number of embryos produced by superovulated heifers. This study was supported by contributions from Resilient Dairy Genome Project and the Natural Sciences and Engineering Research Council.

A Survey Study of Practice Patterns in Management of Very Early Small Cell Lung Cancer in Canada

PURPOSE/OBJECTIVE(S)

Concurrent chemoradiotherapy (CRT) is the gold standard in management of limited-stage small cell lung cancer (LS-SCLC). Local therapy with surgery or stereotactic radiotherapy (SBRT), followed by adjuvant chemotherapy may be appropriate in patients with very early (T1-T2, N0) disease. This study aimed to determine practice patterns for very early LS-SCLC among lung cancer specialists in Canada.

MATERIALS/METHODS

A survey was developed and distributed to Canadian medical and radiation oncologists specializing in lung cancer. The survey consisted of three sections: 1) physician demographics, 2) general practice approach, and 3) preferred approach for three clinical scenarios (1: a peripheral T1 lesion; 2: a central T1 lesion; 3: a peripheral T2 lesion). Responses were analyzed to detect differences in management across cases and among various physician groups.

RESULTS

A total of 77 physicians participated. In case 1, when the patient was eligible for surgery, most respondents (73%) chose surgery with adjuvant chemotherapy as their preferred management, with only 19% choosing CRT. CRT was selected by a higher proportion in case 2 (48%) and case 3 (61%) (p<0.05). If medically operable, most chose CRT over SBRT and adjuvant chemotherapy in all cases. CRT was significantly more popular in case 2 (84%) and case 3 (86%) than in case 1 (55%) (p<0.05). Subgroup analysis showed physicians from Western Canadian were more likely to choose CRT, those from Ontario were more likely to offer SBRT, and those who have spent longer in practice were more likely to choose CRT over local therapy.

CONCLUSION

There is no clear consensus regarding optimal management of patients with very early LS-SCLC among specialists in Canada, with significant variations in practice patterns. CRT remains the most popular strategy in most cases, with surgery and adjuvant chemotherapy preferred for small peripheral lesions. Increasing size of tumor as well as more central location are factors that drive physicians towards choosing CRT. Variation in practice is correlated to region of the country and to physician experience.

Attempted suicide: does lethality matter?

OBJECTIVES

To investigate whether high-lethality suicide attempters align to the demographic and clinical features observed in completed suicide in the national and international literature, and whether low-lethality attempters more closely align with the clinical profile of non-attempter ideators.

METHODS

A retrospective chart review of adult suicide ideators and attempters presenting to an urban tertiary care hospital was performed. Suicide ideators (n = 50) and attempters (n = 50) were coded for variables including demographics and clinical characteristics (e.g. psychiatric diagnosis and previous suicide attempt). Method and lethality of suicide attempt were coded using the medical Lethality Rating Scale.

RESULTS

High-lethality attempters were more likely to be younger in age than low-lethality attempters (p = 0.026) and ideators (p = 0.041). The lethality scores of suicide attempts were significantly inversely correlated with age (p = 0.017).

CONCLUSIONS

Our study adds to the small but increasing body of literature investigating the characteristics of high-lethality suicide attempters and suggests younger adult age is a risk factor for a high-lethality attempt. Further understanding of this unique group would be aided by widespread agreement on the definition of a high-lethality suicide attempt and longitudinal studies of this cohort.

Invited review: Iodine level in dairy products-A feed-to-fork overview

The theme of iodine in the dairy sector is of particular interest due to the involvement and the interconnection of several stakeholders along the dairy food chain. Iodine plays a fundamental role in animal nutrition and physiology, and in cattle it is an essential micronutrient during lactation and for fetal development and the calf's growth. Its correct use in food supplementation is crucial to guarantee the animal's recommended daily requirement to avoid excess intake and long-term toxicity. Milk iodine is fundamental for public health, being one of the major sources of iodine in Mediterranean and Western diets. Public authorities and the scientific community have made great efforts to address how and to what extent different drivers may affect milk iodine concentration. The scientific literature concurs that the amount of iodine administered through animal feed and mineral supplements is the most important factor affecting its concentration in milk of most common dairy species. Additionally, farming practices related to milking (e.g., use of iodized teat sanitizers), herd management (e.g., pasture vs. confinement), and other environmental factors (e.g., seasonality) have been identified as sources of variation of milk iodine concentration. Overall, the aim of this review is to provide a multilevel overview on the mechanisms that contribute to the iodine concentration of milk and dairy products.

Developing a Diagnostic Multivariable Prediction Model for Urinary Tract Cancer in Patients Referred with Haematuria: Results from the IDENTIFY Collaborative Study

BACKGROUND

Patient factors associated with urinary tract cancer can be used to risk stratify patients referred with haematuria, prioritising those with a higher risk of cancer for prompt investigation.

OBJECTIVE

To develop a prediction model for urinary tract cancer in patients referred with haematuria.

DESIGN, SETTING, AND PARTICIPANTS

A prospective observational study was conducted in 10 282 patients from 110 hospitals across 26 countries, aged ≥16 yr and referred to secondary care with haematuria. Patients with a known or previous urological malignancy were excluded.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary outcomes were the presence or absence of urinary tract cancer (bladder cancer, upper tract urothelial cancer [UTUC], and renal cancer). Mixed-effect multivariable logistic regression was performed with site and country as random effects and clinically important patient-level candidate predictors, chosen a priori, as fixed effects. Predictors were selected primarily using clinical reasoning, in addition to backward stepwise selection. Calibration and discrimination were calculated, and bootstrap validation was performed to calculate optimism.

RESULTS AND LIMITATIONS

The unadjusted prevalence was 17.2% (n = 1763) for bladder cancer, 1.20% (n = 123) for UTUC, and 1.00% (n = 103) for renal cancer. The final model included predictors of increased risk (visible haematuria, age, smoking history, male sex, and family history) and reduced risk (previous haematuria investigations, urinary tract infection, dysuria/suprapubic pain, anticoagulation, catheter use, and previous pelvic radiotherapy). The area under the receiver operating characteristic curve of the final model was 0.86 (95% confidence interval 0.85-0.87). The model is limited to patients without previous urological malignancy.

CONCLUSIONS

This cancer prediction model is the first to consider established and novel urinary tract cancer diagnostic markers. It can be used in secondary care for risk stratifying patients and aid the clinician's decision-making process in prioritising patients for investigation.

PATIENT SUMMARY

We have developed a tool that uses a person's characteristics to determine the risk of cancer if that person develops blood in the urine (haematuria). This can be used to help prioritise patients for further investigation.

HBM4EU feasibility studies: Lessons learned in combining health and human biomonitoring studies

Background

The European Human Biomonitoring Initiative (HBM4EU) is a program protecting humans from the health effects of chemicals. The goal of HBM4EU is to make use of human biomonitoring (HBM) to assess human exposure to chemicals in Europe to better understand the associated health effects for citizens and to improve chemical risk assessment. Harmonisation and sustainable implementation of the HBM programme across Europe are important aims. In parallel to HBM studies, health examination surveys (HESs), dietary surveys, and disease specific health surveys are conducted in many European countries. In HESs, information collected by questionnaire(s) is supplemented with physical examinations and analysis of biomarkers from biological samples. HBM and HES use similar sample and data collection methods and infrastructures hence combining the two is being explored.

Methods

Within HBM4EU, three feasibility studies (Finland, Germany, and UK/England) were conducted to evaluate opportunities and obstacles in combining HBM and health studies. We describe the contents and differences of these feasibility studies, and discuss the matters of shared benefits, obstacles, and lessons learned.

Results

Benefits of combining HBM and HESs include the use of shared infrastructures, participants receiving additional health information from HES, and higher participation rates. Obstacles can be encountered when obtaining ethical approval and during time-consuming and complicated preparatory phases. Recruitment of participants and low participation rates are common concerns and designing participant-friendly questionnaires is important. Unexpected events such as the COVID-19 pandemic can cause challenges to studies. Furthermore, experiences from several countries demonstrated that long-term funding for combined studies can be difficult to obtain.

Conclusions

In the future, incorporating HBM modules into HESs can provide a feasible and cost-effective method to conduct HBM studies.

Key messages

• The European Human Biomonitoring Initiative (HBM4EU) protects humans from the health effects of chemicals in Europe. HBM4EU uses human biomonitoring (HBM) to evaluate human exposure to chemicals.

• In addition to HBM studies, health examination surveys (HESs) are conducted. In the future, incorporating HBM modules into HESs can provide a feasible and cost-effective method to conduct HBM studies.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Very low-calorie diet in patients with longstanding type 2 diabetes mellitus: a study of real-world outcomes

Introduction: There is a paucity of evidence regarding the efficacy of a very low-calorie diet (VLCD) in the real-world setting. We evaluated outcomes in patients with type 2 diabetes mellitus (T2DM) who underwent VLCD. Methods: This retrospective observational study included all patients who had undergone VLCD from 2014 to 2017 (n=61). The VLCD consisted of an eight-week 800 kcal/day dietary restriction. Metabolic parameters and medications were recorded at baseline, immediately post-VLCD and at 6 and 12 months. Results: There was a significant reduction in weight of 9.96 kg (p<0.001) immediately post-VLCD, with net weight loss sustained to 12 months (p<0.05). There was a significant reduction in body mass index (BMI) sustained to 12 months (p<0.05). Paired HbA1c data were available for 38 patients. There was a significant reduction in HbA1c of 13.29 mmol/mol immediately post-VLCD (p<0.001), however no significant reduction was observed at 12 months (p>0.05). 78.7% patients had a reduction in T2DM medication burden post-VLCD, sustained in 44.3% of patients at 12 months. Analysis of patients with T2DM diagnosis duration >6 years demonstrated statistically significant weight loss sustained to 12 months (p<0.001). Conclusion: Our results demonstrate sustained reduction in BMI and weight, reduction in medication burden and temporary reduction in HbA1c in patients with T2DM undertaking a VLCD in the real-world setting

A pilot randomised controlled trial of befriending by volunteers in people with intellectual disability and depressive symptoms

BACKGROUND

People with intellectual disability (ID) are more likely to experience chronic depression compared with the general population, which may be compounded by loneliness and lower levels of social support. Befriending aims to provide social support and promote engagement in community activities. No randomised controlled trials have examined whether befriending improves symptoms of depression and social outcomes in people with ID. The aim of this pilot trial was to assess the feasibility and acceptability of a future larger trial of one-to-one befriending by volunteers in people with ID and depressive symptoms.

METHODS

Participants were adults with mild or moderate ID with a score of 5 or more on the Glasgow Depression Scale for People with Learning Disabilities (GDS-LD). They were randomised to the intervention arm (matched to a volunteer befriender for 6 months) or the control arm (usual care). Volunteers received training and supervision provided by two community befriending schemes. The main outcomes were feasibility of recruitment (minimum target n = 35), retention rate of participants, adherence (minimum 10 meetings), acceptability of the intervention, changes in depressive symptoms (assessed at baseline and 6 months) and feasibility of collecting data for a health economic analysis.

RESULTS

Recruitment was challenging, and only 16 participants with ID and 10 volunteers were recruited. Six participants were matched with a volunteer and no participants dropped out (except for two volunteers). Four participants completed 10 meetings (mean 11.8). Befriending was thought to be acceptable, but modifications were suggested. An exploratory analysis suggested that GDS-LD score was lower in the intervention group compared with the control group after adjusting for baseline scores, but not significant (adjusted mean difference: -4.0; 95% confidence interval: -11.2 to 3.2).

CONCLUSIONS

A large trial would not be feasible based on the recruitment strategies employed in this study. A further feasibility study addressing these challenges or the use of other study designs should be considered.

The IDENTIFY study: the investigation and detection of urological neoplasia in patients referred with suspected urinary tract cancer - a multicentre observational study

OBJECTIVE

To evaluate the contemporary prevalence of urinary tract cancer (bladder cancer, upper tract urothelial cancer [UTUC] and renal cancer) in patients referred to secondary care with haematuria, adjusted for established patient risk markers and geographical variation.

PATIENTS AND METHODS

This was an international multicentre prospective observational study. We included patients aged ≥16 years, referred to secondary care with suspected urinary tract cancer. Patients with a known or previous urological malignancy were excluded. We estimated the prevalence of bladder cancer, UTUC, renal cancer and prostate cancer; stratified by age, type of haematuria, sex, and smoking. We used a multivariable mixed-effects logistic regression to adjust cancer prevalence for age, type of haematuria, sex, smoking, hospitals, and countries.

RESULTS

Of the 11 059 patients assessed for eligibility, 10 896 were included from 110 hospitals across 26 countries. The overall adjusted cancer prevalence (n = 2257) was 28.2% (95% confidence interval [CI] 22.3-34.1), bladder cancer (n = 1951) 24.7% (95% CI 19.1-30.2), UTUC (n = 128) 1.14% (95% CI 0.77-1.52), renal cancer (n = 107) 1.05% (95% CI 0.80-1.29), and prostate cancer (n = 124) 1.75% (95% CI 1.32-2.18). The odds ratios for patient risk markers in the model for all cancers were: age 1.04 (95% CI 1.03-1.05; P < 0.001), visible haematuria 3.47 (95% CI 2.90-4.15; P < 0.001), male sex 1.30 (95% CI 1.14-1.50; P < 0.001), and smoking 2.70 (95% CI 2.30-3.18; P < 0.001).

CONCLUSIONS

A better understanding of cancer prevalence across an international population is required to inform clinical guidelines. We are the first to report urinary tract cancer prevalence across an international population in patients referred to secondary care, adjusted for patient risk markers and geographical variation. Bladder cancer was the most prevalent disease. Visible haematuria was the strongest predictor for urinary tract cancer.

92 Reshaping the Diagnostic Pathways for Investigation of Haematuria During and After The COVID-19 Pandemic: Diagnostic Accuracy of Strategies for Detection of Bladder Cancer from The IDENTIFY Cohort Study

Introduction

Diagnostic haematuria services have been reduced due to the COVID-19 pandemic, compromising patient care, and necessitating a more pragmatic pathway.

Method

The IDENTIFY study was an international, prospective, multicentre cohort study of over 11,000 patients referred to secondary care for investigation of haematuria. Using this data, we developed strategies using combinations of imaging and cytology as triage tests to maximise cancer detection within a pragmatic pathway.

Results

8112 patients (74·4%) received an ultrasound or a CT urogram, with or without cytology. 5737 (70·7%) patients had visible haematuria (VH) and 2375 (29·3%) had non-visible haematuria (NVH). Diagnostic test performance was used to determine optimal age cut-offs for four proposed strategies. We recommended proceeding directly to transurethral resection of bladder tumour for patients of any age with positive triage tests for cancer. Patients with negative triage tests under 35-years-old with VH, or under 50-years-old with NVH can safely be discharged without undergoing flexible cystoscopy. The remaining patients may undergo flexible cystoscopy, with a greater priority for older patients to capture high risk bladder cancer.

Conclusions

We suggest diagnostic strategies in patients with haematuria, which focus on detection of bladder cancer, whilst reducing the burden to healthcare services in a resource-limited setting.

O6 Reshaping the diagnostic pathways for investigation of haematuria during and after the COVID-19 pandemic: Diagnostic accuracy of strategies for the detection of bladder cancer from the IDENTIFY cohort study

Background

Haematuria often requires investigation with an imaging test and flexible cystoscopy to rule out urinary tract cancers. With a reduction in diagnostic services due to the COVID-19 pandemic there is a risk of compromise in the care of patients referred with haematuria. We aimed to provide a pragmatic strategy that optimises the use of scarce resources by reducing patient visits to hospital and allocating the appropriate diagnostic tests according to risk of bladder cancer.

Methods

The IDENTIFY study was an international, prospective, multicentre cohort study of over 11,000 patients referred to secondary care for investigation of newly suspected urinary tract cancer. Patients underwent cystoscopy, imaging tests, urine cytology and transurethral resection of bladder tumour (TURBT), where indicated. We developed strategies using combinations of imaging and cytology as triage tests to flexible cystoscopy. These strategies aimed to maximise cancer detection within a pragmatic pathway in a resource-limited environment.

Findings

8112 patients (74·4%) received an ultrasound or a CT urogram, with or without cytology. 5737 (70·7%) patients had visible haematuria (VH) and 2375 (29·3%) had non-visible haematuria (NVH). Amongst all patients, 1474 (18·2%) had bladder cancer; 1333 (23·2%) in VH group and 141 (5·94%) in NVH group. Diagnostic test performance was used to determine optimal age cut-offs for each proposed strategy. We recommended proceeding directly to TURBT for patients of any age with positive triage tests for cancer. Patients with negative triage tests under 35-years-old with VH, or under 50-years-old with NVH can safely be discharged without undergoing flexible cystoscopy. The remaining patients may undergo flexible cystoscopy, with a greater priority for older patients (threshold of 60-years-old with VH, or 70-years-old with NVH) to capture high risk bladder cancer.

Interpretation

We suggest diagnostic strategies in patients with haematuria, which focus on detection of bladder cancer, whilst reducing the burden to healthcare services in a resource-limited setting.

Written in the stars: did your specialty choose you?

PURPOSE OF THE STUDY

Established over 2000 years ago, horoscopes remain a regular feature in contemporary society. We aimed to assess whether there could be a link between zodiac sign and medical occupation, asking the question-did your specialty choose you?

STUDY DESIGN

A questionnaire-based study was distributed using an online survey tool. Questions explored the zodiac sign, specialty preferences and personality features of physicians.

RESULTS

1923 physicians responded between February and March 2020. Variations in personality types between different medical specialties were observed, introverts being highly represented in oncology (71.4%) and rheumatology (65.4%), and extroverts in sexual health (55%), gastroenterology (44.4%) and obstetrics and gynaecology (44.2%) (p<0.01). Proportions of zodiac signs in each specialty also varied; for example, cardiologists were more likely to be Leo compared with Aries (14.4% vs 3.9%, p=0.047), medical physicians more likely Capricorn than Aquarius (10.4% vs 6.7%, p=0.02) and obstetricians and gynaecologists more likely Pisces than Sagittarius (17.5% vs 0%, p=0.036). Intensive care was the most commonly reported second choice career, but this also varied between zodiac signs and specialties. Fountain pen use was associated with extroversion (p=0.049) and gastroenterology (p<0.01).

CONCLUSIONS

Personality types vary in different specialties. There may be links to zodiac signs which warrant further investigation.