Patient perceptions of palliative care in the process of allogeneic hematopoietic cell transplantation

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Background: Allogeneic hematopoietic cell transplantation (allo-HCT) is associated with significant short- and long-term sequelae that affect patients’ overall quality of life (QoL) and their physical and psychological well-being. Studies have shown improvement in patient QoL and physician satisfaction with palliative care involvement in the allo-HCT process. However, patient and physician perceptions regarding palliative care often impact timely referral. We conducted a prospective study to examine patient perceptions of palliative care both before and after palliative care consultation during evaluation for allo-HCT. Methods: This is a prospective, single-center study, of patients > 18 years of age, who were referred for a palliative care consultation as part of standard evaluation for allo-HCT. Patients were administered a pre- and post-visit internally derived questionnaire to assess their understanding and comfort level with palliative care. The primary objective of this study was to examine patient perceptions of palliative care consultation during evaluation for allo-HCT. Primary end point was the change in patient pre- and post- questionnaire responses. Secondary endpoint was the completion of advance care planning documentation pre- and post- consultation. Results: We enrolled 32 patients (male = 14) undergoing evaluation for allo-HCT with a primary diagnosis of AML (n = 8), NHL (n = 8), MDS (n = 7), ALL (n = 2), and other (n = 7). Following consultation with palliative care there was a statistically significant increase in patient understanding of the reason for the appointment, p = 0.0006. There was also a significant increase in patient’s knowledge of palliative care, with only 28% describing their knowledge as “good” or “excellent” prior to consultation and 79.3% after consultation, p < 0.0001. There was an observed positive, non-statistically significant, trend in patient comfort level with palliative medicine with only 20.7% (n = 6) describing their comfort as “high” or “very high” prior to consultation and 51.7% (n = 15) after consultation, p = 0.60. There was a higher rate of completion of advance care planning documentation following consultation with palliative medicine 56.3% vs 71.4%, p = 0.042. Conclusions: Palliative care consultation prior to allo-HCT increases a patient’s understanding of the role of palliative medicine as part of their allo-HCT and improves advance care planning. These findings need to be validated in a larger, multicenter, patient cohort.

A comparison of cannula insufflation device performance for emergency front of neck airway

BACKGROUND

Pediatric emergency front of neck airway guidelines recommend oxygenation via cannula cricothyroidotomy or tracheotomy.

AIM

The primary aim was to measure test lung pressures and volumes generated by cannula insufflation devices recommended for emergency front of neck airway compared with a pressure limit of 50 cm H₂ O and volume limit of 20 ml/kg. The secondary aim was to calculate pressure and volume variability. The primary end point was test lung expansion.

METHOD

Adult, child, and infant airway models, each with three degrees of upper airway obstruction, were oxygenated using six cannula insufflation devices: 3-way stopcock, Rapid-O₂ , Manujet, Enk oxygen flow modulator, Ventrain, and self-inflating bags. Test lung pressures and volumes were recorded.

RESULTS

Pressures and volumes from all devices were highly variable, despite oxygen flow calibration and strict adherence to oxygen insufflation protocols. With upper airway occlusion, pressures >50 cm H₂ 0 were produced by Rapid-O₂ and Enk oxygen flow meter in adult and infant lungs, 3-way stopcock in adult and child lungs, and Manujet in all lung sizes. Ventrain produced acceptable pressures <35 cm H₂ O in all models. Test lung volumes >20 ml/kg were recorded in airway models with fully obstructed proximal airways using Rapid-O₂ and Enk oxygen flow meter in infant lungs, and Manujet in all lung sizes. Rapid-O₂ produced lung volumes >20 ml/kg in the infant model with partially obstructed and open upper airways. Test lung volumes >20 ml/kg were produced by the 3-way stopcock in adult, child, and infant models. Insufflation was unsuccessful with the self-inflating bag. Ventrain produced acceptable volumes <7 ml/kg in all airway models.

CONCLUSION

Rapid-O₂ , Enkoxygen flow meter, Manujet, and 3-way stopcock oxygenation devices produced highly variable and excessive airway pressures and volumes in models with obstructed upper airways. Self-inflating bag insufflation was unsuccessful. Ventrain was the only device that insufflated oxygen with acceptable pressures and volumes in adult, child, and infant airway models with any degree of airway obstruction.

Predictors of varying levels of risks posed by fixated individuals to British public figures

Concerning approaches and communications to the Royal Family and other British public figures are relatively numerous. This paper examines over 2000 such cases logged over a three-year period in the United Kingdom. Using police and health data, the paper conducts a series of bivariate and multivariate analyses to demonstrate the predictors of what types of risk are posed by an individual case (e.g., communicate only, approach, security breach). The results showed that (a) the rates of serious mental disorders are higher among this sample than the general population base rate, (b) approachers were significantly more likely than communicators to suffer from serious mental disorders, (c) approachers were significantly more likely than communicators to have a history of substance use and abuse problems, (d) approachers were significantly more likely than communicators to have a history of violent behavior against property and persons, and (e) the motivations of approachers and communicators significantly differ. The paper concludes with a consideration of the implications for threat assessment and management.

A cluster randomized controlled trial comparing Virtual Learning Collaborative and Technical Assistance strategies to implement an early palliative care program for patients with advanced cancer and their caregivers: a study protocol

BACKGROUND

Virtual Learning Collaboratives (VLC), learning communities focused on a common purpose, are used frequently in healthcare settings to implement best practices. Yet, there is limited research testing the effectiveness of this approach compared to other implementation strategies. This study evaluates the effectiveness of a VLC compared to Technical Assistance (TA) among community oncology practices implementing ENABLE (Educate, Nurture, Advise, Before Life Ends), an evidence-based, early palliative care telehealth, psycho-educational intervention for patients with newly diagnosed advanced cancer and their caregivers.

METHODS

Using Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) and Proctor's Implementation Outcomes Frameworks, this two-arm hybrid type-III cluster-randomized controlled trial (RCT) will compare two implementation strategies, VLC versus TA, among the 48 National Cancer Institute Community Oncology Research Program (NCORP) practice clusters that have not historically provided palliative care to all patients with advanced cancer. Three cohorts of practice clusters will be randomized to the study arms. Each practice cluster will recruit 15-27 patients and a family caregiver to participate in ENABLE. The primary study outcome is ENABLE uptake (patient level), i.e., the proportion of eligible patients who complete the ENABLE program (receive a palliative care assessment and complete the six ENABLE sessions over 12 weeks). The secondary outcome is overall program implementation (practice cluster level), as measured by the General Organizational Index at baseline, 6, and 12 months. Exploratory aims assess patient and caregiver mood and quality of life outcomes at baseline, 12, and 24 weeks. Practice cluster randomization will seek to keep the proportion of rural practices, practice sizes, and minority patients seen within each practice balanced across the two study arms.

DISCUSSION

This study will advance the field of implementation science by evaluating VLC effectiveness, a commonly used but understudied, implementation strategy. The study will advance the field of palliative care by building the capacity and infrastructure to implement an early palliative care program in community oncology practices.

TRIAL REGISTRATION

Clinicaltrials.gov . NCT04062552; Pre-results. Registered: August 20, 2019. https://clinicaltrials.gov/ct2/show/NCT04062552?term=NCT04062552&draw=2&rank=1.

Telehealth in Palliative Care: Communication Strategies From the COVID-19 Pandemic

Palliative care was once believed to be too high-touch to be delivered via telehealth. However, numerous studies have demonstrated the positive effects of palliative care delivered through telehealth. Because the COVID-19 pandemic has quickly shifted how health care is delivered to patients with cancer, particularly because of their immunocompromised status and the risks associated with unnecessary exposures in the clinic, previous lessons from palliative care research studies can be used to inform practice. This article presents a case study that illustrates evidence and best practices for continuing to deliver palliative care via telehealth after COVID-19 restrictions are lifted.

A cue-to-action pilot project to increase screening mammography

OBJECTIVES

Screening mammography is a preventive exam used to detect breast cancer in asymptomatic women. This cue-to-action pilot project sought to determine if outreach, education, and incentive would increase uptake of screening mammography among women aged 52 to 74 years who are members of a community-based health insurance plan.

STUDY DESIGN

Cohort study design with retrospective and prospective components.

METHODS

Women were eligible to participate in accordance with the CMS Quality Rating System technical specification for breast cancer screening. Eligible women with no documented screening for a mammogram from January 1, 2016, through November 7, 2017, were invited to participate in a campaign that included outreach about screening mammography as a no-cost covered benefit, education about screening mammography to detect asymptomatic disease, and a gift card to a local grocery merchant if the member obtained screening mammography by December 31, 2017.

RESULTS

During December 2017, 20.8% (27/130) of eligible women obtained a screening mammogram compared with 7.8% (5/64) of eligible women during the nonintervention reference period of December 2016. Mammography screening increased by 170% during the study period in comparison with the reference period of a year earlier (prevalence ratio [PR], 2.7; 95% CI, 1.1-6.6; P = .02).

CONCLUSIONS

A one-time, time-limited cue-to-action pilot project consisting of outreach, education, and incentive increased uptake of screening mammography by women enrolled in a community health insurance plan providing health insurance coverage as part of the Affordable Care Act. This increase is statistically significant in the intervention period compared with the reference period (PR, 2.7; 95% CI, 1.1-6.6; P = .02). Despite a small sample size, the magnitude of the effect for this pilot study is encouraging and warrants future studies in a larger population.

The CB1R rs2023239 receptor gene variant significantly affects the reinforcing effects of nicotine, but not cue reactivity, in human smokers

INTRODUCTION

The cannabinoid CB1 receptor (CB1R) has been shown in preclinical studies to be involved in nicotine reinforcement and relapse-like behavior. The common single nucleotide polymorphism (SNP) rs2023239 may code for an alternative CB1R protein, alter CB1R expression, and be involved in nicotine dependence. To date, no study has explored the relationship between this SNP in CB1R and specific phenotypes of nicotine dependence.

METHODS

The current study investigated the influence of CB1R rs2023239 in nicotine reinforcement and craving in regular cigarette smokers. Current smokers (n = 104, cigarettes per day ≥ 10) were genetically grouped (C allele group vs. No C allele group) and underwent laboratory measures of nicotine reinforcement and smoking cue-elicited craving. Nicotine reinforcement was assessed using a forced choice paradigm, while a cue-reactivity procedure measured cue-elicited craving.

RESULTS

These results show that smokers with the C allele variant (CC + CT genotypes) experienced a lower nicotine reinforcement effect compared to those without the C allele (TT genotype). These results were similar in both our subjective and behavioral reinforcement measures, though the subjective effects did not withstand controlling for race. There was no difference between genotype groups with respect to cue-elicited craving, suggesting a lack of influence in cue reactivity.

CONCLUSION

Taken together, these results suggest that the variation in the CB1R (i.e., rs2023239 SNP) may play a larger role in nicotine reinforcement compared to cue reactivity. This work provides impetus to further understand the physiological mechanisms that explain how CB1Rs influence nicotine dependence phenotypes.

Using Health Insurance Network Provider Data and Public Data Sets to Identify SARS-CoV-2 Vaccinators in the USA

Objective: Mass vaccination planning is occurring at all levels of government in advance of regulatory approval and manufacture of a SARS-CoV-2 vaccine for distribution sometime in 2021. We outline a methodology in which both health insurance provider network data and publicly available data sources can be used to identify and plan for SARS-CoV-2 vaccinator capacity at the county level.

Methods: Sendero Health Plans, Inc. provider network data, Texas State Board of Pharmacy data, US Census Bureau data, and H1N1 monovalent vaccine data were utilized to identify providers with demonstrated capacity to vaccinate the population in Travis County, Texas to achieve an estimated SARS-CoV-2 herd immunity target of 67%.

Results: Within the Sendero network, 2,356 non-pharmacy providers were identified with 788 (33.4%) practicing in primary care and 1,569 (66.6%) practicing as specialists. Of the total, 686 (29.1%) provided at least one immunization between January 1, 2019 and September 30, 2020. There are 300 pharmacies with active licenses in Travis County with 161 (53.7%) classified as community pharmacies. We estimate that 1,707,098 doses of a 2-dose SARS-CoV-2 vaccine series will need to be administered within Travis County, Texas to achieve the estimated 67% herd immunity threshold to disrupt person-to-person transmission of the SARS-CoV-2 virus based on 2020 census data.

Conclusion: A community-based health insurance plan can use data from its provider network and public data sources to support the CDC call to action to identify SARS-CoV-2 vaccinators in the community, including physicians, nurse practitioners, physician assistants, and pharmacies in order to provide macro level estimates of SARS-CoV-2 administration and throughput.

Efforts to Reduce Infections in Delayed Sternal Closure Patients: A Survey of Pediatric Practice

BACKGROUND

Pediatric patients with sternum left open after cardiac surgery experience a higher risk for sternal wound infection (SWI). These infections are costly for programs, payers, and patients and their families. Despite efforts by individual programs to reduce infections in patients undergoing delayed sternal closure (DSC), there are no established guidelines that address preventive procedures. The purpose of this study was to determine the practice of pediatric cardiac surgery programs to prevent infection in their DSC patients and if preventive measures were associated with less infections.

METHODS

A 33 question survey on institutional practices was sent to chief surgeons at pediatric cardiac surgery programs in the United States.

RESULTS

Twenty-eight (35%) surgical programs responded. The mean number of pediatric cardiac bypass operations performed by programs in 2016 was 227 (range: 69-872). Data represented 6,484 patients <18 years of age who underwent cardiac surgery with 807 (12%) of those undergoing DSC. One hundred fifty-eight (2.4%) of all patients and 51 (6.3%) of the DSC patients developed a SWI. Patients with DSC who received preoperative baths were less likely to become infected (5.9% vs 15.8%; P = .015). Patients in programs with feeding protocols had fewer infections (5.7% vs 14.8%; P = .008).

CONCLUSIONS

The results of this survey of children's cardiac surgery programs describe their practices to reduce infection rates in DSC patients. A multicenter project on wound care and closure techniques that might impact this costly complication is needed.

Mortality in Tonga over three triennia, 2010-2018

BACKGROUND

Tonga is a South Pacific Island country with a population of 100,651 (2016 Census). This study examines Tongan infant mortality rates (IMR), under-five mortality rates (U5MR), adult mortality and life expectancy (LE) at birth from 2010 to 2018 using a recent collation of empirical mortality data over the past decade for comparison with other previously published mortality estimates.

METHODS

Routinely collected mortality data for 2010-2018 from the Ministry of Health, national (Vaiola) hospital, community nursing reports, and the Civil Registry, were consolidated by deterministic and probabilistic linkage of individual death records. Completeness of empirical mortality reporting was assessed by capture-recapture analysis. The reconciled data were aggregated into triennia to reduce stochastic variation, and used to estimate IMR and U5MR (per 1000 live births), adult mortality (15-59, 15-34, 35-59, and 15-64 years), and LE at birth, employing the hypothetical cohort method (with statistical testing). Mortality trends and differences were assessed by Poisson regression. Mortality findings were compared with published national and international agency estimates.

RESULTS

Over the three triennia in 2010-2018, levels varied minimally for IMR (12-14) and U5MR (15-19) per 1000 births (both ns, p > 0.05), and also for male LE at birth of 64-65 years, and female LE at birth 69-70 years. Cumulated risks of adult mortality were significantly higher in men than women; period mortality increases in 15-59-year women from 18 to 21% were significant (p < 0.05). Estimated completeness of the reconciled data was > 95%. International agencies reported generally comparable estimates of IMR and U5MR, with varying uncertainty intervals; but they reported significantly lower adult mortality and higher LE than the empirical estimates from this study.

CONCLUSIONS

Life expectancy in Tonga over 2010-2018 has remained relatively low and static, with low IMR and U5MR, indicating the substantial impact from premature adult mortality. This analysis of empirical data (> 95% complete) indicates lower LE and higher premature adult mortality than previously reported by international agencies using indirect and modelled methods. Continued integration of mortality recording and data systems in Tonga is important for improving the completeness and accuracy of mortality estimation for local health monitoring and planning.

Mapping social reward and punishment processing in the human brain: A voxel-based meta-analysis of neuroimaging findings using the social incentive delay task

Social rewards or punishments motivate human learning and behaviour, and alterations in the brain circuits involved in the processing of these stimuli have been linked with several neuropsychiatric disorders. However, questions still remain about the exact neural substrates implicated in social reward and punishment processing. Here, we conducted four Anisotropic Effect Size Signed Differential Mapping voxel-based meta-analyses of fMRI studies investigating the neural correlates of the anticipation and receipt of social rewards and punishments using the Social Incentive Delay task. We found that the anticipation of both social rewards and social punishment avoidance recruits a wide network of areas including the basal ganglia, the midbrain, the dorsal anterior cingulate cortex, the supplementary motor area, the anterior insula, the occipital gyrus and other frontal, temporal, parietal and cerebellar regions not captured in previous coordinate-based meta-analysis. We identified decreases in the BOLD signal during the anticipation of both social reward and punishment avoidance in regions of the default-mode network that were missed in individual studies likely due to a lack of power. Receipt of social rewards engaged a robust network of brain regions including the ventromedial frontal and orbitofrontal cortices, the anterior cingulate cortex, the amygdala, the hippocampus, the occipital cortex and the brainstem, but not the basal ganglia. Receipt of social punishments increased the BOLD signal in the orbitofrontal cortex, superior and inferior frontal gyri, lateral occipital cortex and the insula. In contrast to the receipt of social rewards, we also observed a decrease in the BOLD signal in the basal ganglia in response to the receipt of social punishments. Our results provide a better understanding of the brain circuitry involved in the processing of social rewards and punishment. Furthermore, they can inform hypotheses regarding brain areas where disruption in activity may be associated with dysfunctional social incentive processing during disease.

Pulse shape discrimination and exploration of scintillation signals using convolutional neural networks

We demonstrate the use of a convolutional neural network to perform neutron-gamma pulse shape discrimination, where the only inputs to the network are the raw digitised silicon photomultiplier signals from a dual scintillator detector element made of 6Li F:ZnS(Ag) scintillator and PVT plastic. A realistic labelled dataset was created to train the network by exposing the detector to an AmBe source, and a data-driven method utilising a separate photomultiplier tube was used to assign labels to the recorded signals. This approach is compared to the charge integration and continuous wavelet transform methods and a simpler artificial neural net. It is found to provide superior levels of discrimination, achieving an area under the curve of 0.996 ± 0.003. We find that the neural network is capable of extracting interpretable features directly from the raw data. In addition, by visualising the high-dimensional representations of the network with the t-SNE algorithm, we discover that not only is this method robust to minor mislabeling of the training dataset but that it is possible to identify an underlying substructure within the signals that goes beyond the original labelling. This technique could be utilised to explore and cluster complex, raw detector data in a novel way that may reveal more insights than standard analysis methods.

Hepatitis C Antibody Screening Among Baby Boomers by a Community-Based Health Insurance Company

Infection with the hepatitis C virus (HCV) is the most commonly reported bloodborne infection in the United States. Individuals born between 1945–1965, the baby boomers, account for approximately 75% of all chronic HCV infections in the United States. The purpose of this study was to determine if a 6-week intervention, including outreach, education, and incentive, by a community-based health insurance company could improve uptake of HCV antibody screening among the 1945–1965 birth cohort. Individuals were eligible to participate in this campaign if they were born on or after January 1, 1945 and on or before December 31, 1965, had health insurance with Sendero Health Plans during the intervention period, and had no evidence of having received an HCV antibody test prior to the campaign start date. The 6-week campaign period was from November 14, 2018 through December 31, 2018. A gift card incentive was provided if HCV screening was completed on or before December 31, 2018. A total of 5287 individuals were eligible to participate in the campaign. Members who were baby boomers were 3.36 times more likely to receive HCV antibody screening during the intervention period in 2018 than during a similar period in 2017 (prevalence ratio = 3.36; P < 0.0001; 95% confidence interval: 2.71, 4.16). Health officials have established the identification, treatment, and elimination of HCV as a national policy objective. Using an outreach, education, and incentive approach, Sendero Health Plans improved uptake of HCV antibody screening among the high-risk baby boomer population.

Inducing remission of Type 2 diabetes in the Caribbean: findings from a mixed methods feasibility study of a low-calorie liquid diet-based intervention in Barbados

AIM

In a high proportion of people with recently diagnosed Type 2 diabetes, a short (2-3-month) low-calorie diet is able to restore normal glucose and insulin metabolism. The aim of this study was to determine the feasibility of this approach in Barbados.

METHODS

Twenty-five individuals with Type 2 diabetes diagnosed within past 6 years, not on insulin, BMI ≥ 27 kg/m² were recruited. Hypoglycaemic medication was stopped on commencement of the 8-week liquid (760 calorie) diet. Insulin response was assessed in meal tests at baseline, 8 weeks and 8 months. Semi-structured interviews, analysed thematically, explored participants' experiences. 'Responders' were those with fasting plasma glucose (FPG) < 7 mmol/l at 8 weeks.

RESULTS

Ten men and 15 women (mean age 48, range 26-68 years) participated. Mean (sd) BMI was 34.2 kg/m² (6.0); FPG 9.2 mmol/l (2.2). Mean weight loss at 8 weeks and 8 months was 10.1 kg [95% confidence interval (CI) 8.1, 12.0] and 8.2 kg (95% CI 5.8, 10.6); FPG was lower by 2.2 mmol/l (95% CI 1.2, 3.2) and 1.7 mmol/l (95% CI 0.8, 2.7) respectively. Nine of 11 (82%) of those who lost ≥ 10 kg were 'responders' compared with 6 of 14 (43%) who lost < 10 kg (P = 0.048). The 30-min insulin increment was higher in responders at baseline and follow-up (P ≤ 0.01). A food culture based on starchy foods and pressures to eat large amounts at social events were among the challenges identified by participants.

CONCLUSIONS

The feasibility of this approach to weight loss and diabetes remission in a predominantly black population in Barbados was demonstrated.

Anticipating Urinary Retention Following Total Hip and Total Knee Replacements

Introduction

Urinary retention is a widely recognised postoperative complication. Although anecdotally lower limb arthroplasty is linked with high rates of urinary retention, there are no current accepted standards for determining which patients are at higher risk and should therefore be offered intra operative catheterisation.

Materials and Methods

One hundred patients, 55 females and 45 males, who underwent uncomplicated total hip or total knee replacements at Furness General Hospital were recruited between January and April 2017.

Results

Post-operative urinary retention was seen frequently, with 38 patients (38%) requiring post-operative catheterisation. Twenty-one males (46%) developed postoperative retention compared to 17 (30%) of females, representing a statistically significant increase in risk seen in male patients. (p 0.009). Post-operative urinary retention requiring catheterisation was associated with increasing age, with those over 75 years having a significantly higher risk than those less than 75 years irrespective of gender (p 0.04). There was no significant difference in urinary retention rates between patients who had general (n=21) or spinal anaesthetic (n=79) with 33% of GA patients and 39% of spinal anaesthetic patients requiring catheterisation (p 0.17).

Conclusion

There are increased rates of urinary retention seen in lower limb arthroplasty patients than those described in the general surgical population, with male patients and all those over 75 years of age having a significantly higher risk. Clinically, it may therefore be sensible to consider offering routine intra operative catheterisation to this cohort of patients.

Improving understanding of type 2 diabetes remission: research recommendations from Diabetes UK's 2019 remission workshop

AIM

To describe the process and outputs of a workshop convened to identify key priorities for future research in the area of remission of type 2 diabetes, and provide recommendations to researchers and research funders on how best to address them. With the ultimate aim of enabling the remission of type 2 diabetes to become a possibility for more people.

METHODS

A 1-day research workshop was conducted, bringing together 31 researchers, people living with diabetes, healthcare professionals and members of staff from Diabetes UK to identify and prioritize recommendations for future research into remission of type 2 diabetes.

RESULTS

Workshop attendees identified 10 key themes for further research. Four of these themes were prioritized for further focus: (i) understanding how to personalize lifestyle approaches based on biology, patient choice and subtypes; (ii) understanding the biology of remission; (iii) understanding the most effective approaches to implementation of lifestyle interventions; and (iv) understanding the best approaches to combining therapies (gut hormones, other drugs, lifestyle approaches and bariatric surgery).

CONCLUSIONS

This paper outlines recommendations to address the current gaps in knowledge related to remission of type 2 diabetes.

Review of papers published in The British Journal of Oral and Maxillofacial Surgery and The Journal of Orthodontics regarding three-dimensional computerised planning in orthognathic surgery: 2015 - 2019

This review paper summarises articles regarding orthognathic surgical planning and computerised technology, which were published in two leading national journals in both oral and maxillofacial surgery and orthodontics. This article aims to keep readers up to date with the literature published in this rapidly progressing field.

Data on the modulatory effects of a single bolus dexamethasone on the surface marker expression of various leucocyte subsets

Dexamethasone is frequently administered to surgical patients for anti-emetic prophylaxis. We have examined the immunomodulatory effects of a single bolus of dexamethasone on circulating peripheral blood mononuclear cells (PBMCs) in the same 10 healthy male volunteers, previously used in our investigation on early in vivo effects of a single anti-emetic dose of dexamethasone on innate immune cell gene expression and activation [1]. Blood samples were drawn at baseline, 2 h, 4 h and 24 h. Immune cell phenotypes were examined with flow cytometry. In this data article the expression strength of markers involved in immune activation and immunosuppression as well as maturation, migration, cell death and responsiveness to signalling on monocyte and cDC subsets, as well as NK cells, CD4+ and CD8+ T cells and regulatory T cells (Treg) are presented. These data improve our understanding of the immunomodulatory effects of the glucocorticoid dexamethasone in-vivo, which may be important for the optimisation of treatment regimens as well as the evaluation of new indications for glucocorticoid treatment.

GW190521: A Binary Black Hole Merger with a Total Mass of 150 M_{⊙}

On May 21, 2019 at 03:02:29 UTC Advanced LIGO and Advanced Virgo observed a short duration gravitational-wave signal, GW190521, with a three-detector network signal-to-noise ratio of 14.7, and an estimated false-alarm rate of 1 in 4900 yr using a search sensitive to generic transients. If GW190521 is from a quasicircular binary inspiral, then the detected signal is consistent with the merger of two black holes with masses of 85_{-14}^{+21}  M_{⊙} and 66_{-18}^{+17}  M_{⊙} (90% credible intervals). We infer that the primary black hole mass lies within the gap produced by (pulsational) pair-instability supernova processes, with only a 0.32% probability of being below 65  M_{⊙}. We calculate the mass of the remnant to be 142_{-16}^{+28}  M_{⊙}, which can be considered an intermediate mass black hole (IMBH). The luminosity distance of the source is 5.3_{-2.6}^{+2.4}  Gpc, corresponding to a redshift of 0.82_{-0.34}^{+0.28}. The inferred rate of mergers similar to GW190521 is 0.13_{-0.11}^{+0.30}  Gpc^{-3} yr^{-1}.

A review of technical notes published in BJOMS: a comparison 10 years on

Technical notes are known to be a popular method of publishing novel surgical techniques, up-to-date technological advances, and tricks of the trade in oral and maxillofacial surgery (OMFS). The British Journal of Oral and Maxillofacial Surgery (BJOMS) has a dedicated section for such papers, and this article explores the publication of technical notes over the last two years. In addition, comparison is made with previous reviews of technical notes in this journal a decade ago, to explore the progression of diversity and evolving topics of interest to the oral and maxillofacial surgery community.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Behaviour change during dietary Type 2 diabetes remission: a longitudinal qualitative evaluation of an intervention using a very low energy diet

AIM

To understand the process of behaviour change through the experiences of people with Type 2 diabetes engaged in an 8-month diabetes remission intervention including a 2-month weight loss phase with the use of a very low energy diet (VLED), and a 6-month, structured weight maintenance phase.

METHODS

Data were collected in three semi-structured interviews at baseline, week 8 (end of the weight loss phase), and month 8 (end of the weight maintenance phase). Longitudinal inductive thematic analysis was used to analyse participants' narratives and identify change over time.

RESULTS

Eleven of 18 participants completed all three interviews. The following themes of change were identified in their narratives: (1) 'Building behavioural autonomy' as a process of growing confidence to engage in health behaviours that are independent of those of other people; (2) 'Behavioural contagion' describing how one's new health behaviours tend to affect those of other people; (3) 'From rigid to flexible restraint', reflecting the changes in attitudes and behaviours required for a successful adaptation from weight loss to weight maintenance; and (4) 'Shift in identity', representing changes in the participants' perceptions of themselves.

CONCLUSIONS

This longitudinal qualitative study provided new insights into how behaviour change is experienced by people with Type 2 diabetes engaged on a weight management intervention using VLED, contributing to theoretical and practical understanding of weight management behaviours. The themes identify potential areas in which individuals can be supported in achieving dietary diabetes remission and long-term maintenance of weight loss.

Reoperation in Zygomatico-orbital Trauma: A Review of Patients With Suboptimal Outcomes Following Initial Repair

Introduction

Treatment to restore anatomy, function, and aesthetics after trauma should involve as little surgical insult as possible. As such, repeated procedures may suggest failed initial management. To date, no predictive factors for failure of primary surgery have been identified.

Objectives

The aim of this review was to identify factors affecting the requirement for reoperation following treatment of zygomatico-orbital injuries.

Study Design and Methods

A retrospective review of patients undergoing surgery for zygomatico-orbital fractures between 2011 and 2019 in a single UK major trauma center was undertaken. All operative notes and imaging were reviewed independently by 2 authors to classify the fracture patterns for both zygomatic and orbital components of the injury. For all cases, the mode of preoperative imaging the grade of operating surgeon, materials used for fixation, and the surgical approaches were recorded.

Results

Coding data identified 432 patients who underwent surgery for zygomatico-orbital fractures. In total, 116 cases were treated with closed reduction and 316 with open reduction and internal fixation; 20 cases required reoperation. There were no significant differences identified between cases requiring reoperation and those who did not.

Conclusions

A need for repeated surgery is rare. However, this review identified an increased risk of infection of fixation when an intraoral approach was used and highlights the potential benefits that can be achieved by open reduction and internal fixation when more conservative approaches fail to achieve the desired outcome.

Community intervention for cardiovascular disease risk factors in Kalutara, Sri Lanka

BACKGROUND

The effectiveness of a 2015-17 community intervention to reduce cardiovascular disease (CVD) and type 2 diabetes (T2DM) risk factors is assessed in a Sri Lanka adult population, using a before-and-after study design.

METHODS

Four contiguous Public Health Midwife (PHM) areas in Kalutara district (Western Province) were exposed to a Sri Lankan designed community health promotion initiatives (without screening) to lower CVD and T2DM risk factors. Pre- and post-intervention surveys (2014, n=1,019; 2017, n=908) were of 25-64 year males (M) and females (F) from dissimilar randomly selected clusters (villages or settlements) from PHMs, with probability of selection proportional to population size, followed by household sampling, then individual selection to yield equal-probability samples. Differences in resting blood pressure (BP), fasting plasma glucose (FPG), total cholesterol, body mass index and tobacco smoking, adjusting for cluster sampling, age and socio-economic differences, were examined.

RESULTS

Hypertension prevalence declined from 25% to 16% (F) (p<.0001), and 21% to 17% (M). Both mean systolic and diastolic BP declined. T2DM declined from 18% to 13% (F), and 18% to 15% (M), as did mean fasting plasma glucose. Elevated total cholesterol declined from 21% to 15% in women (p=0.003) and mean cholesterol declined. Frequency distributions, medians and means of these continuous CVD risk factors shifted to lower levels, and were mostly statistically significant (p< 0.05).

CONCLUSIONS

Community health promotion can lower key CVD and T2DM risk factors. Lowering tobacco consumption in males and obesity remain challenges in Sri Lanka.

A Randomized Controlled Trial to Increase Diabetic Retinopathy Screening by a Community-Based Health Insurance Plan in Central Texas - 2017

PURPOSE

Diabetic retinopathy is a leading cause of blindness worldwide. In the United States, the prevalence of diabetic retinopathy is 26% - 33%. Providing preventive care to individuals with diabetes is important to prevent microvascular complications in the eye. This study reports on the results of a randomized controlled trial to determine how using specific cues to action combined with the provision of a free eye exam might positively influence the rate of diabetic retinopathy screening among individuals with diabetes.

METHODS

Individuals were eligible to participate in this campaign if they had a diagnosis of type 2 diabetes or were prescribed a diabetes drug, were members of the health insurance plan during the intervention period and had no evidence of receiving a retinal eye exam prior to the campaign period. The six-week campaign period started on September 19, 2017 and ended on October 31, 2017. A total of 1,454 individuals with type 2 diabetes were randomly assigned to a control group or to one of three intervention groups. Each intervention group included the provision of a free eye exam.

RESULTS

A total of 148 (10.1%) individuals obtained a retinal eye exam during the six-week campaign period with 38 persons (6.8%) in the control group, 38 (15.3%) in the incentive group, 41 (16.5%) in the education group, and 31 (12.4%) in the incentive and education group. Individual intervention comparisons with the referent group yielded statistical significance using the adjusted pairwise alpha of P = .008 for the incentive group (RR = 2.08; 95% CI, 1.36-3.19; P =.0006) and for the education group (RR = 2.23; 95% CI, 1.47-3.39; P =.0001), but not in the incentive plus education group (RR = 1.73; 95% CI, 1.10-2.73; P =.017).

CONCLUSION

This study supports the use of targeted cues to action combined with the provision of a free eye exam to increase the rates of diabetic retinopathy screening among individuals with diabetes who have health insurance coverage under the Affordable Care Act in a Central Texas population.

Exploring the role of the Ser9Gly (rs6280) Dopamine D3 receptor polymorphism in nicotine reinforcement and cue-elicited craving

Preclinical studies show that the dopamine D3 receptor (D3R) is involved in the reinstatement of drug seeking and motivation for drugs of abuse. A D3R gene variant, Ser9Gly (rs6280) has been linked to nicotine dependence, yet the mechanisms underlying its involvement in nicotine dependence is unclear. This study investigated the relationship between the Ser9Gly variant and measures of both nicotine reinforcement and cue-elicited craving. Phenotypes of smoking behaviors were assessed in genetically grouped (Glycine vs. No Glycine carriers) current smokers (n = 104, ≥ 10 cigarettes per day). Laboratory measures included a forced choice session (to measure reinforcement of nicotine containing vs. denicotinized cigarettes), and a cue-reactivity session (to measure smoking cues vs. neutral cues elicited craving). The forced choice procedure revealed that subjective ratings were significantly higher in response to nicotinized compared to denicotinized cigarettes; however the Ser9Gly variant did not influence this effect. By comparison, smoking cues elicited greater craving over time compared to neutral cues, and Glycine carriers of the Ser9Gly D3R variant seem to experience a significant blunted cue-elicited craving effect. Results support D3R involvement in nicotine cue reactivity. However, more research is needed to reveal how this gene variant modulates various aspects of nicotine dependence.

88 The Truth Behind the Pubic Rami Fracture: Identification of Pelvic Fragility Fractures at A University Teaching Hospital

Introduction

Older patients presenting with pelvic fragility fractures (PFF) is an increasing epidemic. The most common pelvic fracture identified by plain radiograph is pubic rami fracture. These fractures are painful and often require admission to hospital. However, despite optimal analgesia, many of these patients struggle to mobilise and may have fractures of the posterior pelvic ring, which are overlooked and not visible on plain radiograph imaging. We aimed to quantify the number of patients progressing to further pelvic imaging in the form of computed tomography (CT) or magnetic resonance imaging (MRI) and the presence of concurrent fractures.

Methods

Prospective screening of pelvic imaging in patients aged over 70 years was undertaken at Nottingham University Hospitals NHS Trust over an 8-month period from October 2018.

Results

103 predominantly female (83%) patients were confirmed to have an acute fragility fracture of the pubic rami on plain radiograph. 19% of patients were discharged direct from the Emergency Department, 45% were admitted to Health Care of Older People (HCOP) teams, 30% to Trauma and Orthopaedic (T&O) teams and 6% to other specialities. 25% of the patients admitted underwent further pelvic imaging, which confirmed fragility fractures of the pubic rami in 88%, with 40% showing acetabular fractures and 68% showing sacral fractures of all types. A further 10 patients were diagnosed with pubic rami insufficiency fractures on further imaging, having had a normal initial radiograph, but had been admitted with poor mobility due to groin pain. In these 10 patients, 20% also had an acetabular fracture and 60% sacral fractures. Overall, 59% of patients with pubic rami fractures had an ipsilateral sacral fracture; a Type 1 Lateral Compression pelvic fracture by AO classification.

Conclusions

Pubic rami fractures are a significant problem in older people and often require admission to hospital. Further imaging confirms these fractures are complex, with co-existing fractures of the acetabulum and sacrum common. However despite this, only a quarter of patients admitted had further imaging. Where pelvic fractures are missed or severity not appreciated, appropriate pain control can be more difficult to achieve. With the potential for minimally invasive surgical options to aid pain management in sacral fractures, it may be prudent for all patients hospitalised with suspected or confirmed pelvic fracture to undergo further imaging.

Forging a New Frontier: Providing Palliative Care to People With Cancer in Rural and Remote Areas

Mounting evidence supports oncology organizations' recommendations of early palliative care as a cancer care best practice for patients with advanced cancer and/or high symptom burden. However, few trials on which these best practices are based have included rural and remote community-based oncology care. Therefore, little is known about whether early palliative care models are applicable in these low-resource areas. This literature synthesis identifies some of the challenges of integrating palliative care in rural and remote cancer care. Prominent themes include being mindful of rural culture; adapting traditional geographically based specialty care delivery models to under-resourced rural practices; and using novel palliative care education delivery methods to increase community-based health professional, layperson, and family palliative expertise to account for limited local specialty palliative care resources. Although there are many limitations, many rural and remote communities also have strengths in their capacity to provide high-quality care by capitalizing on close-knit, committed community practitioners, especially if there are receptive local palliative and hospice care champions. Hence, adapting palliative care models, using culturally appropriate novel delivery methods, and providing remote education and support to existing community providers are promising advances to aid rural people to manage serious illness and to die in place. Reformulating health policy and nurturing academic-community partnerships that support best practices are critical components of providing early palliative care for everyone everywhere.

Relaxing Floors: Fractal Fluency in the Built Environment

This year's cover artists are members of a newly formed team of designers and scientists known as the Science and Design Laboratory, along with flooring manufacturing experts from the Mohawk Group. This unique collab-oration creates patterns for installation on the floors of versatile commercial, public and private spaces including airports, hospitals, offices and homes. Their goal is to create human-centered designs based on psychology experiments that investigate the positive impacts of viewing fractal patterns. These include reduced physiological stress levels, enhanced cognitive skills, and heightened concentration. Here, the fractal construction process and the resulting fractal characteristics of these designs are explained.

Prospects for observing and localizing gravitational-wave transients with Advanced LIGO, Advanced Virgo and KAGRA

We present our current best estimate of the plausible observing scenarios for the Advanced LIGO, Advanced Virgo and KAGRA gravitational-wave detectors over the next several years, with the intention of providing information to facilitate planning for multi-messenger astronomy with gravitational waves. We estimate the sensitivity of the network to transient gravitational-wave signals for the third (O3), fourth (O4) and fifth observing (O5) runs, including the planned upgrades of the Advanced LIGO and Advanced Virgo detectors. We study the capability of the network to determine the sky location of the source for gravitational-wave signals from the inspiral of binary systems of compact objects, that is binary neutron star, neutron star-black hole, and binary black hole systems. The ability to localize the sources is given as a sky-area probability, luminosity distance, and comoving volume. The median sky localization area (90% credible region) is expected to be a few hundreds of square degrees for all types of binary systems during O3 with the Advanced LIGO and Virgo (HLV) network. The median sky localization area will improve to a few tens of square degrees during O4 with the Advanced LIGO, Virgo, and KAGRA (HLVK) network. During O3, the median localization volume (90% credible region) is expected to be on the order of 10 5 , 10 6 , 10 7 Mpc 3 for binary neutron star, neutron star-black hole, and binary black hole systems, respectively. The localization volume in O4 is expected to be about a factor two smaller than in O3. We predict a detection count of 1 - 1 + 12 ( 10 - 10 + 52 ) for binary neutron star mergers, of 0 - 0 + 19 ( 1 - 1 + 91 ) for neutron star-black hole mergers, and 17 - 11 + 22 ( 79 - 44 + 89 ) for binary black hole mergers in a one-calendar-year observing run of the HLV network during O3 (HLVK network during O4). We evaluate sensitivity and localization expectations for unmodeled signal searches, including the search for intermediate mass black hole binary mergers.

Detergent-free extraction of a functional low-expressing GPCR from a human cell line

Dopamine receptors (DRs) are class A G-Protein Coupled Receptors (GPCRs) prevalent in the central nervous system (CNS). These receptors mediate physiological functions ranging from voluntary movement and reward recognition to hormonal regulation and hypertension. Drugs targeting dopaminergic neurotransmission have been employed to treat several neurological and psychiatric disorders, including Parkinson's disease, schizophrenia, Huntington's disease, attention deficit hyperactivity disorder (ADHD), and Tourette's syndrome. In vivo, incorporation of GPCRs into lipid membranes is known to be key to their biological function and, by inference, maintenance of their tertiary structure. A further significant challenge in the structural and biochemical characterization of human DRs is their low levels of expression in mammalian cells. Thus, the purification and enrichment of DRs whilst retaining their structural integrity and function is highly desirable for biophysical studies. A promising new approach is the use of styrene-maleic acid (SMA) copolymer to solubilize GPCRs directly in their native environment, to produce polymer-assembled Lipodisqs (LQs). We have developed a novel methodology to yield detergent-free D1-containing Lipodisqs directly from HEK293f cells expressing wild-type human dopamine receptor 1 (D1). We demonstrate that D1 in the Lipodisq retains activity comparable to that in the native environment and report, for the first time, the affinity constant for the interaction of the peptide neurotransmitter neurotensin (NT) with D1, in the native state.

Enumeration of Total Coliforms and E. coli in Foods by the SimPlate® Coliform and E. coli Color Indicator Method and Conventional Culture Methods: Collaborative Study

The relative effectiveness of the SimPlate® Coliform and E. coli Color Indicator (CEc-CI) method was compared to the AOAC 3-tube Most Probable Number (MPN) methods for enumerating and confirming coliforms and Escherichia coli in foods (966.23 and 966.24). In this study, test portions were prepared and analyzed according to the conditions stated in both the AOAC methods and SimPlate directions for use. Six food types were artificially contaminated with coliform bacteria and E. coli: frozen burritos, frozen broccoli, fluid pasteurized milk, whole almond nut meats, cheese, and powdered cake mix. Method comparisons were conducted. Overall, the SimPlate method demonstrated &lt;0.3 log difference for total coliform and E. coli counts compared to the AOAC reference methods for the majority of food types and levels analyzed. In all cases, the repeatability and reproducibility of the SimPlate CEc-CI method were not different from those of the reference methods and in certain cases, were statistically better than those of the AOAC 3-tube MPN methods. These results indicate that the SimPlate CEc-CI method and the reference culture methods are comparable for enumeration of both total coliforms and E. coli in foods.

QOLP-41. ASSESSING CAREGIVERS’ OF PATIENTS WITH PRIMARY BRAIN TUMORS EXPERIENCES WITH AND NEEDS RELATED TO SEIZURE MANAGEMENT

Family caregivers of persons with primary brain tumors report high levels of distress. Information is limited, however, regarding family caregivers’ experiences and needs concerning the risk and management of seizures in this population. In this qualitative descriptive study, we conducted one-on-one interviews to describe the experiences of family caregivers’ of persons with primary brain tumors who have had and who have not yet had a seizure. We sought information on how they coped with this issue and what information they needed regarding management of out-of-the-hospital seizures. We conducted 15 interviews using study-specific interview protocols; 10 caregivers with seizure experience and 5 caregivers without seizure experience. Caregivers were, on average, 52 years old, predominately white (93.3%), college graduates (66.7%), and were employed full-time (53.3%). The relationship between caregiver and care recipient was spouse (46.7%), other family member (46.7%), and friend (6.6%). Most caregivers provided care everyday (46.7%) and for more than 8 hours per day (33.3%). Themes emerged around three major domains: 1) caregiver challenges regarding seizures, 2) desired resources/information about seizures, and 3) timing of delivery of these resources. Caregivers often reported being fearful of seizures and the majority (93%) expressed difficulty with knowing when to call EMS. In terms of desired resources, opinions were split between preferring written materials versus online resources with most participants (87%) stating that videos or graphics detailing seizures would be helpful. In terms of delivery timing, most (66.7%) thought that training should come after diagnosis versus at the time of diagnosis citing reasons such as too much other information to absorb and overall inability to focus. Future studies will use this information to develop and pilot a seizure-focused supportive caregiver intervention that is tailored and caregiver-directed and that can be incorporated into standard neuro-oncology clinical practice.

A systematic review and computational modelling analysis of unilateral montages in electroconvulsive therapy

OBJECTIVE

To examine the clinical outcomes of ECT unilateral placements compared in prior studies and apply insights from computational modelling to understand differences between placements.

METHODS

PubMed, Embase, Scopus and PsycINFO and reference lists were systematically searched for studies of depressed patients where two unilateral placements were compared and clinical outcomes were reported. Computational modelling was done to generate electric field maps for each unilateral placement identified in the systematic review.

RESULTS

A total of 29 studies met criteria for inclusion. Eight studies reported efficacy outcomes and 23 studies reported cognitive outcomes. Most studies found no significant difference in efficacy between right unilateral (RUL) and left unilateral (LUL) ECT, and no difference was found between temporo-parietal and fronto-temporal ECT. For the majority of studies, RUL placements had better verbal anterograde memory outcomes compared with the LUL placements. There was some evidence suggestive of cognitive advantages for fronto-frontal and fronto-parietal placements relative to temporo-parietal ECT.

CONCLUSIONS

For efficacy, studies mainly focused on the comparison of right vs. left hemispheric stimulation, with the available evidence suggesting no substantive difference. RUL placements tended to have better verbal anterograde memory outcomes relative to LUL placements, though limited differences were found between the RUL placements.

Search for Subsolar Mass Ultracompact Binaries in Advanced LIGO's Second Observing Run

We present a search for subsolar mass ultracompact objects in data obtained during Advanced LIGO's second observing run. In contrast to a previous search of Advanced LIGO data from the first observing run, this search includes the effects of component spin on the gravitational waveform. We identify no viable gravitational-wave candidates consistent with subsolar mass ultracompact binaries with at least one component between 0.2  M_{⊙}-1.0  M_{⊙}. We use the null result to constrain the binary merger rate of (0.2  M_{⊙}, 0.2  M_{⊙}) binaries to be less than 3.7×10^{5}  Gpc^{-3} yr^{-1} and the binary merger rate of (1.0  M_{⊙}, 1.0  M_{⊙}) binaries to be less than 5.2×10^{3}  Gpc^{-3} yr^{-1}. Subsolar mass ultracompact objects are not expected to form via known stellar evolution channels, though it has been suggested that primordial density fluctuations or particle dark matter with cooling mechanisms and/or nuclear interactions could form black holes with subsolar masses. Assuming a particular primordial black hole (PBH) formation model, we constrain a population of merging 0.2  M_{⊙} black holes to account for less than 16% of the dark matter density and a population of merging 1.0  M_{⊙} black holes to account for less than 2% of the dark matter density. We discuss how constraints on the merger rate and dark matter fraction may be extended to arbitrary black hole population models that predict subsolar mass binaries.

What isn't measured isn't done - eight years with no progress in Aboriginal and Torres Strait Islander adult influenza and pneumococcal vaccination

OBJECTIVES

To describe and compare vaccination coverage for Aboriginal and Torres Strait Islander (hereafter referred to as Indigenous) adults in 2004-05 and 2012-13, including the impact of national vaccination funding initiatives.

METHODS

National Aboriginal and Torres Strait Islander Health cross-sectional surveys - 2004-05 (n=5,757) and 2012-13 (n=5,482) - were compared. Self-reported influenza and pneumococcal vaccination coverage among Indigenous adults was analysed by age, remoteness, gender and risk factor status.

RESULTS

Influenza vaccination coverage among Indigenous adults in 2004-05 and 2012-13 remained low. While coverage increased for those aged 18-49 years from 23% to 29%, it declined for those aged ≥65 years from 84% to 74%. For remote areas, influenza coverage among those aged 50-64 years declined from 76% to 66%. Pneumococcal vaccination coverage remained very low and declined across all age groups in 2004-05 and 2012-13 (50-64 years: 30% to 23%). For remote areas, pneumococcal coverage declined among those aged 50-64 years from 52% to 32%.

CONCLUSIONS

Indigenous adult vaccination coverage for influenza and pneumococcal disease remains unacceptably low. Between 2004-05 and 2012-13, declines occurred in pneumococcal vaccination coverage across all age groups ≥18 years. Despite national funding of influenza vaccine in 2010, there was no increase in influenza coverage, except for the 18-49-year age group. Implications for public health: Current approaches to promote, deliver and monitor vaccination of Indigenous adults are inadequate.

A Bioinformatics Approach to Establishing Novel Transforming Growth Factor-Beta Target Genes in Glioblastoma

Introduction

TGFβ inhibition is becoming an increasingly exciting prospect for the treatment of glioblastoma (GBM) as more about its efficacy is understood. However, there is little demonstrated improvement in patient outcomes from clinical trials using small molecule inhibitors of the TGFβ receptors. Clearly, the potential of TGFβ therapy has not yet been realised. We scrutinised the TGFβ canonical genes at a cytogenetic, genetic and gene expression level for novel therapeutic targets.

Materials and Methods

10 canonical TGFβ genes were analysed. Karyotypes were interpreted using the International System for Human Cytogenetic Nomenclature and graphics generated using the Cytogenetic Data Analysis System. Analysis and generation of graphics were carried out using The Cancer Genome Atlas (TCGA) Provisional Glioblastoma set of 290 whole-exome-sequenced tumours via cBioPortal. mRNA expression data were extracted from The Cancer Genome Atlas (TCGA) via cBioPortal. Kaplan-Meier graphs were generated using GraphPad Prism®, for which pairwise log rank comparisons were conducted to determine a difference in both overall survival (OS) and disease-free, progression-free (DFPF) survival.

Results

At cytogenetic and genetic levels, TGFβ genes are not markedly altered in GBM. However, mRNA expression of TGFβ2 is enhanced in GBM compared to other cancers. In addition, we correlated upregulation of both SMAD7 and SARA with improved OS and upregulation of SARA with improved DFPF survival.

Conclusions

TGFβ2 upregulation may be associated with GBM tumourigenesis and SMAD7 and SARA upregulation may be associated with improved survival. We demonstrate that three canonical genes have therapeutic potential, but their conflicting roles must be further understood before TGFβ-modulating therapies are successful.

Facial soft tissue thicknesses in craniofacial identification: Data collection protocols and associated measurement errors

Facial soft tissue thicknesses (FSTT) form a key component of craniofacial identification methods, but as for any data, embedded measurement errors are highly pertinent. These in part dictate the effective resolution of the measurements. As herein reviewed, measurement methods are highly varied in FSTT studies and associated measurement errors have generally not been paid much attention. Less than half (44%) of 95 FSTT studies comment on measurement error and not all of these provide specific quantification. Where informative error measurement protocols are employed (5% of studies), the mean error magnitudes range from 3% to 45% rTEM and are typically in the order of 10-20%. These values demonstrate that FSTT measurement errors are similar in size to (and likely larger than) the magnitudes of many biological effects being chased. As a result, the attribution of small millimeter or submillimeter differences in FSTT to biological variables must be undertaken with caution, especially where they have not been repeated across different studies/samples. To improve the integrity of FSTT studies and the reporting of FSTT measurement errors, we propose the following standard: (1) calculate the technical error of measurement (TEM or rTEM) in any FSTT research work; (2) assess the error embedded in the full data collection procedure; and (3) conduct validation testing of FSTT means proposed for point estimation prior to publication to ensure newly calculated FSTT means provide improvements. In order to facilitate the latter, a freely available R tool TDValidator that uses the C-Table data for validation testing is provided.

Reflections on working in public-figure threat management

The Fixated Threat Assessment Centre (FTAC) manages the risk posed to public figures by fixated individuals by paying attention to their correspondence and approaches and liaising with the mental health and criminal justice agencies responsible for their management. This paper offers a narrative reflection on the clinical experience of this unusual work. The clinical population is significantly different from that seen in mainstream mental health services, with a preponderance of delusional disorders and paraphrenias. The interface with mental health and criminal justice systems around the UK and internationally also offers a unique perspective on the functioning and malfunctioning of these services, and we attempt to describe and make sense of these experiences.