Current management of adults receiving oral anti-cancer medications: A scoping review protocol

Oncology has been undergoing a profound transition in the last ten years with the increased usage in oral anti-cancer medication. Approximately 25% of all anti-cancer medication is now designed for oral use and this is likely to increase prospectively. These treatments are convenient for patients and are often preferred by them, yet there are similar safety and toxicity concerns as there are to intravenous treatment. Oral anti-cancer medications (OAMs) have the potential to alleviate capacity issues in cancer treating units as patients receive their treatment at home, however there remains a requirement for safe and efficient assessment and care. Consequently, the management of patients on OAMs is of paramount importance. The optimum setting, whether within primary or secondary care, in addition to the appropriate health care professional to carry out patient assessment and monitoring needs to be established. This paper presents a protocol for a scoping review which aims to systematically and comprehensively map the literature on the current management of adults receiving OAMs. The review will follow the published guidance to direct the various steps involved. The protocol will be guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) framework to ensure methodological and reporting quality. Independent full text review will be performed by two reviewers and any disagreements resolved through discussion with a third reviewer. The process will be iterative in nature. This scoping review will provide a narrative synthesis and map the literature on the management of individuals receiving OAMs. This work is an appropriate initial stage in presenting the literature to inform the subsequent steps in a multi-phased research study which aims to establish and analyse the safety and efficacy of an integrated care model for the management of patients receiving OAM in the community by an advanced practitioner.

The future distribution of wetland birds breeding in Europe validated against observed changes in distribution

Wetland bird species have been declining in population size worldwide as climate warming and land-use change affect their suitable habitats. We used species distribution models (SDMs) to predict changes in range dynamics for 64 non-passerine wetland birds breeding in Europe, including range size, position of centroid, and margins. We fitted the SDMs with data collected for the first European Breeding Bird Atlas and climate and land-use data to predict distributional changes over a century (the 1970s–2070s). The predicted annual changes were then compared to observed annual changes in range size and range centroid over a time period of 30 years using data from the second European Breeding Bird Atlas. Our models successfully predicted ca. 75% of the 64 bird species to contract their breeding range in the future, while the remaining species (mostly southerly breeding species) were predicted to expand their breeding ranges northward. The northern margins of southerly species and southern margins of northerly species, both, predicted to shift northward. Predicted changes in range size and shifts in range centroids were broadly positively associated with the observed changes, although some species deviated markedly from the predictions. The predicted average shift in core distributions was ca. 5 km yr−1 towards the north (5% northeast, 45% north, and 40% northwest), compared to a slower observed average shift of ca. 3.9 km yr−1. Predicted changes in range centroids were generally larger than observed changes, which suggests that bird distribution changes may lag behind environmental changes leading to ‘climate debt’. We suggest that predictions of SDMs should be viewed as qualitative rather than quantitative outcomes, indicating that care should be taken concerning single species. Still, our results highlight the urgent need for management actions such as wetland creation and restoration to improve wetland birds’ resilience to the expected environmental changes in the future.

OUP accepted manuscript

Background

Healthcare requires patient feedback to improve outcomes and experience. This study undertook a systematic review of the depth, variability, and digital suitability of current patient-reported outcome measures (PROMs) in patients undergoing laparoscopic cholecystectomy.

Methods

A PROSPERO-registered (registration number CRD42021261707) systematic review was undertaken for all relevant English language articles using PubMed version of MEDLINE, Scopus, and Web of Science electronic databases in June 2021. The search used Boolean operators and wildcards and included the keywords: laparoscopic cholecystectomy AND patient outcome OR patient-reported outcome OR patient-reported outcome measure OR PRO OR PROM. Medical Subjects Heading terms were used to search PubMed and Scopus. Articles published from 1 January 2011 to 2 June 2021 were included.

Results

A total of 4960 individual articles were reviewed in this study, of which 44 were found to evaluate PROMs in patients undergoing laparoscopic cholecystectomy and underwent methodological index for non-randomized studies (MINORS) grading. Twenty-one articles spanning 19 countries and four continents met all inclusion criteria and were included in the qualitative data synthesis. There was significant heterogeneity in PROMs identified with eight different comprehensive PROM tools used in the 21 studies. There was wide variation in the time points at which PROMs were recorded. Fourteen of 21 studies recorded PROMs before and after surgery, and 7 of 21 recorded PROMs only after surgery. Follow-up intervals ranged from 3 days to 2 years after surgery.

Conclusions

This study identified that while post-laparoscopic cholecystectomy PROMs are infrequently measured currently, tools are widely available to achieve this in clinical practice. PROMs may not capture all the outcomes but should be incorporated into future cholecystectomy outcome research. The EQ-5D™ (EuroQoL Group, Rotterdam, the Netherlands) provides a simple platform for the modern digital era.

Batch-produced, GIS-informed range maps for birds based on provenanced, crowd-sourced data inform conservation assessments

Accurate maps of species ranges are essential to inform conservation, but time-consuming to produce and update. Given the pace of change of knowledge about species distributions and shifts in ranges under climate change and land use, a need exists for timely mapping approaches that enable batch processing employing widely available data. We develop a systematic approach of batch-processing range maps and derived Area of Habitat maps for terrestrial bird species with published ranges below 125,000 km2 in Central and South America. (Area of Habitat is the habitat available to a species within its range.) We combine existing range maps with the rapidly expanding crowd-sourced eBird data of presences and absences from frequently surveyed locations, plus readily accessible, high resolution satellite data on forest cover and elevation to map the Area of Habitat available to each species. Users can interrogate the maps produced to see details of the observations that contributed to the ranges. Previous estimates of Areas of Habitat were constrained within the published ranges and thus were, by definition, smaller-typically about 30%. This reflects how little habitat within suitable elevation ranges exists within the published ranges. Our results show that on average, Areas of Habitat are 12% larger than published ranges, reflecting the often-considerable extent that eBird records expand the known distributions of species. Interestingly, there are substantial differences between threatened and non-threatened species. Some 40% of Critically Endangered, 43% of Endangered, and 55% of Vulnerable species have Areas of Habitat larger than their published ranges, compared with 31% for Near Threatened and Least Concern species. The important finding for conservation is that threatened species are generally more widespread than previously estimated.

Umbilical hernia repair and recurrence: need for a clinical trial?

Introduction

Umbilical hernia repair, despite its perceived simplicity, is associated with recurrence between 2.7 and 27%, in mesh repair and non mesh repair respectively. Many factors are recognized contributors to recurrence however multiple defects in the linea alba, known to occur in up to 30% of patients, appear to have been overlooked by surgeons.

Aims

This systematic review assessed reporting of second or multiple linea alba defects in patients undergoing umbilical hernia repair to establish if these anatomical variations could contribute to recurrence along with other potential factors.

Methods

A systematic review of all published English language articles was undertaken using databases PubMed, Embase, Web of Science and Cochrane Library from January 2014 to 2019. The search terms ‘Umbilical hernia’ AND ‘repair’ AND ‘recurrence’ were used across all databases. Analysis was specified in advance to avoid selection bias, was registered with PROSPERO (154173) and adhered to PRISMA statement.

Results

Six hundred and forty-six initial papers were refined to 10 following article review and grading. The presence of multiple linea alba defects as a contributor to recurrence was not reported in the literature. One paper mentioned the exclusion of six participants from their study due multiple defects. In all 11 factors were significantly associated with umbilical hernia recurrence. These included: large defect, primary closure without mesh, high BMI in 5/10 publications; smoking, diabetes mellitus, surgical site Infection (SSI) and concurrent hernia in 3/10. In addition, the type of mesh, advanced age, liver disease and non-closure of the defect were identified in individual papers.

Conclusion

This study identified many factors already known to contribute to umbilical hernia recurrence in adults, but the existence of multiple defects in the linea, despite it prevalence, has evaded investigators. Surgeons need to be consider documentation of this potential confounder which may contribute to recurrence.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-021-01358-1.

Reduced human activity during COVID-19 alters avian land use across North America

The COVID-19 pandemic resulted in extraordinary declines in human mobility, which, in turn, may affect wildlife. Using records of more than 4.3 million birds observed by volunteers from March to May 2017–2020 across Canada and the United States, we found that counts of 66 (80%) of 82 focal bird species changed in pandemic-altered areas, usually increasing in comparison to prepandemic abundances in urban habitat, near major roads and airports, and in counties where lockdowns were more pronounced or occurred at the same time as peak bird migration. Our results indicate that human activity affects many of North America’s birds and suggest that we could make urban spaces more attractive to birds by reducing traffic and mitigating the disturbance from human transportation after we emerge from the pandemic.

Current management of adults receiving oral anti-cancer medications: A scoping review

PURPOSE

Oral anti-cancer medication (OAM) has revolutionised oncology care. Due to their potential toxicities and associated safety challenges ongoing assessment and monitoring is essential; currently generally performed in acute care settings. Internationally there exists a transformative vision to shift patient care from acute to primary care. A nurse-led integrated model of care could be developed for OAM patient management in primary care. The aim of this study was to examine international literature regarding current clinical management practices for assessment and monitoring of patients receiving OAM.

METHODS

Following PRISMA-ScR guidelines, databases MEDLINE, CINAHL and Web of Science were searched for English studies published between 2010 and 2020 using keywords: assessment, cancer, care, management, oral anticancer medications. Articles were screened and assessed for eligibility. From eligible studies, data were extracted to summarize, collate and make a narrative account of the findings.

RESULTS

2261 papers were reviewed, 14 met inclusion criteria. Three phases of management are reported: 1. Patient treatment plan development; 2. Patient education; 3. Patient monitoring. Within these phases seven specific stages of care were identified broadly representing the patient's journey: (1) treatment decision, (2) prescribing of OAM, (3) OAM dispensing and administration, (4) maximising patient safety (5) ongoing patient assessment (6) patient support (7) communication with other health-care professionals.

CONCLUSIONS

Despite a paucity of international literature, a dedicated OAM clinic was endorsed as a means to achieve improved care. Nurses and pharmacists were identified as being of particular importance especially in education and ongoing management of patients receiving OAMs.

Mismatch between bird species sensitivity and the protection of intact habitats across the Americas

Protected areas are highly heterogeneous in their effectiveness at buffering human pressure, which may hamper their ability to conserve species highly sensitive to human activities. Here, we use 60 million bird observations from eBird to estimate the sensitivity to human pressure of each bird species breeding in the Americas. Concerningly, we find that ecoregions hosting large proportions of high-sensitivity species, concentrated in tropical biomes, do not have more intact protected habitat. Moreover, 266 high-sensitivity species have little or no intact protected habitat within their distributions. Finally, we show that protected area intactness is decreasing faster where high-sensitivity species concentrate. Our results highlight a major mismatch between species conservation needs and the coverage of intact protected habitats, which likely hampers the long-term effectiveness of protected areas at retaining species. We highlight ecoregions where protection and management of intact habitats, complemented by restoration, is urgently needed.

Benefits of protected areas for nonbreeding waterbirds adjusting their distributions under climate warming

Climate warming is driving changes in species distributions and community composition. Many species have a so-called climatic debt, that is, shifts in range lag behind shifts in temperature isoclines. Inside protected areas (PAs), community changes in response to climate warming can be facilitated by greater colonization rates by warm-dwelling species, but also mitigated by lowering extirpation rates of cold-dwelling species. An evaluation of the relative importance of colonization-extirpation processes is important to inform conservation strategies that aim for both climate debt reduction and species conservation. We assessed the colonization-extirpation dynamics involved in community changes in response to climate inside and outside PAs. To do so, we used 25 years of occurrence data of nonbreeding waterbirds in the western Palearctic (97 species, 7071 sites, 39 countries, 1993-2017). We used a community temperature index (CTI) framework based on species thermal affinities to investigate species turnover induced by temperature increase. We determined whether thermal community adjustment was associated with colonization by warm-dwelling species or extirpation of cold-dwelling species by modeling change in standard deviation of the CTI (CTI_SD ). Using linear mixed-effects models, we investigated whether communities in PAs had lower climatic debt and different patterns of community change than communities outside PAs. For CTI and CTI_SD combined, communities inside PAs had more species, higher colonization, lower extirpation, and lower climatic debt (16%) than communities outside PAs. Thus, our results suggest that PAs facilitate 2 independent processes that shape community dynamics and maintain biodiversity. The community adjustment was, however, not sufficiently fast to keep pace with the large temperature increases in the central and northeastern western Palearctic. Our results underline the potential of combining CTI and CTI_SD metrics to improve understanding of the colonization-extirpation patterns driven by climate warming.

Development of an artificial intelligence-based assessment model for prediction of embryo viability using static images captured by optical light microscopy during IVF

STUDY QUESTION

Can an artificial intelligence (AI)-based model predict human embryo viability using images captured by optical light microscopy?

SUMMARY ANSWER

We have combined computer vision image processing methods and deep learning techniques to create the non-invasive Life Whisperer AI model for robust prediction of embryo viability, as measured by clinical pregnancy outcome, using single static images of Day 5 blastocysts obtained from standard optical light microscope systems.

WHAT IS KNOWN ALREADY

Embryo selection following IVF is a critical factor in determining the success of ensuing pregnancy. Traditional morphokinetic grading by trained embryologists can be subjective and variable, and other complementary techniques, such as time-lapse imaging, require costly equipment and have not reliably demonstrated predictive ability for the endpoint of clinical pregnancy. AI methods are being investigated as a promising means for improving embryo selection and predicting implantation and pregnancy outcomes.

STUDY DESIGN, SIZE, DURATION

These studies involved analysis of retrospectively collected data including standard optical light microscope images and clinical outcomes of 8886 embryos from 11 different IVF clinics, across three different countries, between 2011 and 2018.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The AI-based model was trained using static two-dimensional optical light microscope images with known clinical pregnancy outcome as measured by fetal heartbeat to provide a confidence score for prediction of pregnancy. Predictive accuracy was determined by evaluating sensitivity, specificity and overall weighted accuracy, and was visualized using histograms of the distributions of predictions. Comparison to embryologists’ predictive accuracy was performed using a binary classification approach and a 5-band ranking comparison.

MAIN RESULTS AND THE ROLE OF CHANCE

The Life Whisperer AI model showed a sensitivity of 70.1% for viable embryos while maintaining a specificity of 60.5% for non-viable embryos across three independent blind test sets from different clinics. The weighted overall accuracy in each blind test set was >63%, with a combined accuracy of 64.3% across both viable and non-viable embryos, demonstrating model robustness and generalizability beyond the result expected from chance. Distributions of predictions showed clear separation of correctly and incorrectly classified embryos. Binary comparison of viable/non-viable embryo classification demonstrated an improvement of 24.7% over embryologists’ accuracy (P = 0.047, n = 2, Student’s t test), and 5-band ranking comparison demonstrated an improvement of 42.0% over embryologists (P = 0.028, n = 2, Student’s t test).

LIMITATIONS, REASONS FOR CAUTION

The AI model developed here is limited to analysis of Day 5 embryos; therefore, further evaluation or modification of the model is needed to incorporate information from different time points. The endpoint described is clinical pregnancy as measured by fetal heartbeat, and this does not indicate the probability of live birth. The current investigation was performed with retrospectively collected data, and hence it will be of importance to collect data prospectively to assess real-world use of the AI model.

WIDER IMPLICATIONS OF THE FINDINGS

These studies demonstrated an improved predictive ability for evaluation of embryo viability when compared with embryologists’ traditional morphokinetic grading methods. The superior accuracy of the Life Whisperer AI model could lead to improved pregnancy success rates in IVF when used in a clinical setting. It could also potentially assist in standardization of embryo selection methods across multiple clinical environments, while eliminating the need for complex time-lapse imaging equipment. Finally, the cloud-based software application used to apply the Life Whisperer AI model in clinical practice makes it broadly applicable and globally scalable to IVF clinics worldwide.

STUDY FUNDING/COMPETING INTEREST(S)

Life Whisperer Diagnostics, Pty Ltd is a wholly owned subsidiary of the parent company, Presagen Pty Ltd. Funding for the study was provided by Presagen with grant funding received from the South Australian Government: Research, Commercialisation and Startup Fund (RCSF). ‘In kind’ support and embryology expertise to guide algorithm development were provided by Ovation Fertility. J.M.M.H., D.P. and M.P. are co-owners of Life Whisperer and Presagen. Presagen has filed a provisional patent for the technology described in this manuscript (52985P pending). A.P.M. owns stock in Life Whisperer, and S.M.D., A.J., T.N. and A.P.M. are employees of Life Whisperer.

Systematic Review and Meta-Analysis of Wound Bundles in Emergency Midline Laparotomy Identifies That It Is Time for Improvement

BACKGROUND

Emergency midline laparotomy is the cornerstone of survival in patients with peritonitis. While bundling of care elements has been shown to optimize outcomes, this has focused on elective rather than emergency abdominal surgery. The aim of this study was to undertake a systematic review and meta-analysis of factors affecting the development of surgical site infection (SSI) in patients undergoing midline emergency laparotomy.

METHODS

An ethically approved, PROSPERO registered (ID: CRD42020193246) meta-analysis and systematic review, searching PubMed, Scopus, Web of Science and Cochrane Library electronic databases from January 2015 to June 2020 and adhering to PRISMA guidelines was undertaken. Search headings included "emergency surgery", "laparotomy", "surgical site infection", "midline incision" and "wound bundle". Suitable publications were graded using Methodological Index for Non-Randomised Studies (MINORS); papers scoring ≥16/24 were included for data analysis. The primary outcome in this study was SSI rates following the use of wound bundles. Secondary outcomes consisted of the effect of the individual interventions included in the bundles and the SSI rates for superficial and deep infections. Five studies focusing on closure techniques were grouped to assess their effect on SSI.

RESULTS

This study identified 1875 articles. A total of 58 were potentially suitable, and 11 were included after applying MINORS score. The final cohort included 2,856 patients from eight countries. Three papers came from the USA, two papers from Japan and the remainder from Denmark, England, Iran, Netherlands, Spain and Turkey. There was a 32% non-significant SSI reduction after the implementation of wound bundles (RR = 0.68; CI, 0.39-1.17; p = 0.16). In bundles used for technical closure the reduction in SSI of 15% was non-significant (RR = 0.85; CI, 0.57-1.26; p = 0.41). Analysis of an effective wound bundle was limited due to insufficient data.

CONCLUSIONS

This study identified a significant deficit in the world literature relating to emergency laparotomy and wound outcome optimisation. Given the global burden of emergency general surgery urgent action is needed to assess bundle's ability to potentially improve outcome after emergency laparotomy.

Regional variation in the impacts of the COVID-19 pandemic on the quantity and quality of data collected by the project eBird

The COVID-19 pandemic has likely affected natural systems around the world; the curtailment of human activity has also affected the collection of data needed to identify the indirect effects of this pandemic on natural systems. We describe how the outbreak of COVID-19 disease, and associated stay-at-home orders in four political regions, have affected the quantity and quality of data collected by participants in one volunteer-based bird monitoring project, eBird. The four regions were selected both for their early and prolonged periods of mandated changes to human activity, and because of the high densities of observations collected. We compared the months of April 2020 with April in previous years. The most notable change was in the landscapes in which observations were made: in all but one region human-dominated landscapes were proportionally more common in the data in April 2020, and observations made near the rarer wetland habitat were less prevalent. We also found subtler changes in quantity of data collected, as well as in observer effort within observation periods. Finally, we found that these effects of COVID-19 disease varied across the political units, and thus we conclude that any analyses of eBird data will require region-specific examination of whether there have been any changes to the data collection process during the COVID-19 pandemic that would need to be taken into account.

Current management of adults receiving oral anti-cancer medications: A scoping review protocol

Oncology has been undergoing a profound transition in the last ten years or more with the increase in oral anti-cancer medications. Approximately 25% of all anti-cancer medication is now designed for oral use and this is likely to increase prospectively. These treatments are convenient for patients and are often preferred by them, yet there are similar safely and toxicity concerns as there are to intravenous treatment. Oral anti-cancer medications (OAMs) have the potential to alleviate capacity issues in cancer treating units as patients receive their treatment at home, however there remains a requirement for safe and efficient assessment and care. Consequently, the management of patients on oral anti-cancer is of paramount importance but as to the location of such patient assessment and monitoring and by which health care professional is subject to ongoing debate.  This paper presents a protocol for a scoping review which aims to systematically and comprehensively map the available literature on the current management of adults receiving oral anti-cancer medications. The scoping review will follow the published guidance to direct the various steps involved. The report will be guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) framework to ensure methodological and reporting quality.  The review will be performed by two reviewers and checked by a third reviewer and will be iterative in the process. This scoping review will provide a narrative synthesis and map the extent of available literature on the management of individuals receiving oral anti-cancer medication. This work is an appropriate initial stage in presenting the literature to inform the subsequent steps in a multi-phased research study which aims to establish and analyse the safety and efficacy of an integrated care model for the management of patients receiving OAM in the community by an advanced nurse.

Wintering bird communities are tracking climate change faster than breeding communities

Global climate change is driving species' distributions towards the poles and mountain tops during both non-breeding and breeding seasons, leading to changes in the composition of natural communities. However, the degree of season differences in climate-driven community shifts has not been thoroughly investigated at large spatial scales. We compared the rates of change in the community composition during both winter (non-breeding season) and summer (breeding) and their relation to temperature changes. Based on continental-scale data from Europe and North America, we examined changes in bird community composition using the community temperature index (CTI) approach and compared the changes with observed regional temperature changes during 1980-2016. CTI increased faster in winter than in summer. This seasonal discrepancy is probably because individuals are less site-faithful in winter, and can more readily shift their wintering sites in response to weather in comparison to the breeding season. Regional long-term changes in community composition were positively associated with regional temperature changes during both seasons, but the pattern was only significant during summer due to high annual variability in winter communities. Annual changes in community composition were positively associated with the annual temperature changes during both seasons. Our results were broadly consistent across continents, suggesting some climate-driven restructuring in both European and North American avian communities. Because community composition has changed much faster during the winter than during the breeding season, it is important to increase our knowledge about climate-driven impacts during the less-studied non-breeding season.

A meta-analysis of the use of intraoperative cholangiography; time to revisit our approach to cholecystectomy?

BACKGROUND

Despite some evidence of improved survival with intraoperative cholangiography during cholecystectomy, debate has raged about its benefit, in part because of its questionable benefit, time, and resources required to complete.

METHODS

An International Prospective Register of Systematic Reviews-registered (ID CRD42018102154) meta-analysis following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using PubMed, Scopus, Web of Science, and Cochrane library from 2003 to 2018 was undertaken including search strategy "intraoperative AND cholangiogra* AND cholecystectomy." Articles scoring ≥ 16 for comparative and ≥ 10 for noncomparative using the Methodological Index for Non-Randomized Studies criteria were included. A dichotomous random effects meta-analysis using the Mantel-Haenszel method performed on Review Manager Version 5.3 was carried out.

RESULTS

Of 2,059 articles reviewed, 62 met criteria for final analysis. The mean rate of intraoperative cholangiography was 38.8% (range 1.6%-96.4%).There was greater detection of bile duct stones during cholecystectomy with routine intraoperative cholangiography compared with selective intraoperative cholangiography (odds ratio = 3.28, confidence interval = 2.80-3.86, P value < .001). While bile duct injury during cholecystectomy was less with intraoperative cholangiography (0.39%) than without intraoperative cholangiography (0.43%), it was not statistically significant (odds ratio = 0.88, confidence interval = 0.65-1.19, P value = .41). Readmission following cholecystectomy with intraoperative cholangiography was 3.0% compared to 3.5% without intraoperative cholangiography (odds ratio = 0.91, confidence interval = 0.78-1.06, P value = .23).

CONCLUSION

The use of intraoperative cholangiography still has its place in cholecystectomy based on the detection of choledocholithiasis and the potential reduction of unfavorable outcomes associated with common bile duct stones. This meta-analysis, the first to review intraoperative cholangiography use, identified a marked variation in cholangiography use. Retrospective studies limit the ability to critically define association between intraoperative cholangiography use and bile duct injury.

Evaluating Impact Using Time-Series Data

Humanity's impact on the environment is increasing, as are strategies to conserve biodiversity, but a lack of understanding about how interventions affect ecological and conservation outcomes hampers decision-making. Time series are often used to assess impacts, but ecologists tend to compare average values from before to after an impact; overlooking the potential for the intervention to elicit a change in trend. Without methods that allow for a range of responses, erroneous conclusions can be drawn, especially for large, multi-time-series datasets, which are increasingly available. Drawing on literature in other disciplines and pioneering work in ecology, we present a standardised framework to robustly assesses how interventions, like natural disasters or conservation policies, affect ecological time series.

Prothrombin complex concentrate vs. fresh frozen plasma in adult patients undergoing heart surgery - a pilot randomised controlled trial (PROPHESY trial)

There is equipoise regarding the use of prothrombin complex concentrate vs. fresh frozen plasma in bleeding patients undergoing cardiac surgery. We performed a pilot randomised controlled trial to determine the recruitment rate for a large trial, comparing the impact of prothrombin complex concentrate vs. fresh frozen plasma on haemostasis (1 h and 24 h post-intervention), and assessing safety. Adult patients who developed bleeding within 24 h of cardiac surgery that required coagulation factor replacement were randomly allocated to receive prothrombin complex concentrate (15 IU.kg^-1 based on factor IX) or fresh frozen plasma (15 ml.kg^-1 ). If bleeding continued after the first administration of prothrombin complex concentrate or fresh frozen plasma administration, standard care was administered. From February 2019 to October 2019, 180 patients were screened, of which 134 (74.4% (95%CI 67-81%)) consented, 59 bled excessively and 50 were randomly allocated; 25 in each arm, recruitment rate 35% (95%CI 27-44%). There were 23 trial protocol deviations, 137 adverse events (75 prothrombin complex concentrate vs. 62 fresh frozen plasma) and 18 serious adverse events (5 prothrombin complex concentrate vs. 13 fresh frozen plasma). There was no increase in thromboembolic events with prothrombin complex concentrate. No patient withdrew from the study, four were lost to follow-up and two died. At 1 h after administration of the intervention there was a significant increase in fibrinogen, Factor V, Factor XII, Factor XIII, α₂ -antiplasmin and antithrombin levels in the fresh frozen plasma arm, while Factor II and Factor X were significantly higher in the prothrombin complex concentrate group. At 24 h, there were no significant differences in clotting factor levels. We conclude that recruitment to a larger study is feasible. Haemostatic tests have provided useful insight into the haemostatic changes following prothrombin complex concentrate or fresh frozen plasma administration. A definitive trial is needed to ascertain the benefits and safety for each.