PEGASUS: the Design of an Intervention to Facilitate Shared Decision-making in Breast Reconstruction

Studies have found varying levels of satisfaction after breast reconstruction surgery with a substantial group of patients reporting some level of regret about their decision. The variable outcomes reported by women undergoing breast reconstruction surgery suggest a role for improved pre-operative communication and shared decision-making (SDM) between patient and health professional. Pragmatic approaches such as decision aids have been evaluated, but the aim of the Patient Expectations and Goals Assisting Shared Understanding of Surgery (PEGASUS) intervention is to facilitate closer interaction between the patient and clinical team. PEGASUS is a standardised two-stage process, in which patients' goals are first elicited, ranked in importance and recorded before being used to frame discussion and decision-making with the surgeon managing care. Following the Medical Research Council (MRC) model, feasibility and acceptability studies have already been reported and a 4-year multicentre randomised controlled trial of 180 participants is underway, (completion 2020). This paper therefore focuses on the design of the intervention itself, in line with recent advice that interventions, in comparison with evaluations, commonly lack a theoretical base and are often under reported. We report a retrospective application of the Capability, Opportunity, Motivation-Behaviour (COM-B) model to provide explicit detail of each step in the intervention design. This is intended to facilitate replication by other clinicians and to provide systematic guidance for others wishing to develop PEGASUS as a strategy for implementing SDM in other clinical populations. Trial Registration: ISRCTN 18000391 (DOI 10.1186/ISRCTN18000391) 27/01/2016.

Tolerability of four-drug antiretroviral combination therapy in primary HIV-1 infection

Objectives

Rapid initiation of antiretroviral therapy (ART) is important for individuals with high baseline viral loads, such as in primary HIV‐1 infection (PHI). Four‐drug regimens are sometimes considered; however, data are lacking on tolerability. We aimed to evaluate the tolerability of four‐drug regimens used in the Research in Viral Eradication of HIV‐1 Reservoirs (RIVER) study.

Methods

At enrolment, ART‐naïve adult participants or those newly commenced on ART were initiated or intensified to four‐drug regimens within 4 weeks of PHI. Rapid start was defined as pre‐confirmation or ≤ 7 days of confirmed diagnosis. Primary and secondary outcomes were patient‐reported adherence measured by 7‐day recall and regimen switches between enrolment and randomization, respectively.

Results

Overall, 54 men were included: 72.2% were of white ethnicity, with a median age of 32 years old, 42.6% had a viral load of ≥ 100 000 HIV‐1 RNA copies/mL, and in 92.6% sex with men was the mode of acquisition of HIV‐1. Twenty (37%) started a four‐drug regimen and 34 (63%) were intensified. Rapid ART initiation occurred in 28%, 100% started in ≤ 4 weeks. By weeks 4, 12, and 24, 37.0%, 69.0%, and 94.0% were undetectable (viral load < 50 copies/mL), respectively. Adherence rates of 100% at weeks 4, 12, 22 and 24 were reported in 88.9%, 87.0%, 82.4% and 94.1% of participants, respectively. Five individuals switched to three drugs, four changed their regimen constituents, and two switched post‐randomization.

Conclusions

Overall, four‐drug regimens were well tolerated and had high levels of adherence. Whilst their benefit over three‐drug regimens is lacking, our findings should provide reassurance if a temporarily intensified regimen is clinically indicated to help facilitate treatment.

The nature and importance of women's goals for immediate and delayed breast reconstruction

OBJECTIVES

Increasingly, women undergo breast reconstruction (BR) surgery to restore health-related and psychosocial quality of life after mastectomy. Most research focuses on BR outcomes rather than women's pre-surgical expectations of, and goals for, immediate (IBR) or delayed (DBR) procedures, yet such information could support women's decision-making. This study aimed to investigate women's BR goals, whether they differed according surgery timing (IBR or DBR), and the importance women placed on them.

METHODS

Seventy-six women considering DBR (n = 50) or IBR (n = 26) at a UK hospital were encouraged to clarify their BR goals and rate the importance of achieving each one. Content analysis categorised and counted the frequency of the goals they reported.

RESULTS

Fifteen goal categories (7 surgical, e.g. scarring; 8 psychosocial/lifestyle, e.g. feeling feminine) were identified. Many (e.g. scarring, intimacy) were reported by a similar percentage of women in each surgical group, however, differences were identified (e.g. breast sensation was not mentioned by women considering IBR). Women reported more psychosocial (n = 206) than surgical goals (n = 160). Further, an independent t-tests revealed that women in both groups placed significantly more importance on the psychosocial (M = 9.4) than surgical goals (M = 8.5).

CONCLUSIONS

This study highlights the variety of goals women have for BR, the importance they attach to them, and differences and similarities between those seeking IBR and DBR. Future research should consider whether BR goals are met, how goal achievement influences satisfaction with outcome over time and how best to incorporate goals into pre-surgical treatment decision-making.

Life of a droplet: Buoyant vortex dynamics drives the fate of micro-particle expiratory ejecta

We show that the dynamics of the expiratory cloud ejected during human respiratory events can be modeled by extending the theory of buoyant vortex rings with an initial momentum. We embed the integral conservation laws that govern the cloud's motion into the model of an expanding vortex to determine the velocity field inside and outside the cloud. We then apply a Lagrangian particle-tracking model to calculate the trajectories of the mucosalivary droplets suspended within the cloud. Our results show very good agreement with the available experimental data. The vortex is shown to have a significant effect on suspending the droplets present in the cloud, increasing the time they remain airborne and extending their range further than predicted by the existing models. We also study the role that initial conditions have on the maximum streamwise range of the droplets, finding that decreasing the angle of projection can reduce the spread of the droplets by an order of meters. Finally, we discuss the importance of these findings in the context of informing public health policies and global information campaigns to slow down the spread of respiratory viruses.

Major risk factors for sexual minority young people's mental and physical health: findings from a county-wide school-based health needs assessment

BACKGROUND

Childhood health is an important adult health predictor. Sexual orientation is increasingly recognized as influential on children and young people's (CYP) mental and physical health.

METHODS

Data came from a cross-sectional survey of year 9 children attending schools in two local authorities in the north-west of England, including mental and physical health indicators, and demographic characteristics including sexual orientation. The sample of 8058 represented 67.8% of the eligible population. Data were analysed by sexual orientation, sexual majority or sexual minority.

RESULTS

Children reporting their sexual orientation as sexual minority reported worse mental and physical health outcomes and behaviours than sexual majority peers; had higher odds of being lonely (odds ratios (OR) = 8.24, 95% C.I.: 6.56-10.37), having self-harmed (OR = 7.28, 95% C.I.: 5.78-9.15), being bullied (OR = 4.76, 95% C.I.: 3.74-6.05) or perceiving themselves as overweight (OR = 2.40, 95% C.I.: 1.89-3.06).

CONCLUSIONS

It is important to identify and support children in a sexual minority. Research is required to understand differences between children within sexual minorities and the impact on outcomes and rights. Health and social policy and services, should respond to the vulnerabilities of sexual minority CYP.

Orientation mapping with Kikuchi patterns generated from a focused STEM probe and indexing with commercially available EDAX software

Relating a crystal's microscopic structure-such as orientation and size-to a material's macroscopic properties is of great importance in materials science. Although most crystal orientation microscopy is performed in the scanning electron microscope (SEM), transmission electron microscopy (TEM)-based methods have a number of benefits, including higher spatial resolution. Current TEM orientation methods have either specific hardware requirements or use software that has limited scope, utility, or availability. In this article, a technique is described for orientation mapping using Kikuchi diffraction patterns generated from a focused STEM probe. One key advantage is that indexing and analysis of the patterns and maps occurs in the robust OIM Analysis software, currently widely used for electron backscatter diffraction (EBSD) and transmission Kikuchi diffraction (TKD) analysis. It was found that with minimal to no image processing and by changing only a few software parameters, reliable indexing of Kikuchi patterns is possible. Three samples, a deformed β-Titanium (Ti), a medium carbon heat-treated steel, and BaCe_0.8Y_0.2O_3-δ were tested to determine the effectiveness of the approach. In all three measurements the algorithms effectively and reliably determined the phases and the crystal orientations of the features measured. For the two orientation maps produced, less than 5% of the patterns were misindexed including boundary areas where overlapping patterns existed. An angular resolution of 0.15° was achieved while features <25 nm were able to be spatially resolved.

Identifying latent tuberculosis in high-risk populations: systematic review and meta-analysis of test accuracy

BACKGROUND: The relative accuracy of interferon-gamma release assays (IGRAs) and the tuberculin skin test (TST) in identifying latent tuberculosis infection (LTBI) is uncertain.OBJECTIVE: To perform a systematic review and meta-analysis to compare the sensitivity and specificity of IGRAs and TST for the prediction of progression to clinical tuberculosis (TB).METHODS: We searched electronic databases (e.g., MEDLINE and EMBASE) from December 2009 to September 2018 for prospective studies that followed up individuals who had undergone testing with commercial IGRAs and/or TST but had not received treatment based on the test result. The sensitivity and specificity estimates were pooled using a Bayesian bivariate random-effects model.RESULTS: Twenty-five studies, mostly with moderate to high risk of bias and a mean follow-up time ranging from 1 to 5 years were included. TST (10–15 mm) tended to have lower sensitivity and higher specificity than QuantiFERON® Gold In-Tube, T-SPOT®.TB and TST (5 mm). The evidence did not indicate that any test outperformed the others due to wide and overlapping 95% credible intervals.CONCLUSION: The evidence following individuals who had undergone testing for LTBI and had progressed to clinical TB is sparse. We did not find that IGRAs were superior to TST or vice versa; however, as our findings are based on a small number of studies with methodological limitations and great uncertainty around the pooled estimates, the results should be interpreted with caution.

Thermal burns of the spectacle associated with supplementary heating in native New Zealand geckos

Case history: Gradual onset of ocular opacity was observed in three gold-striped geckos (Woodworthia chrysosiretica), and five Pacific geckos (Dactylocnemis pacificus) held in two adjacent terrariums in a zoological institution located in the North Island of New Zealand. Ultraviolet light and heat had been provided for the previous 3-4 years by a fluorescent bulb, but in the last 4 weeks of winter a ceramic heat bulb had been added, situated 10 cm above the upper mesh of the cageClinical findings: All eight geckos presented with mostly bilateral lesions of varying severity confined to the central or upper quadrant of the spectacles. These lesions ranged from variable areas of opacity within the stroma of the spectacle to similarly distributed ulcers of the surface epithelium of both spectacles. The spectacle lesions in the Pacific geckos responded well to treatment with topical combined antimicrobial therapy, within 18-29 days. The gold-striped geckos suffered complications including dysecdysis, severe spectacle ulceration and perforation, mycotic spectaculitis, and widespread mycotic dermatitis resulting in death or leading to euthanasia.Pathological findings: In the three gold-striped geckos, there were extensive areas of deep ulceration and replacement of the spectacle with a thick serocellular crust containing large numbers of fungal elements. The affected areas of the stroma were expanded by large deposits of proteinaceous and mucinous material, pyknotic cellular debris and moderate numbers of heterophils and macrophages as well as infiltrating fungal hyphae.Diagnosis: Mycotic spectaculitis with ulceration and perforation, and disseminated mycotic dermatitis likely secondary to thermal burns.Clinical relevance: This is the first report of thermal burns of the spectacle in any reptile. There was species variation in the burn severity with gold-striped geckos showing more severe lesions, possibly due to a mix of behavioural and anatomical factors. The thermal burns to the spectacles in three cases were complicated by delayed healing, perforation, dysecdysis and severe mycotic infection.

The acoustic emission from asperity interactions in mixed lubrication

Gears typically operate in mixed lubrication conditions, where the lubricant film is too thin to prevent opposing surface asperities from interacting with each other. The likelihood/intensity of interactions is indicated by the Λ ratio: the ratio of smooth surface film thickness to surface roughness. Researchers have asserted that asperity interactions are the predominant cause of acoustic emission (AE) in healthy gear contacts. However, direct experiments on gears have yet to yield a clear relationship between the Asperity AE (AAE) and Λ ratio, this is in part due to the complexity of gear tooth contacts. In this paper, a disc rig was used to simulate a simplified gear contact so that the fundamental relationship between AAE and Λ could be investigated more effectively. By varying oil temperature and entrainment speed, a wide spectrum of lubrication conditions was generated. In contrast to other published studies, an independent measurement technique, the contact voltage (CV), was used to verify the amount of interactions, and repeated roughness measurements were used to confirm minimal surface wear. A simple, consistent and precise relationship between AAE amplitude and Λ was identified and defined for changes from full-film to mixed lubrication. Within the mixed lubrication regime, the AAE amplitude increased exponentially as Λ decreased at all speeds tested. It was also observed that an increase in speed always resulted in an increase in AAE amplitude, independently of any changes in Λ. This direct effect of speed was modelled so that the AAE could be predicted for any combination of speed and Λ within the tested envelope. This paper links gear contact tribology and AE with new precision and clearly demonstrates the potential of using AAE as a sensitive monitoring technique for the lubrication condition of gears.

Robust forensic matching of confiscated horns to individual poached African rhinoceros

Black and white rhinoceros (Diceros bicornis and Ceratotherium simum) are iconic African species that are classified by the International Union for the Conservation of Nature (IUCN) as Critically Endangered and Near Threatened (http://www.iucnredlist.org/), respectively [1]. At the end of the 19^th century, Southern white rhinoceros (Ceratotherium simum simum) numbers had declined to fewer than 50 animals in the Hluhluwe-iMfolozi region of the KwaZulu-Natal (KZN) province of South Africa, mainly due to uncontrolled hunting [2,3]. Efforts by the Natal Parks Board facilitated an increase in population to over 20,000 in 2015 through aggressive conservation management [2]. Black rhinoceros (Diceros bicornis) populations declined from several hundred thousand in the early 19^th century to ∼65,000 in 1970 and to ∼2,400 by 1995 [1] with subsequent genetic reduction, also due to hunting, land clearances and later poaching [4]. In South Africa, rhinoceros poaching incidents have increased from 13 in 2007 to 1,215 in 2014 [1]. This has occurred despite strict trade bans on rhinoceros products and strict enforcement in recent years.

Retrieval of critically ill adults using extracorporeal membrane oxygenation: the nine-year experience in New South Wales

In New South Wales, a coordinated extracorporeal membrane oxygenation (ECMO) retrieval program has been in operation since 2007. This study describes the characteristics and outcomes of patients transported by this service. We performed a retrospective observational study and included patients who were transported on ECMO to either of two adult tertiary referral hospitals in Sydney, New South Wales, between February 28, 2007 and February 29, 2016. One hundred and sixty-four ECMO-facilitated transports occurred, involving 160 patients. Of these, 118 patients (74%) were treated with veno-venous (VV) ECMO and 42 patients (26%) were treated with veno-arterial ECMO. The mean (standard deviation, SD) age was 40.4 (15.0) years. Seventy-seven transports (47%) occurred within metropolitan Sydney, 52 (32%) were from rural or regional areas within NSW, 17 (10%) were interstate transfers and 18 (11%) were international transfers. Transfers were by road (58%), fixed wing aircraft (27%) or helicopter (15%). No deaths occurred during transport. The median (interquartile range) duration of ECMO treatment was 8.9 (5.2-15.3) days. One hundred and nineteen patients (74%) were successfully weaned from ECMO and 109 (68%) survived to hospital discharge or transfer. In patients treated with VV ECMO, age, sequential organ failure assessment score, pre-existing immunosuppressive disease, pre-existing diabetes, renal failure requiring dialysis and failed prone positioning prior to ECMO were independently associated with increased mortality. ECMO-facilitated patient transport is feasible, safe, and results in acceptable short-term outcomes. The NSW ECMO Retrieval Service provides specialised support to patients with severe respiratory and cardiovascular illness, who may otherwise be too unstable to undergo inter-hospital transfer to access advanced cardiovascular and critical care services.

Experimental and Numerical Study of Micropitting Initiation in Real Rough Surfaces in a Micro-elastohydrodynamic Lubrication Regime

Micropitting is a form of surface fatigue damage that happens at the surface roughness scale in lubricated contacts in commonly used machine elements, such as gears and bearings. It occurs where the specific film thickness (ratio of smooth surface film thickness to composite surface roughness) is sufficiently low for the contacts to operate in the mixed lubrication regime, where the load is in part carried by direct asperity contacts. Micropitting is currently seen as a greater issue for gear designers than is regular pitting fatigue failure as the latter can be avoided by control of steel cleanliness. This paper describes the results of both theoretical and experimental studies of the onset of micropitting in test disks operated in the mixed lubrication regime. A series of twin disk mixed-lubrication experiments were performed in order to examine the evolution of micropitting damage during repeated cyclic loading of surface roughness asperities as they pass through the contact. Representative measurements of the surfaces used in the experimental work were then evaluated using a numerical model which combines a transient line contact micro-elastohydrodynamic lubrication (micro-EHL) simulation with a calculation of elastic sub-surface stresses. This model generated time-history of stresses within a block of material as it passes through the contact, based on the instantaneous surface contact pressure and traction at each point in the computing mesh at each timestep. This stress time-history was then used within a shear-strain-based fatigue model to calculate the cumulative damage experienced by the surface due to the loading sequence experienced during the experiments. The proposed micro-EHL model results and the experimental study were shown to agree well in terms of predicting the number of loading cycles that are required for the initial micropitting to occur.

Correction to: Spectrum of movement disorders and neurotransmitter abnormalities in paediatric POLG disease

Due to a typesetting error the wrong Table 2 was used. The correct Table 2 is shown here.

Spectrum of movement disorders and neurotransmitter abnormalities in paediatric POLG disease

OBJECTIVES

To describe the spectrum of movement disorders and cerebrospinal fluid (CSF) neurotransmitter profiles in paediatric patients with POLG disease.

METHODS

We identified children with genetically confirmed POLG disease, in whom CSF neurotransmitter analysis had been undertaken. Clinical data were collected retrospectively. CSF neurotransmitter levels were compared to both standardised age-related reference ranges and to non-POLG patients presenting with status epilepticus.

RESULTS

Forty-one patients with POLG disease were identified. Almost 50% of the patients had documented evidence of a movement disorder, including non-epileptic myoclonus, choreoathetosis and ataxia. CSF neurotransmitter analysis was undertaken in 15 cases and abnormalities were seen in the majority (87%) of cases tested. In many patients, distinctive patterns were evident, including raised neopterin, homovanillic acid and 5-hydroxyindoleacetic acid levels.

CONCLUSIONS

Children with POLG mutations can manifest with a wide spectrum of abnormal movements, which are often prominent features of the clinical syndrome. Underlying pathophysiology is probably multifactorial, and aberrant monoamine metabolism is likely to play a role.

Short- and long-term clinical outcomes of use of beta-interferon or glatiramer acetate for people with clinically isolated syndrome: a systematic review of randomised controlled trials and network meta-analysis

Background

Beta-interferon (IFN-β) and glatiramer acetate (GA) have been evaluated in people with clinically isolated syndrome (CIS) with the aim to delay a second clinical attack and a diagnosis of clinically definite multiple sclerosis (CDMS). We systematically reviewed trials evaluating the short- and long-term clinical effectiveness of these drugs in CIS.

Methods

We searched multiple electronic databases. We selected randomised controlled studies (RCTs) conducted in CIS patients and where the interventions were IFN-β and GA. Main outcomes were time to CDMS, and discontinuation due to adverse events (AE). We compared interventions using random-effect network meta-analyses (NMA). We also reported outcomes from long-term open-label extension (OLE) studies.

Results

We identified five primary studies. Four had open-label extensions following double-blind periods comparing outcomes between early vs delayed DMT. Short-term clinical results (double-blind period) showed that all drugs delayed CDMS compared to placebo. Indirect comparisons did not suggest superiority of any one active drug over another. We could not undertake a NMA for discontinuation due to AE. Long-term clinical results (OLE studies) showed that the risk of developing CDMS was consistently reduced across studies after early DMT treatment compared to delayed DMT (HR = 0.64, 95% CI 0.55, 0.74). No data supported the benefit of DMTs in reducing the time to, and magnitude of, disability progression.

Conclusions

Meta-analyses confirmed that IFN-β and GA delay time to CDMS compared to placebo. In the absence of evidence that early DMTs can reduce disability progression, future research is needed to better identify patients most likely to benefit from long-term DMTs.

Electronic supplementary material

The online version of this article (10.1007/s00415-018-8752-8) contains supplementary material, which is available to authorized users.