Key Drivers and Facilitators of the Choice to Use mHealth Technology in People With Neurological Conditions: Observational Study

Background

There is increasing interest in the potential uses of mobile health (mHealth) technologies, such as wearable biosensors, as supplements for the care of people with neurological conditions. However, adherence is low, especially over long periods. If people are to benefit from these resources, we need a better long-term understanding of what influences patient engagement. Previous research suggests that engagement is moderated by several barriers and facilitators, but their relative importance is unknown.

Objective

To determine preferences and the relative importance of user-generated factors influencing engagement with mHealth technologies for 2 common neurological conditions with a relapsing-remitting course: multiple sclerosis (MS) and epilepsy.

Methods

In a discrete choice experiment, people with a diagnosis of MS (n=141) or epilepsy (n=175) were asked to select their preferred technology from a series of 8 vignettes with 4 characteristics: privacy, clinical support, established benefit, and device accuracy; each of these characteristics was greater or lower in each vignette. These characteristics had previously been emphasized by people with MS and or epilepsy as influencing engagement with technology. Mixed multinomial logistic regression models were used to establish which characteristics were most likely to affect engagement. Subgroup analyses explored the effects of demographic factors (such as age, gender, and education), acceptance of and familiarity with mobile technology, neurological diagnosis (MS or epilepsy), and symptoms that could influence motivation (such as depression).

Results

Analysis of the responses to the discrete choice experiment validated previous qualitative findings that a higher level of privacy, greater clinical support, increased perceived benefit, and better device accuracy are important to people with a neurological condition. Accuracy was perceived as the most important factor, followed by privacy. Clinical support was the least valued of the attributes. People were prepared to trade a modest amount of accuracy to achieve an improvement in privacy, but less likely to make this compromise for other factors. The type of neurological condition (epilepsy or MS) did not influence these preferences, nor did the age, gender, or mental health status of the participants. Those who were less accepting of technology were the most concerned about privacy and those with a lower level of education were prepared to trade accuracy for more clinical support.

Conclusions

For people with neurological conditions such as epilepsy and MS, accuracy (ie, the ability to detect symptoms) is of the greatest interest. However, there are individual differences, and people who are less accepting of technology may need far greater reassurance about data privacy. People with lower levels of education value greater clinician involvement. These patient preferences should be considered when designing mHealth technologies.

Data Visualization for Chronic Neurological and Mental Health Condition Self-management: Systematic Review of User Perspectives

BACKGROUND

Remote measurement technologies (RMT) such as mobile health devices and apps are increasingly used by those living with chronic neurological and mental health conditions. RMT enables real-world data collection and regular feedback, providing users with insights about their own conditions. Data visualizations are an integral part of RMT, although little is known about visualization design preferences from the perspectives of those living with chronic conditions.

OBJECTIVE

The aim of this review was to explore the experiences and preferences of individuals with chronic neurological and mental health conditions on data visualizations derived from RMT to manage health.

METHODS

In this systematic review, we searched peer-reviewed literature and conference proceedings (PubMed, IEEE Xplore, EMBASE, Web of Science, Association for Computing Machinery Computer-Human Interface proceedings, and the Cochrane Library) for original papers published between January 2007 and September 2021 that reported perspectives on data visualization of people living with chronic neurological and mental health conditions. Two reviewers independently screened each abstract and full-text article, with disagreements resolved through discussion. Studies were critically appraised, and extracted data underwent thematic synthesis.

RESULTS

We identified 35 eligible publications from 31 studies representing 12 conditions. Coded data coalesced into 3 themes: desire for data visualization, impact of visualizations on condition management, and visualization design considerations. Data visualizations were viewed as an integral part of users' experiences with RMT, impacting satisfaction and engagement. However, user preferences were diverse and often conflicting both between and within conditions.

CONCLUSIONS

When used effectively, data visualizations are valuable, engaging components of RMT. They can provide structure and insight, allowing individuals to manage their own health more effectively. However, visualizations are not "one-size-fits-all," and it is important to engage with potential users during visualization design to understand when, how, and with whom the visualizations will be used to manage health.

Seed coat color genetics and genotype × environment effects in yellow beans via machine-learning and genome-wide association

Common bean (Phaseolus vulgaris L.) is consumed worldwide, with strong regional preferences for seed appearance characteristics. Colors of the seed coat, hilum ring, and corona are all important, along with susceptibility to postharvest darkening, which decreases seed value. This study aimed to characterize a collection of 295 yellow bean genotypes for seed appearance and postharvest darkening, evaluate genotype × environment (G × E) effects and map those traits via genome-wide association analysis. Yellow bean germplasm were grown for 2 yr in Michigan and Nebraska and seed were evaluated for L*a*b* color values, postharvest darkening, and hilum ring and corona colors. A model to exclude the hilum ring and corona of the seeds, black background, and light reflection was developed by using machine learning, allowing for targeted and efficient L*a*b* value extraction from the seed coat. The G × E effects were significant for the color values, and Michigan-grown seeds were darker than Nebraska-grown seeds. Single-nucleotide polymorphisms (SNPs) were associated with L* and hilum ring color on Pv10 near the J gene involved in mature seed coat color and hilum ring color. A SNP on Pv07 associated with L*, a*, postharvest darkening, and hilum ring and corona colors was near the P gene, the ground factor gene for seed coat color expression. The machine-learning-aided model used to extract color values from the seed coat, the wide variability in seed morphology traits, and the associated SNPs provide tools for future breeding and research efforts to meet consumers' expectations for bean seed appearance.

Identifying schizophrenia stigma on Twitter: a proof of principle model using service user supervised machine learning

Stigma has negative effects on people with mental health problems by making them less likely to seek help. We develop a proof of principle service user supervised machine learning pipeline to identify stigmatising tweets reliably and understand the prevalence of public schizophrenia stigma on Twitter. A service user group advised on the machine learning model evaluation metric (fewest false negatives) and features for machine learning. We collected 13,313 public tweets on schizophrenia between January and May 2018. Two service user researchers manually identified stigma in 746 English tweets; 80% were used to train eight models, and 20% for testing. The two models with fewest false negatives were compared in two service user validation exercises, and the best model used to classify all extracted public English tweets. Tweets classed as stigmatising by service users were more negative in sentiment (t (744) = 12.02, p < 0.001 [95% CI: 0.196–0.273]). Our linear Support Vector Machine was the best performing model with fewest false negatives and higher service user validation. This model identified public stigma in 47% of English tweets (n5,676) which were more negative in sentiment (t (12,143) = 64.38, p < 0.001 [95% CI: 0.29–0.31]). Machine learning can identify stigmatising tweets at large scale, with service user involvement. Given the prevalence of stigma, there is an urgent need for education and online campaigns to reduce it. Machine learning can provide a real time metric on their success.

The Spontaneous Course of Human Herpesvirus 6 DNA-Associated Myocarditis and the Effect of Immunosuppressive Intervention

Introduction: This study investigated the spontaneous clinical course of patients with endomyocardial biopsy (EMB)-proven lymphocytic myocarditis and cardiac human herpesvirus 6 (HHV6) DNA presence, and the effectiveness of steroid-based intervention in HHV6-positive patients. Results: 756 heart failure (HF) patients underwent an EMB procedure to determine the underlying cause of unexplained HF. Low levels of HHV6 DNA, detectable by nested PCR only, were found in 10.4% of the cases (n = 79) of which 62% (n = 49) showed myocardial inflammation. The spontaneous course of patients with EMB-proven HHV6 DNA-associated lymphocytic myocarditis (n = 26) showed significant improvements in the left ventricular ejection fraction (LVEF) and clinical symptoms, respectively, in 15/26 (60%) patients, 3–12 months after disease onset. EMB mRNA expression of components of the NLRP3 inflammasome pathway and protein analysis of cardiac remodeling markers, analyzed by real-time PCR and MALDI mass spectrometry, respectively, did not differ between HHV6-positive and -negative patients. In another cohort of patients with ongoing symptoms related to lymphocytic myocarditis associated with cardiac levels of HHV6-DNA copy numbers <500 copies/µg cardiac DNA, quantified by real-time PCR, the efficacy and safety of steroid-based immunosuppression for six months was investigated. Steroid-based immunosuppression improved the LVEF (≥5%) in 8/10 patients and reduced cardiac inflammation in 7/10 patients, without an increase in cardiac HHV6 DNA levels in follow-up EMBs. Conclusion: Low HHV6 DNA levels are frequently detected in the myocardium, independent of inflammation. In patients with lymphocytic myocarditis with low levels of HHV6 DNA, the spontaneous clinical improvement is nearby 60%. In selected symptomatic patients with cardiac HHV6 DNA copy numbers less than 500 copies/µg cardiac DNA and without signs of an active systemic HHV6 infection, steroid-based therapy was found to be effective and safe. This finding needs to be further confirmed in large, randomized trials.

Investigation of Carers’ Perspectives of Dementia Misconceptions on Twitter: Focus Group Study

Background

Dementia misconceptions on social media are common, with negative effects on people with the condition, their carers, and those who know them. This study codeveloped a thematic framework with carers to understand the forms these misconceptions take on Twitter.

Objective

The aim of this study is to identify and analyze types of dementia conversations on Twitter using participatory methods.

Methods

A total of 3 focus groups with dementia carers were held to develop a framework of dementia misconceptions based on their experiences. Dementia-related tweets were collected from Twitter’s official application programming interface using neutral and negative search terms defined by the literature and by carers (N=48,211). A sample of these tweets was selected with equal numbers of neutral and negative words (n=1497), which was validated in individual ratings by carers. We then used the framework to analyze, in detail, a sample of carer-rated negative tweets (n=863).

Results

A total of 25.94% (12,507/48,211) of our tweet corpus contained negative search terms about dementia. The carers’ framework had 3 negative and 3 neutral categories. Our thematic analysis of carer-rated negative tweets found 9 themes, including the use of weaponizing language to insult politicians (469/863, 54.3%), using dehumanizing or outdated words or statements about members of the public (n=143, 16.6%), unfounded claims about the cures or causes of dementia (n=11, 1.3%), or providing armchair diagnoses of dementia (n=21, 2.4%).

Conclusions

This is the first study to use participatory methods to develop a framework that identifies dementia misconceptions on Twitter. We show that misconceptions and stigmatizing language are not rare. They manifest through minimizing and underestimating language. Web-based campaigns aiming to reduce discrimination and stigma about dementia could target those who use negative vocabulary and reduce the misconceptions that are being propagated, thus improving general awareness.

TP6.2.26 Innovations Towards Achieving Environmentally Sustainable Operating Theatres: A Systematic Review

Introduction

The NHS accounts for 5.4% of the UK’s total carbon foot print, with the perioperative environment being the most resource hungry aspect of the hospital. The aim of this systematic review was to assimilate the published studies concerning the sustainability of the perioperative environment, focusing on the impact of implemented interventions.

Methods

A systematic review was performed using Pubmed, OVIC, Embase, Cochrane database of systematic reviews and Medline. Original manuscripts describing interventions aimed at improving operating theatre environmental sustainability were included.

Results

648 abstracts were screened with 33 manuscripts included. Studies were divided into broad themes; recycling and waste management, waste reduction, reuse, reprocessing or life cycle analysis, energy and resource reduction and anaesthetic gases. This review summarises the interventions identified and their resulting effects on theatre sustainability.

Discussion

This systematic review has identified simple, yet highly effective interventions across a variety of themes that can lead to improved environmental sustainability of surgical operating theatres. Combining these interventions will likely result in a synergistic improvement to the environmental impact of surgery.

Antithyroid drugs in Graves' hyperthyroidism: differences between "block and replace" and "titration" regimes in frequency of euthyroidism and Graves' orbitopathy during treatment

PURPOSE

Whereas antithyroid drugs (ATD) are the preferred treatment modality for Graves' hyperthyroidism (GH), there is still controversy about the optimal regimen for delivering ATD. To evaluate whether 'Block and Replace' (B + R) and 'Titration' (T) regimes are equivalent in terms of frequency of euthyroidism and Graves' Orbitopathy (GO) during ATD therapy.

METHODS

A prospective multicentre observational cohort study of 344 patients with GH but no GO at baseline. Patients were treated with ATD for 18 months according to B + R or T regimen in line with their institution's policy.

RESULTS

Baseline characteristics were similar in both groups. In the treatment period between 6 and 18 months thyrotropin (TSH) slightly increased in both groups, but TSH was on average 0.59 mU/L (95% CI 0.27-0.85) lower in the B + R group at all time points (p = 0.026). Serum free thyroxine (FT4) remained stable during the same interval, with a tendency to higher values in the B + R group. The point-prevalence of euthyroidism (TSH and FT4 within their reference ranges) increased with longer duration of ATD in both groups; it was always higher in the T group than in the B + R group: 48 and 24%, respectively, at 6 months, 81 and 58% at 12 months, and 87 and 63% at 18 months (p < 0.002). There were no significant differences between the B + R and T regimens with respect to the fall in thyrotropin binding inhibiting immunoglobulins (TBII) or thyroid peroxidase antibodies (TPO-Ab). GO developed in 15.9% of all patients: 9.1 and 17.8% in B + R group and T group, respectively, (p = 0.096). GO was mild in 13% and moderate-to-severe in 2%.

CONCLUSION

The prevalence of biochemical euthyroidism during treatment with antithyroid drugs is higher during T compared to B + R regimen. De novo development of GO did not differ significantly between the two regimens, although it tended to be higher in the T group. Whether one regimen is clinically more advantageous than the other remains unclear.

Keeping well in a COVID-19 crisis: a qualitative study formulating the perspectives of mental health service users and carers

BACKGROUND

People with existing mental health conditions may be particularly vulnerable to the psychological effect of the COVID-19 pandemic. But their positive and negative appraisals, and coping behaviour could prevent or ameliorate future problems.

OBJECTIVE

To explore the emotional experiences, thought processes and coping behaviours of people with existing mental health problems and carers living through the pandemic.

METHODS

UK participants who identified as a mental health service user (N18), a carer (N5) or both (N8) participated in 30-minute semi-structured remote interviews (31 March 2020 to 9 April 2020). The interviews investigated the effects of social distancing and self-isolation on mental health and the ways in which people were coping. Data were analysed using a framework analysis. Three service user researchers charted data into a framework matrix (consisting of three broad categories: "emotional responses", "thoughts" and "behaviours") and then used an inductive process to capture other contextual themes.

RESULTS

Common emotional responses were fear, sadness and anger but despite negative emotions and uncertainty appraisals, participants described efforts to cope and maintain their mental wellbeing. This emphasised an increased reliance on technology, which enabled social contact and occupational or leisure activities. Participants also spoke about the importance of continued and adapted mental health service provision, and the advantages and disadvantages associated with changes in their living environment, life schedule and social interactions.

CONCLUSION

This study builds on a growing number of qualitative accounts of how mental health service users and carers experienced and coped with extreme social distancing measures early in the COVID-19 pandemic. Rather than a state of helplessness this study contains a clear message of resourcefulness and resilience in the context of fear and uncertainty.

Contamination of domestic groundwater systems by verotoxigenic escherichia coli (VTEC), 2003-2019: A global scoping review

Verocytotoxin-producing E. coli (VTEC) are important agents of diarrhoeal disease in humans globally. As a noted waterborne disease, emphasis has been given to the study VTEC in surface waters, readily susceptible to microbial contamination. Conversely, the status of VTEC in potable groundwater sources, generally regarded as a "safe" drinking-water supply remains largely understudied. As such, this investigation presents the first scoping review seeking to determine the global prevalence of VTEC in groundwater supply sources intended for human consumption. Twenty-three peer-reviewed studies were identified and included for data extraction. Groundwater sample and supply detection rates (estimated 0.6 and 1.3%, respectively) indicate VTEC is infrequently present in domestic groundwater sources. However, where generic (fecal indicator) E. coli are present, the VTEC to E. coli ratio was found to be 9.9%, representing a latent health concern for groundwater consumers. Geographically, extracted data indicates higher VTEC detection rates in urban (5.4%) and peri‑urban (4.9%) environments than in rural areas (0.9%); however, this finding is confounded by the predominance of research studies in lower income regions. Climate trends indicate local environments classified as 'temperate' (14/554; 2.5%) and 'cold' (8/392; 2%) accounted for a majority of supply sources with VTEC present, with similar detection rates encountered among supplies sampled during periods typically characterized by 'high' precipitation (15/649; 2.3%). Proposed prevalence figures may find application in preventive risk-based catchment and groundwater quality management including development of Quantitative Microbial Risk Assessments (QMRA). Notwithstanding, to an extent, a large geographical disparity in available investigations, lack of standardized reporting, and bias in source selection, restrict the transferability of research findings. Overall, the mechanisms responsible for VTEC transport and ingress into groundwater supplies remain ambiguous, representing a critical knowledge gap, and denoting a distinctive lack of integration between hydrogeological and public health research. Key recommendations and guidelines are provided for prospective studies directed at increasingly integrative and multi-disciplinary research.

Case report: Total enterectomy following complete small bowel ischaemia in the post-peritonectomy setting

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Small bowel resection following total ischaemia is feasible post-peritonectomy.

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VAC dressing and skin grafting was beneficial following wound dehiscence.

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Small bowel transplant is a potential means to avoid complications of long-term TPN.

Introduction

This report presents the rare case of a patient with complete bowel ischaemia following parastomal hernia, leading to total bowel resection, with consideration of post-operative complications and wound management.

Presentation of case

A 59 year old female was found to have complete small bowel ischaemia on exploratory laparatomy, on a background of recurrent appendiceal adenomucinosis, for which she had received previous peritonectomy, cholecystectomy, total colectomy, and partial small bowel resection. The patient was managed with total enterectomy and post-operative total parenteral nutrition.

Discussion

Total enterectomy represents a significant challenge in the postperitonectomy setting, including consideration of wound management with the empty abdomen, and the potential of small bowel transplant in management.

Conclusion

Resection of the small bowel following total small bowel ischaemia is feasible in the post-peritonectomy setting, given appropriate post-operative care and wound management. However, long-term survival remains challenging, especially without small bowel transplant.

THU0002 SOLVING THE COMPLEX MHC ASSOCIATIONS IN SLE IDENTIFIES SEX-RELATED GENE EFFECTS

Background:

Genome-wide association analyses reveal that the Major Histocompatibility Complex (MHC) is the site of the strongest association signals in SLE and Sjögren’s syndrome. This associations in lupus and Sjögren’s syndrome are linked toHLAalleles: HLA-DRB1*03:01 and HLA-DRB1*15:01 (in Europeans). The DRB1*03:01 allele resides on an extended MHC haplotype which includes loss of the complement C4A gene. Whether C4 makes a genetic contribution to SLE/Sjogren’s risk has been a long standing issue of contention1. In comparison, it has been shown that elevated copy number of C4 is a genetic risk factor for schizophrenia2.

Objectives:

To define the causal MHC genes in SLE/Sjogren’s accommodating both structural and highly polymorphic variation.

Methods:

Use NG sequencing data from across the MHC to generate a panel of variants that inform class III structural variation involving the candidate genes coding complementC4AandC4Bas described2. To further improve the resolution of the association using transancestral mapping approach in SLE: examining cohorts of European ancestry (from ImmunoChip) and data from the MHC region of an African-American GWAS in SLE.

Results:

Comparing European and African data, we have shown that the association signals in SLE can be best explained by signals arising from 1) copy number variation of the complement component 4 (C4) genes in the MHC locus (Fig. 1) and 2) by a shared region in the class II region on the HLA-DRB1*15:01 (in Europeans) and HLA-DRB1*15:03 (in Africans) that likely operates to elevated HLA class II gene expression (Fig. 2). TheC4locus generates a 7-fold variation in risk for lupus (95% CI: 5.88-8.61;p<10-117in total) and 16-fold variation in risk for Sjögren’s syndrome (95% CI: 8.59-30.89;p<10-23in total), withC4Aprotecting more strongly thanC4Bin both illnesses. In schizophrenia, elevated C4 copy number elevates disease risk, whereas in SLE and Sjögren’s lower copy numbers ofC4genes correlate with higher disease risk. In all three illnesses,C4alleles acted more strongly in men than in women: common combinations ofC4AandC4Bgenerated 14-fold variation in risk for lupus and 31-fold variation in risk for Sjögren’s syndrome in men (versus 6-fold and 15-fold among women respectively) and affected schizophrenia risk about twice as strongly in men as in women. At a protein level, both C4 and its effector (C3) were present at greater levels in men than women in cerebrospinal fluid (p<10-5for both C4 and C3) and plasma among adults ages 20-50, corresponding to the ages of differential disease vulnerability. Sex differences in complement protein levels may help explain the larger effects ofC4alleles in men, women’s greater risk of SLE and Sjogren’s, and men’s greater vulnerability in schizophrenia.

Figure 1.

Loss ofC4is risk in African and European ancestry cohorts. A = C4A, B = C4B, A-B = C4A + C4B (L) = Long form (with HERV), (S) = short form

Figure 2.

Common class II association after removing C4 signal

Conclusion:

These results nominate the complement system as a source of sexual dimorphism in vulnerability to diverse illnesses.

References:

[1]Hanscombe KB, Morris DL, Noble JAet al. Hum Mol Genet. 2018; 27(21): 3813-3824.

[2]Sekar A, Bialas AR, de Rivera Het al. Nature.2016; 530(7589): 177-83.

Acknowledgments:

This work was supported by the National Human Genome Research Institute (HG006855), the National Institute of Mental Health (MH112491, MH105641, MH105653), and the Stanley Center for Psychiatric Research. The KCL/GSTT biomedical research centre.

Disclosure of Interests:

Nolan Kamitaki: None declared, Bob Handsaker: None declared, David Morris: None declared, Carl Langefeld: None declared, Robert Graham Employee of: Genentech, Speakers bureau: Genentech, Lindsey Criswell: None declared, Steve McCarroll: None declared, Tim Vyse: None declared

THU0018 GENETIC FACTORS AND RESPONSE TO RITUXIMAB THERAPY IN SLE

Background:

The biologic drug Rituximab (anti-CD20) is used therapeutically in SLE, however the clinical response to the therapy, which is expensive, is quite variable. Factors influencing the efficacy have been challenging to determine. The MRC funded MASTERPLANS consortium has investigated prognostic factors that determine the therapeutic response to biologic therapy in SLE. Genetics has not been studied on a large scale in this context. SLE is a complex clinical phenotype, it is likewise a complex genetic trait, although it has recently been shown that polygenic risk scores do have a relationship to the severity of the disease (1). In addition, genetic risk factors for SLE, coded at the IgG Fc gamma receptor locus, have the potential to influence antibody-dependent cell-mediated cytotoxicity.

Objectives:

To determine whether the genetics influences the clinical outcome of therapy with Rituximab. The study used both genome-wide data in the form of genetic risk scores as well as specific genetic data at a candidate locus, namely the IgG Fc gamma receptor locus

Methods:

Samples from the BILAG Biologics Register (BILAG BR) of individuals treated with Rituximab were subject to genome-wide genotyping with Illumina GSA V2 chip. Genetic risk scores (GRS) were calculated through a weighted risk sum. Genetic variation at the IgG Fc gamma receptor locus is not captured well on genotyping chips and hence common coding and copy number variation was studied using Multiplex Ligation-dependent Probe Amplification (MLPA) and sequencing.

Results:

BILAG-BR samples for SLE part of receiving Rituximab therapy were genotyped on GSA chip, 573 samples passed QC and were used in principal components analysis (PCA), among them, 310 samples both have RTX treatment information and GRS calculated. Examining the population using PCA in the informative samples revealed that the largest distinction, European versus African ancestry did not correlate with Rituximab response. When GRS was determined in the Responders versus the Non-responders there was a weak correlation with those with a higher risk score showing a tendency to be in the responder group (Fig. 1). We also examined variation at the IgG Fc gamma receptor locus, polymorphisms of which are associated with SLE and have been correlated with therapeutic outcome in lymphoma (2). In a subset of the BILAG-BR cohort, we show that carriage of the SLE risk allele atFCGR3A(158F) was enriched in the ‘responder at some point’ group compared to the non-responder group (P=0.03, Chi-square).

Conclusion:

We present preliminary data indicating that genetics at both the genome wide level and at theFCGRlocus show some influence on the outcome of therapy with Rituximab in SLE; more data are required in order to draw firm conclusions.

References:

[1]Reid S et al. High genetic risk score is associated with early disease onset, damage accrual and decreased survival in systemic lupus erythematosus.Ann Rheum Dis.2019 Dec 11. [Epub ahead of print]

[2]Weng WK, Levy R. Two immunoglobulin G fragment C receptor polymorphisms independently predict response to rituximab in patients with follicular lymphoma. J Clin Oncol. 2003;21(21):3940–3947.

Acknowledgments:

King’s and GSTT Biomedical Research Centre and M01665X/1MRC Stratified Medicine grant

Disclosure of Interests:

Lu Liu: None declared, Ariella Amar: None declared, James Robinson: None declared, Ian N. Bruce Grant/research support from: Genzyme Sanofi, GSK, and UCB, Consultant of: Eli Lilly, AstraZeneca, UCB, Iltoo, and Merck Serono, Speakers bureau: UCB, David Morris: None declared, Tim Vyse: None declared

Cryptosporidium spp. in groundwater supplies intended for human consumption - A descriptive review of global prevalence, risk factors and knowledge gaps

Cryptosporidiosis is one of the leading causes of diarrhoeal illness and mortality induced by protozoan pathogens worldwide. As a largely waterborne disease, emphasis has been given to the study of Cryptosporidium spp. in surface waters, readily susceptible to pathogenic contamination. Conversely, the status of Cryptosporidium in potable groundwater sources, generally regarded as a pristine and "safe" drinking-water supply owing to (sub)-soil protection, remains largely unknown. As such, this investigation presents the first literature review aimed to ascertain the global prevalence of Cryptosporidium in groundwater supply sources intended for human consumption. Thirty-seven peer-reviewed studies were identified and included in the review. Groundwater sample and supply detection rates (estimated 10-20%) indicate Cryptosporidium is frequently present in domestic groundwater sources, representing a latent health concern for groundwater consumers. Specifically, sample (10.4%) and source (19.1%) detection rates deriving from comprehensive "temporal" investigations are put forward as representative of a contamination 'baseline' for Cryptosporidium in 'domestic' groundwater supplies. Proposed 'baseline' prevalence figures are largely applicable in preventive risk-based catchment and groundwater quality management including the formulation of Quantitative Microbial Risk Assessment (QMRA). Notwithstanding, a large geographical disparity in available investigations and lack of standardized reporting restrict the transferability of research findings. Overall, the mechanisms responsible for Cryptosporidium transport and ingress into groundwater supplies remain ambiguous, representing a critical knowledge gap, and denoting a distinctive lack of integration between groundwater and public-health sub-disciplines among investigations. Key recommendations and guidelines are provided for prospective studies directed at more integrative and multi-disciplinary research.

Safety of hospital discharge before return of bowel function after elective colorectal surgery

BACKGROUND

Ileus is common after colorectal surgery and is associated with an increased risk of postoperative complications. Identifying features of normal bowel recovery and the appropriateness for hospital discharge is challenging. This study explored the safety of hospital discharge before the return of bowel function.

METHODS

A prospective, multicentre cohort study was undertaken across an international collaborative network. Adult patients undergoing elective colorectal resection between January and April 2018 were included. The main outcome of interest was readmission to hospital within 30 days of surgery. The impact of discharge timing according to the return of bowel function was explored using multivariable regression analysis. Other outcomes were postoperative complications within 30 days of surgery, measured using the Clavien-Dindo classification system.

RESULTS

A total of 3288 patients were included in the analysis, of whom 301 (9·2 per cent) were discharged before the return of bowel function. The median duration of hospital stay for patients discharged before and after return of bowel function was 5 (i.q.r. 4-7) and 7 (6-8) days respectively (P < 0·001). There were no significant differences in rates of readmission between these groups (6·6 versus 8·0 per cent; P = 0·499), and this remained the case after multivariable adjustment for baseline differences (odds ratio 0·90, 95 per cent c.i. 0·55 to 1·46; P = 0·659). Rates of postoperative complications were also similar in those discharged before versus after return of bowel function (minor: 34·7 versus 39·5 per cent; major 3·3 versus 3·4 per cent; P = 0·110).

CONCLUSION

Discharge before return of bowel function after elective colorectal surgery appears to be safe in appropriately selected patients.

Vismodegib for periocular basal cell carcinoma: an international multicentre case series

INTRODUCTION

Vismodegib (Erivedge, Genentech) is a first-in-class inhibitor of the hedgehog (Hh) pathway, which is licensed for use in locally advanced basal cell carcinoma (BCC) and metastatic BCC. The National Institute for Health and Care Excellence withdrew recommendation for use of vismodegib secondary to a lack of data comparing vismodegib to standard supportive care. The purpose of this multicentre, international case series is to report outcomes of patients with locally advanced periocular BCC who have been treated with vismodegib.

METHODS

The medical records of all patients treated with vismodegib were retrospectively reviewed across seven institutions in the United Kingdom, Australia, and New Zealand.

RESULTS

Thirteen patients were identified. Seven (54%) patients were male. All BCCs were ill-defined, with seven (58%) having orbital involvement at presentation. Median treatment time was 7 months (range 2-36 months). Eleven out of 13 patients developed side effects, the most common being fatigue in six patients (46%). Median follow-up was 24 months (range 12-48 months). Complete response was found in 5/13 patients (38%) and a partial response in 8/13 patients (62%). Six patients had further surgery after vismodegib, with three classed as globe-sparing operations. Three patients developed recurrence (23%). Three patients (23%) ultimately underwent exenteration.

DISCUSSION

This study demonstrates vismodegib to be a well-tolerated treatment which may, in some cases, facilitate globe-sparing surgery and hence avoid disfiguring operations such as exenteration. Uncertainty does remain regarding the long-term outcomes of patients treated with vismodegib.