Co-design of data collection with participants of the Aberdeen Children of the 1950s cohort study

Background

The Aberdeen Children of the 1950s (ACONF) cohort comprises 12,150 people born in Scotland in the 50s. It contains rich early life data, questionnaire data from mid-life and linked electronic health records. Involving participants in designing future data collection is key to ensure research is acceptable and reflects public priorities.

Aim

Gather ACONF members views to inform how to: research healthy ageing, optimise recruitment and maximise participation.

Methods

3 co-design workshops with 30 ACONF members. A discussion was led by a facilitator using guidance questions developed by the study team. Workshops were recorded and transcribed.

Results

Participants viewed healthy ageing as keeping socially and physically active, taking responsibility for oneself and having a positive attitude to ageing. Research priorities were dementia, improvements in the social care system and engaging hard-to-reach groups. Members were keen for future research involvement. Recruitment may be maximised by: more information online, involving participants in recruiting other study members and clarity about potential benefits to themselves or others. It was acceptable to ask their offspring to participate. There were high levels of trust in researchers, but ongoing data protection is vital. Participation may be improved by regular contact (informing members of results, engagement events, phone “apps”). Participants viewed various data collection methods (questionnaires, applications, wearable devices, in-person tests, DNA collection and electronic record linkage) as acceptable.

Conclusions

Participant involvement is a fundamental part of securing a social license for research. Participants were in favour of ongoing research, including recruitment of their children. The workshops highlighted key considerations for future research and data collection.

Key messages

Co-design is vital for highlighting research topics which are important and relevant to the general population. Co-design can highlight strategies for maximising research participation and securing a social license for research.

Does dissemination of guidelines alone increase the use of palliative single-fraction radiotherapy? Initial report of a longitudinal change management campaign at a provincial cancer program

Background

Despite level 1 evidence demonstrating the equivalence of single-fraction radiotherapy (sfrt) and multiple-fraction radiotherapy (mfrt) for the palliation of painful bone metastases, sfrt remains underused. In 2015, to encourage the sustainable use of palliative radiation oncology resources, CancerCare Manitoba disseminated, to each radiation oncologist in Manitoba, guidelines from Choosing Wisely Canada (cwc) that recommend sfrt. We assessed whether dissemination of the guidelines influenced sfrt use in Manitoba in 2016, and we identified factors associated with mfrt.

Methods

All patients treated with palliative radiotherapy for bone metastasis in Manitoba from 1 January 2016 to 31 December 2016 were identified from the provincial radiotherapy database. Patient, treatment, and disease characteristics were extracted from the electronic medical record and tabulated by fractionation schedule. Univariable and multivariable logistic regression analyses were performed to identify risk factors associated with mfrt.

Results

In 2016, 807 patients (mean age: 70 years; range: 35-96 years) received palliative radiotherapy for bone metastasis, with 69% of the patients having uncomplicated bone metastasis. The most common primary malignancies were prostate (27.1%), lung (20.6%), and breast cancer (15.9%). In 62% of cases, mfrt was used-a proportion that was unchanged from 2015. On multivariable analysis, a gastrointestinal [odds ratio (or): 5.3] or lung primary (or: 3.3), complicated bone metastasis (or: 4.3), and treatment at a subsidiary site (or: 4.4) increased the odds of mfrt use.

Conclusions

Dissemination of cwc recommendations alone did not increase sfrt use by radiation oncologists in 2016. A more comprehensive knowledge translation effort is therefore warranted and is now underway to encourage increased uptake of sfrt in Manitoba.

P300 response modulation reflects breaches of non-probabilistic expectations

In oddball paradigms, infrequent stimuli elicit larger P300 event related potentials (ERPs) than frequent ones. One hypothesis is that P300 modulations reflect the degree of “surprise” associated with unexpected stimuli. That is the P300 represents how unlikely the stimulus is and this signal is then used to update the observer’s expectations. It could be hypothesized that P300 is modulated by any factor affecting an observer’s expectations, not only target probability. Alternatively, the P300 may reflect an evaluative process engaged whenever a discrepancy between task context and sensory inputs arises, irrespective of the latter probability. In previous ERP studies, stimulus probability was often the only determinant of task set confounding the effects of stimulus probability and set stimulus discrepancy. In this study, we used a speeded luminance detection task. The target was preceded by a central cue that predicted its location. The probability that the target was valid, i.e. would appear at the cued location was manipulated by varying the reliability of the cue. Reaction times were modulated by probabilistic expectations based on cue reliability and target validity while P300 was affected by target validity only. We conclude that increased P300 amplitude reflects primarily breaches of non-probabilistic expectations, rather than target probability.

Parents' Perceptions and Experiences of Parenting Programmes: A Systematic Review and Metasynthesis of the Qualitative Literature

Supporting parents to meet the challenges of their caregiving role is identified as a public health concern and a priority in policies internationally. Quantitative research has established the efficacy of parenting programmes but less is understood about the key aspects that make interventions meaningful and helpful to families. We aimed to explore parents' experiences and perceptions of parenting programmes in order to highlight the parent voice and identify key factors that parents perceive to be meaningful and improve our understanding of the acceptability and perceived benefits of parenting programmes. Six key electronic databases were searched systematically for qualitative research and eligibility for inclusion was established. A thematic synthesis was undertaken. Twenty-six studies were included, spanning 17 years of parenting research and involving 822 parents. Three main themes and nine subthemes were identified: (1) a family's journey (prior to the parenting programme, outcomes (including changes in the parent, child and wider family) and post-intervention), (2) aspects perceived to be important or valuable (group leader or facilitator, programme content and delivery and value of the group) and (3) challenges or difficulties (barriers to engagement or attendance, programme content and suggestions for improvement). Reported outcomes of parenting programmes included changes in the parent alongside changes in the child and family more widely. Key recommendations to improve provision of accessible, clinically and cost-effective interventions for parents include ensuring high-quality training and supervision of facilitators, balancing flexibility and fidelity to ensure tailored content to meet individual needs, a sensitivity to parental adversity, the need for wider familial support and the availability of ongoing support following the end of a parenting programme.

The long-term health effects of attending a selective school: a natural experiment

BACKGROUND

Education is widely associated with better physical and mental health, but isolating its causal effect is difficult because education is linked with many socioeconomic advantages. One way to isolate education's effect is to consider environments where similar students are assigned to different educational experiences based on objective criteria. Here we measure the health effects of assignment to selective schooling based on test score, a widely debated educational policy.

METHODS

In 1960s Britain, children were assigned to secondary schools via a test taken at age 11. We used regression discontinuity analysis to measure health differences in 5039 people who were separated into selective and non-selective schools this way. We measured selective schooling's effect on six outcomes: mid-life self-reports of health, mental health, and life limitation due to health, as well as chronic disease burden derived from hospital records in mid-life and later life, and the likelihood of dying prematurely. The analysis plan was accepted as a registered report while we were blind to the health outcome data.

RESULTS

Effect estimates for selective schooling were as follows: self-reported health, 0.1 worse on a 4-point scale (95%CI - 0.2 to 0); mental health, 0.2 worse on a 16-point scale (- 0.5 to 0.1); likelihood of life limitation due to health, 5 percentage points higher (- 1 to 10); mid-life chronic disease diagnoses, 3 fewer/100 people (- 9 to + 4); late-life chronic disease diagnoses, 9 more/100 people (- 3 to + 20); and risk of dying before age 60, no difference (- 2 to 3 percentage points). Extensive sensitivity analyses gave estimates consistent with these results. In summary, effects ranged from 0.10-0.15 standard deviations worse for self-reported health, and from 0.02 standard deviations better to 0.07 worse for records-derived health. However, they were too imprecise to allow the conclusion that selective schooling was detrimental.

CONCLUSIONS

We found that people who attended selective secondary school had more advantaged economic backgrounds, higher IQs, higher likelihood of getting a university degree, and better health. However, we did not find that selective schooling itself improved health. This lack of a positive influence of selective secondary schooling on health was consistent despite varying a wide range of model assumptions.

Impulse Control Disorders in Dopamine Agonist-Treated Hyperprolactinemia: Prevalence and Risk Factors

CONTEXT

There are growing reports of dopamine agonist (DA)-induced impulse control disorders (ICDs) in hyperprolactinemic patients. However, the magnitude of this risk and predictive factors remain uncertain.

OBJECTIVE

To determine ICD prevalence and risk factors in DA-treated hyperprolactinemic patients compared to community controls.

DESIGN, SETTING AND PARTICIPANTS

Multicenter cross-sectional analysis of 113 patients and 99 healthy controls.

MAIN OUTCOME MEASURES

Participants completed a neuropsychological questionnaire consisting of the Depression Anxiety Stress Scale (DASS21), Questionnaire for Impulsive-Compulsive Disorders in Parkinson's Disease (QUIP-S), Hypersexual Behavior Inventory (HBI), Hypersexual Behavior Consequences Scale and Social Desirability Response Set Scale. Demographic and clinical data were collated to determine ICD risk factors. Patients testing positive for an ICD were offered a semistructured psychological interview.

RESULTS

Patients were more likely than controls to test positive by QUIP-S for any ICD (61.1 vs 42.4%, P = .01), hypersexuality (22.1 vs 8.1%, P = .009), compulsive buying (15.9 vs 6.1%, P = .041) and punding (18.6 vs 6.1%, P = 0.012), and by HBI for hypersexuality (8.0 vs 0.0%, P = 0.004). Independent risk factors were male sex (odds ratio [OR] 13.85), eugonadism (OR 7.85), Hardy's tumor score and psychiatric comorbidity (OR 6.86) for hypersexuality, and age (OR 0.95) for compulsive buying. DASS21 subset scores were higher in patients vs controls and in patients with vs without different ICDs. Only 19/51 (37.3%) interviewed patients were aware of the relationship between DAs and ICDs before the study.

CONCLUSIONS

DA therapy poses a high, previously underestimated risk of ICDs, especially in the form of hypersexuality in eugonadal men.

Trends in Mental Health Presentations to a Paediatric Emergency Department

Aims This study aimed to analyse trends in mental health presentations to the Emergency Department (ED), which anecdotally had increased over the past decade. Methods The ED's electronic 'Symphony' system was used to identify the annual number of presentations categorised as having a mental health complaint from 2006-2017. A detailed analysis was performed on presentations over a one-year period. Results The number of presentations increased from 69 in 2006 to a peak of 432 in 2016 (526% increase). The overall admission rate was 33.3%(n=99), while 52.5%(n=156) of presentations occurred outside of standard working hours. Similar increases were documented by other ED's worldwide, and the WHO estimate that neuropsychiatric disorders will become one of the top five causes of morbidity, mortality and disability among children by 2020. Conclusion With the number of mental health presentations dramatically increasing, carefully designed and integrated strategies are required to pro-actively tackle this growing epidemic.

Complex abdominal wall hernia repair with biologic mesh in elderly: a propensity matched analysis

Background

Complex abdominal wall reconstruction (CAWR) has become a common surgical procedure both in non-elderly and elderly patients.

Objective

The aim of this study is to analyze the outcomes of the elderly compared to nonelderly undergoing CAWR using propensity score matching.

Methods

All patients who underwent CAWR using porcine-derived, non-crosslinked acellular dermal matrix (ADM) (Strattice™) between January 2014 and July 2017 were studied retrospectively. Propensity matched analysis was performed for risk adjustment in multivariable analysis and for one-to-one matching. The outcomes were analyzed for differences in postoperative complications, reoperations, mortality, hospital length of stay and adverse discharge disposition.

Results

One hundred-thirty-six patients were identified during the study period. Non-elderly (aged 18–64 years) constituted 70% (n = 95) and elderly (aged ≥ 65 years) comprised 30% of the overall patient population (n = 41). Seventy-three (56.7%) were females. After adjustment through the propensity score, which included 35 pairs, the surgical site infection (p = 1.000), wound necrosis (p = 1.000), the need for mechanical ventilation (p = 0.259), mortality (p = 0.083), reoperation rate (p = 0.141), hospital length of stay (p = 0.206), and discharge disposition (p = 0.795) were similar.

Conclusion

Elderly patients undergoing CAWR with biological mesh have comparable outcomes with non-elderly patients when using propensity matching score.

Treatment of heart failure with sodium glucose co-transporter-2 inhibitors in people with type 2 diabetes mellitus: current evidence and future directions

Diabetes is one the most common comorbidities among people with established heart failure. Interest in heart failure as an outcome among people with diabetes has emerged since it was shown that there was an association between increased risk of hospitalization for heart failure with use of thiazolidinediones and some dipeptidyl peptidase-4 inhibitors. Recently, sodium-glucose co-transporter-2 inhibitors were shown to lead to a reduction in the risk of cardiovascular death and hospitalization for heart failure in people with Type 2 diabetes mellitus and either cardiovascular risk factors or atherosclerotic cardiovascular disease. These findings appear to be consistent in people both with and without a baseline history of heart failure. Based on current evidence there are several clinical scenarios in which the use of sodium-glucose co-transporter-2 inhibitors would be justified for people with heart failure and atherosclerotic cardiovascular disease: (1) in people with a new diagnosis of Type 2 diabetes and for whom anti-hyperglycaemic management strategies are being considered; (2) in people with sub-optimal glycaemic control, regardless of baseline antihyperglycaemic therapy; and (3) in people with symptomatic heart failure (or other high-risk features such as recent hospitalization for heart failure), if glycaemic control is optimized and the individual is on a sulfonylurea or dipeptidyl peptidase-4 inhibitor; here, it may be reasonable to consider substituting one of those therapies for a sodium-glucose co-transporter-2 inhibitor. There are now a number of ongoing trials evaluating the role of sodium-glucose co-transporter-2 inhibitors as therapy for people with established heart failure (with preserved or with reduced ejection fraction) and regardless of the presence of diabetes. These trials will provide the evidence for the safety and efficacy of sodium-glucose co-transporter-2 inhibitors among people with established heart failure.

Co-design of data collection with participants of the Aberdeen Children of the 1950s cohort study

Background The Aberdeen Children of the 1950s (ACONF) cohort contains 12,150 individuals born in Aberdeen, Scotland in the 1950s. The study includes rich early life data, information from questionnaire in middle age, and linkage to electronic healthcare records. Involving the participants in designing future data collection and research is key to ensure research is acceptable and reflects public priorities. Aim To gather ACONF participants’ views to inform how to: define healthy ageing, optimise recruitment and maximise participation. Method We undertook three co-design workshops with 8 to 10 ACONF members. The workshops operated as a discussion, led by a facilitator using guidance questions developed by the study team. Workshops were recorded and transcribed. Results Healthy ageing: Participants viewed healthy ageing as keeping socially and physically active, taking responsibility for oneself and having a positive attitude to ageing. Key research priorities were: dementia, healthy living advice, improvements in the social care system and engaging hard-to-reach groups. Optimising recruitment and participation: Participants were keen for further involvement in research. Recruitment may be maximised by: more information online, involving participants in recruitment of other study members and clarity about potential benefits to themselves or others. It is acceptable to ask their offspring to participate. There were high levels of trust in researchers, but ongoing data protection is vital. Participation may be improved by regular contact (informing participants of results, engagement events, newsletters, mobile phone “apps”). Participants were happy with data collection methods: questionnaires, applications, wearable devices, and in-person tests. They raised no concerns regarding DNA collection and electronic record linkage. Conclusion Participant involvement in research is a fundamental part of securing a social license for research. Participants were in favour of ongoing research, including recruitment of their children and linkage of electronic records. The workshops highlighted key considerations for future research and data collection.

P2482Sex-based differences in cardioprotective role of SGLT-2 inhibitors in patients with type 2 diabetes mellitus

Background

Randomized studies have shown that sodium-glucose cotransporter-2 inhibitors (SGLT2i) reduce major cardiovascular events in patients with type 2 diabetes mellitus. However, it is not known whether there are significant sex-based differences in the cardioprotective role of SGLT-2 inhibitors.

Purpose

To investigate whether sex differences exist in reduction of major cardiovascular events (MACE)in patients with type 2 diabetes mellitus when treated with SGLT2i.

Methods

A comprehensive PubMed search was conducted using keywords, (“Diabetes” AND (“Dapagliflozin” OR “Empagliflozin” OR “Canagliflozin” OR “Ertugliflozin”) AND “Outcomes”) that resulted in a total of 221 studies. Studies were included in our meta-analysis if they were randomized controlled trials, placebo-controlled, reported MACE as the primary outcome and reported sex-based subgroup analyses of these outcomes. Only 2 RCTs (EMPA-REG and DECLARE-TIMI 58) met our inclusion criteria.The sex-based event data for both trials was pooled to calculate risk ratios (RR) with 95% confidence intervals (CI). Analyses was performed using Comprehensive Meta-analysis (CMA) software. Fixed effect models, random effect models and mixed effect models were used.

Results

Pooled datafrom the 2 RCTs (EMPA-REG and DECLARE-TIMI 58) resulted in a total of 24,180 patients who were included in our primary analysis. Of these, 2331 patients were reported to have MACE. In our pooled data, SGLT2i reduced MACE in patients with diabetes with an overall risk ratio of 0.92 (0.85–0.99), p=0.03 (I2=0, p=0.31)using fixed effect model (Table 1). We also performed subgroup analysis of the pooled data categorizing by sex and using mixed effect model. Our subgroup analysis by sex showed a Q statistic of 1.88 with p-value of 0.17 suggesting that there is no significant difference in MACE reduction between men and women with diabetes when treated with SGLT2i. However, on further analyzing the sex differences in the individual trials, we found that women may have greater reduction in MACE compared with their male counterparts (RR in females: 0.66 (0.42–1.04); RR in males: 0.92 (0.84–1.00)), however this finding did not meet statistical significance (Table 2).

Conclusion

Our meta-analysis included the pooled data from 2 major RCTs (EMPA-REG and DECLARE-TIMI 58) assessing the cardioprotective role of SGLT2i in diabetic patients and shows that SGLT2i significantly reduce the risk of major adverse CV events in patients with type 2 diabetes mellitus. However, we did not find any significant sex-based differences in reduction of MACE between men and women with diabetes when treated with SGLT2i.

P3522Vagus nerve stimulation for chronic heart failure: differences in therapy delivery and clinical efficacy in ANTHEM-HF, INOVATE-HF, and NECTAR-HF

Background

Vagus Nerve Stimulation (VNS) is meant to deliver Autonomic Regulation Therapy (ART) to neurological targets with sufficient neuromodulation (NM) to ameliorate chronic heart failure (CHF). VNS delivery consists of its intensity (a combination of pulse amplitude, pulse frequency, and pulse duration), polarity, duty cycle (DC; stimulation “on” time and “off” time), and mode (continuous, or intermittent and periodic). In the ANTHEM-HF Pilot Study patients with CHF and reduced ejection fraction (HFrEF), VNS intensity was up-titrated until a change in heart rate (HR) dynamics was objectively confirmed. This did not require any change in GDMT and was associated with significant improvements in LVEF, 6-minute walk distance (6MWD), Minnesota Living with HF (MLWHF) score, and HR variability.

Methods

Qualitative and quantitative analyses used data from peer-reviewed publications and other sources in the public domain to compare VNS delivery in ANTHEM-HF, INOVATE-HF, and NECTAR-HF.

Results (Table): Up-titration of VNS intensity was attempted in all 3 studies. In contrast to ANTHEM-HF, INOVATE-HF aimed only at peripheral neural targets. VNS intensity was delivered at a lower pulse frequency, and had a variable DC as a consequence of R-wave synchronization and only intermittent, periodic stimulation. In NECTAR-HF VNS intensity was delivered at a higher pulse frequency, and this was associated with intolerable adverse off-target effects which restricted VNS up-titration. Significant improvements in EF, 6MWD, MLWHF, and SDNN occurred in ANTHEM-HF relative to the other studies.

ANTHEM-HF (n=60) INOVATE-HF (n=436) NECTAR-HF (n=63) Neural Target Central/Peripheral Peripheral Central/Peripheral Delivery Site Left or right CVN Right CVN Right CVN Delivery Intensity:   Amplitude (milliamperes) 2.0±0.6 3.9±1.0 1.4±0.8   Frequency (Hertz) 10 1–2 20   Duration (microseconds) 250 500 300 Electrode Polarity (Cathode) Caudal Cephalad Caudal Duty Cycle 23% 25% 17% On Time/Off Time (seconds) 18/62 Variable 10/50 Mode of Delivery Cyclic/Continuous Intermittent/Periodic Cyclic/Continuous Clinical Efficacy at 6 Months:   EF 32.4±7.2 to 37.2±10.4 Not available 30.5±6.0 to 32.7±6.4   6MWD 287±66 to 346±78 317±109 to 347±123 Not available   MLWHFS 40±14 to 21±10 Not available 44.2±22.2 to 35.8±20.8   SDNN 94±26 to 111±50 Not available 146±48 to 130±52 Values reported as mean ± standard deviation; CVN = Cervical vagus nerve. *p<0.05 versus NECTAR-HF; **p<0.05 versus INOVATE-HF; ***p<0.025 versus NECTAR-HF; ****p<0.001 versus NECTAR-HF (Analysis using two-sample t-test of the means).

Conclusion

VNS differed in ANTHEM-HF when compared to INOVATE-HF and NECTAR-HF. The neural targets, pulse frequencies for titration, and the DC for NM were different. VNS in ANTHEM-HF was clinically efficacious. The ongoing ANTHEM-HFrEF Pivotal Study uses a similar paradigm.

Acknowledgement/Funding

LivaNova PLC

Central sensitization increases the pupil dilation elicited by mechanical pinprick stimulation

High-frequency electrical stimulation (HFS) of skin nociceptors triggers central sensitization (CS), manifested as increased pinprick sensitivity of the skin surrounding the site of HFS. Our aim was to assess the effect of CS on pinprick-evoked pupil dilation responses (PDRs) and pinprick-evoked brain potentials (PEPs). We hypothesized that the increase in the positive wave of PEPs following HFS would result from an enhanced pinprick-evoked phasic response of the locus coeruleus-noradrenergic system (LC-NS), indicated by enhanced PDRs. In 14 healthy volunteers, 64- and 96-mN pinprick stimuli were delivered to the left and right forearms, before and 20 minutes after HFS was applied to one of the two forearms. Both PEPs and pinprick-evoked PDRs were recorded. After HFS, pinprick stimuli were perceived as more intense at the HFS-treated arm compared with baseline and control site, and this increase was similar for both stimulation intensities. Importantly, the pinprick-evoked PDR was also increased, and the increase was stronger for 64- compared with 96-mN stimulation. This is in line with our previous results showing a stronger increase of the PEP positivity at 64 vs. 96-mN stimulation and suggests that the increase in PEP positivity observed in previous studies could relate, at least in part, to enhanced LC-NS activity. However, there was no increase of the PEP positivity in the present study, indicating that enhanced LC-NS activity is not the only determinant of the HFS-induced enhancement of PEPs. Altogether, our results indicate that PDRs are more sensitive for detecting CS than PEPs. NEW & NOTEWORTHY We provide the first demonstration in humans that activity-dependent central sensitization increases pinprick-evoked autonomic arousal measured by enhanced pupil dilation response.

Respiratory and upper limb function as outcome measures in ambulant and non-ambulant subjects with Duchenne muscular dystrophy: A prospective multicentre study

The field of translational research in Duchenne muscular dystrophy (DMD) has been transformed in the last decade by a number of therapeutic targets, mostly studied in ambulant patients. A paucity of studies focus on measures that capture the non-ambulant stage of the disease, and the transition between the ambulant and non-ambulant phase. In this prospective natural history study, we report the results of a comprehensive assessment of respiratory, upper limb function and upper limb muscle strength in a group of 89 DMD boys followed in 3 European countries, 81 receiving corticosteroids, spanning a wide age range (5-18 years) and functional abilities, from ambulant (n = 60) to non-ambulant (n = 29). Respiratory decline could be detected in the early ambulatory phase using Peak Expiratory Flow percentage predicted (PEF%), despite glucocorticoid use (mean annual decline: 4.08, 95% CI [-7.44,-0.72], p = 0.02 in ambulant; 4.81, 95% CI [-6.79,-2.82], p < 0.001 in non-ambulant). FVC% captured disease progression in non-ambulant DMD subjects, with an annual loss of 5.47% (95% CI [-6.48,-4.45], p < 0.001). Upper limb function measured with the Performance of Upper Limb (PUL 1.2) showed an annual loss of 4.13 points (95% CI [-4.79,3.47], p < 0.001) in the non-ambulant cohort. Measures of upper limb strength (MyoGrip and MyoPinch) showed a continuous decline independent of the ambulatory status, when reported as percentage predicted (grip force -5.51%, 95% CI [-6.54,-4.48], p < 0.001 in ambulant and a slower decline -2.86%; 95% CI -3.29,-2.43, p < 0.001, in non-ambulant; pinch force: -2.66%, 95% CI [-3.82,-1.51], p < 0.001 in ambulant and -2.23%, 95% CI [-2.92,-1.53], p < 0.001 in non-ambulant). Furthermore, we also explored the novel concept of a composite endpoint by combining respiratory, upper limb function and force domains: we were able to identify clear clinical progression in patients in whom an isolated measurement of only one of these domains failed to appreciate the yearly change. Our study contributes to the field of natural history of DMD, linking the ambulant and non-ambulant phases of the disease, and suggests that composite scores should be explored further.

Heparin-induced Thrombocytopenia and the Use of r-Hirudin during Cardiopulmonary Bypass

We report the successful use of r-hirudin (lepirudin) for cardiopulmonary bypass in a 67-year-old man who developed heparin-induced thrombocytopenia type II during heparin treatment of an extensive deep venous thrombosis. Lepirudin was monitored by the modified ecarin clotting time in a “mobile laboratory” set up next to the cardiac theatre, aiming for lepirudin levels of 3.5 to 4.5 μg/ml during bypass.

Exploring Variations in the Content of Cancer-Specific Treatment Guidelines: An International Cancer Benchmarking Partnership (ICBP) Study

Background: Cancer-specific treatment guidelines aim to provide robust evidence-based recommendations for clinicians to ensure optimal disease management for patients. The content of these guidelines can greatly affect a patients' access to optimal treatment. However, the extent of international variation in guideline content remains understudied. Aim: Phase 2 of ICBP explores several factors that may be contributing to differences in cancer survival outcomes. Module 7 investigates differences in 'access to treatment' across seven participating countries (Canada, Australia, New Zealand, the UK, Ireland, Norway and Denmark). This project specifically aims to explore how variation in guideline content for cancer-specific treatment modalities may be contributing to differences in international survival outcomes. Methods: We reviewed cancer treatment guidelines across the seven ICBP countries that fulfill standard methodological criteria and are widely used in clinical care. This study includes a selected range of national and international guidelines recognizing that some participating countries do not produce their own site-specific guidelines and instead draw on international bodies (e.g., ESMO oncology clinical practice guidelines). We reviewed treatment guidelines for three cancer sites (stomach, pancreas and lung), recording points of content variation that were considered clinically significant and relevant to emerging findings from the ICBP survival benchmarking study. Results: Differences in the content of guidelines were found for each cancer site to varying degrees. Some guidelines showed a large degree of similarity which reflects strong consensuses in the evidence base. Others exhibited stark differences in recommendations for the type of surgical technique implemented, when to administer chemotherapy, use and type of radiotherapy and the extent of palliative care. Some differences may partly be explained by differences in the timeliness of some bodies to produce new guidelines, while others may stem from differences in how bodies evaluate the robustness and validity of high-profile phase III trials. Conclusion: This study found variation in the content of treatment guidelines. The extent to which this variation contributes to differences in international cancer outcomes warrants further exploration, as does additional content analyses of national guidelines for low- and middle-income countries. Our findings may prompt a move by clinical and policy stakeholders toward the standardization of international treatment guidelines, particularly in cases where content variation is marginal and given that guideline development processes are highly labor- and resource-intensive. This study also highlights the need to improve communications between national and international guideline bodies, when recommendations vary significantly, to reach international consensuses on areas of controversy regarding cancer site-specific treatment modalities.