C-13 Sex Differences in Cognitive and Neurobiological Markers of Alzheimer's Disease

Objective

Previous work has demonstrated that intra-individual cognitive variability (IICV) has predictive power similar to traditional Alzheimer’s disease (AD) biomarkers, such as CSF or hippocampal volume (HV) loss. Genetic factors, such as sex, have been identified as predictors of cognitive decline. Analysis of sex differences in IICV and other biomarkers may elucidate additional dimensions of this metric.

Method

Baseline neurocognitive test and neuroimaging data from 335 participants with ≥2 visits enrolled in the Wisconsin Alzheimer’s Disease Research Center Clinical Core were included. Z-scores were calculated comparing individual performance to group performance by test (Rey Auditory Verbal Learning Test (Learning and Delayed Recall), Trail Making Test (A and B), and either Boston Naming Test (BNT) or Multilingual Naming Test (MINT)). MINT scores were converted to BNT scores using the NACC Crosswalk Study. The standard deviation of z-scores across tests was calculated to determine IICV. Characteristics by sex were compared using Mann-Whitney and Fisher’s Exact tests. Spearman’s Rho was calculated to compare IICV and HV (relative to intercranial volume).

Results

At baseline (Table 1): (1) Males had more education than females; (2) females had both higher relative HV and IICV; and (3) in females, relative HV demonstrated a weak positive correlation with baseline IICV (Figure 1).

Conclusions

IICV has previously demonstrated potential as a cost-effective non-invasive marker of preclinical AD. In females, larger relative HV and its correlation with IICV may be due to differences in metabolic brain age or concurrent progression of HV and IICV through the AD process. Analyses of other biopsychosocial factors are needed.

C-12 Race and Sex Differences in Cognitive and Neurobiological Markers of Alzheimer's Disease

Objective

Intra-Individual Cognitive Variability (IICV) previously demonstrated predictive power similar to AD biomarkers (i.e., CSF and hippocampal volume (HV) loss). Previous work suggested sex differences in relative HV and IICV. Additionally, IICV differs in whites and underrepresented racial groups (URG). Our objective was to analyze these sex differences in white and URG participants.

Method

Baseline neurocognitive test and neuroimaging data from 335 cognitively healthy participants with ≥2 visits enrolled in the Wisconsin ADRC Clinical Core were included. Z-scores were calculated comparing individual performance to group performance by test (Rey Auditory Verbal Learning Test (Learning and Delayed Recall), Trail Making Test (A and B), and either Boston Naming Test (BNT) or Multilingual Naming Test (MINT)). MINT scores were converted to BNT scores using the NACC Crosswalk Study. The standard deviation of z-scores across tests was calculated to determine IICV. Characteristics by race and sex were compared using Mann-Whitney, Fisher’s Exact, and Kruskal-Wallis tests. Spearman’s Rho was calculated to compare baseline IICV and relative HV.

Results

At baseline (Table 1), differences across racial groups in age, years of education, relative HV, and IICV were identified. Sex and racial group differences were identified (Table 2). A weak positive correlation between HV and IICV was seen in white females (Figure 1).

Conclusions

IICV has potential to become a cost-effective, non-invasive marker of preclinical AD. Again, correlation between HV and IICV was seen, but only in white females. Analyses suggest group differences between white and URG males and females. However, more data is needed to further explore these differences.

Primary excision margins, sentinel lymph node biopsy, and completion lymph node dissection in cutaneous melanoma: a clinical practice guideline

Background

For patients who are diagnosed with early-stage cutaneous melanoma, the principal therapy is wide surgical excision of the primary tumour and assessment of lymph nodes. The purpose of the present guideline was to update the 2010 Cancer Care Ontario guideline on wide local excision margins and sentinel lymph node biopsy (slnb), including treatment of the positive sentinel node, for melanomas of the trunk, extremities, and head and neck.

Methods

Using Ovid, the medline and embase electronic databases were systematically searched for systematic reviews and primary literature evaluating narrow compared with wide excision margins and the use of slnb for melanoma of the truck and extremities and of the head and neck. Search timelines ran from 2010 through week 25 of 2017.

Results

Four systematic reviews were chosen for inclusion in the evidence base. Where systematic reviews were available, the search of the primary literature was conducted starting from the end date of the search in the reviews. Where systematic reviews were absent, the search for primary literature ran from 2010 forward. Of 1213 primary studies identified, 8 met the inclusion criteria. Two randomized controlled trials were used to inform the recommendation on completion lymph node dissection.Key updated recommendations include:■ Wide local excision margins should be 2 cm for melanomas of the trunk, extremities, and head and neck that exceed 2 mm in depth.■ slnb should be offered to patients with melanomas of the trunk, extremities, and head and neck that exceed 0.8 mm in depth.■ Patients with sentinel node metastasis should be considered for nodal observation with ultrasonography rather than for completion lymph node dissection.

Conclusions

Recommendations for primary excision margins, sentinel lymph node biopsy, and completion lymph node dissection in patients with cutaneous melanoma have been updated based on the current literature.

Rapid initiation of antiretroviral therapy for people living with HIV

BACKGROUND

Despite antiretroviral therapy (ART) being widely available, HIV continues to cause substantial illness and premature death in low-and-middle-income countries. High rates of loss to follow-up after HIV diagnosis can delay people starting ART. Starting ART within seven days of HIV diagnosis (rapid ART initiation) could reduce loss to follow-up, improve virological suppression rates, and reduce mortality.

OBJECTIVES

To assess the effects of interventions for rapid initiation of ART (defined as offering ART within seven days of HIV diagnosis) on treatment outcomes and mortality in people living with HIV. We also aimed to describe the characteristics of rapid ART interventions used in the included studies.

SEARCH METHODS

We searched CENTRAL, the Cochrane Database of Systematic Reviews, MEDLINE, Embase, and four other databases up to 14 August 2018. There was no restriction on date, language, or publication status. We also searched ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform, and websites for unpublished literature, including conference abstracts.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) that compared rapid ART versus standard care in people living with HIV. Children, adults, and adolescents from any setting were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the eligibility of the studies identified in the search, assessed the risk of bias and extracted data. The primary outcomes were mortality and virological suppression at 12 months. We have presented all outcomes using risk ratios (RR), with 95% confidence intervals (CIs). Where appropriate, we pooled the results in meta-analysis. We assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS

We included seven studies with 18,011 participants in the review. All studies were carried out in low- and middle-income countries in adults aged 18 years old or older. Only one study included pregnant women.In all the studies, the rapid ART intervention was offered as part of a package that included several cointerventions targeting individuals, health workers and health system processes delivered alongside rapid ART that aimed to facilitate uptake and adherence to ART.Comparing rapid ART with standard initiation probably results in greater viral suppression at 12 months (RR 1.18, 95% CI 1.10 to 1.27; 2719 participants, 4 studies; moderate-certainty evidence) and better ART uptake at 12 months (RR 1.09, 95% CI 1.06 to 1.12; 3713 participants, 4 studies; moderate-certainty evidence), and may improve retention in care at 12 months (RR 1.22, 95% CI 1.11 to 1.35; 5001 participants, 6 studies; low-certainty evidence). Rapid ART initiation was associated with a lower mortality estimate, however the CIs included no effect when compared to standard of care (RR 0.72, 95% CI 0.51 to 1.01; 5451 participants, 7 studies; very low-certainty evidence). It is uncertain whether rapid ART has an effect on modification of ART treatment regimens as data are lacking (RR 7.89, 95% CI 0.76 to 81.74; 977 participants, 2 studies; very low-certainty evidence). There was insufficient evidence to draw conclusions on the occurrence of adverse events.

AUTHORS' CONCLUSIONS

RCTs that include initiation of ART within one week of diagnosis appear to improve outcomes across the HIV treatment cascade in low- and middle-income settings. The studies demonstrating these effects delivered rapid ART combined with several setting-specific cointerventions. This highlights the need for pragmatic research to identify feasible packages that assure the effects seen in the trials when delivered through complex health systems.

You did not turn up… I did not realise I was invited…: understanding male attitudes towards engagement in fertility and reproductive health discussions

STUDY QUESTION

What are the underlying reasons for low male engagement in fertility and reproductive health discussions and decision-making?

SUMMARY ANSWER

The perception of women's primacy in fertility and reproductive health limits the extent to which men believe their engagement is important.

WHAT IS KNOWN ALREADY

Active participation of men in the process of informed decision-making regarding childbearing is beneficial for mother, father, and child. However, in research studies in these areas, little attention has been given to men. Additionally, there is poor engagement by men, as well as a dearth of information from, and on, the male perspective.

STUDY DESIGN SIZE DURATION

In total, 35 semi-structured telephone and face-to-face interviews were conducted in an office setting with three groups: 13 lay women, 13 lay men, and 9 (2 male and 7 female) healthcare professionals. Interviews took place between October 2016 and February 2017.

PARTICIPANTS/MATERIALS SETTING METHODS

Participants were men and women of reproductive age from the general population and healthcare professionals who had completed an online fertility awareness survey and agreed to follow-up interviews. Interviews were audio recorded and lasted ~1 hour, during which participants were asked to provide their views on childbearing decision-making, and male and female representation in fertility and reproductive health. Data was transcribed verbatim and analysed qualitatively via framework analysis.

MAIN RESULTS AND THE ROLE OF CHANCE

Both men and women saw fertility as a woman's issue, but from different viewpoints. Women saw it from the perspective of societal stereotypes regarding male and female roles, whereas men tended to defer to the woman's primacy in reproductive decisions. Men generally wanted to be involved in childbearing discussions and improve their fertility knowledge. However, they felt they did not have a voice on the topic because discussions have traditionally focused on women. The notion that men are not expected to be interested and engaged thus becomes a self-fulfilling prophecy. Healthcare professionals agreed that fertility was perceived as the woman's domain, but also highlighted that poor male involvement is typically observed across healthcare needs and is not necessarily unique to fertility and reproductive health.

LIMITATIONS REASONS FOR CAUTION

Due to the online recruitment method, there is a potential bias towards respondents of higher, rather than lower, socioeconomic status within the general population.

WIDER IMPLICATIONS OF THE FINDINGS

Fertility tends to be seen as a private topic. Additional concerted effort by reproductive health researchers, charity organisations, educators, healthcare service providers, and policy makers is needed to proactively encourage male involvement in reproductive decision-making. This can be achieved through normalising and breaking taboos around the topic, male-friendly research study design approaches, male-inclusive reproductive healthcare services, implementation of health policies that recognise the needs of men, encouraging male research staff representation, and age-appropriate educational programmes on sexual and reproductive health, which include boys and adolescents from a young age.

STUDY FUNDING/COMPETING INTERESTS

Research funding was received from SPD Development Co. Ltd. B.G. and S.J. are employed by SPD Development Co. Ltd. None of the other authors have any conflict of interest related to the discussed topic.

TRIAL REGISTRATION NUMBER

Not applicable.

MVA85A vaccine to enhance BCG for preventing tuberculosis

BACKGROUND

Tuberculosis causes more deaths than any other infectious disease globally. Bacillus Calmette-Guérin (BCG) is the only available vaccine, but protection is incomplete and variable. The modified Vaccinia Ankara virus expressing antigen 85A (MVA85A) is a viral vector vaccine produced to prevent tuberculosis.

OBJECTIVES

To assess and summarize the effects of the MVA85A vaccine boosting BCG in humans.

SEARCH METHODS

We searched the Cochrane Infectious Diseases Group Specialized Register; Central Register of Controlled Trials (CENTRAL); MEDLINE (PubMed); Embase (Ovid); and four other databases. We searched the WHO ICTRP and ClinicalTrials.gov. All searches were run up to 10 May 2018.

SELECTION CRITERIA

We evaluated randomized controlled trials of MVA85A vaccine given with BCG in people regardless of age or HIV status.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the eligibility and risk of bias of trials, and extracted and analyzed data. The primary outcome was active tuberculosis disease. We summarized dichotomous outcomes using risk ratios (RR) and risk differences (RD), with 95% confidence intervals (CI). Where appropriate, we combined data in meta-analyses. Where meta-analysis was inappropriate, we summarized results narratively.

MAIN RESULTS

The search identified six studies relating to four Phase 2 randomized controlled trials enrolling 3838 participants. Funding was by government bodies, charities, and philanthropic donors. Five studies included infants, one of them infants born to HIV-positive mothers. One study included adults living with HIV. All trials included authors from Oxford University who led the laboratory development of the vaccine. Participants received intradermal MVA85A after BCG in some studies, and before selective deferred BCG in HIV-exposed infants.The largest trial in 2797 African children was well conducted with low risk of bias for most parameters. Risk of bias was uncertain for selective reporting because there were no precise case definition endpoints for active tuberculosis published prior to the trial analysis.MVA85A added to BCG compared to BCG alone probably has no effect on the risk of developing microbiologically confirmed tuberculosis (RR 0.97, 95% CI 0.58 to 1.62; 3439 participants, 2 trials; moderate-certainty evidence), or the risk of starting on tuberculosis treatment (RR 1.10, 95% CI 0.92 to 1.33; 3687 participants, 3 trials; moderate-certainty evidence). MVA85A probably has no effect on the risk of developing latent tuberculosis (RR 1.01, 95% CI 0.85 to 1.21; 3831 participants, 4 trials; moderate-certainty evidence). Vaccinating people with MVA85A in addition to BCG did not cause life-threatening serious adverse effects (RD 0.00, 95% CI -0.00 to 0.00; 3692 participants, 3 trials; high-certainty evidence). Vaccination with MVA85A is probably associated with an increased risk of local skin adverse effects (3187 participants, 3 trials; moderate-certainty evidence), but not systemic adverse effect related to vaccination (144 participants, 1 trial; low-certainty evidence). This safety profile is consistent with Phase 1 studies which outlined a transient, superficial reaction local to the injection site and mild short-lived symptoms such as malaise and fever.

AUTHORS' CONCLUSIONS

MVA85A delivered by intradermal injection in addition to BCG is safe but not effective in reducing the risk of developing tuberculosis.

Cultural values, coping, and hope in Yup'ik communities facing rapid cultural change

Historical trauma and rapid cultural change contribute to a high burden of stress in Alaska Native communities. The goal of the Yup'ik Experiences of Stress and Coping Project was to better understand stress and coping in Yup'ik communities and the role of cultural values and practices in coping. Sixty Yup'ik adults aged 18-84 years took part in semistructured interviews. They discussed how they coped with salient stressful experiences and shared the things that bought them hope and peace. Interview themes were identified and inter-relationships between themes were explored through social network analysis. Participants discussed the importance of cultural traditions in coping, including subsistence, dancing and drumming, intergenerational transmission of knowledge, and reflective awareness of interconnections with others. Participants found strength in family relationships, spirituality, helping others, and coming together as a community. Three coping clusters emerged: Ilaliurucaraq (be welcoming) involved opening one's frame of mind and building connections; Yuuyaraq (Yup'ik way of life) focused on Yup'ik traditions and values; and Assircaarturluni Yuuyaraq (try to live a better life) involved healing from historical trauma. Findings illustrate the resilience and evolving strengths of rural Yup'ik communities facing a continually changing cultural landscape and provide information for developing community-driven culturally based interventions.

Maintaining relevance in HIV systematic reviews: an evaluation of Cochrane reviews

BACKGROUND

Research turnover in the HIV field is rapid, and as a result, maintaining high-quality, up-to-date, and relevant systematic reviews is a challenge. One approach is to frequently update published reviews.

METHODS

We evaluated the methods and relevance of all HIV systematic reviews and protocols published in the Cochrane Library over a 16-year period (2000-2016) to determine the need to update published reviews or complete of reviews in progress.

RESULTS

Of 148 published reviews and protocols, 129 (87%) were identified as not for updating or progression to publication, mostly due to research questions which were either entirely outdated or addressed questions in an outdated manner (N = 89; 60%); this was anticipated for older reviews, but was found also to be the case for recent publications. Some research questions were also inadequately conceptualized, particularly when complex pragmatic trials or behavioral interventions were included.

CONCLUSIONS

We suggest that authors clearly characterize interventions and synthesis approaches in their review protocols. In research fields, such as HIV, where questions change frequently, systematic reviews and protocols should be regularly re-evaluated to ensure relevance to current questions. This process of re-evaluation should be incorporated into the methods of living systematic reviews.

Resilience or robustness: identifying topological vulnerabilities in rail networks

Many critical infrastructure systems have network structures and are under stress. Despite their national importance, the complexity of large-scale transport networks means that we do not fully understand their vulnerabilities to cascade failures. The research conducted through this paper examines the interdependent rail networks in Greater London and surrounding commuter area. We focus on the morning commuter hours, where the system is under the most demand stress. There is increasing evidence that the topological shape of the network plays an important role in dynamic cascades. Here, we examine whether the different topological measures of resilience (stability) or robustness (failure) are more appropriate for understanding poor railway performance. The results show that resilience, not robustness, has a strong correlation with the consumer experience statistics. Our results are a way of describing the complexity of cascade dynamics on networks without the involvement of detailed agent-based models, showing that cascade effects are more responsible for poor performance than failures. The network science analysis hints at pathways towards making the network structure more resilient by reducing feedback loops.

Albendazole alone or in combination with microfilaricidal drugs for lymphatic filariasis

BACKGROUND

The Global Programme to Eliminate Lymphatic Filariasis recommends mass treatment of albendazole co-administered with the microfilaricidal (antifilarial) drugs diethylcarbamazine (DEC) or ivermectin; and recommends albendazole alone in areas where loiasis is endemic.

OBJECTIVES

To assess the effects of albendazole alone, and the effects of adding albendazole to DEC or ivermectin, in people and communities with lymphatic filariasis.

SEARCH METHODS

We searched the Cochrane Infectious Diseases Group Specialized Register, the Cochrane Central Register of Controlled Trials, MEDLINE (PubMed), Embase (OVID), LILACS (BIREME), and reference lists of included trials. We also searched the World Health Organization (WHO) International Clinical Trials Registry Platform and ClinicalTrials.gov to identify ongoing trials. We performed all searches up to 15 January 2018.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) and cluster-RCTs that compared albendazole to placebo or no placebo, or compared albendazole combined with a microfilaricidal drug to a microfilaricidal drug alone, given to people known to have lymphatic filariasis or communities where lymphatic filariasis was known to be endemic. We sought data on measures of transmission potential (microfilariae (mf) prevalence and density); markers of adult worm infection (antigenaemia prevalence and density, and adult worm prevalence detected by ultrasound); and data on clinical disease and adverse events.

DATA COLLECTION AND ANALYSIS

At least two review authors independently assessed the trials, evaluated the risks of bias, and extracted data. The main analysis examined albendazole overall, whether given alone or added to a microfilaricidal drug. We used data collected from all randomized individuals at time of longest follow-up (up to 12 months) for meta-analysis of outcomes. We evaluated mf density data up to six months and at 12 months follow-up to ensure that we did not miss any subtle temporal effects. We conducted additional analyses for different follow-up periods and whether trials reported on individuals known to be infected or both infected and uninfected. We analysed dichotomous data using the risk ratio (RR) with a 95% confidence interval (CI). We could not meta-analyse data on parasite density outcomes and we summarized them in tables. Where data were missing, we contacted trial authors. We used GRADE to assess the certainty of evidence.

MAIN RESULTS

We included 13 trials (12 individually-randomized and one small cluster-randomized trial) with 8713 participants in total. No trials evaluated population-level effects of albendazole in mass drug administration programmes. Seven trials enrolled people with a variety of inclusion criteria related to filarial infection, and six trials enrolled individuals from endemic areas. Outcomes were reported as end or change values. Mf and antigen density data were reported using the geometric mean, log mean and arithmetic mean, and reductions in density were variously calculated. Two trials discounted any increases in mf density in individuals at follow-up by setting any density increase to zero.For mf prevalence over two weeks to 12 months, albendazole alone or added to another microfilaricidal drug makes little or no difference (RR 0.95, 95% CI 0.85 to 1.07; 5027 participants, 12 trials, high-certainty evidence). For mf density there is no trend, with some trials reporting a greater reduction in mf density with albendazole and others a greater reduction with the control group. For mf density up to six months and at 12 months, we do not know if albendazole has an effect (one to six months: 1216 participants, 10 trials, very low-certainty evidence; at 12 months: 1052 participants, 9 trials, very low-certainty evidence).For antigenaemia prevalence between six to 12 months, albendazole alone or added to another microfilaricidal drug makes little or no difference (RR 1.04, 95% CI 0.97 to 1.12; 3774 participants, 7 trials, high-certainty evidence). For antigen density over six to 12 months, the trend shows little or no effect of albendazole; but we do not know if albendazole has an effect on antigen density (1374 participants, 5 trials, very low-certainty evidence). For adult worm prevalence detected by ultrasound at 12 months, albendazole added to a microfilaricidal drug may make little or no difference (RR 1.16, 95% CI 0.72 to 1.86; 165 participants, 3 trials, low-certainty evidence).For people reporting adverse events, albendazole makes little or no difference (RR 0.97, 95% CI 0.84 to 1.13; 2894 participants, 6 trials, high-certainty evidence).We also provide meta-analyses and GRADE tables by drug, as operationally this may be of interest: for albendazole versus placebo (4 trials, 1870 participants); for albendazole with DEC compared to DEC alone (8 trials, 3405 participants); and albendazole with ivermectin compared to ivermectin alone (4 trials, 3438 participants).

AUTHORS' CONCLUSIONS

There is good evidence that albendazole makes little difference to clearing microfilaraemia or adult filarial worms in the 12 months post-treatment. This finding is consistent in trials evaluating albendazole alone, or added to DEC or ivermectin. Trials reporting mf density included small numbers of participants, calculated density data variously, and gave inconsistent results.The review raises questions over whether albendazole has any important contribution to the elimination of lymphatic filariasis. To inform policy for areas with loiasis where only albendazole can be used, it may be worth conducting placebo-controlled trials of albendazole alone.

Landing biomechanics in anterior cruciate ligament reconstructed females who pass or fail a functional test battery

BACKGROUND

A functional test battery (FTB) has been proposed to determine return to full activity following anterior cruciate ligament reconstruction (ACLR). However, there is little biomechanical evidence of FTB usefulness. The purpose of this study was to compare knee joint landing and cutting biomechanics between ACLR patients who passed (ACLR-Pass), failed (ACLR-Fail), and healthy females (Healthy) before and after exercise.

METHODS

Thirty females were included: 10 ACLR-Pass, eight ACLR-Fail and 12 Healthy. Participants performed a FTB consisting of The 2000 International Knee Documentation Committee Subjective Knee Evaluation Form, the Knee Outcome Survey Activities of Daily Living Scale, and quadricep strength and single-leg hop tests. Double-leg jump landing (DLJL) and single-leg jump cutting (SLJC) biomechanics were assessed before and after exercise.

RESULTS

Significant main effects of exercise were found during DLJL: lesser knee flexion angle at initial contact after exercise (before exercise: 15.8 ± 5.0, after exercise: 14.2 ± 5.4, P = 0.01, ηp 2 = 0.25); and during SLJC: smaller peak knee extension moment (before exercise: -0.33 ± 0.1, after exercise: -0.31 ± 0.1, P = 0.02, ηp 2 = 0.18). While there was a significant group by time interaction effect with lesser peak knee flexion angle after exercise, this interaction effect was likely driven by a reduction in peak knee flexion in only the Healthy group.

CONCLUSIONS

Healthy females exhibited a reduction in peak knee flexion during SLJC after exercise. However, there were no differences in ACLR knee biomechanics during DLJL and SLJC performed before and after exercise.

Search for CP Violation in Neutrino and Antineutrino Oscillations by the T2K Experiment with 2.2×10^{21} Protons on Target

The T2K experiment measures muon neutrino disappearance and electron neutrino appearance in accelerator-produced neutrino and antineutrino beams. With an exposure of 14.7(7.6)×10^{20} protons on target in the neutrino (antineutrino) mode, 89 ν_{e} candidates and seven anti-ν_{e} candidates are observed, while 67.5 and 9.0 are expected for δ_{CP}=0 and normal mass ordering. The obtained 2σ confidence interval for the CP-violating phase, δ_{CP}, does not include the CP-conserving cases (δ_{CP}=0, π). The best-fit values of other parameters are sin^{2}θ_{23}=0.526_{-0.036}^{+0.032} and Δm_{32}^{2}=2.463_{-0.070}^{+0.071}×10^{-3}  eV^{2}/c^{4}.

Simultaneous visualization of wall motion, beam propagation, and implosion symmetry on the National Ignition Facility (invited)

Achieving a symmetric implosion in National Ignition Facility indirect drive targets requires understanding and control of dynamic changes to the laser power transport in the hohlraum. We developed a new experimental platform to simultaneously visualize wall-plasma motion and dynamic laser power transport in the hohlraum and are using it to investigate correlations of these measurements with the imploded capsule symmetry. In a series of experiments where we made one single parameter variation, we show the value of this new platform in developing an understanding of laser transport and implosion symmetry. This platform also provides a new way to evaluate dynamic performance of advanced hohlraum designs.

Defining, Measuring and Preventing the Diagnosis of Cancer as an Emergency: A Critical Review of Current Evidence

Background: Many patients with cancer are diagnosed through an emergency presentation, which is associated with inferior clinical and patient-reported outcomes compared with those of patients who are diagnosed electively or through screening. Reducing the proportion of patients with cancer who are diagnosed as emergencies is, therefore, desirable; however, the optimal means of achieving this aim are uncertain owing to the involvement of different tumor, patient and health-care factors, often in combination. Methods: We searched the literature to identify all population-based studies that examined emergency presentation as a diagnosis or independent variable. Results: Most relevant evidence relates to patients with colorectal or lung cancer in a few economically developed countries, and defines emergency presentations contextually (that is, whether patients presented to emergency health-care services and/or received emergency treatment shortly before their diagnosis) as opposed to clinically (whether patients presented with life-threatening manifestations of their cancer). Consistent inequalities in the risk of emergency presentations by patient characteristics and cancer type have been described, but limited evidence is available on whether, and how, such presentations can be prevented. Evidence on patients' symptoms and health-care use before presentation as an emergency is sparse. Conclusion: In this review, we describe the extent, causes and implications of a diagnosis of cancer following an emergency presentation, and provide recommendations for public health and health-care interventions, and research efforts aimed at addressing this underresearched aspect of cancer diagnosis.

Variation in 'Fast-Track' Referrals for Suspected Cancer by Patient Characteristic and Cancer Diagnosis: Evidence From 670,000 Patients With Cancers of 35 Different Sites

Background: In England, 'fast-track' (also known as 'two-week wait') general practitioner referrals for suspected cancer in symptomatic patients are used to shorten diagnostic intervals and are supported by clinical guidelines. However, the use of the fast-track pathway may vary for different patient groups. Methods:  We examined data from 669,220 patients with 35 cancers diagnosed 2006-2010 following either fast-track or nonfast track primary-to-secondary care referrals using a bespoke English dataset, the 'Routes to Diagnosis' data. We estimated the proportion of fast-track referrals by sociodemographic characteristics and cancer diagnosis and used logistic regression to estimate respective crude and adjusted odds ratios. We additionally explored whether sociodemographic associations varied by cancer. Results:  There were large variations in the odds of fast-track referral by cancer ( P < 0.001). Patients with testicular and breast cancer were most likely to have been diagnosed after a fast-track referral (adjusted odds ratios 2.73 and 2.35 respectively, using rectal cancer as reference); while patients with brain cancer and leukemias least likely (adjusted odds ratios 0.05 and 0.09 respectively for brain cancer and acute myeloid leukemia). There were sex, age and deprivation differences in the odds of fast-track referral ( P < 0.013), which varied in their size and direction for patients with different cancers ( P < 0.001). For example, fast-track referrals were least likely in younger women with endometrial cancer and in older men with testicular cancer. Conclusion: Fast-track referrals are less likely for cancers characterized by nonspecific presenting symptoms and patients belonging to low incidence demographic strata. Interventions beyond clinical guidelines for “alarm” symptoms are needed to improve diagnostic timeliness.

CT versus MR Imaging in Estimating Cochlear Radiation Dose during Gamma Knife Surgery for Vestibular Schwannomas

BACKGROUND AND PURPOSE

Leksell stereotactic radiosurgery is an effective option for patients with vestibular schwannomas. Some centers use a combination of stereotactic CT fused with stereotactic MR imaging to achieve an optimal target definition as well as minimize the radiation dose delivered to adjacent structures that correlate with hearing outcomes. The present prospective study was designed to determine whether there is cochlear dose variability between MR imaging and CT.

MATERIALS AND METHODS

Fifty consecutive patients underwent stereotactic radiosurgery for vestibular schwannomas. Dose-planning was performed using high-definition fused stereotactic MR imaging and stereotactic CT images. The 3D cochlear volume was determined by delineating the cochlea on both CT and T2-weighted MR imaging. The mean radiation dose, maximum dose, and 3- and 4.20-Gy cochlear volumes were identified using standard Leksell Gamma Knife software.

RESULTS

The median mean radiation dose delivered to the cochlea was 3.50 Gy (range, 1.20-6.80 Gy) on CT and 3.40 Gy (range, 1-6.70 Gy) on MR imaging (concordance correlation coefficient = 0.86, r ² = 0.9, P ≤ .001). The median maximum dose delivered to the cochlea was 6.7 Gy on CT and 6.6 Gy on MR imaging (concordance correlation coefficient = 0.89, r ² = 0.90, P ≤ .001). Dose-volume histograms generated from CT and MR imaging demonstrated a strong level of correlation in estimating the 3- and 4.20-Gy volumes (concordance correlation coefficient = 0.81, r ² = 0.82, P ≤ .001 and concordance correlation coefficient = 0.87, r ² = 0.89, P ≤ .001).

CONCLUSIONS

Both MR imaging and CT provide similar cochlear dose parameters. Despite the reported superiority of CT in identifying bony structures, high-definition MR imaging alone is sufficient to identify the radiation doses delivered to the cochlea.

Primary antifungal prophylaxis for cryptococcal disease in HIV-positive people

BACKGROUND

Cryptococcal disease remains one of the main causes of death in HIV-positive people who have low cluster of differentiation 4 (CD4) cell counts. Currently, the World Health Organization (WHO) recommends screening HIV-positive people with low CD4 counts for cryptococcal antigenaemia (CrAg), and treating those who are CrAg-positive. This Cochrane Review examined the effects of an approach where those with low CD4 counts received regular prophylactic antifungals, such as fluconazole.

OBJECTIVES

To assess the efficacy and safety of antifungal drugs for the primary prevention of cryptococcal disease in adults and children who are HIV-positive.

SEARCH METHODS

We searched the CENTRAL, MEDLINE PubMed, Embase OVID, CINAHL EBSCOHost, WHO International Clinical Trials Registry Platform (WHO ICTRP), ClinicalTrials.gov, conference proceedings for the International AIDS Society (IAS) and Conference on Retroviruses and Opportunistic Infections (CROI), and reference lists of relevant articles up to 31 August 2017.

SELECTION CRITERIA

Randomized controlled trials of adults and children, who are HIV-positive with low CD4 counts, without a current or prior diagnosis of cryptococcal disease that compared any antifungal drug taken as primary prophylaxis to placebo or standard care.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed eligibility and risk of bias, and extracted and analysed data. The primary outcome was all-cause mortality. We summarized all outcomes using risk ratios (RR) with 95% confidence intervals (CI). Where appropriate, we pooled data in meta-analyses. We assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS

Nine trials, enrolling 5426 participants, met the inclusion criteria of this review. Six trials administered fluconazole, while three trials administered itraconazole.Antifungal prophylaxis may make little or no difference to all-cause mortality (RR 1.07, 95% CI 0.80 to 1.43; 6 trials, 3220 participants; low-certainty evidence). For cryptococcal specific outcomes, prophylaxis probably reduces the risk of developing cryptococcal disease (RR 0.29, 95% CI 0.17 to 0.49; 7 trials, 5000 participants; moderate-certainty evidence), and probably reduces deaths due to cryptococcal disease (RR 0.29, 95% CI 0.11 to 0.72; 5 trials, 3813 participants; moderate-certainty evidence). Fluconazole prophylaxis may make no clear difference to the risk of developing clinically resistant Candida disease (RR 0.93, 95% CI 0.56 to 1.56; 3 trials, 1198 participants; low-certainty evidence); however, there may be an increased detection of fluconazole-resistant Candida isolates from surveillance cultures (RR 1.25, 95% CI 1.00 to 1.55; 3 trials, 539 participants; low-certainty evidence). Antifungal prophylaxis was generally well-tolerated with probably no clear difference in the risk of discontinuation of antifungal prophylaxis compared with placebo (RR 1.01, 95% CI 0.91 to 1.13; 4 trials, 2317 participants; moderate-certainty evidence). Antifungal prophylaxis may also make no difference to the risk of having any adverse event (RR 1.07, 95% CI 0.88 to 1.30; 4 trials, 2317 participants; low-certainty evidence), or a serious adverse event (RR 1.08, 95% CI 0.83 to 1.41; 4 trials, 888 participants; low-certainty evidence) when compared to placebo or standard care.

AUTHORS' CONCLUSIONS

Antifungal prophylaxis reduced the risk of developing and dying from cryptococcal disease. Therefore, where CrAG screening is not available, antifungal prophylaxis may be used in patients with low CD4 counts at diagnosis and who are at risk of developing cryptococcal disease.

Ribavirin for treating Crimean Congo haemorrhagic fever

BACKGROUND

Crimean Congo haemorrhagic fever (CCHF) is a tick-borne disease that occurs in parts of Asia, Europe and Africa. Since 2000 the infection has caused epidemics in Turkey, Iran, Russia, Uganda and Pakistan. Good-quality general supportive medical care helps reduce mortality. There is uncertainty and controversy about treating CCHF with the antiviral drug ribavirin.

OBJECTIVES

To assess the effects of ribavirin for treating people with Crimean Congo haemorrhagic fever.

SEARCH METHODS

We searched the Cochrane Infectious Diseases Group Specialized Register; the Central Register of Controlled Trials (CENTRAL); MEDLINE (PubMed); Embase (OVID); Science Citation Index-Expanded, Social Sciences Citation index, conference proceedings (Web of Science); and CINAHL (EBSCOHost). We also searched the WHO International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov for trials in progress. We conducted all searches up to 16 October 2017. We also contacted experts in the field and obtained further studies from these sources.

SELECTION CRITERIA

We evaluated studies assessing the use of ribavirin in people with suspected or confirmed Crimean Congo haemorrhagic fever. We included randomised control trials (RCTs); non-randomised studies (NRSs) that included more than 10 participants designed as cohort studies with comparators; and case-control studies.

DATA COLLECTION AND ANALYSIS

Two review authors assessed eligibility, risk of bias, and extracted data. For non-randomized studies we used the ROBINS-I tool to assess risk of bias. The main effects analysis included all studies where we judged the risk of bias to be low, moderate or high. We summarized dichotomous outcomes using risk ratios (RRs) and continuous outcomes using mean differences (MDs), and used meta-analyses where appropriate. We carried out a subsidiary appraisal and analysis of studies with critical risk of bias for the primary outcome, as these are often cited to support using ribavirin.

MAIN RESULTS

For the main effects analysis, five studies met our inclusion criteria: one RCT with 136 participants and four non-randomized studies with 612 participants. We excluded 18 non-randomized studies with critical risk of bias, where none had attempted to control for confounding.We do not know if ribavirin reduces mortality (1 RCT; RR 1.13, 95% confidence interval (CI) 0.29 to 4.32; 136 participants; very low-certainty evidence; 3 non-randomized studies; RR 0.72, 95% CI 0.41 to 1.28; 549 participants; very low-certainty evidence). We do not know if ribavirin reduces the length of stay in hospital (1 RCT: mean difference (MD) 0.70 days, 95% CI -0.39 to 1.79; 136 participants; and 1 non-randomized study: MD -0.80, 95% CI -2.70 to 1.10; 50 participants; very low-certainty evidence). We do not know if it reduces the risk of patients needing platelet transfusions (1 RCT: RR 1.23, 95% CI 0.77 to 1.96; 136 participants; very low-certainty evidence). For adverse effects (including haemolytic anaemia and a need to discontinue treatment), we do not know whether there is an increased risk with ribavirin in people with CCHF as data are insufficient.We do not know if adding ribavirin to early supportive care improves outcomes. One non-randomized study assessed mortality in people receiving ribavirin and supportive care within four days or less from symptom onset compared to after four days since symptom onset: mortality was lower in the group receiving early supportive care and ribavirin, but it is not possible to distinguish between the effects of ribavirin and early supportive medical care alone.In the subsidiary analysis, 18 studies compared people receiving ribavirin with those not receiving ribavirin. All had a critical risk of bias due to confounding, reflected in the mortality point estimates favouring ribavirin.

AUTHORS' CONCLUSIONS

We do not know if ribavirin is effective for treating Crimean Congo haemorrhagic fever. Non-randomized studies are often cited as evidence of an effect, but the risk of bias in these studies is high.

High throughput generation and characterization of replication-competent clade C transmitter-founder simian human immunodeficiency viruses

Traditional restriction endonuclease-based cloning has been routinely used to generate replication-competent simian-human immunodeficiency viruses (SHIV) and simian tropic HIV (stHIV). This approach requires the existence of suitable restriction sites or the introduction of nucleotide changes to create them. Here, using an In-Fusion cloning technique that involves homologous recombination, we generated SHIVs and stHIVs based on epidemiologically linked clade C transmitted/founder HIV molecular clones from Zambia. Replacing vif from these HIV molecular clones with vif of SIVmac239 resulted in chimeric genomes used to generate infectious stHIV viruses. Likewise, exchanging HIV env genes and introducing N375 mutations to enhance macaque CD4 binding site and cloned into a SHIVAD8-EO backbone. The generated SHIVs and stHIV were infectious in TZMbl and ZB5 cells, as well as macaque PBMCs. Therefore, this method can replace traditional methods and be a valuable tool for the rapid generation and testing of molecular clones of stHIV and SHIV based on primary clinical isolates will be valuable to generate rapid novel challenge viruses for HIV vaccine/cure studies.

Mental health care needs and preferences for mothers of children with a disability

BACKGROUND

Mothers of children with a disability are at increased risk of poor mental health compared with mothers of typically developing children. The aim of the study was to describe the mental health care needs and preferences for support of mothers of children and young people aged 0-25 years with a disability.

METHODS

A cross-sectional study was used, using an online survey with 294 mothers of children with a disability. Questions were asked about mental health, perceived need for support, barriers to accessing mental health care, and preferences for support. Descriptive and chi-squared analyses were performed.

RESULTS

High rates of mental ill health were self-identified in the previous 12 months, with reported clinically significant depression (44%), anxiety (42%), and suicidality (22%). Nearly half (48%) of the mothers reported high to very high psychological distress. Although 75% of mothers perceived a need for professional support, only 58% attempted to access this. Key barriers to accessing support were caregiving duties making it difficult to schedule appointments (45%) and not perceiving the mental health problem as serious enough to require help (36%). Individual counselling was the preferred type of support (66%) followed by professionally guided relaxation (49%) and education about mental health (47%). Support was considered most critical at the time of diagnosis and during medical intervention for their child.

CONCLUSIONS

Although mental health problems were common and mothers perceived the need for professional help, several key barriers were preventing mothers from accessing help. Our study suggests that improving mothers' knowledge of when and where to seek help (mental health literacy) may encourage their access to support. There also needs to be more accessible treatment to mothers given the high care demands that are placed upon them.

Robust, tunable, and high purity triggered single photon source at room temperature using a nitrogen-vacancy defect in diamond in an open microcavity

We report progress in the development of tunable room temperature triggered single photon sources based on single nitrogen-vacancy (NV) centres in nanodiamond coupled to open access optical micro-cavities. The feeding of fluorescence from an NV centre into the cavity mode increases the spectral density of the emission and results in an output stream of triggered single photons with spectral line width of order 1 nm, tunable in the range 640 - 700 nm. We record single photon purities exceeding 96% and estimated device efficiencies up to 3%. We compare performance using plano-concave microcavities with radii of curvature from 25 μm to 4 μm and show that up to 17% of the total emission is fed into the TEM₀₀ mode. Pulsed Hanbury-Brown Twiss (HBT) interferometry shows that an improvement in single photon purity is facilitated due to the increased spectral density.

Isolated Lateral Meniscal Tear in the Dog

degenerative changes of the involved stifle joint associated with a “bucket handle” tear of the caudal body of the lateral meniscus. Surgical excision of the torn section of meniscus was beneficial in the first patient but this patient had persistant difficulty with the leg after exercise. Gross and microscopic pathology of the involved stifle in the second patient showed the meniscal lesion to be associated with severe cartilage fibrillation of the overlying lateral femoral condyle. As in human beings, the mechanism of injury may have been placement of the foot during vigorous external rotation of the femur with the stifle flexed. Extension of the limb from this position could have resulted in an isolated tear of the lateral meniscus.

Relaxation dynamics of maximally clustered networks

We study the relaxation dynamics of fully clustered networks (maximal number of triangles) to an unclustered state under two different edge dynamics-the double-edge swap, corresponding to degree-preserving randomization of the configuration model, and single edge replacement, corresponding to full randomization of the Erdős-Rényi random graph. We derive expressions for the time evolution of the degree distribution, edge multiplicity distribution and clustering coefficient. We show that under both dynamics networks undergo a continuous phase transition in which a giant connected component is formed. We calculate the position of the phase transition analytically using the Erdős-Rényi phenomenology.

Bayesian Networks to Compare Pest Control Interventions on Commodities Along Agricultural Production Chains

The production of an agricultural commodity involves a sequence of processes: planting/growing, harvesting, sorting/grading, postharvest treatment, packing, and exporting. A Bayesian network has been developed to represent the level of potential infestation of an agricultural commodity by a specified pest along an agricultural production chain. It reflects the dependency of this infestation on the predicted level of pest challenge, the anticipated susceptibility of the commodity to the pest, the level of impact from pest control measures as designed, and any variation from that due to uncertainty in measure efficacy. The objective of this Bayesian network is to facilitate agreement between national governments of the exporters and importers on a set of phytosanitary measures to meet specific phytosanitary measure requirements to achieve target levels of protection against regulated pests. The model can be used to compare the performance of different combinations of measures under different scenarios of pest challenge, making use of available measure performance data. A case study is presented using a model developed for a fruit fly pest on dragon fruit in Vietnam; the model parameters and results are illustrative and do not imply a particular level of fruit fly infestation of these exports; rather, they provide the most likely, alternative, or worst-case scenarios of the impact of measures. As a means to facilitate agreement for trade, the model provides a framework to support communication between exporters and importers about any differences in perceptions of the risk reduction achieved by pest control measures deployed during the commodity production chain.

Women in academic psychiatry in the United Kingdom

Although there seems to be a shared impression that the proportion of women in academic psychiatry is substantially lower than in National Health Service (NHS) posts, we are not aware of any empirical data on this. In the USA, women physicians have been shown to be more likely to pursue an academic career than men (Nonnemaker, 2000), but the number who advance to Professor appears significantly lower than expected (Reiser et al, 1993; Nonnemaker, 2000). Women in academic psychiatry in Canada also appear less likely to advance to senior positions than their male colleagues (Penfold, 1987). A recent survey of 44 academic institutions in the UK, carried out by the National Centre for Social Research (Blake & La Valle, 2000), found that women occupied lower grade academic posts than their male counterparts and therefore were less eligible to apply for project research grants. Those that were eligible were as successful in gaining funding as their male colleagues.

Changes in health services usage associated with insulin initiation in primary care

Insulin initiation is often delayed in primary care partly because of clinician concerns about the additional clinical work. This study describes health services usage (HSU) pre- and post-insulin initiation in people with type 2 diabetes and out-of-target glycaemic levels. Secondary analysis of participant data from the Stepping Up randomised controlled trial of a model of care for insulin initiation in general practice was undertaken. For 142 people who commenced insulin, HSU in the 6 months prior was compared to that in the 12 months following insulin initiation. Overall, HSU events increased in the 6 months following insulin initiation from a median (IQR) of 18 (15, 29) to 23 (16, 36); (P=0.05), mostly because of an increase in general practitioner (GP) consultations (6 (4, 10) to 8 (5, 11); (P=0.01)). HSU and GP consultations subsequently returned to baseline at 12 months. There was no effect on hospitalisations or specialist consultations. Insulin initiation is associated with a small increase in GP consultations that reverts to baseline after 12 months without affecting other health services. This study can inform health services planning and resource allocation at practice and health policy levels to support insulin initiation in general practice.

Variation in 'fast-track' referrals for suspected cancer by patient characteristic and cancer diagnosis: evidence from 670 000 patients with cancers of 35 different sites

BACKGROUND

In England, 'fast-track' (also known as 'two-week wait') general practitioner referrals for suspected cancer in symptomatic patients are used to shorten diagnostic intervals and are supported by clinical guidelines. However, the use of the fast-track pathway may vary for different patient groups.

METHODS

We examined data from 669 220 patients with 35 cancers diagnosed in 2006-2010 following either fast-track or 'routine' primary-to-secondary care referrals using 'Routes to Diagnosis' data. We estimated the proportion of fast-track referrals by sociodemographic characteristic and cancer site and used logistic regression to estimate respective crude and adjusted odds ratios. We additionally explored whether sociodemographic associations varied by cancer.

RESULTS

There were large variations in the odds of fast-track referral by cancer (P<0.001). Patients with testicular and breast cancer were most likely to have been diagnosed after a fast-track referral (adjusted odds ratios 2.73 and 2.35, respectively, using rectal cancer as reference); whereas patients with brain cancer and leukaemias least likely (adjusted odds ratios 0.05 and 0.09, respectively, for brain cancer and acute myeloid leukaemia). There were sex, age and deprivation differences in the odds of fast-track referral (P<0.013) that varied in their size and direction for patients with different cancers (P<0.001). For example, fast-track referrals were least likely in younger women with endometrial cancer and in older men with testicular cancer.

CONCLUSIONS

Fast-track referrals are less likely for cancers characterised by nonspecific presenting symptoms and patients belonging to low cancer incidence demographic groups. Interventions beyond clinical guidelines for 'alarm' symptoms are needed to improve diagnostic timeliness.