858 Transoral Robotic Surgery: Comparing the Geography of Research Publications with The Global Burden of Disease

Introduction

Transoral robotic surgery (TORS) is increasingly used for the resection of oropharyngeal tumours. It is unclear if there is equitable access to this innovative technique worldwide, specifically in areas of greatest need. This study aimed to map the geographic distribution of publications on TORS and compare this to global disease burden.

Method

Systematic searches identified all studies of TORS from inception to 2018. The country of origin of each study was identified. The incidence and age standardised rate (ASR) of oropharyngeal cancer for each country was obtained from The Global Cancer Observatory (GLOBOCAN) database. World Bank classifications of countries by income level were obtained.

Results

A total of 132 studies were identified. The majority (96%) were published in high-income countries, 2% in lower-middle, and 2% in upper-middle income countries. Eighty-nine were published in the USA, the country with the second-highest incidence of oropharyngeal cancer worldwide (13% of total), but 20th by ASR. The greatest incidence was in India (21%), however this was the source of only 2% of studies. Of the ten countries with the highest incidence, eight were represented in published studies, in comparison to four of the top 10 by ASR.

Conclusions

There is evident disparity in the geographical distribution of published studies of TORS. This disparity may represent unequal access to surgical technologies, or a lack of evaluation of the technology in different healthcare settings. This may impact the generalisability of research findings. Equitable access to novel surgical technologies is ethical and can help address global disease burden.

A human biomonitoring (HBM) Global Registry Framework: Further advancement of HBM research following the FAIR principles

Data generated by the rapidly evolving human biomonitoring (HBM) programmes are providing invaluable opportunities to support and advance regulatory risk assessment and management of chemicals in occupational and environmental health domains. However, heterogeneity across studies, in terms of design, terminology, biomarker nomenclature, and data formats, limits our capacity to compare and integrate data sets retrospectively (reuse). Registration of HBM studies is common for clinical trials; however, the study designs and resulting data collections cannot be traced easily. We argue that an HBM Global Registry Framework (HBM GRF) could be the solution to several of challenges hampering the (re)use of HBM (meta)data. The aim is to develop a global, host-independent HBM registry framework based on the use of harmonised open-access protocol templates from designing, undertaking of an HBM study to the use and possible reuse of the resulting HBM (meta)data. This framework should apply FAIR (Findable, Accessible, Interoperable and Reusable) principles as a core data management strategy to enable the (re)use of HBM (meta)data to its full potential through the data value chain. Moreover, we believe that implementation of FAIR principles is a fundamental enabler for digital transformation within environmental health. The HBM GRF would encompass internationally harmonised and agreed open access templates for HBM study protocols, structured web-based functionalities to deposit, find, and access harmonised protocols of HBM studies. Registration of HBM studies using the HBM GRF is anticipated to increase FAIRness of the resulting (meta)data. It is also considered that harmonisation of existing data sets could be performed retrospectively. As a consequence, data wrangling activities to make data ready for analysis will be minimised. In addition, this framework would enable the HBM (inter)national community to trace new HBM studies already in the planning phase and their results once finalised. The HBM GRF could also serve as a platform enhancing communication between scientists, risk assessors, and risk managers/policy makers. The planned European Partnership for the Assessment of Risk from Chemicals (PARC) work along these lines, based on the experience obtained in previous joint European initiatives. Therefore, PARC could very well bring a first demonstration of first essential functionalities within the development of the HBM GRF.

Post COVID-19: a solution scan of options for preventing future zoonotic epidemics

The crisis generated by the emergence and pandemic spread of COVID-19 has thrown into the global spotlight the dangers associated with novel diseases, as well as the key role of animals, especially wild animals, as potential sources of pathogens to humans. There is a widespread demand for a new relationship with wild and domestic animals, including suggested bans on hunting, wildlife trade, wet markets or consumption of wild animals. However, such policies risk ignoring essential elements of the problem as well as alienating and increasing hardship for local communities across the world, and might be unachievable at scale. There is thus a need for a more complex package of policy and practical responses. We undertook a solution scan to identify and collate 161 possible options for reducing the risks of further epidemic disease transmission from animals to humans, including potential further SARS-CoV-2 transmission (original or variants). We include all categories of animals in our responses (i.e. wildlife, captive, unmanaged/feral and domestic livestock and pets) and focus on pathogens (especially viruses) that, once transmitted from animals to humans, could acquire epidemic potential through high rates of human-to-human transmission. This excludes measures to prevent well-known zoonotic diseases, such as rabies, that cannot readily transmit between humans. We focused solutions on societal measures, excluding the development of vaccines and other preventive therapeutic medicine and veterinary medicine options that are discussed elsewhere. We derived our solutions through reading the scientific literature, NGO position papers, and industry guidelines, collating our own experiences, and consulting experts in different fields. Herein, we review the major zoonotic transmission pathways and present an extensive list of options. The potential solutions are organised according to the key stages of the trade chain and encompass solutions that can be applied at the local, regional and international scales. This is a set of options targeted at practitioners and policy makers to encourage careful examination of possible courses of action, validating their impact and documenting outcomes.

The psychophysiological response during post-traumatic stress disorder treatment with modular motion-assisted memory desensitisation and reconsolidation (3MDR)

Background: Psychophysiological changes are part of post-traumatic stress disorder (PTSD) symptomatology and can signal emotional engagement during psychological treatment. Objectives: The aim of this study was to explore psychophysiological responses during multi-modular motion-assisted memory desensitization and reconsolidation (3MDR) therapy. Increased self-reported distress, substantially increased heart rate (HR) and breathing rate (BR) were expected at the start of therapy and predicted to improve over time. Since physical exercise demands during therapy were low, any large HR or BR responses were considered part of the psychophysiological response. Methods: This study used pooled data collected during a randomized controlled trial of 3MDR, which demonstrated significant improvement as measured by the Clinician Administered PTSD Scale. Whilst attending therapy, HR and BR data, subjective units of distress (SUD) score and phrases to describe feelings whilst exposed to trauma-related images were collected continuously from 37 UK male military veterans with PTSD. Results: HR and BR were significantly increased throughout all sessions (p < .01 for both). Whilst HR was raised slightly remaining on average below 100 beats/minute, BR was increased substantially with average values between 40 and 50 breaths/minute. SUD scores were very high during therapy which concurred with the many negative feelings experienced during therapy sessions. Across the course of the treatment, SUD scores (p < .01) and negative feelings were reduced (p < .001), and positive feelings have increased (p < .01) significantly, reflecting improvements in clinicians assessed PTSD symptoms. Across therapy sessions, HR (p = .888) and BR (p = .466) responses did not change. Conclusions: The strong psychophysiological response alongside high levels of self-reported distress and negative feelings is interpreted as high emotional engagement during therapy. A novel finding was the very significant BR increase throughout recorded sessions. Future PTSD research should include BR response to therapy and explore breathing control as a treatment target.

474 Increasing the Availability of Operation Notes at Hand Surgery Follow-Up Through the Use of Electronic Operation Notes

Introduction

The availability of operation notes is crucial to provide high-quality post-operative care. This clinical audit evaluates the availability of operation notes at post-operative follow-up, in a Tertiary Hand Unit, before and after implementation of electronic operation notes.

Method

This was a prospective audit analysing the availability of operation notes at the first post-operative hand surgery appointment. The initial data collection was over a 6-week period (July – August 2019). Following this, a standardised electronic operation note template was created in line with BSSH Hand Trauma Guidelines and RCS Good Surgical Practice. Six months later, a re-audit was conducted over a 4-week period (March 2020).

Results

The initial audit included 104 adult patients, with operation notes available for 64% (n = 67) of patients, and 94% (n = 63) of those were in paper format. Following implementation of electronic operation notes, the re-audit included 53 adult patients. For these patients, 96% (n = 51) of their operation notes were available, and 96% (n = 49) of the operation notes were electronic.

Conclusions

These findings demonstrate that electronic operation notes greatly increased the availability of operation notes at follow-up This innovation has significant implications for upholding well-coordinated continuity of care for patients undergoing surgery.

HBM4EU chromates study - Reflection and lessons learnt from designing and undertaking a collaborative European biomonitoring study on occupational exposure to hexavalent chromium

The EU human biomonitoring initiative, HBM4EU, aims to co-ordinate and advance human biomonitoring (HBM) across Europe. As part of HBM4EU, we presented a protocol for a multicentre study to characterize occupational exposure to hexavalent chromium (Cr(VI)) in nine European countries (HBM4EU chromates study). This study intended to collect data on current occupational exposure and to test new indicators for chromium (Cr) biomonitoring (Cr(VI) in exhaled breath condensate and Cr in red blood cells), in addition to traditional urinary total Cr analyses. Also, data from occupational hygiene samples and biomarkers of early biological effects, including genetic and epigenetic effects, was obtained, complementing the biomonitoring information. Data collection and analysis was completed, with the project findings being made separately available. As HBM4EU prepares to embark on further European wide biomonitoring studies, we considered it important to reflect on the experiences gained through our harmonised approach. Several practical aspects are highlighted for improvement in future studies, e.g., more thorough/earlier training on the implementation of standard operating procedures for field researchers, training on the use of the data entry template, as well as improved company communications. The HBM4EU chromates study team considered that the study had successfully demonstrated the feasibility of conducting a harmonised multicentre investigation able to achieve the research aims and objectives. This was largely attributable to the engaged multidisciplinary network, committed to deliver clearly understood goals. Such networks take time and investment to develop, but are priceless in terms of their ability to deliver and facilitate knowledge sharing and collaboration.

Biomonitoring for Occupational Exposure to Diisocyanates: A Systematic Review

Diisocyanates are a group of chemicals that are widely used in occupational settings. They are known to induce various health effects, including skin- and respiratory tract sensitization resulting in allergic dermatitis and asthma. Exposure to diisocyanates has been studied in the past decades by using different types of biomonitoring markers and matrices. The aim of this review as part of the HBM4EU project was to assess: (i) which biomarkers and matrices have been used for biomonitoring diisocyanates and what are their strengths and limitations; (ii) what are (current) biomonitoring levels of the major diisocyanates (and metabolites) in workers; and (iii) to characterize potential research gaps. For this purpose we conducted a systematic literature search for the time period 2000–end 2018, thereby focussing on three types of diisocyanates which account for the vast majority of the total isocyanate market volume: hexamethylene diisocyanate (HDI), toluene diisocyanate (TDI), and 4,4′-methylenediphenyl diisocyanate (MDI). A total of 28 publications were identified which fulfilled the review inclusion criteria. The majority of these studies (93%) investigated the corresponding diamines in either urine or plasma, but adducts have also been investigated by several research groups. Studies on HDI were mostly in the motor vehicle repair industry [with urinary hexamethylene diamine result ranging from 0.03 to 146.5 µmol mol⁻¹ creatinine]. For TDI, there is mostly data on foam production [results for urinary toluene diamine ranging from ~0.01 to 97 µmol mol⁻¹ creatinine] whereas the available MDI data are mainly from the polyurethane industry (results for methylenediphenyl diamine range from 0.01 to 32.7 µmol mol⁻¹ creatinine). About half of the studies published were prior to 2010 hence might not reflect current workplace exposure. There is large variability within and between studies and across sectors which could be potentially explained by several factors including worker or workplace variability, short half-lives of biomarkers, and differences in sampling strategies and analytical techniques. We identified several research gaps which could further be taken into account when studying diisocyanates biomonitoring levels: (i) the development of specific biomarkers is promising (e.g. to study oligomers of HDI which have been largely neglected to date) but needs more research before they can be widely applied, (ii) since analytical methods differ between studies a more uniform approach would make comparisons between studies easier, and (iii) dermal absorption seems a possible exposure route and needs to be further investigated. The use of MDI, TDI, and HDI has been recently proposed to be restricted in the European Union unless specific conditions for workers’ training and risk management measures apply. This review has highlighted the need for a harmonized approach to establishing a baseline against which the success of the restriction can be evaluated.

A rapid review of barriers to oral healthcare for people with protected characteristics

Introduction The Equality Act 2010 sets out nine protected characteristics and serves to protect every individual against discrimination. The Act places emphasis on the need to reduce inequalities. An understanding, therefore, of existing barriers to oral healthcare for people with protected characteristics is required to inform policy and the commissioning of services.Aim To conduct a rapid review of current UK literature on barriers to oral healthcare for people with protected characteristics.Methods Electronic searching using Medline via Ovid limited to publications in English from the UK. Publication types included primary and secondary evidence from peer-reviewed journals and reports.Results From a total of 462 citations, 52 articles were included in the final review. Common barriers experienced across the protected characteristic groups were identified in addition to specific barriers experienced by those with protected characteristics.Conclusion This rapid review identified barriers to oral healthcare for people with protected characteristics at individual and organisational levels. Gaps identified in the literature include a lack of information available for barriers experienced by people due to sexual orientation, marital/civil partnership status and gender reassignment. Additionally, there is a gap in the evidence available on policy barriers to oral healthcare for people with protected characteristics.

A rapid review of variation in the use of dental general anaesthetics in children

Introduction The use of dental general anaesthetics (DGAs) remains a cause for concern due to additional strains placed on health services. There are numerous factors influencing the prevalence and use of DGAs, and understanding these is an important first step in addressing the issue.Aim Conduct a rapid review of current peer-reviewed and grey literature on the variation in the use of DGAs in children.Methods Electronic searching using Medline via Ovid covering DGA articles from 1998 onwards, written in English. Publication types included primary and secondary sources from peer-reviewed journals and reports, as well as grey literature.Results From 935 results, 171 articles were included in the final review. Themes emerging from the literature included discussions of DGA variation, variations in standards of service provision by health services, and the socio-demographic and geographical characteristics of children. Prominent socio-demographic and geographical characteristics included age, other health conditions, ethnic and cultural background, socioeconomic status and deprivation, and geographical location.Conclusions This review identified numerous variations in the patterns associated with DGA provision and uptake at both a health service and individual level. The findings demonstrate the complicated and multifaceted nature of DGA practices worldwide.

National patterns in paediatric hospital admissions for dental extractions in England

OBJECTIVES

Paediatric hospital admissions for dental extractions remain a cause for concern, despite decreasing levels of dental diseases in some areas of the country. While local investigations have taken place, little is known about national patterns, and how the relationship between the number of hospital admissions and key independent variables differs across England. The aim of this study was to examine spatial differences in the number of paediatric hospital admissions for extractions in relation to four key independent variables: dental caries, deprivation, units of dental activity and child access to dentists.

METHODS

Hospital admissions data (for all dental-related reasons) were taken from the Hospital Episode Statistics (HES) for England (2017/18) for children and adolescents aged up to 19 years. All data were collected at local authority level. Geographically weighted regression was used to examine associations between the number of hospital admissions and the independent variables, as well as the strength of these associations and how they differed spatially.

RESULTS

Geographically weighted regression revealed considerable differences in the associations between the number of paediatric hospital admissions and the independent variables across England, with distinct regional clusters identified in the data. Some areas exhibited positive associations between independent variables and the number of hospital admissions, such as in Yorkshire and areas of south-west, south-east and north-west England, where greater mean dmft scores were associated with greater numbers of hospital admissions. Negative associations were also found, such as in south-west, north-west and North East England, where higher deprivation scores were associated with lower admission numbers. Despite the patterns found, a much smaller sample of the associations between the independent variables and the number of hospital admissions was statistically significant.

CONCLUSIONS

This analysis allows for a better understanding of the spatial associations between the number of hospital admissions and key independent variables, as well as how changes to these independent variables may affect the number of admissions in each local authority. These findings should be considered in the context of the limitations of HES dataset.

Acceptability, safety, and patterns of use of oral tenofovir disoproxil fumarate and emtricitabine for HIV pre-exposure prophylaxis in South African adolescents: an open-label single-arm phase 2 trial

BACKGROUND

HIV incidence among adolescents in southern Africa remains unacceptably high. Pre-exposure prophylaxis (PrEP) is an effective HIV prevention intervention but there are few data on its implementation among adolescents. We aimed to investigate the safety, feasibility, and acceptability of PrEP with oral tenofovir disoproxil fumarate and emtricitabine as part of a comprehensive HIV prevention package in an adolescent population in South Africa.

METHODS

This open-label single-arm phase 2 study (PlusPills) was done in two research clinics in Cape Town and Johannesburg, South Africa. Adolescents aged 15-19 years were recruited into the study through recruitment events and outreach in the community. Potential participants were eligible for enrolment if they reported being sexually active. Exclusion criteria were a positive test for HIV or pregnancy at enrolment, breastfeeding, or any relevant co-morbidities. Participants were given oral tenofovir disoproxil fumarate and emtricitabine for PrEP to take daily for the first 12 weeks and were then given the choice to opt in or out of PrEP use at three monthly intervals during scheduled clinic visits. Participants were invited to monthly visits for adherence counselling and HIV testing during the study period. The primary outcomes were acceptability, use, and safety of PrEP. Acceptability was measured by the proportion of participants who reported willingness to take up PrEP and remain on PrEP at each study timepoint. Use was defined as the number of participants who continued to use PrEP after the initial 12-week period until the end of the study (week 48). Safety was measured by grade 2, 3, and 4 laboratory and clinical adverse events using the Division of AIDS table for grading the severity of adult and paediatric adverse events, version 1.0. Dried blood spot samples were collected at each study time-point to measure tenofovir diphosphate concentrations. This trial is registered with ClinicalTrials.gov, NCT02213328.

FINDINGS

Between April 28, 2015, and Nov 11, 2016, 244 participants were screened, and 148 participants were enrolled (median age was 18 years; 99 participants [67%] were female) and initiated PrEP. PrEP was stopped by 26 of the 148 (18%) participants at 12 weeks. Cumulative PrEP opt-out, from the total cohort, was 41% (60 of 148 participants) at week 24 and 43% (63 of 148 participants) at week 36. PrEP was well tolerated with only minor adverse events (grade 2) thought to be related to study drug, which included headache (n=4, 3%), gastrointestinal upset (n=8, 5%), and skin rash (n=2, 1%). Two participants (1%) experienced grade 3 weight loss, which was deemed related to the study drug and resolved fully when PrEP was discontinued. Tenofovir diphosphate concentrations were detectable (>16 fmol/punch) in dried blood spot samples in 108 (92%) of 118 participants who reported PrEP use at week 12, in 74 (74%) of 100 participants at week 24, and in 22 (59%) of 37 participants by the study end at week 48.

INTERPRETATION

In this cohort of self-selected South African adolescents at risk of HIV acquisition, PrEP appears safe and tolerable in those who continued use. PrEP use decreased throughout the course of the study as the number of planned study visits declined. Adolescents in southern Africa needs access to PrEP with tailored adherence support and possibly the option for more frequent and flexible visit schedules.

FUNDING

National Institute of Allergy and Infectious Diseases of the US National Institutes of Health.

The burgeoning role of global health diplomacy to alleviate suffering of cancer patients in low- and middle-income countries

The science of global health diplomacy (GHD) consists of cross-disciplinary, multistakeholder credentials comprised of national security, public health, international affairs, management, law, economics and trade policy. GHD is well placed to bring about better and improved multilateral stakeholder leverage and outcomes in the prevention and control of cancer. It is important to create an evidence base that provides clear and specific guidance for health practitioners in low- and middle-income countries (LMICs) through involvement of all stakeholders. GHD can assist LMICs to negotiate across multilateral stakeholders to integrate prevention, treatment and palliative care of cancer into their commercial and trade policies.