Guidelines for reporting on CBCT scans

The aim of a radiographic report is to provide an accurate interpretation of images to facilitate the diagnostic process, and when indicated prompt the appropriate management for the patient. It is part of the patient's clinical records. This paper describes the imaging chain involved in the cone beam computed tomography (CBCT) workflow from referring to reporting on a CBCT scan. It provides guidelines on the essential information required before and immediately after a CBCT scan is taken, and optimizing the viewing conditions. Finally, it describes a framework for a systematic, comprehensive and tailored CBCT radiographic report. It is aimed at endodontists, clinicians and radiologists reporting on CBCT scans of the dentoalveolar region.

A systematic review of the impact of cigarettes and electronic cigarettes in otology

BACKGROUND

The detrimental systemic effects of cigarette smoking are well established. Though less pronounced in the field of otology, they are proposed to contribute to the global burden of unaddressed hearing loss. Recently, in efforts to stop smoking, individuals have used electronic cigarettes of which the long-term safety data are largely unknown. This study aimed to conduct a systematic review of cigarette smoking and electronic cigarette effects in the field of otology.

METHOD

Relevant articles were identified by a National Institute for Health and Care Excellence healthcare database literature search and by scanning the references of relevant articles and reviews.

RESULTS

A total of 473 articles were identified, with 43 articles included in the review after trials were excluded.

CONCLUSION

Cigarette smoking is associated with recurrent otitis media, otitis media with effusion and sensorineural hearing loss in children exposed to second-hand smoke. In adults, it is associated with active and aggressive chronic suppurative otitis media, worse tympanoplasty success rates, increased post-operative complications and sensorineural hearing loss that is more pronounced in the long term and at high frequencies. The effects of e-cigarettes in otology are largely unknown.

Plasma desmosine, a biomarker of elastin degradation, predicts outcomes in coronary artery disease

Background

Recent evidence from animal studies suggests that elastin degradation accelerates atherosclerosis and increases risk of plaque rupture and subsequent myocardial infarction and stroke. Desmosine is an elastin-specific degradation product. We analysed the prognostic value of plasma desmosine (pDES) in a cohort of patients with coronary artery disease (CAD).

Methods

Patients with CAD (n=400) undergoing elective coronary angiography were prospectively recruited over 3 years and had bloods drawn for analysis of pDES using a validated stable isotope dilution liquid chromatography-tandem mass spectrometry method. Patients were followed up for 12 months for major adverse cardiovascular events (MACE: composite of death, myocardial infarction, target vessel repeat revascularisation, target lesion revascularisation, and heart failure hospital admission). The upper limit of normal for pDES is 0.35 ng/mL. The predictive value of pDES for MACE was analysed with Cox-proportional hazards ratio (HR) model and Kaplan-Meier survival analysis.

Results

During follow-up, there were 36 MACE events. Median pDES level across the entire cohort was 0.3 ng/mL (IQR 0.23–0.41 ng/mL). Patients with a pDES level >0.35 ng/mL were more likely to be male and older with a mean age of 69.7±10.3 years, have a history of prior stroke or transient ischaemic attack (TIA) and COPD. In univariable analysis, a pDES level of >0.35 ng/mL was associated with an increased risk of MACE (HR 4.76, 95% CI: 2.34–9.68, p<0.001). In multivariable analysis, pDES >0.35 ng/mL was associated with risk of MACE after adjustment for age, sex, COPD status and previous stroke and TIA (HR 3.97; 95% CI: 1.82–8.67, p=0.001) (Figure).

Conclusion

Increased elastin degradation as measured by elevated pDES levels, predicts outcomes in patients with CAD independent of traditional cardiovascular risk factors and may play a role as a future biomarker in these patients.

Kaplan-Meier survival analysis

Funding Acknowledgement

Type of funding source: None

Diagnosis and management of tropomyosin receptor kinase (TRK) fusion sarcomas: expert recommendations from the World Sarcoma Network

Sarcomas are a heterogeneous group of malignancies with mesenchymal lineage differentiation. The discovery of neurotrophic tyrosine receptor kinase (NTRK) gene fusions as tissue-agnostic oncogenic drivers has led to new personalized therapies for a subset of patients with sarcoma in the form of tropomyosin receptor kinase (TRK) inhibitors. NTRK gene rearrangements and fusion transcripts can be detected with different molecular pathology techniques, while TRK protein expression can be demonstrated with immunohistochemistry. The rarity and diagnostic complexity of NTRK gene fusions raise a number of questions and challenges for clinicians. To address these challenges, the World Sarcoma Network convened two meetings of expert adult oncologists and pathologists and subsequently developed this article to provide practical guidance on the management of patients with sarcoma harboring NTRK gene fusions. We propose a diagnostic strategy that considers disease stage and histologic and molecular subtypes to facilitate routine testing for TRK expression and subsequent testing for NTRK gene fusions.

Ovarian Carcinosarcoma with Malignant Neuroectodermal Components (Teratoid Carcinosarcoma) - A Rare Entity

Introduction/Objective

Ovarian carcinosarcoma is an aggressive tumor accounting for 2% of all ovarian malignancies. Ovarian carcinosarcoma with malignant neuroectodermal components is exceedingly rare and only four cases have been previously reported. Here we report a series of three cases in 65(case 1), 61 (case 2) and 72 (case 3) year old females.

Methods

All patients presented with pelvic mass and elevated CA125. They underwent hysterectomy, bilateral salpingo-oophorectomy, omentectomy and tumor-debulking, along with lymph node dissection (2,3) and appendectomy (3). The FIGO stages were IIIC (1,3) or IIA (2). Case #2 experienced pelvic recurrence three months after initiating platinum based chemotherapy and was treated with BEP. She died of metastatic disease ten months after initial surgery. Case #3 is a current case and is being treated with chemotherapy. Case #1 was an outside consult and was lost to follow–up.

Results

Grossly the dominant ovarian mass measured 25 (left), 20 (left) and 21 (right) cm. The cut surfaces were hetergenous tan, yellow, partially cystic and solid with hemorrhage and necrosis. Microscopically, they showed mixed morphology of carcinomatous, sarcomatous, and undifferentiated neuroectodermal component. The carcinomatous element showed squamous cell carcinoma and adenocarcinoma. The sarcomatous component included rhabdomyosarcoma, chondrosarcoma and liposarcoma. The undifferentiated neuroectodermal component consisted of nested or solid primitive cells. All three cases showed fetal-appearing teratoid squamous cell epithelium with clear cytoplasm. The contralateral ovary and extraovarian metastatic implants were either carcinosarcoma, carcinoma or contained all three components.

Conclusion

Case #1 and 3 also showed a yolk sac component. All lymph nodes (2,3) were negative for metastatic tumor at the time of initial surgery. Case #2 had first recurrence in retroperitoneal lymph node showing mature neural tissue. Her second recurrence in abdomen was undifferentiated neuroblastoma. Immunohistochemical studies included CK7, CK20, CDX2, NapsinA, S100, GFAP, PAX-8, CK5/6, P63, AE1/AE3, desmin, Myf-4, CD56, glypican3, AFB, CD99, chromogranin, synaptophysin, NF, NeuN, calretinin, and inhibin. The staining pattern was consistent with histologic interpretation. These cases histologically resemble to so-called “teratoid carcinosarcoma” of paranasal sinuses. The histogenesis remains unknown.

The Wild West of Emergency Use Authorizations for SARS-CoV-2 Testing: What Could Be the True Sensitivity?

Introduction/Objective

SARS-CoV-2 is a pandemic that has required mobilization to meet urgent needs. In this mobilization, emergency use authorizations (EUA) have been issued by the FDA to expedite the deployment of these tests. This has led to a situation whereby sensitivity has not been rigorously studied for any of the assays with EUAs. Estimates can be extrapolated from the limited samples documented by the company in their instructions for use (IFU). Although the nationwide shortage of testing reagents prevent parallel testing of multiple platforms on all specimens, observations of repeat specimens at the Veteran Affairs Medical Center (VAMC) provides the first study in the literature of more complete data for SARS-CoV-2 nucleic acid (RT-PCR) assay on sensitivity on the Abbott (Abbott Park Ill) and Cepheid (Sunnyvale CA) assays.

Methods

A retrospective search was performed for all test results for SARS-CoV-2 by RT-PCR from 3/1/2020 to 4/14/2020 at Corporal Michael J. Crescenz Medical Center, in order to evaluate the sensitivity on Abbott m2000 and Cepheid platforms. Results across multiple reference laboratories and in-house testing platforms were collated in a table with all patients clinically requiring repeat testing recorded.

Results

114/863 patients had repeat testing. The tests were performed initially by outside reference laboratories (25 patients), on the Abbott m2000 (63 patients), and Cepheid Infinity (26 patients). 15/114 (13%) had discordant results on repeat testing. This included 1 test initially done by a reference laboratory. 8 days after the initial result from the reference lab, a positive for the same patient was identified on the Abbott platform. 11 initial Abbott results were discordant on further repeat testing on two platforms - Abbott (6 patients) and Cepheid (5 patients) 1-6 days later. In addition, 3 initial Cepheid were discordant on further repeat testing by the same Cepheid platform (1-16 days later).

Conclusion

While the instructions for use for both platforms suggest 100% sensitivity and specificity (due to the 100% positive and negative percent agreement in limited specimens), the true sensitivity is less than 100%, particularly early in the course of the infection. In our study, the positive percent agreement (surrogate for sensitivity) was 83% for initial Abbott tests, 88% for initial Cepheid tests, and 95% by Reference laboratory platform.

Technologies for Preparation of Solid and Granular Jaggery: A Review

Jaggery is unrefined sugar used in all countries of the world under different names prepared from sugarcane juice. It is a tastemaker and color maker rather than being just a sweetener. Jaggery is rich in minerals and vitamins contained more than of refined sugar. Nowadays people are very conscious about health and current food consumption. People are concentrating mainly on high-quality foods with low capital investment. Jaggery is one of the products which is cheaply and easily available to all categories of people. To meet market demand and jaggery export, with a short period of production though it is consumed throughout the year, the high quality and hygiene jaggery can be prepared by increasing the plant efficiency by considering the modifications in the design of the furnace, pan, rate of bagasse consumption, rate of heat transfer from hot flue gases. The production can also be increased by practicing good manufacturing practice (GMP), by preparing other products like liquid jaggery and granular jaggery in addition to solid jaggery. This paper discusses the various up-gradation technologies of jaggery preparation and besides, this paper gives an overview of various forms of jaggery preparation from different sources of input along with automation and advanced jaggery making process.

Morphological analysis of palatal rugae patterns in a population of Maharashtrian ancestry: a cross-sectional study

AIM

To analyze the morphological parameters of palatal rugae in a population of Maharashtrian ancestry.

MATERIAL AND METHODS

This study was conducted on 1000 subjects of Maharashtrian ancestry with at least 3 generations on the mother's and father's side. Their palatal impressions were obtained with alginate and the casts were analyzed for length, shape and direction of palatal rugae.

RESULTS

Our results showed that the most predominant rugae were primary followed by secondary and fragmentary with significant differences between them. The most prevalent rugae shapes found were straight followed by wavy followed by curved with significant differences between them. According to direction, forward rugae were significantly higher than perpendicular rugae and backward rugae.

CONCLUSION

The rugae are considered to have population specific configurations. This baseline data of patterns of palatal rugae in a sample of Maharashtrian ancestry may serve `as an accessory tool' for population identification in Forensic Dentistry.

Diagnostic yields in patients with suspected prostate cancer undergoing MRI as the first-line investigation in routine practice

AIM

To document cancer yields of magnetic resonance imaging (MRI)-directed biopsies in men with suspected prostate cancer referred to secondary care.

MATERIALS AND METHODS

Men with suspected cancer undergoing multiparametric prostate MRI as the first-line investigation were included in the present study. Systematic transrectal prostate biopsies with/without cognitive targeted biopsies were performed. Diagnostic yields of International Society of Urological Pathology (ISUP) ≥2 cancers by the Prostate Imaging Reporting and Data System (PI-RADS) category were recorded. Impacts of prostate-specific antigen (PSA) density on biopsy results and yields of non-targeted biopsies in MRI non-suspicious prostate sextants assessed.

RESULTS

Of 262 men (90.5% biopsy naive), 86 (33%) MRI examinations were negative (PI-RADS 1-2) and 176 (67%) positive (PI-RADS 3: 8%; PI-RADS 4: 21%; PI-RADS 5: 38%). Two hundred and thirteen of 262 patients underwent a biopsy. ISUP ≥2 cancer detection rates were 8% (5/61) for PI-RADS 1-2, 18% (3/17) for PI-RADS 3, 49% (22/45) for PI-RADS 4, and 80% (72/90) for PI-RADS 5. Proportions of ISUP ≥2 increased with higher PSA densities in positive patients (%ISUP ≥2 for PSA density groups <0.12, 0.12 to <0.15 and ≥ 0.15 was 0%, 0%, 25% for PI-RADS 3, 21%, 33%, 68% for PI-RADS 4 and 40%, 83%, 89% for PI-RADS 5 respectively). ISUP ≥2 cancers were twice as likely in tumour adjacent sextants (52% versus 24%), without upgrading of gland level histology from insignificant to clinically significant prostate cancer by the sampling of normal-appearing tumour non-adjacent sextants.

CONCLUSIONS

One third of men can avoid biopsy after negative MRI. Cancer detection rates increase with PSA density values within positive MRI suspicion categories. Sampling normal-appearing tumour non-adjacent sextants may be unnecessary for whole-gland therapy.

Optimization of maize-millet based soy fortified composite flour for preparation of RTE extruded products using D-optimal mixture design

Formulation of composite flour comprising of maize (MF), finger millet (FM), defatted soy (DS) and elephant foot yam (YP) was carried out for the preparation of extruded product. The proportion of three major ingredients was varied as maize: 40-55%, finger millet: 20-30%, defatted soy: 10-25% and that of YP was kept constant as 10%. In all 16 experiments were conducted by D-optimal mixture design keeping the upper and lower values of ingredients in the range given above. Extruded products were developed by using twin screw extruder (BTPL lab model) at barrel temperature 100 °C, screw speed 300 rpm and feed moisture content 15% (wb). Physical and functional properties like expansion ratio (ER), bulk density (BD), hardness, water absorption index (WAI) and water solubility index (WSI) of extruded products were analyzed. Composite flour was optimized on the basis of physical and functional properties of extruded products. The values of ER, BD, hardness, WAI and WSI of extruded products were in the range of 2.42-3.30, 0.14-0.26 g cm^-3, 11.15-18.67 N, 5.57-6.87 g g^-1 and 14.42-19.95%, respectively. Variations in proportion of ingredients in the composite blend significantly affected ER, BD, hardness, WAI and WSI of the product. The regression models for ER, BD, hardness, WAI and WSI were developed to explain the effect of ingredients on the response variables. A blend of ingredients in the ratio of 40:30:20:10 (MF:FM:DS:YP) was found to be optimum with a desirability function of 0.82 which resulted extrudate attributes of ER 3.29, BD 0.14 g cm^-3, hardness 11.94 N, WAI 6.13 g g^-1 and WSI 17.07%.

COVID-19 and Involvement of the Corpus Callosum: Potential Effect of the Cytokine Storm?

Neurologic findings are being increasingly recognized in coronavirus disease 2019. We present a patient with a unique involvement of the corpus callosum that we relate to the cytokine storm seen in patients with Severe Acute Respiratory Syndrome coronavirus 2 infection. As the infection is increasingly seen around the world, recognition of these unique patterns may facilitate early identification of the progression of this disease and potentially facilitate appropriate management.

Activity of Cefiderocol Alone and in Combination with Levofloxacin, Minocycline, Polymyxin B, or Trimethoprim-Sulfamethoxazole against Multidrug-Resistant Stenotrophomonas maltophilia

The production of an L1 metallo-β-lactamase and an L2 serine active-site β-lactamase precludes the use of β-lactams for the treatment of Stenotrophomonas maltophilia infections. Preclinical data suggest that cefiderocol is the first approved β-lactam with reliable activity against S. maltophilia, but data on strains resistant to current first-line agents are limited, and no studies have assessed cefiderocol-based combinations. The objective of this study was to evaluate and compare the in vitro activity of cefiderocol alone and in combination with levofloxacin, minocycline, polymyxin B, or trimethoprim-sulfamethoxazole (TMP-SMZ) against a collection of highly resistant clinical S. maltophilia isolates. For this purpose, the MICs of cefiderocol, ceftazidime, levofloxacin, minocycline, polymyxin B, and TMP-SMZ for 37 S. maltophilia isolates not susceptible to levofloxacin and/or TMP-SMZ were determined. Nine strains with various cefiderocol MICs were then tested in time-kill experiments with cefiderocol alone and in combination with comparators. The only agents for which susceptibility rates exceeded 40% were cefiderocol (100%) and minocycline (97.3%). Cefiderocol displayed the lowest MIC50 and MIC90 values (0.125 and 0.5 mg/liter, respectively). In time-kill experiments, synergy was observed when cefiderocol was combined with levofloxacin, minocycline, polymyxin B, or TMP-SMZ against 4/9 (44.4%), 6/9 (66.7%), 5/9 (55.5%), and 6/9 (66.7%) isolates, respectively. These data suggest that cefiderocol displays potent in vitro activity against S. maltophilia, including strains resistant to currently preferred agents. Future dynamic and in vivo studies of cefiderocol alone and in combination are warranted to further define cefiderocol's synergistic capabilities and its place in therapy for S. maltophilia infections.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Patients undergoing primary surgery for oral and oropharyngeal cancer: how many are referred on the two-week wait pathway and by whom?

INTRODUCTION

Available data suggest that the two-week wait referral pathway is ineffective at expediting diagnosis of cancer due to large numbers of inappropriate referrals. This study aimed to compare the referral pathway of 125 patients who had undergone primary surgery for oral and oropharyngeal cancer with 100 who had been two-week wait referrals.

MATERIALS AND METHODS

This was a case note review.

RESULTS

Of the 125 patients who underwent surgery; 47 (38%) were referred via the 2WW pathway. GPs had referred 25 (53%) of the 47 patients and general dental practitioners 22 (47%). The tumour stage was similar regardless of referral pathway (two-week wait or routine). GPs recognised that the two-week wait pathway was needed in 49% of the patients they had referred, whereas the equivalent figure for GDPs was 40%. Of the 100 2WW patients, 52 were biopsied. Of these, nine (9%) were diagnosed with a malignancy. GPs referred 61% of the 100 two-week wait patients and accurately diagnosed five of the cancers (although two were basal cell carcinomas), general dental practitioners the remainder (including one basal cell carcinoma). Overall, 41% of the patients referred on the two-week wait pathway by GPs needed a biopsy, compared with 69% of those referred by general dental practitioners.

CONCLUSIONS

While the criteria for referral on the two-week wait pathway lack discrimination and the majority of referrals proved benign, nearly 40% of surgically treated patients were referred via this pathway, suggesting that it does serve a useful purpose. More patients with cancer were referred by GPs, but more two-week wait referrals by general dental practitioners warranted biopsy.

Paediatric antimicrobial stewardship programmes in the UK's regional children's hospitals

A survey was conducted in UK regional children's hospitals with paediatric intensive care and paediatric infectious disease (PID) departments to describe the characteristics of paediatric antimicrobial stewardship (PAS) programmes. A structured questionnaire was sent to PAS coordinators. 'Audit and feedback' was implemented in 13 out of 17 centres. Microbiology-led services were more likely to implement antimicrobial restriction (75% vs 33% in PID-led services), to focus on broad-spectrum antibiotics, and to review patients with positive blood cultures. PID-led services were more likely to identify patients from e-prescribing or drug charts and review all antimicrobials. A PAS network has been established.

A prospective study on the effect of coronal tooth structure loss on the 4-year clinical survival of root canal retreated teeth and retrospective validation of the Dental Practicality Index

AIM

First, to examine the impact of the residual volume of coronal tooth structure in posterior teeth measured with an intra-oral scanner on the 4-year clinical survival of root canal retreated teeth. Secondly, to assess retrospectively the effectiveness of the Dental Practicality Index (DPI) in predicting the survival of root canal retreated teeth.

METHODOLOGY

A total of 156 posterior root canal treated teeth (140 patients) had baseline periapical radiographs (PA) and cone-beam computed tomography (CBCT) scans taken prior to root canal retreatment. These teeth were followed up with a clinical examination at 1, 2, 3 and 4 years (T12, T24, T36 and T48) with periapical radiographs and CBCT images taken at T12, and PA taken at T24, T36 and T48 where appropriate. Root canal retreated teeth were dichotomized into 'survived' versus 'extracted'. Fisher's exact test was used to determine the association between the volume of remaining coronal tooth structure and the 4-year tooth survival. The Dental Practicality Index for each tooth was established using the preoperative clinical and radiographical data. Fisher's exact test was used to establish a relationship between categorical variables, the total score of DPI vs tooth outcome.

RESULTS

The percentage of extractions associated with teeth with <29.5% remaining coronal tooth structure was 3 times higher (12.5%) compared to that of teeth with a residual tooth structure > 29.5% (3.5%), but with no significant difference (P = 0.073). There was a significant correlation between the outcome of root canal retreatments at 1 year, assessed by both PA and CBCT, and the 4-year survival (Fisher's exact test, P = 0.007 and P = 0.001, respectively). Teeth with DPI scores ≥ 6 were more likely to be extracted than teeth with DPI score < 6 (18.8% vs. 3.9%) (Fisher's exact test, P = 0.045).

CONCLUSION

Teeth with <30% of remaining tooth structure were associated with a survival rate above 80% and teeth with more than 30% of residual tooth structure survived in more than 94% of the cases. The radiographic outcome of root canal treatment can also help to predict tooth survival with teeth having an unfavourable outcome at 1 year more likely to be extracted within 4 years of completion of treatment. The DPI score can potentially be used to identify teeth with failed root canal treatment, which are likely to be extracted following retreatment and cuspal coverage.

0370 Objective Differences in Sleep Timing Between African Americans and Non-Hispanic Whites

Introduction

Prior studies have shown a morning circadian preference for African Americans compared to Non-Hispanic whites, but prior research has shown that self-reported sleep timing is delayed in African Americans compared to whites. No prior studies have evaluated this difference in sleep timing using objective measures of habitual sleep such as actigraphy.

Methods

We analyzed the sleep data from the Multi-Ethnicity Study of Atherosclerosis (MESA), a multi-site community-based cohort with both self-reported and actigraphic measures of habitual sleep variables. Self-reported sleep timing, chronotype as measured by the modified Horne-Ostberg Morningness-Eveningness Questionnaire (MEQ) and actigraphic sleep timing were examined using logistic regression and independent t-tests.

Results

1,430 participants had self-reported sleep data, and 1,405 participants had complete actigraphy data as well. There was no self-reported difference in circadian preference between African Americans and whites (mean MEQ score 17.1 ± 3.6 vs. 17.0 ± 4.0). African Americans were 76% more likely to report a bedtime after midnight on weekdays (odds ratio [OR] 1.8, 95% confidence interval [CI] 1.4, 2.3, p&lt;0.001), and 50% more likely on weekends (OR 1.5, 95% CI 1.2, 1.9, p=0.001) as compared to whites. Actigraphic data showed similar results. African Americans were 80% more likely to have actigraphic sleep onset after midnight on weekdays (OR 1.8, 95% CI 1.4, 2.2) and 137% more likely (OR 2.4,95% CI 1.9, 3.0, p&lt;0.001) on weekends as compared to whites. Actigraphic mid-sleep time was delayed 42 (95% CI 20, 64, p&lt;0.001) minutes on weekdays and 24 (95% CI 6,42, p=0.01) minutes on weekends in African Americans compared to whites.

Conclusion

African Americans had delayed sleep timing compared to whites even though no significant racial differences in chronotype were present. Delayed sleep timing in African Americans may be related to factors other than self-reported circadian preference.

Support

Funding to DC from the American Heart Association, University of Arizona Health Sciences Center and NIH-NHLBI. MESA data obtained from NIH-NHLBI BioLINCC and the National Sleep Research Resource.

A multicentre, randomised controlled trial to compare the clinical and cost-effectiveness of Lee Silverman Voice Treatment versus standard NHS Speech and Language Therapy versus control in Parkinson's disease: a study protocol for a randomised controlled trial

BACKGROUND

Parkinson's disease (PD) affects approximately 145,519 people in the UK. Speech impairments are common with a reported prevalence of 68%, which increase physical and mental demands during conversation, reliance on family and/or carers, and the likelihood of social withdrawal reducing quality of life. In the UK, two approaches to Speech and Language Therapy (SLT) intervention are commonly available: National Health Service (NHS) SLT or Lee Silverman Voice Treatment (LSVT LOUD®). NHS SLT is tailored to the individuals' needs per local practice typically consisting of six to eight weekly sessions; LSVT LOUD® comprises 16 sessions of individual treatment with home-based practice over 4 weeks. The evidence-base for their effectiveness is inconclusive.

METHODS/DESIGN

PD COMM is a phase III, multicentre, three-arm, unblinded, randomised controlled trial. Five hundred and forty-six people with idiopathic PD, reporting speech or voice problems will be enrolled. We will exclude those with a diagnosis of dementia, laryngeal pathology or those who have received SLT for speech problems in the previous 2 years. Following informed consent and completion of baseline assessments, participants will be randomised in a 1:1:1 ratio to no-intervention control, NHS SLT or LSVT LOUD® via a central computer-generated programme, using a minimisation procedure with a random element, to ensure allocation concealment. Participants randomised to the intervention groups will start treatment within 4 (NHS SLT) or 7 (LSVT LOUD®) weeks of randomisation.

PRIMARY OUTCOME

Voice Handicap Index (VHI) total score at 3 months. Secondary outcomes include: VHI subscales, Parkinson's Disease Questionnaire-39; Questionnaire on Acquired Speech Disorders; EuroQol-5D-5 L; ICECAP-O; resource utilisation; adverse events and carer quality of life. Mixed-methods process and health economic evaluations will take place alongside the trial. Assessments will be completed before randomisation and at 3, 6 and 12 months after randomisation. The trial started in December 2015 and will run for 77 months. Recruitment will take place in approximately 42 sites around the UK.

DISCUSSION

The trial will test the hypothesis that SLT is effective for the treatment of speech or voice problems in people with PD compared to no SLT. It will further test whether NHS SLT or LSVT LOUD® provide greater benefit and determine the cost-effectiveness of both interventions.

TRIAL REGISTRATION

International Standard Randomised Controlled Trials Number (ISRCTN) Registry, ID: 12421382. Registered on 18 April 2016.