A smartphone app effectively facilitates mothers' mind-mindedness: A randomized controlled trial

The efficacy of a smartphone app intervention (BabyMind©) in facilitating mind-mindedness was investigated in a randomized controlled trial, assigning mothers and their 6-month-olds (N = 152; 72 girls, 146 White) to intervention or active control conditions. Mothers who had received the BabyMind© app intervention scored higher for appropriate (d = .61, 95% CI .28, .94) and lower for non-attuned (d = -.55, 95% CI -.92, -.18) mind-related comments at follow-up (age 12 months), compared with their control group counterparts. Adjusting for missing data did not alter this pattern of findings. Mothers' baseline parental reflective functioning did not moderate these relations. Results are discussed in terms of the benefits of early intervention and exploring the efficacy of the app in more diverse populations.

Examining the effectiveness of the Gateway conditional caution on health and well-being of young adults committing low-level offences: a randomised controlled trial

BACKGROUND

Young adults who commit low-level offences commonly have a range of health and social needs and are significantly over-represented in the criminal justice system. These young adults may need to attend court and potentially receive penalties including imprisonment. Alternative routes exist, which can help address the underlying causes of offending. Some feel more should be done to help young adults entering the criminal justice system. The Gateway programme was a type of out-of-court disposal developed by Hampshire Constabulary, which aimed to address the complex needs of young adults who commit low-level crimes. This study aimed to evaluate the effectiveness and cost-effectiveness of the Gateway programme, issued as a conditional caution, compared with usual process.

METHODS

The Gateway study was a pragmatic, parallel-group, superiority randomised controlled trial that recruited young adults who had committed a low-level offence from four sites covering Hampshire and Isle of Wight. The primary outcome was mental health and well-being measured using the Warwick-Edinburgh Mental Well-being Scale. Secondary outcomes were quality of life, alcohol and drug use, and recidivism. Outcomes were measured at 4, 16 and 52 weeks postrandomisation.

RESULTS

Due to issues with retention of participants and low data collection rates, recruitment ended early, with 191 eligible participants randomised (Gateway 109; usual process 82). The primary outcome was obtained for 93 (48.7%) participants at 4 weeks, 93 (48.7%) at 16 weeks and 43 (22.5%) at 1 year. The high attrition rates meant that effectiveness could not be assessed as planned.

CONCLUSIONS

Gateway is the first trial in a UK police setting to have a health-related primary outcome requiring individual data collection, rather than focusing solely on recidivism. We demonstrated that it is possible to recruit and randomise from the study population, however follow-up rates were low. Further work is needed to identify ways to facilitate engagement between researchers and vulnerable populations to collect data.

TRIAL REGISTRATION NUMBER

ISRCTN11888938.

Interventions to suppress puberty in adolescents experiencing gender dysphoria or incongruence: a systematic review

BACKGROUND

Treatment to suppress or lessen effects of puberty are outlined in clinical guidelines for adolescents experiencing gender dysphoria/incongruence. Robust evidence concerning risks and benefits is lacking and there is a need to aggregate evidence as new studies are published.

AIM

To identify and synthesise studies assessing the outcomes of puberty suppression in adolescents experiencing gender dysphoria/incongruence.

METHODS

A systematic review and narrative synthesis. Database searches (Medline, Embase, CINAHL, PsycINFO, Web of Science) were performed in April 2022, with results assessed independently by two reviewers. An adapted version of the Newcastle-Ottawa Scale for cohort studies was used to appraise study quality. Only moderate-quality and high-quality studies were synthesised. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guidelines were used.

RESULTS

11 cohort, 8 cross-sectional and 31 pre-post studies were included (n=50). One cross-sectional study was high quality, 25 studies were moderate quality (including 5 cohort studies) and 24 were low quality. Synthesis of moderate-quality and high-quality studies showed consistent evidence demonstrating efficacy for suppressing puberty. Height increased in multiple studies, although not in line with expected growth. Multiple studies reported reductions in bone density during treatment. Limited and/or inconsistent evidence was found in relation to gender dysphoria, psychological and psychosocial health, body satisfaction, cardiometabolic risk, cognitive development and fertility.

CONCLUSIONS

There is a lack of high-quality research assessing puberty suppression in adolescents experiencing gender dysphoria/incongruence. No conclusions can be drawn about the impact on gender dysphoria, mental and psychosocial health or cognitive development. Bone health and height may be compromised during treatment. More recent studies published since April 2022 until January 2024 also support the conclusions of this review.

PROSPERO REGISTRATION NUMBER

CRD42021289659.

Masculinising and feminising hormone interventions for adolescents experiencing gender dysphoria or incongruence: a systematic review

BACKGROUND

Clinical guidelines outline the use of hormones for masculinisation/feminisation in adolescents experiencing gender dysphoria or incongruence. Robust evidence concerning risks and benefits is lacking. There is a need to aggregate evidence as research becomes available.

AIM

Identify and synthesise studies assessing the outcomes of hormones for masculinisation/feminisation in adolescents experiencing gender dysphoria/incongruence.

METHODS

Systematic review and narrative synthesis. Database searches (MEDLINE, Embase, CINAHL, PsycINFO, Web of Science) were performed in April 2022, with results assessed independently by two reviewers. An adapted version of the Newcastle-Ottawa Scale for Cohort Studies was used to assess study quality. Moderate- and high-quality studies were synthesised.

RESULTS

12 cohort, 9 cross-sectional and 32 pre-post studies were included (n=53). One cohort study was high-quality. Other studies were moderate (n=33) and low-quality (n=19). Synthesis of high and moderate-quality studies showed consistent evidence demonstrating induction of puberty, although with varying feminising/masculinising effects. There was limited evidence regarding gender dysphoria, body satisfaction, psychosocial and cognitive outcomes, and fertility. Evidence from mainly pre-post studies with 12-month follow-up showed improvements in psychological outcomes. Inconsistent results were observed for height/growth, bone health and cardiometabolic effects. Most studies included adolescents who received puberty suppression, making it difficult to determine the effects of hormones alone.

CONCLUSIONS

There is a lack of high-quality research assessing the use of hormones in adolescents experiencing gender dysphoria/incongruence. Moderate-quality evidence suggests mental health may be improved during treatment, but robust study is still required. For other outcomes, no conclusions can be drawn. More recent studies published since April 2022 until January 2024 also support the conclusions of this review.PROSPERO registration number: CRD42021289659.

Acceleration and transport of relativistic electrons in the jets of the microquasar SS 433

SS 433 is a microquasar, a stellar binary system that launches collimated relativistic jets. We observed SS 433 in gamma rays using the High Energy Stereoscopic System (H.E.S.S.) and found an energy-dependent shift in the apparent position of the gamma-ray emission from the parsec-scale jets. These observations trace the energetic electron population and indicate that inverse Compton scattering is the emission mechanism of the gamma rays. Our modeling of the energy-dependent gamma-ray morphology constrains the location of particle acceleration and requires an abrupt deceleration of the jet flow. We infer the presence of shocks on either side of the binary system, at distances of 25 to 30 parsecs, and that self-collimation of the precessing jets forms the shocks, which then efficiently accelerate electrons.

Tobacco use in people with severe mental illness: Findings from a multi-country survey of mental health institutions in South Asia

INTRODUCTION

People with severe mental illness (SMI) tend to die early due to cardiovascular and respiratory diseases, which may be linked to tobacco use. There is limited information on tobacco use in people with SMI in low- and middle-income countries where most tobacco users reside. We present novel data on tobacco use in people with SMI and their access to tobacco cessation advice in South Asia.

METHODS

We conducted a multi-country survey of adults with SMI attending mental health facilities in Bangladesh, India, and Pakistan. Using data collected with a standardized WHO STEPS survey tool, we estimated the prevalence and distribution of tobacco use and assessed receipt of tobacco cessation advice.

RESULTS

We recruited 3874 participants with SMI; 46.8% and 15.0% of men and women consumed tobacco, respectively. Smoking prevalence in men varied by country (Bangladesh 42.8%, India 20.1% and Pakistan 31.7%); <4% of women reported smoking in each country. Smokeless tobacco use in men also varied by country (Bangladesh 16.2%, India 18.2% and Pakistan 40.8%); for women, it was higher in Bangladesh (19.1%), but similar in India (9.9%) and Pakistan (9.1%). Just over a third of tobacco users (38.4%) had received advice to quit tobacco. Among smokers, 29.1% (n=244) made at least one quit attempt in the past year. There was strong evidence for the association between tobacco use and the severity of depression (OR=1.29; 95% CI: 1.12-1.48) and anxiety (OR=1.29; 95% CI: 1.12-1.49).

CONCLUSIONS

As observed in high-income countries, we found higher tobacco use in people with SMI, particularly in men compared with rates reported for the general population in South Asia. Tobacco cessation support within mental health services offers an opportunity to close the gap in life expectancy between SMI and the general population.

STUDY REGISTRATION

ISRCTN88485933; https://doi.org/10.1186/ISRCTN88485933 39.

Risk factors associated with overweight and obesity in people with severe mental illness in South Asia: cross-sectional study in Bangladesh, India, and Pakistan

Obesity is one of the major contributors to the excess mortality seen in people with severe mental illness (SMI) and in low- and middle-income countries people with SMI may be at an even greater risk. In this study, we aimed to determine the prevalence of obesity and overweight in people with SMI and investigate the association of obesity and overweight with sociodemographic variables, other physical comorbidities, and health-risk behaviours. This was a multi-country cross-sectional survey study where data were collected from 3989 adults with SMI from three specialist mental health institutions in Bangladesh, India, and Pakistan. The prevalence of overweight and obesity was estimated using Asian BMI thresholds. Multinomial regression models were then used to explore associations between overweight and obesity with various potential determinants. There was a high prevalence of overweight (17·3 %) and obesity (46·2 %). The relative risk of having obesity (compared to normal weight) was double in women (RRR = 2·04) compared with men. Participants who met the WHO recommendations for fruit and vegetable intake had 2·53 (95 % CI: 1·65-3·88) times greater risk of having obesity compared to those not meeting them. Also, the relative risk of having obesity in people with hypertension is 69 % higher than in people without hypertension (RRR = 1·69). In conclusion, obesity is highly prevalent in SMI and associated with chronic disease. The complex relationship between diet and risk of obesity was also highlighted. People with SMI and obesity could benefit from screening for non-communicable diseases, better nutritional education, and context-appropriate lifestyle interventions.

Role of cosyntropin in the prevention of post-dural puncture headache: a propensity-matched retrospective analysis

BACKGROUND

Post-dural puncture headache (PDPH) is a well-documented complication of accidental dural puncture in obstetric patients. Reports have shown successful treatment with adrenocorticotropic hormone (ACTH) but evidence remains low and limited. In this retrospective analysis, we assessed whether prophylactic administration of cosyntropin, a synthetic derivative of ACTH, reduced the incidence of PDPH after accidental dural puncture in parturients.

METHOD

The study population included 132 women with an accidental dural puncture over a three-year period (June 1, 2018 to Oct 31, 2021) at a large tertiary-care center. Patient electronic medical records were reviewed for patient characteristics, prophylactic administration of cosyntropin, PDPH diagnosis, and need for epidural blood patch. Typically, 1 mg of cosyntropin was administered as an intravenous bolus or infusion post-delivery. The propensity score was calculated based on the following factors: age, body mass index, and placement of an intrathecal catheter. Patients were matched allowing 10% variation in scores to reduce potential treatment assignment bias.

RESULTS

A total of 115 patients were included in the final analysis. Intravenous cosyntropin was administered to 65 patients (55.6%). Among those who received cosyntropin, 37 (56.9%) developed PDPH compared with 29 patients (58%) in the no-cosyntropin group (P = 0.08). Epidural blood patch was performed in 21 patients (56.8%) who received cosyntropin and 13 patients (61.7%) who did not (P = 0.70).

CONCLUSION

Prophylactic administration of cosyntropin is not associated with a reduced incidence of PDPH.

Location, location, location: mapping the lymphoma tumor microenvironment using spatial transcriptomics

Lymphomas are a heterogenous group of lymphoid neoplasms with a wide variety of clinical presentations. Response to treatment and prognosis differs both between and within lymphoma subtypes. Improved molecular and genetic profiling has increased our understanding of the factors which drive these clinical dynamics. Immune and non-immune cells within the lymphoma tumor microenvironment (TME) can both play a key role in antitumor immune responses and conversely also support lymphoma growth and survival. A deeper understanding of the lymphoma TME would identify key lymphoma and immune cell interactions which could be disrupted for therapeutic benefit. Single cell RNA sequencing studies have provided a more comprehensive description of the TME, however these studies are limited in that they lack spatial context. Spatial transcriptomics provides a comprehensive analysis of gene expression within tissue and is an attractive technique in lymphoma to both disentangle the complex interactions between lymphoma and TME cells and improve understanding of how lymphoma cells evade the host immune response. This article summarizes current spatial transcriptomic technologies and their use in lymphoma research to date. The resulting data has already enriched our knowledge of the mechanisms and clinical impact of an immunosuppressive TME in lymphoma and the accrual of further studies will provide a fundamental step in the march towards personalized medicine.

A Multicenter Study of Clinical to Planning Target Volume Margins for Adjuvant Partial Breast Irradiation Delivered on the 1.5T MR-Linear Accelerator

PURPOSE/OBJECTIVE(S)

Adjuvant partial breast irradiation (APBI) for early-stage breast cancer patients delivered on a conventional Linac commonly uses a clinical to planning target volume (CTV-PTV) margin of 10 mm. Published data suggest this margin could be reduced using an MR-guided workflow. This study quantifies the CTV to PTV margin for APBI delivered on the 1.5T MR-Linac (MRL) using an Adapt to Position (ATP) workflow.

MATERIALS/METHODS

All target contouring was done as per the IMPORT LOW trial and MRL Consortium guidelines. The CTV is the tumor bed defined by surgical clips including postsurgical changes. A single center cohort of ten patients was used to assess delineation error on ProKnow DS v1.28.0 by measuring CTV contour displacements on the CT planning scans (pCT) delineated by five breast radiation oncologists. All other error components were measured on treatment planning software on another single center cohort of ten patients. Target deformation error was measured as surgical clip displacements between the pCT and daily pre-treatment (pre-Tx) MRI scans. Intrafraction motion was determined by the CTV displacement between pre- and post-treatment MRIs (post-Tx) in available paired images from five patients. Matching error was estimated as the interobserver variation of three MRL radiographers registering the pCT with daily pre-Tx MRI. Technical delivery accuracy was estimated using the results from routine quality assurance measurements. Beam penumbral width (p) was estimated from the clinical treatment plans. The systematic (Σ) and random errors (σ) for each component were calculated in the left/right (X), superior/inferior (Y) and anterior/posterior (Z) directions. The contribution of these errors to the PTV margin, M was calculated using van Herk's formula with α and β being 2.50 and 1.64 respectively.

RESULTS

For APBI using an MRL ATP workflow, a CTV-PTV margin of 5.7 to 7.6 mm is required to achieve a 90% confidence of CTV coverage by the 95% isodose. Individual error components are in. Table 1 delineation error remains the largest component of error.

CONCLUSION

A minimum CTV-PTV margin of 6-8 mm is required for APBI using an MRL ATP workflow. Although smaller than margins used in conventional Linacs, the clinical benefits (in terms of fibrosis risk) of treating APBI patients on an MRL are likely to be modest. Further margin reductions may be possible using an "Adapt to Shape" workflow with daily online recontouring.

Is the Motion Causing a Commotion? Two-Fraction Prostate SBRT on the MR-Linac

PURPOSE/OBJECTIVE(S)

In HERMES (NCT04595019) men with localized prostate cancer are treated on the Unity MR-Linac platform (MRL, Elekta AB, Stockholm) and randomized between stereotactic body radiotherapy (SBRT) with 36.25 Gy in 5 fractions and 24 Gy in 2 fractions. Patients randomized to two fractions receive 24 Gy to the high risk PTV, 20 Gy to the low risk PTV and a boost of 27 Gy to the dominant intraprostatic lesion. This study explores dose received by the target and organs at risk (OARs) when considering intrafraction motion in two fraction SBRT.

MATERIALS/METHODS

Targets and OARs were delineated and a reference plan generated on Monaco v5.40.01 (Elekta). An Adapt-to-Shape (ATS) workflow was used. Contours were propagated to the session MRI (MRIsession) and edited accordingly. Prior to delivery, a verification MRI (MRIverif) was acquired with baseline shifts corrected for using the Adapt-to-Position (ATP-of-ATS) workflow. A post treatment MRI (MRIpost) was acquired after delivery. Men in the 2-fraction arm received each fraction in 2 sub-fractions sequentially on the same day, to mitigate intrafraction motion. The plans of 5 men receiving 2 fraction SBRT were analyzed. The targets, urethra, bladder and rectum were recontoured on the MRIverif and MRIpost. Delivered plans were recalculated on the corresponding MRIverif and MRIpost. The percentage of optimal and mandatory target dose constraints met were calculated. Accumulated OAR doses were calculated by averaging their respective dose statistics across all sub-fractions, conservatively assuming that the same area of the OAR receives the maximum dose each fraction. Analysis was carried out separately for MRIverif and MRIpost as the true 'delivered dose' most likely lies between these two estimates.

RESULTS

There was good coverage across all fractions. The mandatory constraints of CTVpsv V24.0 Gy > 95% and CTVsv V20.0 Gy > 95% were met in 100% of fractions and V2700cGy > 95% in 90% on the MRIpost. Table 3 shows OAR dose.

CONCLUSION

This work demonstrates that target coverage is good, even for the GTV where no margin is applied. With our conservative dose calculation approach, we found dose constraints are exceeded for some patients. However, treatment has been well tolerated, suggesting that that our current dose constraints may be cautious. Once Elekta's True Tracking and automated gating software is implemented at our center we will be able to further improve OAR clinical goal compliance.

Inter-comparison of marine microbiome sampling protocols

Research on marine microbial communities is growing, but studies are hard to compare because of variation in seawater sampling protocols. To help researchers in the inter-comparison of studies that use different seawater sampling methodologies, as well as to help them design future sampling campaigns, we developed the EuroMarine Open Science Exploration initiative (EMOSE). Within the EMOSE framework, we sampled thousands of liters of seawater from a single station in the NW Mediterranean Sea (Service d'Observation du Laboratoire Arago [SOLA], Banyuls-sur-Mer), during one single day. The resulting dataset includes multiple seawater processing approaches, encompassing different material-type kinds of filters (cartridge membrane and flat membrane), three different size fractionations (>0.22 µm, 0.22-3 µm, 3-20 µm and >20 µm), and a number of different seawater volumes ranging from 1 L up to 1000 L. We show that the volume of seawater that is filtered does not have a significant effect on prokaryotic and protist diversity, independently of the sequencing strategy. However, there was a clear difference in alpha and beta diversity between size fractions and between these and "whole water" (with no pre-fractionation). Overall, we recommend care when merging data from datasets that use filters of different pore size, but we consider that the type of filter and volume should not act as confounding variables for the tested sequencing strategies. To the best of our knowledge, this is the first time a publicly available dataset effectively allows for the clarification of the impact of marine microbiome methodological options across a wide range of protocols, including large-scale variations in sampled volume.

Financial incentives for quitting smoking in pregnancy: Are they cost-effective?

AIMS

To evaluate whether adding financial incentives to usual care is cost-effective in encouraging pregnant women to quit tobacco smoking, compared with usual care alone.

DESIGN

Cost-effectiveness analysis (CEA) and cost-utility analysis (CUA) from a health-care provider's perspective, embedded in the Smoking Cessation in Pregnancy Incentives Trial (CPIT III). Long-term analyses were conducted from the same perspective, using an existing Markov model over a life-time horizon.

SETTING

Seven maternity smoking cessation sites in Scotland, England and Northern Ireland in the United Kingdom.

PARTICIPANTS

In the short-term analysis, CPIT III participants were assessed: women 16 years or older, self-reporting as smokers, fewer than 24 weeks pregnant and English-speaking (n = 944). The same population was used for the life-time analysis, plus their infants.

MEASUREMENTS

Costs included financial incentive vouchers and postage, cessation support and nicotine replacement therapy and neonatal stays. The outcome measure was a biochemically verified quit rate for the CEA and quality-adjusted life-years (QALYs) for CUA. Costs are presented in 2020 GBP sterling (£). Data for the life-time analysis came from the trial and were combined with data from published literature embedded in the model, reporting incremental cost per quitter and QALY. A 3.5% discount rate was applied.

FINDINGS

The short-term incremental cost per quitter was £4400 and cost per QALY was £150 000. Results of sensitivity analyses confirmed these results. The long-term analysis combined costs and outcomes for mother and infants; results showed a cost saving of £37 [95% confidence interval (CI]) = £35-106] and increase in QALYs of 0.171 (95% CI = 0.124-0.229). These findings indicate that, over a life-time, financial incentives are cost-saving and improve health outcomes.

CONCLUSIONS

In the United Kingdom, offering up to £400 financial incentives, in addition to usual care, to support pregnant women to stop smoking appears to be highly cost-effective over a life-time for mother and infants.

Centrally acting antihypertensives and alpha-blockers in people at risk of falls: therapeutic dilemmas-a clinical review

PURPOSE

The aim of this clinical review was to summarise the existing knowledge on the adverse effects of alpha-blockers and centrally acting antihypertensives, the effect these may have on falls risk, and guide deprescribing of these medications.

METHODS

Literature searches were conducted using PubMed and Embase. Additional articles were identified by searching reference lists and reference to personal libraries. We discuss the place of alpha-blockers and centrally acting antihypertensives in the treatment of hypertension and methods for deprescribing.

RESULTS

Alpha-blockers and centrally acting antihypertensives are no longer recommended for the treatment of hypertension unless all other agents are contraindicated or not tolerated. These medications carry a significant falls risk and non-falls risk-associated side effects. Tools to aid and guide de-prescribing and monitoring of the withdrawal of these medication classes are available to assist the clinician including information on reducing the risk of withdrawal syndromes.

CONCLUSIONS

Centrally acting antihypertensives and alpha-blockers increase the risk of falls through a variety of mechanisms-principally by increasing the risk of hypotension, orthostatic hypotension, arrhythmias and sedation. These agents should be prioritised for de-prescribing in older frailer individuals. We identify a number of tools and a withdrawal protocol to aid the clinician in identifying and de-prescribing these medications.

Compositional Variations between Adult and Infant Skin Microbiome: An Update

Human skin and its commensal microbiome form the first layer of protection to the outside world. A dynamic microbial ecosystem of bacteria, fungi and viruses, with the potential to respond to external insult, the skin microbiome has been shown to evolve over the life course with an alteration in taxonomic composition responding to altered microenvironmental conditions on human skin. This work sought to investigate the taxonomic, diversity and functional differences between infant and adult leg skin microbiomes. A 16S rRNA gene-based metataxonomic analysis revealed significant differences between the infant and adult skin groups, highlighting differential microbiome profiles at both the genus and species level. Diversity analysis reveals differences in the overall community structure and associated differential predicted functional profiles between the infant and adult skin microbiome suggest differing metabolic processes are present between the groups. These data add to the available information on the dynamic nature of skin microbiome during the life course and highlight the predicted differential microbial metabolic process that exists on infant and adult skin, which may have an impact on the future design and use of cosmetic products that are produced to work in consort with the skin microbiome.

A randomised controlled, feasibility study to establish the acceptability of early outpatient review and early cardiac rehabilitation compared to standard practice after cardiac surgery and viability of a future large-scale trial (FARSTER)

OBJECTIVE

To determine the acceptability and feasibility of delivering early outpatient review following cardiac surgery and early cardiac rehabilitation (CR), compared to standard practice to establish if a future large-scale trial is achievable.

METHODS

A randomised controlled, feasibility trial with embedded health economic evaluation and qualitative interviews, recruited patients aged 18-80 years from two UK cardiac centres who had undergone elective or urgent cardiac surgery via a median sternotomy. Eligible, consenting participants were randomised 1:1 by a remote, centralised randomisation service to postoperative outpatient review 6 weeks after hospital discharge, followed by CR commencement from 8 weeks (control), or postoperative outpatient review 3 weeks after hospital discharge, followed by commencement of CR from 4 weeks (intervention). The primary outcome measures related to trial feasibility including recruitment, retention, CR adherence, and acceptability to participants/staff. Secondary outcome measures included health-rated quality of life using EQ-5D-5L, NHS resource-use, Incremental Shuttle Walk Test (ISWT) distance, 30- and 90-day mortality, surgical site complications and hospital readmission rates.

RESULTS

Fifty participants were randomised (25 per group) and 92% declared fit for CR. Participant retention at final follow-up was 74%; completion rates for outcome data time points ranged from 28 to 92% for ISWT and 68 to 94% for follow-up questionnaires. At each time point, the mean ISWT distance walked was greater in the intervention group compared to the control. Mean utility scores increased from baseline to final follow-up by 0.202 for the intervention (0.188 control). Total costs were £1519 for the intervention (£2043 control). Fifteen participants and a research nurse were interviewed. Many control participants felt their outpatient review and CR could have happened sooner; intervention participants felt the timing was right. The research nurse found obtaining consent for willing patients challenging due to discharge timings.

CONCLUSION

Recruitment and retention rates showed that it would be feasible to undertake a full-scale trial subject to some modifications to maximise recruitment. Lower than expected recruitment and issues with one of the clinical tests were limitations of the study. Most study procedures proved feasible and acceptable to participants, and professionals delivering early CR.

TRIAL REGISTRATION

ISRCTN80441309 (prospectively registered on 24/01/2019).

Challenges and opportunities of sharing animal health data for research and disease management: a case study of bovine tuberculosis

The sharing of animal disease data should be encouraged. The analysis of such data will broaden our knowledge of animal diseases and potentially provide insights into their management. However, the need to conform to data protection rules in the sharing of such data for analysis purposes often poses practical difficulties. This paper sets out the challenges and the methods used for the sharing of animal health data in England, Scotland and Wales - Great Britain - using bovine tuberculosis (bTB) data as a case study. The data sharing described is undertaken by the Animal and Plant Health Agency on behalf of the Department for Environment, Food and Rural Affairs and the Welsh and Scottish Governments. It should be noted that animal health data are held at the level of Great Britain (rather than the United Kingdom - which includes Northern Ireland), as Northern Ireland's Department of Agriculture, Environment and Rural Affairs has its own separate data systems. Bovine tuberculosis is the most significant and costly animal health problem facing cattle farmers in England and Wales. It can be devastating for farmers and farming communities and the control costs for taxpayers in Great Britain are over £150 million a year. The authors describe two methods of data sharing - first, where data are requested by, and delivered to, an academic institution for epidemiological or scientific analysis, and second, where data are proactively published in an accessible and meaningful way. They provide details of an example of the second method, namely, the free-to-access website ‘information bovine TB' (https://ibtb.co.uk), which publishes bTB data for the benefit of the farming community and veterinary health professionals.

Understanding the Benefit of Magnetic Resonance-guided Adaptive Radiotherapy in Rectal Cancer Patients: a Single-centre Study

AIMS

Neoadjuvant chemoradiotherapy followed by surgery is the mainstay of treatment for patients with rectal cancer. Standard clinical target volume (CTV) to planning target volume (PTV) margins of 10 mm are used to accommodate inter- and intrafraction motion of target. Treating on magnetic resonance-integrated linear accelerators (MR-linacs) allows for online manual recontouring and adaptation (MRgART) enabling the reduction of PTV margins. The aim of this study was to investigate motion of the primary CTV (CTVA; gross tumour volume and macroscopic nodes with 10 mm expansion to cover microscopic disease) in order to develop a simultaneous integrated boost protocol for use on MR-linacs.

MATERIALS AND METHODS

Patients suitable for neoadjuvant chemoradiotherapy were recruited for treatment on MR-linac using a two-phase technique; only the five phase 1 fractions on MR-linac were used for analysis. Intrafraction motion of CTVA was measured between pre-treatment and post-treatment MRI scans. In MRgART, isotropically expanded pre-treatment PTV margins from 1 to 10 mm were rigidly propagated to post-treatment MRI to determine overlap with 95% of CTVA. The PTV margin was considered acceptable if overlap was >95% in 90% of fractions. To understand the benefit of MRgART, the same methodology was repeated using a reference computed tomography planning scan for pre-treatment imaging.

RESULTS

In total, nine patients were recruited between January 2018 and December 2020 with T3a-T4, N0-N2, M0 disease. Forty-five fractions were analysed in total. The median motion across all planes was 0 mm, demonstrating minimal intrafraction motion. A PTV margin of 3 and 5mm was found to be acceptable in 96 and 98% of fractions, respectively. When comparing to the computed tomography reference scan, the analysis found that PTV margins to 5 and 10 mm only acceptably covered 51 and 76% of fractions, respectively.

CONCLUSION

PTV margins can be reduced to 3-5 mm in MRgART for rectal cancer treatment on MR-linac within an simultaneous integrated boost protocol.

Rib fracture-related morbidity and mortality for older persons in the era of fascial plane blocks: A cohort study

Introduction

Analgesia is key to successful conservative, nonsurgical management of patients admitted to the hospital with multiple rib fractures. Recently, new fascial plane regional anesthesia techniques have become widely available. We hypothesized that since the introduction of these new regional analgesia techniques, for patients over the age of 65 years, the effect of increasing numbers of rib fractures has been mitigated.

Methods

A retrospective study of patients admitted for the management of rib fractures between 2017 and 2020 was performed. Patients not admitted to the hospital, under the age of 65 years, or with chest trauma other than rib fractures were not eligible for inclusion. The primary outcome of interest was mortality. The secondary outcomes were the incidence of pneumonia and intensive care unit admission. Results were reported as the odds ratio and its 95% confidence interval and associated p-value. Statistical significance was set at [Formula: see text] < 0.05.

Results

Overall, 252 patients were included and 142 patients received a regional anesthesia. The mortality rate was 4% (n = 10) with no association between mortality and number of rib fractures ( p = 0.215). Twenty-four patients (9.5%) developed pneumonia during their hospital stay, again with no association with an increasing number of rib fractures. The intensive care unit admission rate was 13.1% (n = 33) and correlated with an increasing number of fractures (odds ratio = 1.15; 95% confidence interval = 1.01 to 1.31; p = 0.038).

Conclusion

Management including liberal utilization of regional anesthesia for at-risk patients appears to mitigate the effect of increasing numbers of rib fractures on the incidence of mortality and pneumonia.

MRI-guided adaptive radiotherapy for prostate cancer: When do we need to account for intra-fraction motion?

A shift of the daily plan can mitigate target position changes that occur between daily MR acquisition and treatment for MR-linac radiotherapy, but increases the session time. We demonstrated that our workflow strategy and decision-making process, to determine whether a subsequent shift is necessary, is appropriate.

Effect of financial voucher incentives provided with UK stop smoking services on the cessation of smoking in pregnant women (CPIT III): pragmatic, multicentre, single blinded, phase 3, randomised controlled trial

OBJECTIVE

To examine effectiveness, cost effectiveness, generalisability, and acceptability of financial incentives for smoking cessation during pregnancy in addition to variously organised UK stop smoking services.

DESIGN

Pragmatic, multicentre, single blinded, phase 3, randomised controlled trial (Cessation in Pregnancy Incentives Trial phase 3 (CPIT III)).

SETTING

Seven UK stop smoking services provided in primary and secondary care facilities in Scotland, Northern Ireland, and England.

PARTICIPANTS

944 pregnant women (age ≥16 years) who self-reported as being smokers (at least one cigarette in the past week) when asked at first maternity visit, less than 24 weeks' gestation, and notified to the trial team by routine stop smoking services.

INTERVENTIONS

Participants in the control group were offered the standard stop smoking services, which includes the offer of counselling by specially trained workers using withdrawal orientated therapy and the offer of free nicotine replacement therapy. The intervention was the offer of usual support from the stop smoking services and the addition of up to £400 ($440; €455) of LoveToShop financial voucher incentives for engaging with current stop smoking services or to stop smoking, or both, during pregnancy.

MAIN OUTCOME MEASURES

Self-reported smoking cessation in late pregnancy (between 34 and 38 weeks' gestation) corroborated by saliva cotinine (and anabasine if using nicotine replacement products). Results were adjusted for age, smoking years, index of multiple deprivation, Fagerström score, before or after covid, and recruitment site. Secondary outcomes included point and continuous abstinence six months after expected date of delivery, engagement with stop smoking services, biochemically validated abstinence from smoking at four weeks after stop smoking date, birth weight of baby, cost effectiveness, generalisability documenting formats of stop smoking services, and acceptability to pregnant women and their carers.

RESULTS

From 9 January 2018 to 4 April 2020, of 4032 women screened by stop smoking services, 944 people were randomly assigned to the intervention group (n=471) or the control group (n=470). Three people asked for their data to be removed. 126 (27%) of 471 participants stopped smoking from the intervention group and 58 (12%) of 470 from the control group (adjusted odds ratio 2.78 (1.94 to 3.97) P<0.001). Serious adverse events were miscarriages and other expected pregnancy events requiring hospital admission; all serious adverse events were unrelated to the intervention. Most people who stopped smoking from both groups relapsed after their baby was born.

CONCLUSIONS

The offer of up to £400 of financial voucher incentives to stop smoking during pregnancy as an addition to current UK stop smoking services is highly effective. This bolt-on intervention supports new guidance from the UK National Institute for Health and Care Excellence, which includes the addition of financial incentives to support pregnant women to stop smoking. Continuing incentives to 12 months after birth is being examined to prevent relapse.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN15236311.

Automated deep learning quantification of epicardial adiposity on cardiac CT predicts atrial fibrillation risk immediately following cardiac surgery and long-term

Introduction

Epicardial adipose tissue (EAT) is a visceral fat deposit within the pericardial sac which surrounds the heart myocardium and coronary arteries. The automated quantification of EAT volume is possible from routine CCTA scans via a deep-learning approach. The use of automated EAT quantification for the assessment of atrial fibrillation (AF) risk in the post-operative period, and longer-term, has not been previously investigated.

Purpose

To apply a deep-learning approach for automated segmentation of EAT from routine CCTA scans to assess the immediate post-operative and long-term risk of AF conveyed by EAT.

Methods

A deep-learning automated EAT segmentation tool using a 3D Residual-U-Net neural network architecture for 3D volumetric segmentation of CCTA data was created and trained on over 2800 consecutive CCTA performed as part of clinical care in patients with stable chest pain from 2015 onwards within the European arm of the Oxford Risk Factors And Non Invasive Imaging (ORFAN) Study. External validation in 817patients demonstrated excellent correlation between machine and human expert (CCC = 0.972). The prognostic value of deep-learning derived EAT volume was assessed in the AdipoRedOx Study (n=253; UK patients undergoing cardiac surgery) against both immediate in-hospital outcomes and longer-term outcomes from UK-wide NHS data, with adjustment for AF risk factors.

Results

There were 97 cases of new-onset AF in the immediate post-operative period (38.3%). EAT volume was found to be an independent predictor of post-operative AF regardless of body mass index. Utilising the median EAT volume as the cut point, the adjusted hazard ratio (HR [95% CI]) for risk of new-onset post-operative AF in-hospital was 1.56 [1.09–3.85], p&lt;0.01 (Figure 1A). In receiver-operator characteristic analysis EAT volume added significant incremental prognostic power for the discrimination of in-hospital post-operative AF over a traditional risk factor model ΔAUC=0.101, p&lt;0.01 (Figure 1B).

Over a median follow-up period of 89 months there were 48 unique cases (19%) of confirmed AF found in nation-wide NHS hospital episode statistics data for the AdipoRedOx cohort. EAT volume was found to be a significant independent predictor of long-term AF. Utilising the median EAT volume as the cut point, the adjusted HR for risk of new-onset long-term AF following cardiac surgery was 1.25 [1.08–3.17], p&lt;0.01 (Figure 1C).

Conclusions

Automatically segmented EAT volume measured using a deep learning network predicts risk of both short-term new onset AF following cardiac surgery, and long-term risk of AF in the 7 years following the surgery independently of BMI and AF risk factors. This suggests that EAT is a potent mediator of AF risk in the post cardiac surgery setting.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): British Heart Foundation - TG/19/2/34831EU Commission - 965286

Search for Dark Matter Annihilation Signals in the H.E.S.S. Inner Galaxy Survey

The central region of the Milky Way is one of the foremost locations to look for dark matter (DM) signatures. We report the first results on a search for DM particle annihilation signals using new observations from an unprecedented γ-ray survey of the Galactic Center (GC) region, i.e., the Inner Galaxy Survey, at very high energies (≳100  GeV) performed with the H.E.S.S. array of five ground-based Cherenkov telescopes. No significant γ-ray excess is found in the search region of the 2014-2020 dataset and a profile likelihood ratio analysis is carried out to set exclusion limits on the annihilation cross section ⟨σv⟩. Assuming Einasto and Navarro-Frenk-White (NFW) DM density profiles at the GC, these constraints are the strongest obtained so far in the TeV DM mass range. For the Einasto profile, the constraints reach ⟨σv⟩ values of 3.7×10^{-26}  cm^{3} s^{-1} for 1.5 TeV DM mass in the W^{+}W^{-} annihilation channel, and 1.2×10^{-26}  cm^{3} s^{-1} for 0.7 TeV DM mass in the τ^{+}τ^{-} annihilation channel. With the H.E.S.S. Inner Galaxy Survey, ground-based γ-ray observations thus probe ⟨σv⟩ values expected from thermal-relic annihilating TeV DM particles.

Feasibility of tumour-focused adaptive radiotherapy for bladder cancer on the MR-linac

Bladder tumour-focused magnetic resonance image-guided adaptive radiotherapy using a 1.5 Tesla MR-linac is feasible. A full online workflow adapting to anatomy at each fraction is achievable in approximately 30 min. Intra-fraction bladder filling did not compromise target coverage with the class solution employed.

P-436 EndoTime: Non-categorical timing estimates for luteal endometrium

Study question

Can expression measurements of a small panel of genes be used to develop a continuous, non-categorical model for the improvement of endometrial biopsy timing accuracy?

Summary answer

Measuring expression levels of six genes (IL2RB, IGFBP1, CXCL14, DPP4, GPX3, and SLC15A2) is sufficient to obtain and assess substantially more accurate timing estimates.

What is known already

Commercially available endometrial timing approaches based on gene expression require much larger gene sets and use a categorical approach that classifies samples as pre-receptive, receptive, or post-receptive.

Study design, size, duration

Gene expression was measured by RT-qPCR in different sample sets, comprising a total of 664 endometrial biopsies obtained 4 to 12 days after a self-reported positive home ovulation test. A further 36 endometrial samples were profiled by RT-qPCR as well as RNA-sequencing.

Participants/materials, setting, methods

A computational procedure, named ‘EndoTime’, was established that models the temporal profile of each gene and estimates the timing of each sample. Iterating these steps, temporal profiles are gradually refined as sample timings are being updated, and confidence in timing estimates is increased. After convergence, the method reports updated timing estimates for each sample while preserving the overall distribution of time points.

Main results and the role of chance

The Wilcoxon rank-sum test was used to confirm that ordering samples by EndoTime estimates yields sharper temporal expression profiles for held-out genes (not used when determining sample timings) than ordering the same expression values by patient-reported times (GPX3 : p &lt; 0.005; CXCL14 : p &lt; 2.7e-6; DPP4 : p &lt; 3.7e-13). Pearson correlation between EndoTime estimates for the same sample set but based on RT-qPCR or RNA-sequencing data showed high degree of congruency between the two (p = 8.6e-10, R-squared = 0.687). Estimated timings did not differ significantly between control subjects and patients with recurrent pregnancy loss or recurrent implantation failure (p &gt; 0.05).

Limitations, reasons for caution

Timing estimates are informed by glandular gene expression and will only represent the temporal state of other endometrial cell types if in synchrony with the epithelium. Additionally, methods that estimate the day of ovulation are still required as these data are essential inputs in our method.

Wider implications of the findings

Our method is the first to assay the temporal state of endometrial samples on a continuous domain, enabling accurate temporal profiling of any gene in luteal phase biopsies for a wide range of research applications and, potentially, clinical use. It is freely available, open-source software including supporting data sets.

Trial registration number

Not applicable

Modest association between peak exercise blood pressure and ambulatory hypertension in endurance athletes

Funding Acknowledgements

Type of funding sources: None.

Background

An exaggerated blood pressure (BP) response to exercise may be an early indicator of hypertension. However, it is common in endurance athletes and the association between systolic blood pressure (SBP) during exercise and hypertension is not well established in this group.

Purpose

To establish whether there is an association between exercise-induced hypertension (EIH) and clinical hypertension in endurance athletes.

Methods

250 current and former endurance athletes (16-80 years, 75% male) performed a maximal exercise test on a cycle ergometer with BP measured every 2 min. Athletes were diagnosed with EIH based on international guidelines (SBP ≥210mmHg males, ≥190mmHg females). The relationship between SBP and workload was determined by linear regression analysis. Office hypertension was identified from either supine SBP ≥140mmHg or diastolic BP ≥90mmHg, or if treated for hypertension. Gold-standard 24-hour ambulatory blood pressure monitoring (ABPM) was performed in a subset of 42 athletes with EIH and 9 athletes with a normotensive response to exercise (NRE).

Results

On average, peak exercise SBP values were universally high (221±26mmHg in males and 199±21mmHg in females). 71% of athletes (70% of males and 74% of females) met criteria for EIH of which 12% had a peak SBP≥250mmHg. EIH and NRE groups were of similar age, sex, body mass index (BMI) and fitness (Figure 1). The strongest determinant of peak exercise SBP was exercise workload (R=0.78, P&lt;0.001), which remained significant after adjusting for age, sex, BMI and antihypertensive medication (p&lt;0.001) In the full cohort, resting SBP was higher in the EIH group (EIH: 128±13mmHg vs NRE: 122±15mmHg, P=0.006 – Figure 1), however there was a similar prevalence of office hypertension between the EIH (19%) and NRE (15%) groups (P=0.59). This prevalence remained similar (EIH: 13% vs NRE: 10%, P=0.49) after excluding those being treated for hypertension (n=15). In the subset of athletes who underwent 24h ABPM (n=51), there were no diagnoses of clinical hypertension in NRE (n=9, Figure 1). Of the 42 athletes with EIH, a majority (n=32, 76%) were normotensive on ABPM. In the 10 athletes with EIH and hypertension on ABPM, the majority were classified with Grade 1 hypertension (n=5) or daytime hypertension (n=3). Interestingly only two of these athletes would have been identified with office BP measures (see Figure 2).

Conclusion

EIH is common in endurance athletes and is strongly associated with peak exercise workloads suggesting this may be a reflection of superior cardiovascular fitness. In a small proportion of athletes, EIH may be associated with mild hypertension.

Assessing the impact on workflow of placing a pharmacy team in an emergency department

Introduction

The ED in our tertiary referral Hospital was working at capacity and invited pharmacy to send a team for a period to assess the impact they might have on workflow and doctor time, by carrying out detailed (level 2) medicine reconciliations and resolving medicine related issues at the outset.

Aim

To assess the impact that allocating an experienced pharmacist (Independent prescriber) together with a pharmacy technician might have on workflow and patient safety in ED.

Methods

The pharmacy team were directed to managing patients’ medicines carrying out the more comprehensive level 2 (1) medicines reconciliation (MR). This is a more thorough level of MR than that usually carried out on admission by a doctor (Level 1 MR). The time taken to conduct each MR was recorded. Interventions made were categorised by the clinical pharmacist using the MERP index. Five doctors were surveyed and asked how long they usually took to conduct a level 1 MR.

Results

132 MRs were carried out over 5 days. The pharmacist conducted 65 MRs mean time per MR 13.8 minutes SD 6.84 CI 90% (+/- 0.11) and the technician conducted 67 MRs mean time 23.73 minutes SD 11.07 CI 90% (+/- 0.17). The doctor group took 15 minutes (estimated) to conduct a level 1 MR SD 34.85 CI 90% (+/- 0.81). 1013 interventions were made, 15 were judged to be significant in terms of harm or potential harm and a further 128 related to non-prescribing of critical items (see table). A 90% Confidence interval was used reflecting the significant variance in time that a medicine reconciliation can take.

Conclusion

This project had limitations; it was brief, and the number of doctors surveyed few. However, it was adjudged to be a success in terms of doctor time saved (33 hours) and patient safety identifying 14 harm or potential harm occurrences and 128 critical medicines omissions at the outset of the patient journey. Following the project, the trust recognised the impact the team had and has subsequently funded an ED pharmacy team.

References

(1) Improving the Quality of Meds Reconciliation: A Best Practice Resource and Toolkit: V1.1 June 17 Specialist Pharmacy Service. Accessed Oct 2021 Medicines_Reconciliation_Best_Practice_Standards_Toolkit_Vs1.1_June-15-links-updated-Aug-17.pdf (sps.nhs.uk)

(2) Types of Medication Errors | NCC MERP, accessed 7/10/2021. https://www.nccmerp.org/types-medication-errors

Safety of direct oral anticoagulants (DOACs) vs. warfarin for people aged ≥ 75 years with atrial fibrillation: a cohort study

Introduction

Warfarin significantly reduces the risk of stroke in people with atrial fibrillation (AF), but historically has been underused in older people due to complicated dosage regimens. DOACs offer an attractive alternative to warfarin and were shown to be non-inferior in randomised controlled trials, however older people were underrepresented in these trials and there have been few studies investigating outcomes specifically in this high risk group (1).

Aim

To compare the risk of major, non-major, gastrointestinal, and intracranial bleeding between warfarin and DOACs in people aged ≥ 75 years with AF.

Methods

A cohort of patients aged ≥ 75 years with a diagnosis of AF was extracted from the Clinical Practice Research Datalink (CPRD). Patients could enter the study on the date of their first prescription for warfarin or a DOAC between 1/1/2013 and 27/12/2017. Patients were censored on the date of the outcome, death, or leaving the general practice. Switching between anticoagulants and unexposed periods were measured using prescription mapping. Crude and adjusted hazard rates of the risk of bleeding were calculated using a Cox proportional hazards model with oral anticoagulant prescribing as a time varying covariate.

Results

The cohort included 10,149 patients in the warfarin group and 10,237 in the DOAC group. The groups had similar characteristics and the average age was 81 in the warfarin group and 82 in the DOAC group. The table summarises the results. Whilst major and non-major bleeding was similar between all DOACs and warfarin, rivaroxaban was associated with higher risk and apixaban lower risk when analysed separately. Risk of gastrointestinal bleeding was higher with all DOACs and rivaroxaban than warfarin but apixaban was not significantly different. Few intracranial events occurred (n=131).

Conclusion

The results indicate that DOACs as a group are not significantly different to warfarin, however when analysed separately, apixaban may be safer. While the study relies on prescription data and hence it is not known if patients were taking the medications, the large cohort studied is representative of older people who are prescribed these medications in UK primary care.

Reference

(1) Mitchell A, Watson MC, Welsh T, McGrogan A. Effectiveness and safety of direct oral anticoagulants versus vitamin K antagonists for people aged 75 years and over with atrial fibrillation: A systematic review and meta-analyses of observational studies. Journal of Clinical Medicine. 2019; 8 (554).

Unifying the known and unknown microbial coding sequence space

Genes of unknown function are among the biggest challenges in molecular biology, especially in microbial systems, where 40–60% of the predicted genes are unknown. Despite previous attempts, systematic approaches to include the unknown fraction into analytical workflows are still lacking. Here, we present a conceptual framework, its translation into the computational workflow AGNOSTOS and a demonstration on how we can bridge the known-unknown gap in genomes and metagenomes. By analyzing 415,971,742 genes predicted from 1749 metagenomes and 28,941 bacterial and archaeal genomes, we quantify the extent of the unknown fraction, its diversity, and its relevance across multiple organisms and environments. The unknown sequence space is exceptionally diverse, phylogenetically more conserved than the known fraction and predominantly taxonomically restricted at the species level. From the 71 M genes identified to be of unknown function, we compiled a collection of 283,874 lineage-specific genes of unknown function for Cand. Patescibacteria (also known as Candidate Phyla Radiation, CPR), which provides a significant resource to expand our understanding of their unusual biology. Finally, by identifying a target gene of unknown function for antibiotic resistance, we demonstrate how we can enable the generation of hypotheses that can be used to augment experimental data.

It is estimated that scientists do not know what half of microbial genes actually do. When these genes are discovered in microorganisms grown in the lab or found in environmental samples, it is not possible to identify what their roles are. Many of these genes are excluded from further analyses for these reasons, meaning that the study of microbial genes tends to be limited to genes that have already been described.

These limitations hinder research into microbiology, because information from newly discovered genes cannot be integrated to better understand how these organisms work. Experiments to understand what role these genes have in the microorganisms are labor-intensive, so new analytical strategies are needed.

To do this, Vanni et al. developed a new framework to categorize genes with unknown roles, and a computational workflow to integrate them into traditional analyses. When this approach was applied to over 400 million microbial genes (both with known and unknown roles), it showed that the share of genes with unknown functions is only about 30 per cent, smaller than previously thought. The analysis also showed that these genes are very diverse, revealing a huge space for future research and potential applications. Combining their approach with experimental data, Vanni et al. were able to identify a gene with a previously unknown purpose that could be involved in antibiotic resistance.

This system could be useful for other scientists studying microorganisms to get a more complete view of microbial systems. In future, it may also be used to analyze the genetics of other organisms, such as plants and animals.

Alteration of barrier properties, stratum corneum ceramides and microbiome composition in response to lotion application on cosmetic dry skin

Xerosis, commonly referred to as dry skin, is a common dermatological condition affecting almost a third of the population. Successful treatment of the condition traditionally involves the application of cosmetic products facilitating the moisturisation of the skin with a range of ingredients including glycerol and fatty acids. While the effectiveness of these treatments is not in question, limited information exists on the impact on the skin microbiome following use of these products and the improvement in skin hydration. Here, we describe improvements in skin barrier properties together with increased levels of cholesterol, ceramides and long-chain fatty acids following application of Body Lotion. Concomitant alterations in the skin microbiome are also seen via 16S rRNA metataxonomics, in combination with both traditional and novel informatics analysis. Following 5 weeks of lotion use, beneficial skin bacteria are increased, with improvements in microbiome functional potential, and increases in pathways associated with biosynthesis of multiple long chain fatty acids.

Time-resolved hadronic particle acceleration in the recurrent nova RS Ophiuchi

Recurrent novae are repeating thermonuclear explosions in the outer layers of white dwarfs, due to the accretion of fresh material from a binary companion. The shock generated when ejected material slams into the companion star's wind can accelerate particles. We report very-high-energy (VHE, [Formula: see text]) gamma rays from the recurrent nova RS Ophiuchi, up to a month after its 2021 outburst, observed using the High Energy Stereoscopic System. The VHE emission has a similar temporal profile to lower-energy GeV emission, indicating a common origin, with a two-day delay in peak flux. These observations constrain models of time-dependent particle energization, favoring a hadronic emission scenario over the leptonic alternative. Shocks in dense winds provide favorable environments for efficient acceleration of cosmic-rays to very high energies.

Can We Prevent Depression in At-Risk Older Adults Using Self-Help? The UK SHARD Trial of Behavioral Activation

BACKGROUND

Treatment of established depression is the dominant approach to care of older adults, but prevention holds much promise. Self-help interventions are a feasible preventive approach, since they are scalable and low cost. There are few trials in this area. Behavioral Activation (BA) is a credible candidate psychological approach, which has been shown to work in therapist led care but not been trialled in a self-help form.

AIM

To test the effectiveness of an unguided self-help intervention based on BA for older adults.

METHODS

We compared a self-help intervention based on BA for older people (n = 172) to usual care (n = 160) in a pragmatic randomized controlled trial. Outcomes were depression status and severity (PHQ9) and health related quality of life (SF12). The primary timepoint of the primary outcome was depression at 4 months, with longer term follow up at 12 months to test sustained impact of the primary outcome.

RESULTS

At 4 months adjusted PHQ-9 scores for BA self-help were 0.79 lower (95% CI: -1.70 to 0.13; p = 0.09) and the proportion of participants with case-level depression was significantly reduced (BA 31/137 (22.6%) versus usual care 41/141 (29.1%); Odds Ratio 0.48; 95% CI: 0.26-0.92; p = 0.03). There was no PHQ-9 difference at 12 months or for health related quality of life at any point (4 or 12 months).

DISCUSSION

Self-help using BA for older people at risk of depression is a feasible and scalable intervention with potential short-term benefits in preventing depression.

Examining the effectiveness of Gateway-an out-of-court community-based intervention to reduce recidivism and improve the health and well-being of young adults committing low-level offences: study protocol for a randomised controlled trial

BACKGROUND

Young adult offenders represent a third of the UK prison population and are at risk of poor health outcomes including drug and alcohol misuse, self-harm and suicide. Court diversion interventions aim to reduce the negative consequences of formal criminal justice sanctions and focus resources on addressing the root causes of offending. Although diversions are widely used, evidence of their effectiveness has not yet been established. Hampshire Constabulary, working together with local charities, have developed the Gateway programme, an out-of-court intervention aimed at improving the life chances of young adults. Issued as a conditional caution, participants undertake a health and social care needs assessment, attend workshops encouraging analysis of own behaviour and its consequences and agree not to re-offend during the 16-week caution.

METHODS

This is a pragmatic, multi-site, parallel-group, superiority randomised controlled trial with a target sample size of 334. Participants are aged 18-24, reside in Hampshire and Isle of Wight and are being questioned for an eligible low-level offence. Police investigators offer potential participants a chance to receive the Gateway caution, and those interested are also invited to take part in the study. Police officers obtain Stage 1 consent and carry out an eligibility check, after which participants are randomised on a 1:1 basis either to receive Gateway or follow the usual process, such as court appearance or a different conditional caution. Researchers subsequently obtain Stage 2 consent and collect data at weeks 4 and 16, and 1 year post-randomisation. The primary outcome is the Warwick-Edinburgh Mental Well-being Scale (WEMWBS). Secondary outcomes include health status, alcohol and drug use, recidivism and resource use. The primary analysis will compare the WEMWBS score between the two groups at 12 months.

DISCUSSION

This pioneering trial aims to address the evidence gap surrounding diversion in 18-24-year-olds. The findings will inform law enforcement agencies, third sector organisations, policymakers and commissioners, as well as researchers working in related fields and with vulnerable target populations.

TRIAL REGISTRATION

International Standard Randomised Controlled Trial Register ( ISRCTN 11888938 ).

The Seasons of COVID-19: understanding the mood of older adults in the UK through a barometer survey spanning 12 months

During the COVID-19 pandemic, universities have changed to an online or hybrid format. These changes provide the opportunity for universities to be more accessible for all individuals. However, the logistics of university life during a pandemic has exposed significant and potentially enduring challenges and opportunities for designing and maintaining an Age-Friendly University. This study investigates perceptions of students, faculty, and staff in the lens of an age friendly university during the COVID-19 pandemic. This study draws on qualitative and quantitative data from over 10,000 faculty, staff, students, and life-long learners from 26 universities. Five items were asked to constituent groups about their perceptions on their university’s response to COVID-19. Overall, students had the poorest average perception of satisfaction with their university’s overall response to the pandemic, with 62% satisfied compared to 74% and 73% of faculty and staff, respectively. Further, 77% of faculty think the university’s response to continuing education accommodated their needs, compared to 69% of students. Respondents from private universities reported more positive satisfaction than respondents from public universities (M=4.23, SD=0.94; t(df=7405)=6.805, p<.001). Qualitative data suggest that older students and faculty needed more technological assistance during this transition to primarily online learning to keep older members involved in the community. Older staff felt that they were more likely to be furloughed and were the group most likely to not have a choice in working on or off campus.

Providing care for older adults in the Emergency Department: expert clinical recommendations from the European Task Force on Geriatric Emergency Medicine

Aim

The aim was to develop expert clinical recommendations on Geriatric Emergency Medicine to be disseminated across Europe.

Findings

Eight posters with expert clinical guidelines on the most important topics in Geriatric Emergency Medicine are now available through https://posters.geriemeurope.eu/.

Message

Expert clinical recommendations for Geriatric Emergency Medicine in Europe were created and are ready for dissemination across Europe.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41999-021-00578-1.

Purpose

Despite the rapidly expanding knowledge in the field of Geriatric Emergency Medicine in Europe, widespread implementation of change is still lacking. Many opportunities in everyday clinical care are missed to improve care for this susceptible and growing patient group. The aim was to develop expert clinical recommendations on Geriatric Emergency Medicine to be disseminated across Europe.

Methods

A group of multi-disciplinary experts in the field of Geriatric Emergency Medicine in Europe was assembled. Using a modified Delphi procedure, a prioritized list of topics related to Geriatric Emergency Medicine was created. Next, a multi-disciplinary group of nurses, geriatricians and emergency physicians performed a review of recent guidelines and literature to create recommendations. These recommendations were voted upon by a group of experts and placed on visually attractive posters. The expert group identified the following eight subject areas to develop expert recommendations on: Comprehensive Geriatric Assessment in the Emergency Department (ED), age/frailty adjusted risk stratification, delirium and cognitive impairment, medication reviews in the ED for older adults, family involvement, ED environment, silver trauma, end of life care in the acute setting.

Results

Eight posters with expert clinical recommendations on the most important topics in Geriatric Emergency Medicine are now available through https://posters.geriemeurope.eu/.

Conclusion

Expert clinical recommendations for Geriatric Emergency Medicine may help to improve care for older patients in the Emergency Department and are ready for dissemination across Europe.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41999-021-00578-1.

Revealing x-ray and gamma ray temporal and spectral similarities in the GRB 190829A afterglow

Gamma-ray bursts (GRBs), which are bright flashes of gamma rays from extragalactic sources followed by fading afterglow emission, are associated with stellar core collapse events. We report the detection of very-high-energy (VHE) gamma rays from the afterglow of GRB 190829A, between 4 and 56 hours after the trigger, using the High Energy Stereoscopic System (H.E.S.S.). The low luminosity and redshift of GRB 190829A reduce both internal and external absorption, allowing determination of its intrinsic energy spectrum. Between energies of 0.18 and 3.3 tera-electron volts, this spectrum is described by a power law with photon index of 2.07 ± 0.09, similar to the x-ray spectrum. The x-ray and VHE gamma-ray light curves also show similar decay profiles. These similar characteristics in the x-ray and gamma-ray bands challenge GRB afterglow emission scenarios.

Investigating Changes in Patients' Smoking Behavior, Tobacco Dependence, and Motivation to Stop Smoking Following a "Smoke-Free" Mental Health Inpatient Stay: Results From a Longitudinal Survey in England

INTRODUCTION

In line with national guidance, mental health Trusts in England are implementing complete smoke-free policies. We investigated inpatients' changes in smoking behavior, tobacco dependence, vaping, and motivation to stop smoking between pre-admission and post-discharge.

METHODS

We surveyed acute adult mental health inpatients from 14 wards in three mental health Trusts in England in 2019. Structured face-to-face and telephone interviews with patients who smoked on or during admission were conducted during the admission period and at one week and one month after discharge. Data on smoking status; daily cigarette consumption; Heaviness of Smoking Index (HSI); Strength of Urges to Smoke (SUTS); Motivation to Stop Smoking (MTSS) and vaping were collected and analyzed using regression and probit models.

RESULTS

Inpatient smoking prevalence was 51.9%, and a total of 152 of all 555 eligible smokers (27%) were recruited. Attrition was high: 49.3% at the first and 50.7% at the second follow-up interview. Changes in self-reported smoking status, motivation to quit, and vaping did not change significantly over the study period. Cigarette consumption (p < 0.001) and Heaviness of Smoking Index (p < 0.001) modestly reduced. The frequency and strength of urges to smoke (p = 0.011 and 0.012, respectively) decreased modestly after discharge but were scored as high by 57% and 60% of participants during admission respectively. Just over half (56%) reported being offered smoking cessation support on admission.

CONCLUSIONS

This study identified very modest changes in smoking-related outcomes during and after admission and indicates major challenges to smoke-free policy implementation, including limited support for patients who smoke.

IMPLICATIONS

Despite mental health Trusts in England had developed and implemented smoke-free policies to meet national guidelines, adherence to these policies and provision of effective smoking cessation and temporary abstinence support for inpatients admitted to acute adult mental health wards appear to be limited. Patients who smoke on admission are likely to continue to do so during admission and after discharge, and only a very modest change in smoking behaviors appears to take place. Important opportunities to promote smoking cessation in this population are missed. Barriers to effective support need to be identified and addressed.

A multicentre, randomized, parallel group, superiority study to compare the clinical effectiveness and cost-effectiveness of external frame versus internal locking plate for complete articular pilon fracture fixation in adults

AIMS

A pilon fracture is a severe ankle joint injury caused by high-energy trauma, typically affecting men of working age. Although relatively uncommon (5% to 7% of all tibial fractures), this injury causes among the worst functional and health outcomes of any skeletal injury, with a high risk of serious complications and long-term disability, and with devastating consequences on patients' quality of life and financial prospects. Robust evidence to guide treatment is currently lacking. This study aims to evaluate the clinical and cost-effectiveness of two surgical interventions that are most commonly used to treat pilon fractures.

METHODS

A randomized controlled trial (RCT) of 334 adult patients diagnosed with a closed type C pilon fracture will be conducted. Internal locking plate fixation will be compared with external frame fixation. The primary outcome and endpoint will be the Disability Rating Index (a patient self-reported assessment of physical disability) at 12 months. This will also be measured at baseline, three, six, and 24 months after randomization. Secondary outcomes include the Olerud and Molander Ankle Score (OMAS), the five-level EuroQol five-dimenison score (EQ-5D-5L), complications (including bone healing), resource use, work impact, and patient treatment preference. The acceptability of the treatments and study design to patients and health care professionals will be explored through qualitative methods.

DISCUSSION

The two treatments being compared are the most commonly used for this injury, however there is uncertainty over which is most clinically and cost-effective. The Articular Pilon Fracture (ACTIVE) Trial is a sufficiently powered and rigorously designed study to inform clinical decisions for the treatment of adults with this injury. Cite this article: Bone Jt Open 2021;2(3):150-163.

The InterPro protein families and domains database: 20 years on

The InterPro database (https://www.ebi.ac.uk/interpro/) provides an integrative classification of protein sequences into families, and identifies functionally important domains and conserved sites. InterProScan is the underlying software that allows protein and nucleic acid sequences to be searched against InterPro's signatures. Signatures are predictive models which describe protein families, domains or sites, and are provided by multiple databases. InterPro combines signatures representing equivalent families, domains or sites, and provides additional information such as descriptions, literature references and Gene Ontology (GO) terms, to produce a comprehensive resource for protein classification. Founded in 1999, InterPro has become one of the most widely used resources for protein family annotation. Here, we report the status of InterPro (version 81.0) in its 20th year of operation, and its associated software, including updates to database content, the release of a new website and REST API, and performance improvements in InterProScan.

Provision of dietary advice for people with an ileostomy: a survey in the UK and Ireland

AIM

The aim was to explore whether people with an ileostomy in the UK and Ireland receive the dietary advice they require.

METHOD

An online survey with multiple-choice questions asked people with an ileostomy about the dietary advice they received and would have preferred to receive. Participants were recruited via websites of the Ileostomy and Internal Pouch Association and Crohn's and Colitis UK and via social media. People with a current ileostomy, age 16 years or over, and living in the UK or Ireland were eligible for inclusion. Responses were analysed using descriptive statistics.

RESULTS

In all, 291 eligible responses were received and included in the analysis; 201 (69%) received advice on diet for their ileostomy from a healthcare professional or the internet. Of the 90 who did not receive dietary advice, 82 (91%) would have liked advice. Stoma nurses were the most common source of dietary advice (55%), but many other sources were frequently reported. Most (62%) felt that at least some dietary advice they received was conflicting. Over half (55%) felt anxious about managing their diet with a new ileostomy, 39% were confused, and 31% frustrated. Of 291 respondents, 29% received advice from a dietitian compared to 60% who would have preferred advice from a dietitian.

CONCLUSION

Many people undergoing ileostomy surgery do not receive the dietary advice and support they require. Healthcare professionals working with people with an ileostomy should be mindful they are often anxious about their diet and require clear and consistent dietary advice and support.