Planning Considerations for the Primary Lung Tumor Stereotactic Body Radiation Therapy Followed by Concurrent Mediastinal Radiotherapy for Locally-Advanced Non-Small Cell Lung Cancer

PURPOSE/OBJECTIVE(S)

Phase III prospective randomized trial of primary lung tumor stereotactic body radiation therapy followed by concurrent mediastinal chemoradiation for locally-advanced non-small cell lung cancer (NRG LU-008), designed to lower the rates of radiation pneumonitis and improve the progression-free survival, is expected to become active nationally in July 2023. Due to the specific nature of the cases selected for this trial, a new approach to treatment planning had to be developed to satisfy the conditions of the trial. Levice Cancer Institute (Atrium Health, North Carolina) ran the initial Phase II trial and investigated several approaches, providing recommendations for the future dosimetry planning approach.

MATERIALS/METHODS

A total of 60 patients were selected for the initial trial and treated with a combination of SBRT treatment to the primary tumor (50-54 Gy in 3-5 fractions) and conventional IMRT treatment to 60 Gy to the involved lymph nodes for patients with stage 3 or unresectable stage II NSCLC, combined with chemotherapy. Depending on the location of the primary tumor, all cases could be subdivided into no overlap between the SBRT and IMRT targets, adjacent targets, and overlapping targets. All SBRT plans were done with a 6X-FFF beam, advanced dose calculation algorithm, and 0.1 cm grid size. IMRT targets were primarily treated with VMAT plans, though a minority of cases were planned with the DMLC technique, with a 6X beam, advanced dose calculation algorithm, and 0.25 cm grid size. Various approaches to the planning included target cropping, avoidance via adjusting optimization objectives and utilizing the base dose of the SBRT plan to optimize the dose for the IMRT nodal plan. Various geometries utilized in the plan included a variation in the number of arcs, covered arc angles, and the number of beams.

RESULTS

A significant reduction in the side effects was achieved throughout the trial, with only three patients experiencing grade 3 or higher pneumonitis, 3 patients experiencing grade 3 or higher cardiotoxicity, and 1 patient experiencing grade 3 esophagitis. For targets with no significant overlap between the primary tumor and nodal target, standard planning techniques proved to be sufficient. For the overlapping targets, the planning approach of utilizing 2 arcs, >180-degree coverage, for the SBRT plan, and using ¼ of the base SBRT dose to plan the IMRT nodal plan provided the best target coverage while achieving sufficient OAR sparing.

CONCLUSION

Planning the joint SBRT-IMRT plan in the cases of a significant target overlap requires a careful approach, but is feasible with the proposed guideline and should be achievable for any center electing to participate in the NRG LU-008 trial.

The impact of COVID-19 on cancer patients, their carers and oncology health professionals: A qualitative study

OBJECTIVE

Cancer patients, carers and oncology health professionals have been impacted by the COVID-19 pandemic in many ways, but their experiences and psychosocial responses to the pandemic are still being explored. This study aimed to document the experience of Australians living with cancer, family carers, and Oncology health professionals (HPs) when COVID-19 first emerged.

METHODS

In this qualitative study, participants (cancer patients currently receiving treatment, family carers and HPs) completed a semi-structured interview exploring their experiences of COVID-19 and the impact it had on cancer care. Participants also completed the Hospital Anxiety and Depression Scale (patients) and the Depression, Anxiety and Stress Scale (carers and HPs) to assess emotional morbidity. Thematic analysis was undertaken on qualitative data.

RESULTS

32 patients, 16 carers and 29 HPs participated. Qualitative analysis yielded three shared themes: fear and death anxiety, isolation, and uncertainty. For HPs, uncertainty incorporated the potential for moral distress and work-stress. Patients and carers scoring high on anxiety/depression measures were more likely to have advanced disease, expressed greater death anxiety, talked about taking more extreme precautionary measures, and felt more impacted by isolation.

CONCLUSION

Cancer and COVID-19 can have compounding psychological impacts on all those receiving or giving care.

PRACTICE IMPLICATIONS

Screening for distress in patients, and burnout in HPs, is recommended. Increased compassionate access and provision of creative alternatives to face-to-face support are warrented.

Strategic resources for assessing PFAS ecological risks at AFFF sites

The use of aqueous film forming foam (AFFF) in the United States has caused concern about the potential effects of per- and polyfluoroalkyl substances (PFAS) on ecological resources. Moreover, the limited availability of scientific information and a lack of guidance have collectively resulted in significant challenges for ecological risk assessors supporting site-specific investigations and management decisions at PFAS-impacted sites. To address these needs, the environmental science and technology program of the Department of Defense (DoD), the Strategic Environmental Research and Development Program (SERDP), began funding four desktop review projects in 2018. Project teams were tasked with developing strategic guidance for assessing ecological risk at AFFF-impacted DoD sites. The projects focused specifically on ecological risk assessment practices for threatened and endangered (T&E) species; however, the recommendations and approaches presented in the projects are also applicable and adaptable to common species. The present review provides risk assessors and site managers an overview of how the resources provided in these projects can support ecological-risk-based management decisions at AFFF and other PFAS-impacted sites. Additionally, we synthesize perspectives offered by the four projects on a path forward for PFAS ecological risk assessment, including research needs that we recommend should be prioritized by the scientific community. Integr Environ Assess Manag 2021;17:746-752. © 2021 SETAC.

Transepithelial nasal potential difference in patients with, and at risk of acute respiratory distress syndrome

BACKGROUND

Impaired alveolar fluid clearance, determined in part by alveolar sodium transport, is associated with acute respiratory distress syndrome (ARDS). Nasal sodium transport may reflect alveolar transport. The primary objective of this prospective, observational study was to determine if reduced nasal sodium transport, as measured by nasal potential difference (NPD), was predictive of the development of and outcome from ARDS.

METHODS

NPD was measured in 15 healthy controls and in 88 patients: 40 mechanically ventilated patients defined as 'at-risk' for ARDS, 61 mechanically ventilated patients with ARDS (13 who were previously included in the 'at-risk' group) and 8 ARDS survivors on the ward.

RESULTS

In at-risk subjects, maximum NPD (mNPD) was greater in those who developed ARDS (difference -8.4 mV; 95% CI -13.8 to -3.7; p=0.005) and increased mNPD predicted the development of ARDS before its onset (area under the curve (AUC) 0.75; 95% CI 0.59 to 0.89). In the ARDS group, mNPD was not significantly different for survivors and non-survivors (p=0.076), and mNPD was a modest predictor of death (AUC 0.60; 95% CI 0.45 to 0.75). mNPD was greater in subjects with ARDS (-30.8 mV) than in at-risk subjects (-24.2 mV) and controls (-19.9 mV) (p<0.001). NPD values were not significantly different for survivors and controls (p=0.18).

CONCLUSIONS

Increased NPD predicts the development of ARDS in at-risk subjects but does not predict mortality. NPD increases before ARDS develops, is greater during ARDS, but is not significantly different for controls and survivors. These results may reflect the upregulated sodium transport necessary for alveolar fluid clearance in ARDS. NPD may be useful as a biomarker of endogenous mechanisms to stimulate sodium transport. Larger studies are now needed to confirm these associations and predictive performance.

To assess the confidence levels of psychiatrists in physical healthcare competencies in one irish region, and to explore whether confidence was related to learning opportunities

Introduction

The bi-directional relationship between mental and physical illness is well established. Therefore, in order to lower the already high mortality rates associated with psychiatric disorders, physical health issues must be closely monitored in this population [1,2]. A recent Lancet commission highlights emerging strategies and recommendations for improvement of physical health outcomes in patients with chronic mental disorders. These strategies involve better integration of physical and mental health care, combined with broader implementation of lifestyle interventions to reduce elevated cardiometabolic risk and attenuate medication side-effects [3].

Objectives

To assess psychiatrists’ confidence levels in physical healthcare competencies; to explore whether confidence was related to learning opportunities.

Methods

Physical healthcare learning objectives were extracted from the Irish College of Psychiatrists’ training curriculum. An electronic questionnaire was sent to 50 psychiatrists in one Irish healthcare region with a catchment area of c. 450,000. Participants had to rate confidence levels for each competency on a five-point Likert scale and the availability of learning opportunities for attaining each competency.

Results

66% response rate was achieved. A majority reported confidence in cardiovascular examination, interpreting blood results and evaluating comorbidities. A minority reported confidence in interpreting imaging, electrocardiograms and recognising medical emergencies. This corresponds to a relative paucity of learning opportunities.

Conclusions

Clinical implication Programmes for trainee doctors and CME opportunities for consultant psychiatrists would benefit from an emphasis on physical health examination and modules on interpreting investigations and the recognition of medical emergencies.

PFAS Exposure Pathways for Humans and Wildlife: A Synthesis of Current Knowledge and Key Gaps in Understanding

We synthesize current understanding of the magnitudes and methods for assessing human and wildlife exposures to poly- and perfluoroalkyl substances (PFAS). Most human exposure assessments have focused on 2 to 5 legacy PFAS, and wildlife assessments are typically limited to targeted PFAS (up to ~30 substances). However, shifts in chemical production are occurring rapidly, and targeted methods for detecting PFAS have not kept pace with these changes. Total fluorine measurements complemented by suspect screening using high-resolution mass spectrometry are thus emerging as essential tools for PFAS exposure assessment. Such methods enable researchers to better understand contributions from precursor compounds that degrade into terminal perfluoroalkyl acids. Available data suggest that diet is the major human exposure pathway for some PFAS, but there is large variability across populations and PFAS compounds. Additional data on total fluorine in exposure media and the fraction of unidentified organofluorine are needed. Drinking water has been established as the major exposure source in contaminated communities. As water supplies are remediated, for the general population, exposures from dust, personal care products, indoor environments, and other sources may be more important. A major challenge for exposure assessments is the lack of statistically representative population surveys. For wildlife, bioaccumulation processes differ substantially between PFAS and neutral lipophilic organic compounds, prompting a reevaluation of traditional bioaccumulation metrics. There is evidence that both phospholipids and proteins are important for the tissue partitioning and accumulation of PFAS. New mechanistic models for PFAS bioaccumulation are being developed that will assist in wildlife risk evaluations. Environ Toxicol Chem 2021;40:631-657. © 2020 SETAC.

Effect of Ultraviolet C Disinfection Treatment on the Nanomechanical and Topographic Properties of N95 Respirator Filtration Microfibers

Ultraviolet germicidal irradiation (UVGI) N95 filtering facepiece respirator (FFR) treatment is considered an effective decontamination approach to address the supply shortage of N95 FFRs during the ongoing Covid-19 pandemic. In this study, we investigated the nanomechanical and topographic properties of filtration fibers that have been exposed to different doses of UVC radiation. UVC exposure was shown to decrease both Young’s modulus (E), hardness (H) and fiber width, as measured on individual polypropylene (PP) fibers. Our results also show that the PP microfiber layer loses its strength when N95 respirators are exposed to an accumulated UVC dose during the process of decontamination, and the PP fiber width also exhibits a logarithmic decrease during UVC exposure. The nanoscale measurement results on individual fibers suggest that maximum cycles of UVC disinfection treatment should be limited due to excessive accumulated dose, which has the potential to decrease the fiber breaking strength.

Impact of maternal obesity on fetal cardiac screening: which follow-up strategy is cost-effective?

OBJECTIVE

To perform a cost-effectiveness analysis of different follow-up strategies for non-obese and obese women who had incomplete fetal cardiac screening for major congenital heart disease (CHD).

METHODS

Three decision-analytic models, one each for non-obese, obese and Class-III-obese women, were developed to compare five follow-up strategies for initial suboptimal fetal cardiac screening. The five strategies were: (1) no follow-up ultrasound (US) examination but direct referral to fetal echocardiography (FE); (2) one follow-up US, then FE if fetal cardiac views were still suboptimal; (3) up to two follow-up US, then FE if fetal cardiac views were still suboptimal; (4) one follow-up US and no FE; and (5) up to two follow-up US and no FE. The models were designed to identify fetuses with major CHD in a theoretical cohort of 4 000 000 births in the USA. Outcomes related to neonatal mortality and neurodevelopmental disability were evaluated. A cost-effectiveness willingness-to-pay threshold was set at US$100 000 per quality-adjusted life year (QALY). Base-case and sensitivity analysis and Monte-Carlo simulation were performed.

RESULTS

In our base-case models for all body mass index (BMI) groups, no follow-up US, but direct referral to FE led to the best outcomes, detecting 7%, 25% and 82% more fetuses with CHD in non-obese, obese and Class-III-obese women, respectively, compared with the baseline strategy of one follow-up US and no FE. However, no follow-up US, but direct referral to FE was above the US$100 000/QALY threshold and therefore not cost-effective. The cost-effective strategy for all BMI groups was one follow-up US and no FE. Both up to two follow-up US with no FE and up to two follow-up US with FE were dominated (being more costly and less effective), while one follow-up US with FE was over the cost-effectiveness threshold. One follow-up US and no FE was the optimal strategy in 97%, 93% and 86% of trials in Monte-Carlo simulation for non-obese, obese and Class-III-obese models, respectively.

CONCLUSION

For both non-obese and obese women with incomplete fetal cardiac screening, the optimal CHD follow-up screening strategy is no further US and immediate referral to FE; however, this strategy is not cost-effective. Considering costs, one follow-up US and no FE is the preferred strategy. For both obese and non-obese women, Monte-Carlo simulations showed clearly that one follow-up US and no FE was the optimal strategy. Both non-obese and obese women with initial incomplete cardiac screening examination should therefore be offered one follow-up US. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Detection of fetal cardiac anomalies: cost-effectiveness of increased number of cardiac views

OBJECTIVE

To compare the recommended three-view fetal heart screening method to detect major congenital heart disease (CHD) with more elaborate screening strategies to determine the cost-effective strategy in unselected (low-risk) pregnancies.

METHODS

A decision-analytic model was designed to compare four screening strategies to identify fetuses with major CHD in a theoretical cohort of 4 000 000 births in the USA. The four strategies were: (1) three views: four-chamber view (4CV) and views of the left (LVOT) and right (RVOT) ventricular outflow tracts; (2) five views: 4CV, LVOT, RVOT and longitudinal views of the ductal arch and aortic arch; (3) five axial views: 4CV, LVOT, RVOT, three-vessel (3V) view and three-vessels-and-trachea view; and (4) six views: 4CV, LVOT, RVOT and 3V views and longitudinal views of the ductal arch and aortic arch. Outcomes related to neonatal mortality and neurodevelopmental disability were evaluated. The analysis was performed from a healthcare-system perspective, with a cost-effectiveness willingness-to-pay threshold set at $100 000 per quality-adjusted life year (QALY). Baseline analysis, one-way sensitivity analysis and Monte-Carlo simulation were performed.

RESULTS

In our baseline model, screening with five axial views was the optimal strategy, detecting 3520 more CHDs, and resulting in 259 fewer children with neurodevelopmental disability, 40 fewer neonatal deaths and only slightly higher costs, compared with screening with the currently recommended three views. Screening with six views was more effective, but also cost considerably more, compared with screening with five axial views, and had an incremental cost of $490 023/QALY, which was over the willingness-to-pay threshold. The five-view strategy was dominated by the other three strategies, i.e. it was more costly and less effective in comparison. The data were robust when tested with Monte-Carlo and one-way sensitivity analysis.

CONCLUSION

Although current guidelines recommend a minimum of three views for detecting CHD during the mid-trimester anatomy scan, screening with five axial views is a cost-effective strategy that may lead to improved outcome compared with three-view screening. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.

The Social and Psychological Correlates of Happiness in Seventeen European Countries: Analysis of Data from the European Social Survey

Background:

Happiness has been associated with a number of individual and societal factors, but much of the individual-to-individual variation in happiness remains unexplained. The purpose of this paper is to examine a broad range of social and psychological correlates of self-rated happiness in Europe.

Methods:

We used data from the European Social Survey to determine levels of happiness in individuals (n=30,816) from seventeen European countries and to identify associations between happiness and age, gender, family relationships, satisfaction with income, employment status, community trust, satisfaction with health, satisfaction with democracy, religious belief and country of residence.

Results:

Self-rated happiness varies significantly between European countries, with individuals in Denmark reporting the highest levels of happiness and individuals in Bulgaria reporting the lowest levels. On multi-variable analysis, happiness is positively correlated with younger age, satisfaction with household income, being employed, high community trust and religious belief. Overall, these factors account for 22.5% of the individual-to-individual variation in happiness in Europe.

Conclusion:

For the individual, this study highlights the strength of association between happiness and the individual's attitudes towards various aspects of their personal, household and societal circumstances. For social policy-makers, this study confirms the potential usefulness of civic measures to increase community trust and social capital. Further studies of the inter-relationships between individual and community-level variables would assist in further explaining the variance in happiness between individuals and countries.

Society of pediatric liver transplantation: Current registry status 2011-2018

BACKGROUND

SPLIT was founded in 1995 in order to collect comprehensive prospective data on pediatric liver transplantation, including waiting list data, transplant, and early and late outcomes. Since 2011, data collection of the current registry has been refined to focus on prospective data and outcomes only after transplant to serve as a foundation for the future development of targeted clinical studies.

OBJECTIVE

To report the outcomes of the SPLIT registry from 2011 to 2018.

METHODS

This is a multicenter, cross-sectional analysis characterizing patients transplanted and enrolled in the SPLIT registry between 2011 and 2018. All patients, <18 years of age, received a first liver-only, a combined liver-kidney, or a combined liver-pancreas transplant during this study period.

RESULTS

A total of 1911 recipients from 39 participating centers in North America were registered. Indications included biliary atresia (38.5%), metabolic disease (19.1%), tumors (11.7%), and fulminant liver failure (11.5%). Greater than 50% of recipients were transplanted as either Status 1A/1B or with a MELD/PELD exception score. Incompatible transplants were performed in 4.1%. Kaplan-Meier estimates of 1-year patient and graft survival were 97.3% and 96.6%. First 30 days of surgical complications included reoperation (31.7%), hepatic artery thrombosis (6.3%), and portal vein thrombosis (3.2%). In the first 90 days, biliary tract complications were reported in 13.6%. Acute cellular rejection during first year was 34.7%. At 1 and 2 years of follow-up, 39.2% and 50.6% had normal liver tests on monotherapy (tacrolimus or sirolimus). Further surgical, survival, allograft function, and complications are detailed.

Quality-improvement program for ultrasound-based fetal anatomy screening using large-scale clinical audit

OBJECTIVE

A large-scale audit and peer review of ultrasound images may improve sonographer performance, but is rarely performed consistently as it is time-consuming and expensive. The aim of this study was to perform a large-scale audit of routine fetal anatomy scans to assess if a full clinical audit cycle can improve clinical image-acquisition standards.

METHODS

A large-scale, clinical, retrospective audit was conducted of ultrasound images obtained during all routine anomaly scans performed from 18 + 0 to 22 + 6 weeks' gestation at a UK hospital during 2013 (Cycle 1), to build a baseline understanding of the performance of sonographers. Targeted actions were undertaken in response to the findings with the aim of improving departmental performance. A second full-year audit was then performed of fetal anatomy ultrasound images obtained during the following year (Cycle 2). An independent pool of experienced sonographers used an online tool to assess all scans in terms of two parameters: scan completeness (i.e. were all images archived?) and image quality using objective scoring (i.e. were images of high quality?). Both were assessed in each audit at the departmental level and at the individual sonographer level. A random sample of 10% of scans was used to assess interobserver reproducibility.

RESULTS

In Cycle 1 of the audit, 103 501 ultrasound images from 6257 anomaly examinations performed by 22 sonographers were assessed; in Cycle 2, 153 557 images from 6406 scans performed by 25 sonographers were evaluated. The analysis was performed including the images obtained by the 20 sonographers who participated in both cycles. Departmental median scan completeness improved from 72% in the first year to 78% at the second assessment (P < 0.001); median image-quality score for all fetal views improved from 0.83 to 0.86 (P < 0.001). The improvement was greatest for those sonographers who performed poorest in the first audit; with regards to scan completeness, the poorest performing 15% of sonographers in Cycle 1 improved by more than 30 percentage points, and with regards to image quality, the poorest performing 11% in Cycle 1 showed a more than 10% improvement. Interobserver repeatability of scan completeness and image-quality scores across different fetal views were similar to those in the published literature.

CONCLUSIONS

A clinical audit and a set of targeted actions helped improve sonographer scan-acquisition completeness and scan quality. Such adherence to recommended clinical acquisition standards may increase the likelihood of correct measurement and thereby fetal growth assessment, and should allow better detection of abnormalities. As such a large-scale audit is time consuming, further advantages would be achieved if this process could be automated. © 2018 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.

Evaluation of qSOFA as a Predictor of Mortality Among ICU Patients With Positive Clinical Cultures-A Retrospective Cohort Study

OBJECTIVE

To compare the discriminative value of the quick-sequential organ failure assessment score (qSOFA) to SOFA in a critically ill population, in which a microbial pathogen was isolated within 48 hours of admission to intensive care.

DESIGN

Retrospective cohort study.

SETTING

Academic tertiary referral center from July 2008 to June 2017.

PATIENTS

Hospitalized patients admitted to intensive care unit.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was in-hospital mortality for all patients with confirmed positive microbiological cultures within 48 hours of admission to intensive care unit (ICU). Subgroup analysis was performed on patients with pathogenic bacteremia or positive cultures in cerebrospinal fluid. Of the 11 415 patients analyzed with positive microbiology specimens within 48 hours of admission, 2933 (25.7%) had a qSOFA ≥2. Of these, 16.6% reached the primary outcome of in-hospital mortality. Unsurprisingly, the discriminative value of qSOFA on admission was significantly worse than that of SOFA (0.73 vs 0.76; P = .0004), despite observing a significant association between qSOFA category and in-hospital mortality (P < .0001). In secondary analyses, similar observations were found using qSOFA within 6 and 24 hours of ICU admission. When analysis was focused on patients with pathogenic bacteremia or positive cerebrospinal fluid (CSF) cultures (n = 1646), there was no significant difference between the discriminative value of qSOFA and SOFA (0.75 vs 0.78; P = .17).

CONCLUSIONS

Quick-sequential organ failure assessment score at admission was not superior to SOFA in predicting in-hospital mortality in patients with positive clinical cultures within 48 hours of admission to ICU. Quick-sequential organ failure assessment score at admission to the ICU was associated with mortality and showed reasonable calibration and discrimination. When the analysis was focused on patients with pathogenic bacteremia or positive CSF cultures, qSOFA performed similarly to SOFA in discriminatory those who will die from sepsis.

A blended face-to-face and smartphone intervention for suicide prevention in the construction industry: protocol for a randomized controlled trial with MATES in Construction

BACKGROUND

Construction workers are at elevated risk of suicide. MATES in Construction (MATES) is one of the few suicide prevention programs that explicitly address this problem. The MATES program includes an integrated system of services that supports prevention, early intervention and recovery (i.e., primary, secondary and tertiary prevention) for mental health problems among construction workers. In this protocol, we describe a proposed evaluation of MATESmobile, an electronic platform which will be accessed by workers who have undergone MATES training.

METHODS/DESIGN

In this protocol, we describe a Randomised Controlled Trial (RCT) which seeks to assess whether MATESmobile results in improved literacy regarding suicide prevention, and improved help-seeking and help-offering attitudes among those who have attended MATES training. Secondary outcomes include changes in suicide ideation, suicide attempt and psychological distress. Workers will be recruited prior to MATES face-to-face training. In total, 295 workers will be randomly assigned to the intervention condition (MATESmobile + face-to-face training) and 295 will be randomly allocated to the control (face-to-face training). The intervention will run for 8 weeks. Assessments will be run immediately post intervention, and at 3, 6, and 12 months DISCUSSION: MATESmobile offers the potential to reinforce and enhance the effects of face-to-face training, resulting in greater skills and knowledge in suicide prevention, as well as a reduction in suicidality and distress.

TRIAL REGISTRATION

This trial is registered with the Australian New Zealand Clinical Trials Registry ( ACTRN12619000625178 ; 26 April 2019).

Extended Indications for Extracorporeal Membrane Oxygenation in the Operating Room

Background:

The use of extracorporeal life support (ECLS) for cardiorespiratory support is increasing. Traditional absolute contraindications are currently deemed relative contraindications. Extracorporeal life support is now considered for a wider cohort of patients on a case-by-case basis.

Method:

We performed a review of the literature and examined current Extracorporeal Life Support Organization guidelines that support the use of ECLS in the operating room, based on the underlying pathology and surgical procedure proposed. We discuss specific surgical populations and different modes of ECLS and cannulation strategies.

Results:

Based on the available literature, veno-venous extracorporeal membrane oxygenation (ECMO) can be used for the management of complex tracheobronchial and lung surgery, both in the elective and in the emergent setting. Elective veno-arterial (V-A) ECMO for cardiocirculatory support should be considered in high-risk patients undergoing ventricular tachycardia ablation. Extracorporeal life support should be considered as a potential life-saving intervention in almost all parturients with severe respiratory failure or refractory cardiogenic shock. V-A ECMO should be considered in unanticipated intraoperative cardiac arrest in patients without preexisting end-organ failure.

Conclusion:

As the number of indications for ECLS in the operating room is growing, anesthesiology and surgical staff should become familiar with the perioperative management of patients on ECLS.

Zika and travel in the news: a content analysis of US news stories during the outbreak in 2016-2017

OBJECTIVES

This study aimed to understand what information the US media communicated about Zika virus (ZIKV) and travel in 2016 and 2017.

STUDY DESIGN

We conducted a content analysis of news coverage about ZIKV and travel from April 5, 2016 to March 31, 2017.

METHODS

We obtained a stratified, random sample of English language, US print newspaper and television news coverage about ZIKV and travel. We developed a coding scheme to assess key messages in the news, including how ZIKV is transmitted, the symptoms and outcomes of ZIKV infection, and recommended prevention behaviors.

RESULTS

Almost all news stories mentioned mosquito-borne transmission (96.8%) and just over half mentioned sexual transmission (55.3%). News stories were more likely to talk about ZIKV outcomes (78.8%) than ZIKV symptoms (40.6%). However, outcomes affecting babies were mentioned more frequently than outcomes affecting adults. Recommendations included a wide array of protective behaviors, such as delaying or avoiding travel (77.6%) and using mosquito repellent (41.0%). However, few studies (10.9%) mentioned barriers to practicing ZIKV prevention behaviors.

CONCLUSIONS

Public health organizations and professionals can use these findings to help improve communication about future outbreaks of mosquito-borne illnesses. We also recommend conducting real-time monitoring of news media and frequent content analysis of news stories to ensure coverage provides the information the public needs.

The association between body mass index, primary healthcare use and morbidity in early childhood: findings from the Born In Bradford cohort study

OBJECTIVES

The objective of the article was to examine the association between body mass index (BMI), health and general practice (GP) healthcare use in early childhood.

STUDY DESIGN

This study is a prospective cohort study.

METHODS

Multivariate Poisson and logistic regression models were used to explore the association between BMI and health outcomes using data from the Born In Bradford cohort study, linked to routine data capturing objective measures of BMI at age 5 years, alongside GP appointment rates, GP prescriptions and specific morbidities in the subsequent 3-year period.

RESULTS

Compared with healthy weight, children who were obese at the age of 5 years had significantly higher rates of GP appointments (incident rate ratio 1.14, 95% confidence interval [CI]: 1.06-1.23), GP prescriptions (incident rate ratio 1.15, 95% CI: 1.04-1.27), asthma (odds ratio 1.46, 95% CI: 1.21-1.77), sleep apnoea (odds ratio 2.50, 95% CI: 1.36-4.58), infections (incident rate ratio 1.19, 95% CI: 1.08-1.30), antibiotic prescriptions (incident rate ratio 1.25, 95% CI: 1.10-1.42) and accidents (incident rate ratio 1.20, 95% CI: 1.01-1.42) in the subsequent 3 years. Underweight children were found to have higher rates of GP appointments (incident rate ratio 1.25, 95% CI: 1.04-1.52), but there were no differences between overweight and healthy weight children.

CONCLUSIONS

Childhood obesity was found to be associated with increased primary healthcare use and a range of poorer health outcomes at the age of 8 years, underlining the importance of reducing childhood obesity in early childhood.

Female genital mutilation in the UK- where are we, where do we go next? Involving communities in setting the research agenda

BACKGROUND

Female Genital Mutilation (FGM) is all practices involving cutting, alteration or injury to the female genitalia for non-medical reasons. It is a form of violence against women and children, with no benefits and many harms. In 2014, the UK Government committed to working to eliminate FGM. Steps taken towards this aim included creation of educational and safeguarding resources for professionals, and legislative changes including a mandatory reporting duty for professionals in England and Wales (where if a girl under 18 discloses or is found on examination to have FGM then the professional is mandated to report this to the police), and an FGM Enhanced Dataset applicable to NHS organisations in England requiring the submission of personal data about women and girls who have had FGM to NHS Digital. To date, compliance with dataset returns from primary care services have been low. This report describes using patient and public involvement (PPI) to identify research and service priorities to support communities affected by FGM.

METHODS

We held a series of PPI events (4 focus groups, and a multi-agency seminar) in 2015-2016, following the introduction of these legislative changes, speaking to community members, and professionals involved in their care. We asked participants to consider what they identified as research, knowledge and service priorities to support communities affected by FGM.

RESULTS

The impact of these legislative and reporting requirements on the trust needed for community members to seek to consult health services was identified as important for further research. Priorities for service development were holistic services, that met a woman's needs throughout her lifecourse. Participants emphasised the importance of understanding how to listen, involve and utilise community voices in developing education for professionals, designing services, and developing policy.

CONCLUSIONS

There was a desire for change to develop from within affected communities; any learning and resources need to be co-created and constructed in such a way that they can be effectively shared between women, communities, and professionals. Questions remain about how to define community consultation, how to recognise when it was adequate, and how to hear beyond community activists to hear a wider range of voices.

Tests of size and growth effects on Arctic charr (Salvelinus alpinus) otolith δ18 O and δ13 C values

RATIONALE

Otolith δ¹⁸ O and δ¹³ C values have been used extensively to reconstruct thermal and diet histories. Researchers have suggested that individual growth rate and size may have an effect on otolith isotope ratios and subsequently confound otolith-based thermal and diet reconstructions. As few explicit tests of the effect on fish in freshwater environments exist, here we determine experimentally the potential for related growth rate and size effects on otolith δ¹⁸ O and δ¹³ C values.

METHODS

Fifty Arctic charr were raised in identical conditions for two years after which their otoliths were removed and analyzed for their δ¹⁸ O and δ¹³ C values. The potential effects of final length and the Thermal Growth Coefficient (TGC) on otolith isotope ratios were tested using correlation and regression analysis to determine if significant effects were present and to quantify effects when present.

RESULTS

The analyses indicated that TGC and size had significant and similar positive non-linear relationships with δ¹³ C values and explained 35% and 42% of the variability, respectively. Conversely, both TGC and size were found to have no significant correlation with otolith δ¹⁸ O values. There was no significant correlation between δ¹⁸ O and δ¹³ C values.

CONCLUSIONS

The investigation indicated the presence of linked growth rate and size effects on otolith δ¹³ C values, the nature of which requires further study. Otolith δ¹⁸ O values were unaffected by individual growth rate and size, confirming the applicability of these values to thermal reconstructions of fish habitat.

[Bilio-Digestives Derivative In The Palliative Surgery Of Pancreatic Head Cancer At The CHU Gabriel TOURE]

OBJECTIVES

Our objective was to determine the frequency of bilio-digestive bypass in palliative surgery in pancreatic head cancers, to determine the clinical and para-clinical aspects and to analyze the results of the treatment.

METHODS

This was a-15 year retrospective study from 1999 to 2014 including any patient with confirmed pancreatic cancer in the anatomo-pathology treated by palliative surgery in the department.

RESULTS

In 15 years, we operated152 cases of cancer of the head of the pancreas. The bilio-digestive derivation was performed in 78 patients, or 51.32%. The average age was 58.61 years ± 11.22 years with the extremes of 34 and 79 years old, the sex ratio was 1.44. The disease duration was 4.88 months on average with a standard deviation of 4.28 months and extremes of 1 and 24 months. Courvoisier-Terrier's disease was observed in 76 cases with lesions of the cases. The average pancreatic tumor size was 62.98 mm, and standard deviation = 8.68 with the extremes of45 and 121 mm. We performed a choledoco-duodenal anastomosis and a gastro-entero-anastomosis (GEA) in 85.90% of cases (n = 67), a choledocojejunal anastomosis and a GEA in 7 cases and a choledoco-duodenal anastomosis without GEA in 4 cases. The morbidity and the mortality rates were15.4% and 6.41%, respectively. At six (6) months postsurgery, a complete disappearance the majority of the functional signs was observed.

CONCLUSION

Pancreatic cancer is a slowly developing tumor. Therefore its diagnosis is late; the derivation makes it possible to improve the quality of life of the patients.

The participation of parents of disabled children and young people in health and social care decisions

BACKGROUND

There is widespread acceptance that parents should be fully involved in decisions about their son or daughter's health and social care. This is reflected in partnership models of practice as well as local and national policy across the United Kingdom. Previous research indicates that parents' experiences of decision making with professionals are mixed.

AIM

The research reported here aimed to explore parents' experiences of participating in decisions made with professionals about their disabled son or daughter's care.

DESIGN

This research used mixed methods including survey methodology and qualitative in depth interviews.

SETTING AND PARTICIPANTS

The research was conducted in one Trust in Northern Ireland. Participants were 77 parents of children and young people with a range of impairments aged between 3 and 28 years.

RESULTS

Three themes emerged from the data: taking the lead, not knowing, and getting the balance right. Parents wanted to be involved in all aspects of decision making. Although parents reported many examples of good practice, there were also times when they did not feel listened to or did not have enough information to inform decisions.

DISCUSSION AND CONCLUSION

Parents in this research recounted positive as well as negative experiences. Parents took on a protective role when decisions were made about their son or daughter and at times, reported the need to "fight" for their child. The provision of information remains problematic for these families, and at times, this created a barrier to parents' participation in decision making. Partnership approaches to care that recognize parents' expertise are particularly important to parents when decisions are made with professionals.

A Fuller Picture: Evaluating an Art Therapy Programme in a Multi-disciplinary Mental Health Service

Art therapy has a long history in mental health care but requires an enhanced evidence based in order to better identify its precise role in contemporary services. This paper describes an evaluation of an art therapy programme in an acute adult psychiatry admission unit in Ireland. A mixed method research design was used. Quantitative data were collected through a survey of 35 staff members and 11 service-users. Qualitative data included free-text comments collected in the survey and individual feedback from service-users. Both methods aimed to assess the role of art therapy as part of a multidisciplinary mental health service. Thematic content analysis was employed to analyse qualitative data. Staff demonstrated overwhelming support for art therapy as one element within multidisciplinary services available to patients in the acute psychiatry setting, qualitative feedback associated art therapy with improvements in quality of life and individual support, and emphasised its role as a nonverbal intervention, especially useful for those who find talking therapy difficult. Creative self-expression is valued by staff and service-users as part of the recovery process. Recommendations arising from the research include continuing the art therapy service, expanding it to include rehabilitation patients, provision of information and education sessions to staff and further research to identify other potential long-term effects. The low response of staff and small sample in this study, however, must be noted as limitations to these findings.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Cost-effectiveness analysis of offering free leisure centre memberships to physically inactive members of the public receiving state benefits: a case study

Background

We evaluated the cost-effectiveness of the Give-it-a-Go programme, which offers free leisure centre memberships to physically inactive members of the public in a single London Borough receiving state benefits.

Methods

A decision analytic Markov model was developed to analyse lifetime costs and quality-adjusted life-years (QALYs) of 1025 people recruited to the intervention versus no intervention. In the intervention group, people were offered 4 months of free membership at a leisure centre. Physical activity levels were assessed at 0 and 4 months using the International Physical Activity Questionnaire (IPAQ). Higher levels of physical activity were assumed to decrease the risk of coronary heart disease, stroke and diabetes mellitus type II, as well as improve mental health. Costs were assessed from a National Health Service (NHS) perspective. Uncertainty was assessed using one-way and probabilistic sensitivity analyses.

Results

One-hundred fifty nine participants (15.5 %) completed the programme by attending the leisure centre for 4 months. Compared with no intervention, Give it a Go increased costs by £67.25 and QALYs by 0.0033 (equivalent to 1.21 days in full health) per recruited person. The incremental costs per QALY gained were £20,347. The results were highly sensitive to the magnitude of mental health gain due to physical activity and the duration of the effect of the programme (1 year in the base case analysis). When the mental health gain was omitted from the analysis, the incremental cost per QALY gained increased to almost £1.5 million. In the probabilistic sensitivity analysis, the incremental costs per QALY gained were below £20,000 in 39 % of the 5000 simulations.

Conclusions

Give it a Go did not significantly increase life-expectancy, but had a positive influence on quality of life due to the mental health gain of physical activity. If the increase in physical activity caused by Give it a Go lasts for more than 1 year, the programme would be cost-effective given a willingness to pay for a QALY of £20,000.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-3300-x) contains supplementary material, which is available to authorized users.

Geographic variation in suicide rates in Australian farmers: Why is the problem more frequent in Queensland than in New South Wales?

Research on farmer suicide is limited in explaining the variations in farmers' demographic characteristics. This study examines farmer suicides in two Australian states: Queensland (QLD) and New South Wales (NSW). Standardized suicide rates over 2000-2009 showed a 2 times higher prevalence of suicide in QLD than NSW (147 vs. 92 cases, respectively). Differences in age and suicide method were observed between states, although they do not appear to account for the sizeable intra- and interstate variations. Suicide prevention initiatives for farmers should account for different age groups and also specific place-based risk factors that may vary between and within jurisdictions.

How to assess gay, bisexual and other men who have sex with men for chemsex

OBJECTIVES

Sexualised substance use, 'chemsex', is being increasingly reported by gay, bisexual and other men who have sex with men (GBMSM) in sexual health clinics. We aim to describe the evidence base and practical ways in which clinicians can assess and advise patients disclosing chemsex.

METHODS

We review published literature on chemsex, discuss vulnerability to substance use, highlight the importance of clinical communication and discuss a management approach.

RESULTS

GBMSM are vulnerable to substance use problems, which interplay with mental, physical and sexual health. Knowledge on sexualised drug use and related communication skills are essential to facilitating disclosure. Identifying sexual health and other consequences of harmful drug use may motivate patients to seek change.

CONCLUSIONS

Sexual health clinicians are well placed to make more holistic assessments of GBMSM accessing their services to promote broader sexual health and well-being beyond the management of HIV and sexually transmitted infections (STIs) alone.

Television advertising, not viewing, is associated with negative dietary patterns in children

BACKGROUND

Children's exposure to unhealthy food marketing is a contributor to poor diets and weight gain. Television food advertising, in particular, has been the focus of research and policy discussions.

OBJECTIVES

We aimed to quantify the specific impact of television advertising, as distinct from television viewing generally, on children's usual diet. Methods Four hundred seventeen Australian children aged 10-16 participated in an online survey, which assessed television viewing habits and consumption of 12 frequently advertised unhealthy foods/drinks. Consumption of these foods/drinks was dichotomized (less weekly, weekly or more) and summed (1 point for each item consumed weekly or more) to give cumulative consumption scores.

RESULTS

After adjusting for age and socioeconomic status, there was strong evidence of an increase in unhealthy food score (P < 0.001), drink score (P = 0.002) and food/drink combined score (P < 0.001), with increasing commercial television viewing.

CONCLUSIONS

The link between television viewing and poor diet was strongest for children who watched the most commercial television, and those who were actually exposed to advertisements embedded within programs. This association between advertisement exposure and poor diet emphasizes the need for public policy intervention to reduce children's food advertising exposures.

Language and understanding of cardiopulmonary resuscitation amongst an aged inpatient population

Greater patient involvement in health decision-making requires exchange of information between the patient and the healthcare professionals. Decisions regarding healthcare at the end of life include consideration of cardiopulmonary resuscitation (CPR). The stated objectives of this study were to determine how often language around concepts of resuscitation is used in the community by examination of the English language corpora (ELC); to explore the understanding of the same language by a group of older hospital patients; and to determine the patients' knowledge of the process and success of CPR, as well as the sources of their information. Medical inpatients aged 75 years and older were surveyed to this end in the setting of a tertiary university teaching hospital. Interrogation of the Australian, British and American English Corpora was accomplished by a linguist, and a questionnaire and semi-structured interview were administered to ascertain patient knowledge. We demonstrated that although medical inpatients have some familiarity with terms relating to resuscitation, there is a lack of understanding of the context, process and outcomes of CPR. The predominant sources of information were television and print media. Examination of the ELC revealed a paucity of the use of terms related to resuscitation. This finding indicates that physicians have a duty of care to determine patients' understanding around resuscitation language, and terms used, in discussions of their preferences before assuming their engagement in shared decision-making. More open public discussion around death and resuscitation would increase the general knowledge of the population and would provide a better foundation for the discussions in times of need.

Clinical evaluation of the IONA test: a non-invasive prenatal screening test for trisomies 21, 18 and 13

OBJECTIVE

To evaluate the clinical accuracy of the IONA® test for aneuploidy screening.

METHODS

This was a multicenter blinded study in which plasma samples from pregnant women at increased risk of trisomy 21 underwent cell-free DNA analysis utilizing the IONA test. For each sample, the IONA software generated a likelihood ratio and a maternal age-adjusted probability risk score for trisomies 21, 18 and 13. All results from the IONA test were compared against accepted diagnostic karyotyping.

RESULTS

A total of 442 maternal samples were obtained, of which 437 had test results available for analysis and assessment of clinical accuracy. The IONA test had a detection rate of 100% for trisomies 21 (n = 43; 95% CI, 87.98-100%), 18 (n = 10; 95% CI, 58.72-100%) and 13 (n = 5; 95% CI, 35.88-100%) with cut-offs applied to likelihood ratio (cut-off > 1 considered high risk for trisomy) and probability risk score incorporating adjustment for maternal age (cut-off ≥ 1/150 considered high risk for trisomy). The false-positive rate (FPR) was 0% for trisomies 18 and 13 with both analysis outputs. For trisomy 21, a FPR of 0.3% was observed for the likelihood ratio, but became 0% with adjustment for maternal age.

CONCLUSION

This study indicates that the IONA test is suitable for trisomy screening in a high-risk screening population. The result-interpretation feature of the IONA software should facilitate wider implementation, particularly in local laboratories, and should be a useful addition to the current screening methods for trisomies 21, 18 and 13.

Autoantibodies are not Predictive Markers for the Development of Depressive Symptoms in a Population-Based Cohort of Older Adults

Background

Autoantibodies have been implicated in the etiologic pathway of depressive disorders. Here, we determine the association between the presence of a panel of autoantibodies at baseline and change in depression symptom score over 5-year follow-up in a cohort of healthy elderly Australians.

Methods

Serum samples from 2049 randomly selected subjects enrolled in the Hunter Community Study (HCS) aged 55–85 years were assayed for a range of autoimmune markers (anti-nuclear autoantibodies, extractable nuclear antigen autoantibodies, anti-neutrophil cytoplasmic autoantibodies, thyroid peroxidase autoantibodies, tissue transglutaminase autoantibodies, anti-cardiolipin autoantibodies, rheumatoid factor and cyclic citrullinated peptide autoantibodies) at baseline. Depression symptom score was assessed using the Centre for Epidemiological Study (CES-D) scale at baseline and 5 years later.

Results

Autoantibody prevalence varied amongst our sample with ANA being the most prevalent; positive in 16% and borderline in 36% of study population. No evidence for a relationship was found between change in CES-D score over time and any autoimmune marker. Statins and high cholesterol were significantly associated with change in CES-D score over time in univariate analysis; however, these were probably confounded since they failed to remain significant following multivariable analysis.

Conclusions

Autoantibodies were not associated with change in CES-D score over time. These findings point to an absence of autoimmune mechanisms in the general population or in moderate cases of depression.