Rahnella Aquatilis Endophthalmitis after Intravitreal Injection in an Immunocompetent Patient

PURPOSE

To present a novel case of exogenous Rahnella aquatilis endophthalmitis following an intravitreal injection.

METHODS

Case report.

RESULTS

A 74-year-old male presented with acute progressive vision loss and pain in the left eye, 5 days after an intravitreal injection for diabetic macular edema. The patient was diagnosed with exogenous endophthalmitis and empirically treated with intravitreal injections of vancomycin and ceftazidime as well as topical and oral ciprofloxacin. In follow up two days later, the patient was treated with preoperative povidone-iodine followed by prompt vitrectomy with additional vancomycin and ceftazidime due to pharmacy sterile hood issues that delayed antibiotic availability. Microbiological cultures and two mass spectrometry identification tests confirmed the diagnosis of exogenous Rahnella aquatilis endophthalmitis. Despite the presence of scattered retinal hemorrhagic infarcts involving the macula and subsequent full-thickness atrophic macular holes seen in follow up, the patient achieved a favorable anatomical and functional outcome of BCVA 20/80 at 1 year of follow-up.

CONCLUSION

This case highlights the occurrence of exogenous Rahnella aquatilis endophthalmitis following an intravitreal injection for diabetic macular edema. Prompt diagnosis and treatment produced a favorable outcome relative to other typical Gram-negative Enterobacteriaceae organisms.

Examining temporal trends in psychological distress and the co-occurrence of common substance use in a population-based sample of grade 7-12 students from 2013 to 2019

PURPOSE

Characterizing trends and correlates of adolescent psychological distress is important due to observed global increases over the last 20 years. Substance use is a commonly discussed correlate, though we lack an understanding about how co-occurrence of these concerns has been changing over time.

METHODS

Data came from repeated, representative, cross-sectional surveys of grade 7-12 students across Ontario, Canada conducted biennially from 2013 to 2019. Poisson regression with robust standard errors was used to examine changes in the joint association between psychological distress (operationalized as Kessler-6 [K6] scores ≥ 13) and substance use over time. Weighted prevalence ratios (PR) and their 99% confidence intervals were estimated, where p < 0.01 denotes statistical significance.

RESULTS

The prevalence of psychological distress doubled between 2013 and 2019, with adjusted increases of about 1.2 times each survey year. This biennial increase did not differ based on sex, perceived social standing, school level, or any substance use. Students using substances consistently reported a higher prevalence of psychological distress (between 1.2 times and 2.7 times higher). There were similarly no differential temporal trends based on substance use for very high distress (K6 ≥ 19) or K6 items explored individually.

CONCLUSION

Psychological distress steeply increased among adolescents and substance use remains important to assess and address alongside distress. However, the magnitude of temporal increases appears to be similar for adolescents reporting and not reporting substance use.

Surface electromyography using dry polymeric electrodes

Conventional wet Ag/AgCl electrodes are widely used in electrocardiography, electromyography (EMG), and electroencephalography (EEG) and are considered the gold standard for biopotential measurements. However, these electrodes require substantial skin preparation, are single use, and cannot be used for continuous monitoring (>24 h). For these reasons, dry electrodes are preferable during surface electromyography (sEMG) due to their convenience, durability, and longevity. Dry conductive elastomers (CEs) combine conductivity, flexibility, and stretchability. In this study, CEs combining poly(3,4-ehtylenedioxythiophene):polystyrenesulfonate (PEDOT:PSS) in polyurethane are explored as dry, skin contacting EMG electrodes. This study compares these CE electrodes to commercial wet Ag/AgCl electrodes in five subjects, classifying four movements: open hand, fist, wrist extension, and wrist flexion. Classification accuracy is tested using a backpropagation artificial neural network. The control Ag/AgCl electrodes have a 98.7% classification accuracy, while the dry conductive elastomer electrodes have a classification accuracy of 99.5%. As a conclusion, PEDOT based dry CEs were shown to successfully function as on-skin electrodes for EMG recording, matching the performance of Ag/AgCl electrodes, while addressing the need for minimal skin prep, no gel, and wearable technology.

IBCOx-12 The Endoscopic Sleeve Gastroplasty Produces Durable Physiologic Changes: Results from a Randomized US Clinical Trial

Background

Obesity is associated with faster gastric emptying and altered appetite. Endoscopic sleeve gastroplasty (ESG) has gained global adaptation, but our understanding of its physiologic mechanism of action and durability is limited. We sought to determine changes in gastric emptying, weight loss, and eating behaviors after ESG when compared to moderate-intensity lifestyle interventions (LS) in the short and long-term.

Methods

This is an a priori designed sub-study of a large ongoing multicenter US RCT (MERIT trial), where adults with BMI 30-40 kg/m2 were randomized to ESG versus moderate-intensity LS alone. We measured gastric emptying (T1/2) using a 4- hour gastric emptying breath test at baseline, 3 and 12 months into the study. We reported weight loss outcomes as percent total body weight lost (%TBWL). Changes in three eating behaviour domains (Cognitive Restraint [CR], Emotional Eating [EE], Uncontrolled Eating [UE]) were assessed using the Three-Factor Eating Questionnaire (TFEQ) at 6 months. The primary outcome was the change in T1/2 (minutes) at 3 months, and secondary outcomes were changes in T1/2 at 12 months, %TBWL, and eating behaviours. We used the t-test for the analyses. Linear regression was performed to determine the association between gastric emptying and weight loss.

Results

46 patients were randomized in the study (ESG n=26; LS n=20). Baseline characteristics were similar between the two groups. Out of n=46, n=43, and n=31 subjects have reached 3 and 12 months, respectively. Three patients dropped out of the study. At 3 months, T1/2 (minutes) was delayed in the ESG group (n=24) compared to the LS group (n=19) (170.8 vs. 87.5; p&lt;0.0001). At 12 months, T1/2 was still delayed in the ESG group (n=17) vs. control group (n=14) (133.4 vs. 87.6; p=0.0005), and delayed compared to baseline. %TBWL in the ESG group was 12.3%, 15.1% and 15.7% at 3, 6 and 12 months (p &lt;0.01 compared to baseline), while it was 2.3%, 2.2% and 0.3% (p&gt;0.05 compared to baseline) in the LS group. Greater delays in gastric emptying at 3 months correlated with weight loss at all time points. (Figure 1) At 6 months, significant improvements in the EE and UE domains were seen in both groups, but for CR, only significant improvements were seen in the ESG group. Percent total fasting ghrelin, GLP-1, and PYY increased at 12 months in the ESG group compared to LS control (51%, 51%, 6.3% vs. -9%, 4%, -10.5%). Only 1 SAE managed endoscopically with full recovery was reported in the ESG group.

Conclusions

ESG produces sustained physiologic alterations in appetite regulatory pathways and durable weight-loss. This provides further evidence supporting the clinical adoption of the technique as a durable and effective obesity therapy.

Analysis of rare disruptive germline mutations in 2,135 enriched BRCA-negative breast cancers excludes additional high-impact susceptibility genes

BACKGROUND

Breast cancer has a significant heritable basis, of which approximately 60% remains unexplained. Testing for BRCA1/BRCA2 offers useful discrimination of breast cancer risk within families, and identification of additional breast cancer susceptibility genes could offer clinical utility.

PATIENTS AND METHODS

We included 2,135 invasive breast cancer cases recruited via the BOCS study, a retrospective UK study of familial breast cancer.

ELIGIBILITY CRITERIA

female, BRCA-negative, white European ethnicity, and one of: i) breast cancer family history, ii) bilateral disease, iii) young age of onset (<30 years), iv) concomitant ovarian cancer. We undertook exome sequencing of cases and performed gene-level burden testing of rare damaging variants against those from 51,377 ethnicity-matched population controls from gnomAD.

RESULTS

159/2135 (7.4%) cases had a qualifying variant in an established breast cancer susceptibility gene, with minimal evidence of signal in other cancer susceptibility genes. Known breast cancer susceptibility genes PALB2, CHEK2 and ATM were the only genes to retain statistical significance after correcting for multiple testing. Due to the enrichment of hereditary cases in the series, we had good power (>80%) to detect a gene of BRCA1-like risk (odds ratio = 10.6) down to a population minor allele frequency of 4.6 x 10^-5 (1 in 10,799, less than one tenth that of BRCA1)and of PALB2-like risk (odds ratio = 5.0) down to a population minor allele frequency of 2.8 x 10^-4 (1 in 1,779, less than half that of PALB2). Power was lower for identification of novel moderate penetrance genes (odds ratio = 2-3) like CHEK2 and ATM.

CONCLUSIONS

This is the largest case-control whole-exome analysis of enriched breast cancer published to date. Whilst additional breast cancer susceptibility genes likely exist, those of high penetrance are likely to be of very low mutational frequency. Contention exists regarding the clinical utility of such genes.

Ischaemic preconditioning improves upper-body endurance performance without altering ⩒O2 kinetics

PURPOSE

Whilst pre-exercise ischaemic preconditioning (IPC) can improve lower-body exercise performance, its impact on upper-limb performance has received little attention. This study examines the influence of IPC on upper-body exercise performance and oxygen uptake (⩒O₂) kinetics.

METHODS

Eleven recreationally-active males (24 ± 2 years) completed an arm-crank graded exercise test to exhaustion to determine the power outputs at the ventilatory thresholds (VT1 and VT2) and ⩒O_2peak (40.0 ± 7.4 ml·kg^-1·min^-1). Four main trials were conducted, two following IPC (4 × 5-min, 220 mmHg contralateral upper-limb occlusion), the other two following SHAM (4 × 5-min, 20 mmHg). The first two trials consisted of a 15-minute constant work rate and the last two time-to-exhaustion (TTE) arm-crank tests at the power equivalents of 95% VT1 (LOW) and VT2 (HIGH), respectively. Pulmonary ⩒O₂ kinetics, heart rate, blood-lactate concentration, and rating of perceived exertion were recorded throughout exercise.

RESULTS

TTE during HIGH was longer following IPC than SHAM (459 ± 115 vs 395 ± 102 s, p = 0.004). Mean response time and change in ⩒O₂ between 2-min and end exercise (Δ⩒O₂) were not different between IPC and SHAM for arm-cranking at both LOW (80.3 ± 19.0 vs 90.3 ± 23.5 s [p = 0.06], 457 ± 184 vs 443 ± 245 ml [p = 0.83]) and HIGH (96.6 ± 31.2 vs 92.1 ± 24.4 s [p = 0.65], 617 ± 321 vs 649 ± 230 ml [p = 0.74]). Heart rate, blood-lactate concentration, and rating of perceived exertion did not differ between conditions (all p≥0.05).

CONCLUSION

TTE was longer following IPC during upper-body exercise despite unchanged ⩒O₂ kinetics.

Better Understanding of the Metamorphosis of Pregnancy (BUMP): protocol for a digital feasibility study in women from preconception to postpartum

The Better Understanding the Metamorphosis of Pregnancy (BUMP) study is a longitudinal feasibility study aimed to gain a deeper understanding of the pre-pregnancy and pregnancy symptom experience using digital tools. The present paper describes the protocol for the BUMP study. Over 1000 participants are being recruited through a patient provider-platform and through other channels in the United States (US). Participants in a preconception cohort (BUMP-C) are followed for 6 months, or until conception, while participants in a pregnancy cohort (BUMP) are followed into their fourth trimester. Participants are provided with a smart ring, a smartwatch (BUMP only), and a smart scale (BUMP only) alongside cohort-specific study apps. Participant centric engagement strategies are used that aim to co-design the digital approach with participants while providing knowledge and support. The BUMP study is intended to lay the foundational work for a larger study to determine whether participant co-designed digital tools can be used to detect, track and return multimodal symptoms during the perinatal window to inform individual level symptom trajectories.

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 ).

Cracks in the ice: a digital health initiative disseminating evidence-based information about ‘ice’

Background

Crystal methamphetamine (‘ice') causes significant societal harm and attracts a high level of concern in Australia. Cracks in the Ice (CITI: cracksintheice.org.au) is a digital public health initiative that was developed as part of a national response to concerns about ice. CITI is the first centralised national online portal for evidence-based information and resources about ice in Australia. It provides targeted information and resources for health workers, people who use ice, their family and friends, community groups and schools. CITI was developed collaboratively with input from drug and alcohol experts and over 500 Australian community members, including people with lived experience. A national online survey was conducted to evaluate whether CITI is meeting the needs of the Australian community.

Methods

Eligible participants were Australian residents aged 18 years and over, and were recruited via the CITI website, email direct marketing, and social media. The survey assessed participants' perceptions of CITI (e.g., usability, navigation, utility) and their knowledge and attitudes about ice.

Results

2110 participants completed the survey, including people who use ice, affected family members, health workers, and general community members. Participants' response to CITI was overall positive and their knowledge of ice was generally good, but many held negative or stigmatising attitudes towards ice and people who use it.

Conclusions

Digital public health initiatives stand to overcome structural, geographical, and attitudinal barriers to alcohol and other drug (AOD) prevention efforts. CITI ensures evidence-based information about the drug ice is readily available across all of Australia. Community evaluations have shown that CITI is meeting the needs of the Australian community.

Key messages

Crystal methamphetamine (‘ice’) attracts a high level of concern in Australia. CITI is the first centralised national online portal for evidence-based information and resources about ice. Digital health initiatives stand to overcome structural, geographical, and attitudinal barriers to AOD prevention. Community evaluations ensure these initiatives meet the needs of their end-users.

Computer-assisted subcapital correction osteotomy in slipped capital femoral epiphysis using individualized drill templates

Background

Subcapital osteotomy by means of surgical hip dislocation is a treatment approach offered for moderate-to-severe cases of Slipped Capital Femoral Epiphysis (SCFE). This procedure is demanding, highly dependent on the surgeon’s experience, and requires considerable radiation exposure for monitoring and securing the spatial alignment of the femoral head. We propose the use of individualized drill guides as an accurate method for placing K-wires during subcapital correction osteotomies in SCFE patients.

Methods

Five CT scans of the hip joint from otherwise healthy patients with moderate-to-severe SCFE were selected (ages 11–14). Three dimensional models of each patient’s femur were reconstructed by manual segmentation and physically replicated using additive manufacturing techniques. Five orthopaedic surgeons virtually identified the optimal entry point and direction of the two threaded wires for each case. 3D printed drill guides were designed specific to each surgical plan, with one side shaped to fit the patient’s bone and the other side containing holes to guide the surgical drill. Each surgeon performed three guided (using the drill guides) and three conventional (freehand) simulated procedures on each case. Each femur model was laser scanned and digitally matched to the preoperative model for evaluation of entry points and wire angulations. We compared wire entry point, wire angulation, procedure time and number of x-rays between guided and freehand simulated surgeries.

Results

The guided group (1.4 ± 0.9 mm; 2.5° ± 1.4°) was significantly more accurate than the freehand group (5.8 ± 3.2 mm; 5.3° ± 4.4°) for wire entry location and angulation (p < 0.001). Guided surgeries required significantly less drilling time and intraoperative x-rays (90.5 ± 42.2 s, 3 ± 1 scans) compared to the conventional surgeries (246.8 ± 122.1 s, 14 ± 5 scans) (p < 0.001).

Conclusions

We conclude that CT-based preoperative planning and intraoperative navigation using individualized drill guides allow for improved accuracy of wires, reduced operative time and less radiation exposure in simulated hips.

Clinical relevance

This preliminary study shows promising results, suggesting potential direct benefits to SCFE patients by necessitating less time under anesthesia and less intra-operative radiation exposure to patients, and increasing surgical accuracy.

Randomized, Comparative Study of Full- and Half-Dose Fluorescein Angiography

Purpose:

This study determines whether fluorescein angiography (FA) with a 250-mg dose of fluorescein (half dose) is equal in quality to the standard 500-mg dose of fluorescein (full dose) when using digital ultra-widefield (UWF) technology.

Methods:

In a randomized, prospective study using a UWF imaging system, FAs performed with half dose were compared with angiograms performed with full dose. Imaging studies were reviewed by 4 reviewers based on 6 characteristics: dye transit, macrovasculature, macula detail, microvasculature, leakage, and overall quality. The scores for macrovasculature, macula detail, microvasculature, and overall quality were converted to a fuzzy rating score to confirm results.

Results:

Seventy-nine FAs from 67 patients were reviewed for this study, including 12 patients who had both half-dose and full-dose FAs. Of all the factors studied, only microvasculature received a significantly different score between full dose and half dose that was confirmed by the fuzzy rating scale (3.79 vs 3.53; P = .04). Among those eyes that received both full and half dose, there was no significant difference in any of the 6 factors.

Conclusions:

In a UWF imaging system, aside from looking at fine microvascular abnormalities, the 250-mg dose of fluorescein provided similar results to a 500-mg dose. The images were not significantly different in overall quality.

GP access to FIT increases the proportion of colorectal cancers detected on urgent pathways in symptomatic patients in Nottingham

OBJECTIVE

Service evaluation of GP access to Faecal Immunochemical Test (FIT) for colorectal cancer (CRC) detection in Nottinghamshire and use of FIT for "rule out", "rule in" and "first test selection".

DESIGN

Retrospective audit of FIT results, CRC outcomes and resource utilisation before and after introduction of FIT in Primary Care in November 2017. Data from the new pathway up to December 2018 was compared with previous experience.

RESULTS

Between November 2017 and December 2018, 6747 GP FIT test requests yielded 5733 FIT results, of which 4082 (71.2%) were <4.0 μg Hb/g faeces, 579 (10.1%) were 4.0-9.9 μg Hb/g faeces, 836 (14.6%) were 10.0-149.9 μg Hb/g faeces, and 236 (4.1%) were ≥150.0 μg Hb/g faeces. The proportion of "rule out" results <4.0 μg Hb/g faeces was significantly higher than in the Getting FIT cohort (71.2% vs 60.4%, Chi squared 42.8, p < 0.0001) and the proportion of "rule in" results ≥150.0 μg Hb/g faeces was significantly lower (4.1% vs 8.1%, Chi squared 27.3,P < 0.0001). There was a 33% rise in urgent referrals across Nottingham overall during the evaluation period. 2 CRC diagnoses were made in 4082 patients who had FIT<4.0 μg Hb/g faeces. 58.4% of new CRC diagnoses associated with a positive FIT were early stage cancers (Stage I and II). The proportion of all CRC diagnoses that follow an urgent referral s rose after introduction of FIT.

CONCLUSIONS

FIT allows GP's to select a more appropriate cohort for urgent investigation without a large number of missed diagnoses. FIT appears to promise a "stage migration" effect which may ultimately improve CRC outcomes.

Feasibility and safety study of 22-gauge endoscopic ultrasound (EUS) needles for portal vein sampling in a swine model

Background and study aims  Endoscopic ultrasound (EUS) has been used for portal vein sampling in patients with pancreaticobiliary cancers for enumerating circulating tumor cells but is not yet a standard procedure. Further evaluation is needed to refine the methodology. Therefore, we evaluated the feasibility and safety of 19-gauge (19G) versus a 22-gauge (22 G) EUS fine-needle aspiration needles for portal vein sampling in a swine model. Methods  Celiotomy was performed on two farm pigs. Portal vein sampling occurred transhepatically. We compared 19 G and 22 G needles coated interiorly with saline, heparin or ethylenediaminetetraacetic acid (EDTA). Small- (10 mL) and large- (25 mL) volume blood collections were evaluated. Two different collection methods were tested: direct-to-vial and suction syringe. A bleeding risk trial for saline-coated 19 G and 22 G needles was performed by puncturing the portal vein 20 times. Persistent bleeding after 3 minutes was considered significant. Results  All small-volume collection trials were successful except for 22 G saline-coated needles with direct-to-vial method. All large-volume collection trials were successful when using suction syringe; direct-to-vial method for both 19 G and 22 G needles were unsuccessful. Collection times were shorter for 19 G vs. 22 G needles for both small and large-volume collections ( P  < 0.05). Collection times for saline-coated 22 G needles were longer compared to heparin/EDTA-coated ( P  < 0.05). Bleeding occurred in 10 % punctures with 19 G needles compared to 0 % with 22 G needles. Conclusion  The results of this animal study demonstrate the feasibility and the safety of using 22 G needles for portal vein sampling and can form the basis for a pilot study in patients.

Positive Choices: Addressing the evidence-practice gap in alcohol and other drug prevention

Issue

Alcohol and other drug (AOD) use during adolescence puts young people at risk of juvenile offending, poor educational outcomes, school dropout, and mental health issues. Since parents and school teachers are the primary source of contact for adolescents, it is important that they are equipped with accurate and up-to-date response strategies. There are a number of effective drug prevention strategies, however, they are not widely implemented.

Description of the practice

To address this evidence-practice gap, the Positive Choices initiative was launched in 2015. Positive Choices supports implementation of evidence-based and prevention strategies through provision of training and a centralised information and resources portal for young people, their parents and teachers. The portal contains information factsheets and webinars and was developed in consultation with AOD experts and target users. Drug education resources and curriculum programs meeting pre-specified criteria for relevance, quality and evidence-base are listed in the resources database.

Results

Positive Choices has been accessed by one-million Australian and international users. The most popular resources are videos, factsheets, webinars. In 2019, 71% parents and 65% teachers said that they would continue using the website. Half (54%) of school staff were not currently implementing evidence-based prevention strategies, of these 89% intended to shift to evidence-based practice after using Positive Choices. The majority of the users have said they would recommend the website to their colleagues and friends.

Lessons

Positive Choices is effective in changing users' intentions to implement evidence-based strategies. Drug education programs need to engage parents and teachers if they are to be effective.

Key messages

Positive Choices has increased users’ awareness of evidence-based prevention strategies. Positive Choices has increased users’ intentions to implement evidence-based prevention strategies.

Early clinical outcomes of a rapid colorectal cancer diagnosis pathway using faecal immunochemical testing in Nottingham

AIM

We introduced primary care access to faecal immunochemical testing (FIT) as a stratification tool for symptomatic patients considered to be at risk of colorectal cancer (CRC) prior to urgent referral. We aimed to evaluate clinical and pathway outcomes during the first 6 months of this novel approach.

METHOD

FIT was recommended for all patients who consulted their general practitioner with lower gastrointestinal symptoms other than rectal bleeding and rectal mass. We undertook a retrospective audit of the results of FIT, related clinical outcomes and resource utilization on prospectively logged cases between November 2017 and May 2018.

RESULTS

Of the 1862 FIT kits dispatched by post 91.4% were returned, with a median return time of 7 days (range 2-110 days); however, 1.3% of returned kits could not be analysed. FIT results ≥ 150.0 μg haemoglobin (Hb)/g faeces identified patients with a significantly higher risk of CRC (30.9% vs 1.4%, chi-square 167.1, P < 0.0001). FIT results ≥ 10.0 μg Hb/g faeces identified patients with significantly higher risk of significant noncancer bowel pathology (24.1% vs 4.9%, chi-square 73.6, P < 0.0001) and FIT results < 4.0 μg Hb/g faeces identified a group more likely to have non-CRC pathology (5.1% vs 2.4%, chi-square 3.9, P < 0.05). The CRC detection rate in 531 patients investigated after a FIT result of < 4.0 μg Hb/g faeces was 0.2%. In 899 investigated patients, a FIT result with a threshold of 4.0 μg Hb/g faeces had sensitivity 97.2% (85.5-99.9% CI), specificity 61.4% (58.1-64.7% CI), negative predictive value 99.8% (98.7-100.0% CI) and positive predictive value 9.5% (8.7-10.4% CI).

CONCLUSION

A symptomatic pathway incorporating FIT is feasible and appears more clinically effective than pathways based on age and symptoms alone.

An Open-Source Tool for Anisotropic Radiation Therapy Planning in Neuro-oncology Using DW-MRI Tractography

There is evidence from histopathological studies that glioma tumor cells migrate preferentially along large white matter bundles. If the peritumoral white matter structures can be used to predict the likely trajectory of migrating tumor cells outside of the surgical margin, then this information could be used to inform the delineation of radiation therapy (RT) targets. In theory, an anisotropic expansion that takes large white matter bundle anatomy into account may maximize the chances of treating migrating cancer cells and minimize the amount of brain tissue exposed to high doses of ionizing radiation. Diffusion-weighted MRI (DW-MRI) can be used in combination with fiber tracking algorithms to model the trajectory of large white matter pathways using the direction and magnitude of water movement in tissue. The method presented here is a tool for translating a DW-MRI fiber tracking (tractography) dataset into a white matter path length (WMPL) map that assigns each voxel the shortest distance along a streamline back to a specified region of interest (ROI). We present an open-source WMPL tool, implemented in the package Diffusion Imaging in Python (DIPY), and code to convert the resulting WMPL map to anisotropic contours for RT in a commercial treatment planning system. This proof-of-concept lays the groundwork for future studies to evaluate the clinical value of incorporating tractography modeling into treatment planning.

Attitude towards and factors affecting uptake of population-based BRCA testing in the Ashkenazi Jewish population: a cohort study

OBJECTIVE

To evaluate factors affecting unselected population-based BRCA testing in Ashkenazi Jews (AJ).

DESIGN

Cohort-study set within recruitment to the GCaPPS trial (ISRCTN73338115).

SETTING

North London AJ population.

POPULATION OR SAMPLE

Ashkenazi Jews women/men >18 years, recruited through self-referral.

METHODS

Ashkenazi Jews women/men underwent pre-test counselling for BRCA testing through recruitment clinics (clusters). Consenting individuals provided blood samples for BRCA testing. Data were collected on socio-demographic/family history/knowledge/psychological well-being along with benefits/risks/cultural influences (18-item questionnaire measuring 'attitude'). Four-item Likert-scales analysed initial 'interest' and 'intention-to-test' pre-counselling. Uni- and multivariable logistic regression models evaluated factors affecting uptake/interest/intention to undergo BRCA testing. Statistical inference was based on cluster robust standard errors and joint Wald tests for significance. Item-Response Theory and graded-response models modelled responses to 18-item questionnaire.

MAIN OUTCOME MEASURES

Interest, intention, uptake, attitude towards BRCA testing.

RESULTS

A total of 935 individuals (women = 67%/men = 33%; mean age = 53.8 (SD = 15.02) years) underwent pre-test genetic-counselling. During the pre-counselling, 96% expressed interest in and 60% indicated a clear intention to undergo BRCA testing. Subsequently, 88% opted for BRCA testing. BRCA-related knowledge (P = 0.013) and degree-level education (P = 0.01) were positively and negatively (respectively) associated with intention-to-test. Being married/cohabiting had four-fold higher odds for BRCA testing uptake (P = 0.009). Perceived benefits were associated with higher pre-counselling odds for interest in and intention to undergo BRCA testing. Reduced uncertainty/reassurance were the most important factors contributing to decision-making. Increased importance/concern towards risks/limitations (confidentiality/insurance/emotional impact/inability to prevent cancer/marriage ability/ethnic focus/stigmatisation) were significantly associated with lower odds of uptake of BRCA testing, and discriminated between acceptors and decliners. Male gender/degree-level education (P = 0.001) had weaker correlations, whereas having children showed stronger (P = 0.005) associations with attitudes towards BRCA testing.

CONCLUSIONS

BRCA testing in the AJ population has high acceptability. Pre-test counselling increases awareness of disadvantages/limitations of BRCA testing, influencing final cost-benefit perception and decision-making on undergoing testing.

TWEETABLE ABSTRACT

BRCA testing in Ashkenazi Jews has high acceptability and uptake. Pre-test counselling facilitates informed decision-making.

Service evaluation of faecal immunochemical testing and anaemia for risk stratification in the 2-week-wait pathway for colorectal cancer

Background

New national guidance on urgent referral for investigation of colorectal cancer included faecal occult blood testing in 2015. A service evaluation of faecal immunochemical testing (FIT) and anaemia as risk stratification tools in symptomatic patients suspected of having CRC was undertaken.

Methods

Postal FIT was incorporated into the colorectal cancer 2-week wait (2WW) pathway for all patients without rectal bleeding in 2016. Patients were investigated in the 2WW pathway as normal, and outcomes of investigations were recorded prospectively. Anaemia was defined as a haemoglobin level below 120 g/l in women and 130 g/l in men.

Results

FIT kits were sent to 1106 patients, with an 80·9 per cent return rate; 810 patients completed investigations and 40 colorectal cancers were diagnosed (4·9 per cent). FIT results were significantly higher in patients with anaemia (median (i.q.r.) 4·8 (0·8-34·1) versus 1·2 (0-6·4) μg Hb/g faeces in those without anaemia; P < 0·001). Some 60·4 per cent of patients (538 of 891) had a result lower than 4 μg haemoglobin (Hb) per g faeces (limit of detectability), and 69·7 per cent (621 of 891) had less than 10 μg Hb/g faeces. Some 60 per cent of patients with colorectal cancer had a FIT reading of 150 μg Hb/g faeces or more. For five colorectal cancers diagnosed in patients with a FIT value below 10 μg Hb/g faeces, there was either a palpable rectal mass or the patient was anaemic. A FIT result of more than 4 μg Hb/g faeces had 97·5 per cent sensitivity and 64·5 per cent specificity for a diagnosis of colorectal cancer. A FIT result above 4 μg Hb/g faeces and/or anaemia had a 100 per cent sensitivity and 45·3 per cent specificity for colorectal cancer diagnosis.

Conclusion

FIT is most useful at the extremes of detectability; strongly positive readings predict high rates of colorectal cancer and other significant pathology, whereas very low readings in the absence of anaemia or a palpable rectal mass identify a group with very low risk. High return rates for FIT within this 2WW pathway indicate its acceptability.

125I-Fibrinogen Binding to Platelets in Myeloproliferative Disease

Recent reports have suggested a variation in the density and affinity of fibrinogen binding sites in platelets from patients with myeloproliferative disorders (MPD) which may reflect platelet functional abnormalities in these subjects. We have investigated the binding of 125I-fibrinogen (125I-Fb) to gel-filtered platelets from a large relatively homogeneous group of patients with MPD compared to normal age matched controls. Twenty-two of the patients investigated had polycythaemia vera and four essential thrombocythaemia.

The maximal density and affinity (Kd) of 125I-Fb binding was assessed by saturation analysis in gel-filtered platelets (GFP) stimulated with either 10 εM ADP or 150 mU thrombin. In addition the functional significance of the binding sites was studied by evaluating the response of GFP from the two experimental groups by assessing the effects of increasing concentrations of added fibrinogen on the response to 10 εM ADP using standard light transmission aggregometry.

In both groups the density of fibrinogen binding sites expressed in response to thrombin stimulation was significantly higher (approximately 2-3 fold) than that found in response to ADP. However, fewer binding sites were detected in the MPD group as compared with the control group in response to both ADP and thrombin. The Kd for 125I-Fb was similar for both agonists in normal controls and was significantly lower than that found in the MPD subjects.

Although the 125I-Fb binding study results indicate a significant reduction in both the number and affinity of fibrinogen binding sites in patients with myeloproliferative disorders, the clinical and functional significance of these findings remain uncertain.

Use of volumetric laser endomicroscopy for dysplasia detection at the gastroesophageal junction and gastric cardia

AIM

To determine specific volumetric laser endomicroscopy (VLE) imaging features associated with neoplasia at the gastroesophageal junction (GEJ) and gastric cardia.

METHODS

During esophagogastroduodenoscopy for patients with known or suspected Barrett’s esophagus, VLE was performed before biopsies were taken at endoscopists’ discretion. The gastric cardia was examined on VLE scan from the GEJ (marked by top of gastric folds) to 1 cm distal from the GEJ. The NinePoints VLE console was used to analyze scan segments for characteristics previously found to correlate with normal or abnormal mucosa. Glands were counted individually. Imaging features identified on VLE scan were correlated with biopsy results from the GEJ and cardia region.

RESULTS

This study included 34 cases. Features characteristic of the gastric cardia (gastric rugae, gastric pit architecture, poor penetration) were observed in all (100%) scans. Loss of classic gastric pit architecture was common and there was no difference between those with neoplasia and without (100% vs 74%, P = NS). The abnormal VLE feature of irregular surface was more often seen in patients with neoplasia than those without (100% vs 18%, P < 0.0001), as was heterogeneous scattering (86% vs 41%, P < 0.005) and presence of anomalous glands (100% vs 59%, P < 0.05). The number of anomalous glands did not differ between individual histologic subgroups (ANOVA, P = NS).

CONCLUSION

The transition from esophagus to gastric cardia is reliably identified on VLE. Histologically abnormal cardia mucosa produces abnormal VLE features. Optical coherence tomography algorithms can be expanded for use at the GEJ/cardia.

Population attributable fractions and joint effects of key risk factors for multiple sclerosis

AIM

We examined the combined effect of having multiple key risk factors and the interactions between the key risk factors of multiple sclerosis (MS).

METHODS

We performed an incident case-control study including cases with a first clinical diagnosis of central nervous system demyelination (FCD) and population-based controls.

RESULTS

Compared to those without any risk factors, those with one, two, three, and four or five risk factors had increased odds of being an FCD case of 2.12 (95% confidence interval (CI), 1.11-4.03), 4.31 (95% CI, 2.24-8.31), 7.96 (95% CI, 3.84-16.49), and 21.24 (95% CI, 5.48-82.40), respectively. Only HLA-DR15 and history of infectious mononucleosis interacted significantly on the additive scale (Synergy index, 3.78; p = 0.03). The five key risk factors jointly accounted for 63.8% (95% CI, 43.9-91.4) of FCD onset. High anti-EBNA IgG was another important contributor.

CONCLUSIONS

A high proportion of FCD onset can be explained by the currently known risk factors, with HLA-DR15, ever smoking and low cumulative sun exposure explaining most. We identified a significant interaction between HLA-DR15 and history of IM in predicting an FCD of CNS demyelination, which together with previous observations suggests that this is a true interaction.

Performance analysis of RDF gasification in a two stage fluidized bed-plasma process

The major technical problems faced by stand-alone fluidized bed gasifiers (FBG) for waste-to gas applications are intrinsically related to the composition and physical properties of waste materials, such as RDF. The high quantity of ash and volatile material in RDF can provide a decrease in thermal output, create high ash clinkering, and increase emission of tars and CO2, thus affecting the operability for clean syngas generation at industrial scale. By contrast, a two-stage process which separates primary gasification and selective tar and ash conversion would be inherently more forgiving and stable. This can be achieved with the use of a separate plasma converter, which has been successfully used in conjunction with conventional thermal treatment units, for the ability to 'polish' the producer gas by organic contaminants and collect the inorganic fraction in a molten (and inert) state. This research focused on the performance analysis of a two-stage fluid bed gasification-plasma process to transform solid waste into clean syngas. Thermodynamic assessment using the two-stage equilibrium method was carried out to determine optimum conditions for the gasification of RDF and to understand the limitations and influence of the second stage on the process performance (gas heating value, cold gas efficiency, carbon conversion efficiency), along with other parameters. Comparison with a different thermal refining stage, i.e. thermal cracking (via partial oxidation) was also performed. The analysis is supported by experimental data from a pilot plant.

Medicine-taking experiences and associated factors: comparison between Arabic-speaking and Caucasian English-speaking patients with Type 2 diabetes

AIM

The aim of this study was to explore and compare medication-taking experiences and associated issues in Arabic-speaking and Caucasian English-speaking patients with Type 2 diabetes in Australia.

METHODS

Various healthcare settings in metropolitan Melbourne, Australia, were purposefully selected to obtain a diverse group of participants with Type 2 diabetes. Recruitment occurred at diabetes outpatient clinics in two tertiary referral hospitals, six primary care practices and ten community centres. Face-to-face semi-structured individual interviews and group interviews were employed. All interviews were audiotaped, transcribed and coded thematically. Data collection continued until saturation was reached.

RESULTS

In total, 100 participants were recruited into two groups: 60 were Arabic-speaking and 40 were Caucasian English-speaking. Both groups had similar demographic and clinical characteristics. Only 5% of the Arabic-speaking participants had well-controlled diabetes compared with 17.5% of the participants in the English-speaking group. Arabic-speaking participants actively changed medication regimens on their own without informing their healthcare professionals. Arabic-speaking patients had more knowledge gaps about their prescribed treatments, compared with the English-speaking group. Their use of diabetes medicines was heavily influenced by peers with diabetes and family members; conversely, they feared revealing their diagnosis within the wider Arabic community due to stigma and collective negative social labelling of diabetes. Confidence in non-Arabic-speaking healthcare providers was lacking.

CONCLUSIONS

Findings yielded new insights into medication-taking practices and associated factors in Arabic-speaking patients with diabetes. It is vital that healthcare professionals working with Arabic-speaking patients adapt their treatment approaches to accommodate different beliefs and views about medicines.

Factors associated with the anonymous reporting of lifetime domestic violence in a genitourinary medicine clinic: a patient self-reported questionnaire study

Domestic violence (DV) occurs frequently within the UK, with one in four women and one in six men experiencing DV during their life. DV is the leading cause of morbidity for women aged 19-44 years and is associated with sexual health problems. However, few data exist on the prevalence of DV in UK genitourinary (GU) medicine settings. An anonymous questionnaire was self-completed by patients (n = 476/500) attending Bournemouth GU medicine clinic during July 2009 to explore associations between lifetime DV and sociodemographic, sexual and behavioural factors. Overall, 21% (98/472) reported that they had ever been abused by a partner (12% [27/229] of men and 29% [71/243] of women). Logistic regression highlighted that being female, having children/dependants and use of illicit drugs were the most important factors associated with lifetime DV. Regular staff training on DV is recommended to increase awareness and signposting to relevant services.

Early-life hygiene-related factors affect risk of central nervous system demyelination and asthma differentially

The increasing prevalence of immune-related diseases, including multiple sclerosis, may be partly explained by reduced microbial burden during childhood. Within a multi-centre case-control study population, we examined: (i) the co-morbid immune diseases profile of adults with a first clinical diagnosis of central nervous system demyelination (FCD) and (ii) sibship structure in relation to an autoimmune (FCD) and an allergic (asthma) disease. FCD cases (n = 282) were aged 18-59 years; controls (n = 558) were matched on age, sex and region. Measures include: history of doctor-diagnosed asthma; sibling profile (number; dates of birth); and regular childcare attendance. FCD cases did not differ from controls with regard to personal or family history of allergy, but had a greater likelihood of chronic fatigue syndrome [odds ratio (OR) = 3·11; 95% confidence interval (CI) 1·11, 8·71]. Having any younger siblings showed reduced odds of FCD (OR = 0·68; 95% CI: 0·49, 0·95) but not asthma (OR = 1·47; 95% CI: 0·91, 2·38). In contrast, an increasing number of older siblings was associated with reduced risk of asthma (P trend = 0·04) but not FCD (P trend = 0·66). Allergies were not over-represented among people presenting with FCD. Sibship characteristics influence both FCD and asthma risk but the underlying mechanisms differ, possibly due to the timing of the putative 'sibling effect'.

Occupational exposure and risk of central nervous system demyelination

Inconsistent evidence exists regarding the association between work-related factors and risk of multiple sclerosis (MS). We examined the association between occupational exposures and risk of a first clinical diagnosis of central nervous system demyelination (FCD), which is strongly associated with progression to MS, in a matched case-control study of 276 FCD cases and 538 controls conducted in Australia (2003-2006). Using a personal residence and work calendar, information on occupational history and exposure to chemicals and animals was collected through face-to-face interviews. Few case-control differences were noted. Fewer cases had worked as professionals (≥6 years) than controls (adjusted odds ratio (AOR) = 0.60, 95% confidence interval (CI): 0.37, 0.96). After further adjustment for number of children, cases were more likely to have ever been exposed to livestock than controls (AOR = 1.54, 95% CI: 1.03, 2.29). Among women, there was an increase in FCD risk associated with 10 or more years of exposure to livestock (AOR = 2.78, 95% CI: 1.22, 6.33) or 6 or more years of farming (AOR = 2.00, 95% CI: 1.23, 3.25; also adjusted for number of children). Similar findings were not evident among men. Thus, farming and exposure to livestock may be important factors in the development of FCD among women, with this finding further revealed after the confounding effect of parity or number of children is considered.

Colorectal cancer screening among Chinese American immigrants

The purpose of this study was to examine the factors determining fecal occult blood test (FOBT) uptake in Chinese American immigrants. This study used a prospective, cross-sectional design with convenience sampling. An educational session on colorectal cancer screening (CRS) was provided to the participants during a health fair, and each participant was offered a no-cost FOBT kit. Data was collected over two consecutive years during three different health fairs. A questionnaire was used to collect demographic data. A total of 113 participants were recruited and 72% of them returned the FOBT kit. There was a significant association between having a primary-care physician (PCP) and having CRS in the past, even after controlling for age, gender and the length of time in the US (P = .009). Participants who visited a doctor for health maintenance were less likely to participate in the FOBT, compared to participants who never visited a doctor or who only visited a doctor when they were sick (P = .001). The length of time in the US had a significant effect on having a PCP (P = .002). However, having a PCP or having CRS in the past was not associated with participating in the screening and so was feeling at risk for CRC. In fact, 49% of Chinese women and 45% of Chinese men felt no risk of CRC. Future research and interventions that address knowledge deficits and focus on recent immigrants and their access to health care may have the potential to increase CRS among Chinese American immigrants.