Environmental drivers impact the accumulation and diversity of antibiotic resistance in green stormwater infrastructure

Antibiotic resistance poses an urgent public health concern, with the environment playing a crucial role in the development and dissemination of resistant bacteria. There is a growing body of research indicating that stormwater is a significant source and transport vector of resistance elements. This research sought to characterize the role of green stormwater infrastructure (GSI), designed for stormwater infiltration, in accumulating and propagating antibiotic resistance in the urban water cycle. Sampling included 24 full-scale GSI systems representing three distinct types of GSI - bioswales, bioretention cells, and constructed wetlands. The results indicated that GSI soils accumulate antibiotic resistance genes (ARGs) at elevated concentrations compared to nonengineered soils. Bioretention cells specifically harbored higher abundances of ARGs, suggesting that the type of GSI influences ARG accumulation. Interestingly, ARG diversity in GSI soils was not impacted by the type of GSI design or the diversity of the microbial community and mobile genetic elements. Instead, environmental factors (catchment imperviousness, metals, nutrients, and salts) were identified as significant drivers of ARG diversity. These findings highlight how environmental selective pressures in GSI promote ARG persistence and proliferation independently of the microbial community. Therefore, GSI systems have the potential to be a substantial contributor of abundant and diverse ARGs to the urban water cycle.

High Resolution Study of ^{40}Ca to Constrain Potassium Nucleosynthesis in NGC 2419

The globular cluster NGC 2419 was the first to exhibit a Mg-K anticorrelation, linked to hydrogen burning at temperatures between 80-260 MK. However, the key K-destroying reaction, ^{39}K(p,γ)^{40}Ca, has a large rate uncertainty in this range. We significantly constrain this rate with a high resolution ^{39}K(^{3}He,d)^{40}Ca study. We resolve the E_{r}^{c.m.}=154  keV resonance in ^{39}K+p for the first time, increasing the previous rate by up to a factor 13 and reducing its 1σ width by up to a factor of 42. Reaction network calculations for NGC 2419 suggest that this could lower temperatures needed to reproduce the Mg-K anticorrelation.

Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

A mapping exercise using automated techniques to develop a search strategy to identify systematic review tools

The Systematic Review Toolbox aims provide a web-based catalogue of tools that support various tasks within the systematic review and wider evidence synthesis process. Identifying publications surrounding specific systematic review tools is currently challenging, leading to a high screening burden for few eligible records. We aimed to develop a search strategy that could be regularly and automatically run to identify eligible records for the SR Toolbox, thus reducing time on task and burden for those involved. We undertook a mapping exercise to identify the PubMed IDs of papers indexed within the SR Toolbox. We then used the Yale MeSH Analyser and Visualisation of Similarities (VOS) Viewer text-mining software to identify the most commonly used MeSH terms and text words within the eligible records. These MeSH terms and text words were combined using Boolean Operators into a search strategy for Ovid MEDLINE. Prior to the mapping exercise and search strategy development, 81 software tools and 55 'Other' tools were included within the SR Toolbox. Since implementation of the search strategy, 146 tools have been added. There has been an increase in tools added to the toolbox since the search was developed and its corresponding auto-alert in MEDLINE was originally set up. Developing a search strategy based on a mapping exercise is an effective way of identifying new tools to support the systematic review process. Further research could be conducted to help prioritise records for screening to reduce reviewer burden further and to adapt the strategy for disciplines beyond healthcare.

A narrative review of recent tools and innovations toward automating living systematic reviews and evidence syntheses

Living reviews are an increasingly popular research paradigm. The purpose of a 'living' approach is to allow rapid collation, appraisal and synthesis of evolving evidence on an important research topic, enabling timely influence on patient care and public health policy. However, living reviews are time- and resource-intensive. The accumulation of new evidence and the possibility of developments within the review's research topic can introduce unique challenges into the living review workflow. To investigate the potential of software tools to support living systematic or rapid reviews, we present a narrative review informed by an examination of tools contained on the Systematic Review Toolbox website. We identified 11 tools with relevant functionalities and discuss the important features of these tools with respect to different steps of the living review workflow. Four tools (NestedKnowledge, SWIFT-ActiveScreener, DistillerSR, EPPI-Reviewer) covered multiple, successive steps of the review process, and the remaining tools addressed specific components of the workflow, including scoping and protocol formulation, reference retrieval, automated data extraction, write-up and dissemination of data. We identify several ways in which living reviews can be made more efficient and practical. Most of these focus on general workflow management, or automation through artificial intelligence and machine-learning, in the screening process. More sophisticated uses of automation mostly target living rapid reviews to increase the speed of production or evidence maps to broaden the scope of the map. We use a case study to highlight some of the barriers and challenges to incorporating tools into the living review workflow and processes. These include increased workload, the need for organisation, ensuring timely dissemination and challenges related to the development of bespoke automation tools to facilitate the review process. We describe how current end-user tools address these challenges, and which knowledge gaps remain that could be addressed by future tool development. Dedicated web presences for automatic dissemination of in-progress evidence updates, rather than solely relying on peer-reviewed journal publications, help to make the effort of a living evidence synthesis worthwhile. Despite offering basic living review functionalities, existing end-user tools could be further developed to be interoperable with other tools to support multiple workflow steps seamlessly, to address broader automatic evidence retrieval from a larger variety of sources, and to improve dissemination of evidence between review updates.

Evaluating ChatGPT Performance on the Orthopaedic In-Training Examination

Background

Artificial intelligence (AI) holds potential in improving medical education and healthcare delivery. ChatGPT is a state-of-the-art natural language processing AI model which has shown impressive capabilities, scoring in the top percentiles on numerous standardized examinations, including the Uniform Bar Exam and Scholastic Aptitude Test. The goal of this study was to evaluate ChatGPT performance on the Orthopaedic In-Training Examination (OITE), an assessment of medical knowledge for orthopedic residents.

Methods

OITE 2020, 2021, and 2022 questions without images were inputted into ChatGPT version 3.5 and version 4 (GPT-4) with zero prompting. The performance of ChatGPT was evaluated as a percentage of correct responses and compared with the national average of orthopedic surgery residents at each postgraduate year (PGY) level. ChatGPT was asked to provide a source for its answer, which was categorized as being a journal article, book, or website, and if the source could be verified. Impact factor for the journal cited was also recorded.

Results

ChatGPT answered 196 of 360 answers correctly (54.3%), corresponding to a PGY-1 level. ChatGPT cited a verifiable source in 47.2% of questions, with an average median journal impact factor of 5.4. GPT-4 answered 265 of 360 questions correctly (73.6%), corresponding to the average performance of a PGY-5 and exceeding the corresponding passing score for the American Board of Orthopaedic Surgery Part I Examination of 67%. GPT-4 cited a verifiable source in 87.9% of questions, with an average median journal impact factor of 5.2.

Conclusions

ChatGPT performed above the average PGY-1 level and GPT-4 performed better than the average PGY-5 level, showing major improvement. Further investigation is needed to determine how successive versions of ChatGPT would perform and how to optimize this technology to improve medical education.

Clinical Relevance

AI has the potential to aid in medical education and healthcare delivery.

Economic evaluations of interventions to prevent and control health-care-associated infections: a systematic review

Almost 9 million health-care-associated infections have been estimated to occur each year in European hospitals and long-term care facilities, and these lead to an increase in morbidity, mortality, bed occupancy, and duration of hospital stay. The aim of this systematic review was to review the cost-effectiveness of interventions to limit the spread of health-care-associated infections), framed by WHO infection prevention and control core components. The Embase, National Health Service Economic Evaluation Database, Database of Abstracts of Reviews of Effects, Health Technology Assessment, Cinahl, Scopus, Pediatric Economic Database Evaluation, and Global Index Medicus databases, plus grey literature were searched for studies between Jan 1, 2009, and Aug 10, 2022. Studies were included if they reported interventions including hand hygiene, personal protective equipment, national-level or facility-level infection prevention and control programmes, education and training programmes, environmental cleaning, and surveillance. The British Medical Journal checklist was used to assess the quality of economic evaluations. 67 studies were included in the review. 25 studies evaluated methicillin-resistant Staphylococcus aureus outcomes. 31 studies evaluated screening strategies. The assessed studies that met the minimum quality criteria consisted of economic models. There was some evidence that hand hygiene, environmental cleaning, surveillance, and multimodal interventions were cost-effective. There were few or no studies investigating education and training, personal protective equipment or monitoring, and evaluation of interventions. This Review provides a map of cost-effectiveness data, so that policy makers and researchers can identify the relevant data and then assess the quality and generalisability for their setting.

Improved Measurement of the Evolution of the Reactor Antineutrino Flux and Spectrum at Daya Bay

Reactor neutrino experiments play a crucial role in advancing our knowledge of neutrinos. In this Letter, the evolution of the flux and spectrum as a function of the reactor isotopic content is reported in terms of the inverse-beta-decay yield at Daya Bay with 1958 days of data and improved systematic uncertainties. These measurements are compared with two signature model predictions: the Huber-Mueller model based on the conversion method and the SM2018 model based on the summation method. The measured average flux and spectrum, as well as the flux evolution with the ^{239}Pu isotopic fraction, are inconsistent with the predictions of the Huber-Mueller model. In contrast, the SM2018 model is shown to agree with the average flux and its evolution but fails to describe the energy spectrum. Altering the predicted inverse-beta-decay spectrum from ^{239}Pu fission does not improve the agreement with the measurement for either model. The models can be brought into better agreement with the measurements if either the predicted spectrum due to ^{235}U fission is changed or the predicted ^{235}U, ^{238}U, ^{239}Pu, and ^{241}Pu spectra are changed in equal measure.

Precision Measurement of Reactor Antineutrino Oscillation at Kilometer-Scale Baselines by Daya Bay

We present a new determination of the smallest neutrino mixing angle θ_{13} and the mass-squared difference Δm_{32}^{2} using a final sample of 5.55×10^{6} inverse beta-decay (IBD) candidates with the final-state neutron captured on gadolinium. This sample is selected from the complete dataset obtained by the Daya Bay reactor neutrino experiment in 3158 days of operation. Compared to the previous Daya Bay results, selection of IBD candidates has been optimized, energy calibration refined, and treatment of backgrounds further improved. The resulting oscillation parameters are sin^{2}2θ_{13}=0.0851±0.0024, Δm_{32}^{2}=(2.466±0.060)×10^{-3}  eV^{2} for the normal mass ordering or Δm_{32}^{2}=-(2.571±0.060)×10^{-3}  eV^{2} for the inverted mass ordering.

ScanMedicine: An online search system for medical innovation

ScanMedicine is a novel searching system dedicated to providing health care professionals, patients, carers, the public, decision- and policy-makers, and researchers with open access to the development pipeline underpinning health technology innovations. In the first phase of developing ScanMedicine, we have focused on capturing and consolidating clinical trial records hosted on national and international clinical trials registries and medical device approval data from the FDA. ScanMedicine has been developed based on microservice architecture allowing the system to be constantly improved in a flexible and scalable manner. ScanMedicine offers users a convenient and effective single search interface with interactive visualisation features that can provide an overview of the health technology innovation landscape.

The Systematic Review Toolbox: keeping up to date with tools to support evidence synthesis

BACKGROUND

The Systematic Review (SR) Toolbox was developed in 2014 to collate tools that can be used to support the systematic review process. Since its inception, the breadth of evidence synthesis methodologies has expanded greatly. This work describes the process of updating the SR Toolbox in 2022 to reflect these changes in evidence synthesis methodology. We also briefly analysed included tools and guidance to identify any potential gaps in what is currently available to researchers.

METHODS

We manually extracted all guidance and software tools contained within the SR Toolbox in February 2022. A single reviewer, with a second checking a proportion, extracted and analysed information from records contained within the SR Toolbox using Microsoft Excel. Using this spreadsheet and Microsoft Access, the SR Toolbox was updated to reflect expansion of evidence synthesis methodologies and brief analysis conducted.

RESULTS

The updated version of the SR Toolbox was launched on 13 May 2022, with 235 software tools and 112 guidance documents included. Regarding review families, most software tools (N = 223) and guidance documents (N = 78) were applicable to systematic reviews. However, there were fewer tools and guidance documents applicable to reviews of reviews (N = 66 and N = 22, respectively), while qualitative reviews were less served by guidance documents (N = 19). In terms of review production stages, most guidance documents surrounded quality assessment (N = 70), while software tools related to searching and synthesis (N = 84 and N = 82, respectively). There appears to be a paucity of tools and guidance relating to stakeholder engagement (N = 2 and N = 3, respectively).

CONCLUSIONS

The SR Toolbox provides a platform for those undertaking evidence syntheses to locate guidance and software tools to support different aspects of the review process across multiple review types. However, this work has also identified potential gaps in guidance and software that could inform future research.

Oral nutritional interventions in frail older people who are malnourished or at risk of malnutrition: a systematic review

BACKGROUND

Malnutrition worsens the health of frail older adults. Current treatments for malnutrition may include prescribed oral nutritional supplements, which are multinutrient products containing macronutrients and micronutrients.

OBJECTIVE

To assess the effectiveness and cost-effectiveness of oral nutritional supplements (with or without other dietary interventions) in frail older people who are malnourished or at risk of malnutrition.

DATA SOURCES

MEDLINE, EMBASE, Cochrane Library, Scopus, CINAHL (Cumulative Index to Nursing and Allied Health Literature) and grey literature were searched from inception to 13 September 2021.

REVIEW METHODS

A systematic review and meta-analysis was conducted to evaluate the effectiveness and cost-effectiveness of oral nutritional supplements in frail older people (aged ≥ 65 years) who are malnourished or at risk of malnutrition (defined as undernutrition as per National Institute for Health and Care Excellence guidelines). Meta-analysis and network meta-analysis were undertaken, where feasible, along with a narrative synthesis. A cost-effectiveness review was reported narratively. A de novo model was developed using effectiveness evidence identified in the systematic review to estimate the cost-effectiveness of oral nutritional supplements.

RESULTS

Eleven studies (n = 822 participants) were included in the effectiveness review, six of which were fully or partly funded by industry. Meta-analyses suggested positive effects of oral nutritional supplements compared with standard care for energy intake (kcal) (standardised mean difference 1.02, 95% confidence interval 0.15 to 1.88; very low quality evidence) and poor mobility (mean difference 0.03, p < 0.00001, 95% confidence interval 0.02 to 0.04; very low quality evidence) but no evidence of an effect for body weight (mean difference 1.31, 95% confidence interval -0.05 to 2.66; very low quality evidence) and body mass index (mean difference 0.54, 95% confidence interval -0.03 to 1.11; very low quality evidence). Pooled results for other outcomes were statistically non-significant. There was mixed narrative evidence regarding the effect of oral nutritional supplements on quality of life. Network meta-analysis could be conducted only for body weight and grip strength; there was evidence of an effect for oral nutritional supplements compared with standard care for body weight only. Study quality was mixed; the randomisation method was typically poorly reported. One economic evaluation, in a care home setting, was included. This was a well-conducted study showing that oral nutritional supplements could be cost-effective. Cost-effectiveness analysis suggested that oral nutritional supplements may only be cost-effective for people with lower body mass index (< 21 kg/m2) using cheaper oral nutritional supplements products that require minimal staff time to administer.

LIMITATIONS

The review scope was narrow in focus as few primary studies used frailty measures (or our proxy criteria). This resulted in only 11 included studies. The small evidence base and varied quality of evidence meant that it was not possible to determine accurate estimates of the effectiveness or cost-effectiveness of oral nutritional supplements. Furthermore, only English-language publications were considered.

CONCLUSIONS

Overall, the review found little evidence of oral nutritional supplements having significant effects on reducing malnutrition or its adverse outcomes in frail older adults.

FUTURE WORK

Future research should focus on independent, high-quality, adequately powered studies to investigate oral nutritional supplements alongside other nutritional interventions, with longer-term follow-up and detailed analysis of determinants, intervention components and cost-effectiveness.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42020170906.

FUNDING

This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 51. See the NIHR Journals Library website for further project information.

Extramedullary Hematopoiesis Identified in Pleural Fluid of a Patient with Bilateral Pleural Effusions and Associated Myelofibrosis

Introduction/Objective

Extramedullary hematopoiesis (EMH) is the formation of blood cells outside of the bone marrow medullary spaces. EMH is typically seen in the spleen or liver and in association with bone marrow replacement disorders, hemoglobinopathies, and other hematological disorders. Rarely EMH can occur in the pleural cavity of patients resulting in subsequent pleural effusions. These cases can accurately be diagnosed with identification of megakaryocytes and other hematopoietic elements in the pleural fluid.

Methods/Case Report

We present a 67 year old male with a past medical history of pericardial effusion, Jak 2 positive Myelofibrosis (Post PV/ET), and type II diabetes mellitus, who presented with complaint of shortness of breath for 10 days. The patient did not require oxygen at home and denied any cough or hemoptysis. In the emergency department a Chest X ray was ordered which showed bilateral pulmonary effusions. These effusions were attributed to worsening congestive heart failure, and diuretic therapy was started. With no resolution of the pleural effusions, the decision was made to conduct a thoracentesis and remove the fluid. Interventional radiology then performed a thoracentesis removing 1000 mL from each the left and right pleural spaces. Cytological preparation of the fluid demonstrated myeloid and erythroid precursors as well as occasional megakaryocytes. The diagnosis of extramedullary hematopoiesis was made and the effusion did not recur.

Results (if a Case Study enter NA)

NA.

Conclusion

Extramedullary hematopoiesis of the pleural space is rare. However it must be considered in the differential diagnosis of a patient with persistent effusions and concomitant bone marrow replacement disease such as myelofibrosis. Prompt removal and cytological evaluation of the pleura fluid for hematopoietic elements should be performed in order to diagnose and manage the patient most effectively.

Direct Measurement of Resonances in ^{7}Be(α,γ)^{11}C Relevant to νp-Process Nucleosynthesis

We have performed the first direct measurement of two resonances of the ^{7}Be(α,γ)^{11}C reaction with unknown strengths using an intense radioactive ^{7}Be beam and the DRAGON recoil separator. We report on the first measurement of the 1155 and 1110 keV resonance strengths of 1.73±0.25(stat)±0.40(syst)  eV and 125_{-25}^{+27}(stat)±15(syst)  meV, respectively. The present results have reduced the uncertainty in the ^{7}Be(α,γ)^{11}C reaction rate to ∼9.4%-10.7% over T=1.5-3  GK, which is relevant for nucleosynthesis in the neutrino-driven outflows of core-collapse supernovae (νp process). We find no effect of the new, constrained reaction rate on νp-process nucleosynthesis.

Effectiveness and cost-effectiveness of oral nutritional supplements in frail older people who are malnourished or at risk of malnutrition: a systematic review and meta-analysis

BACKGROUND

Current management of malnutrition can include prescribed oral nutritional supplements (ONS); however, there is uncertainty whether these supplements are effective in people who are older (≥65 years) and frail. We assessed the effectiveness, cost-effectiveness, and adherence and acceptability of ONS in frail older people who are malnourished or at risk of malnutrition.

METHODS

In this systematic review and meta-analysis, five bibliographic databases (MEDLINE, EMBASE, Cochrane Library, Scopus, and CINAHL) and grey literature sources were searched from inception to Sept 13, 2021, to identify studies assessing the effectiveness and cost-effectiveness of ONS (with or without other dietary interventions) in frail older people who are malnourished or at risk of malnutrition. Multiple reviewers independently did study screening, data extraction, and risk of bias assessment. Quality was assessed using version 1.0 of the Cochrane risk of bias tool for randomised controlled trials (RCTs), and the BMJ Drummond checklist was used to assess the quality of the included cost-effectiveness study. A meta-analysis was done for the effectiveness review; for the other reviews, a narrative synthesis approach was used. This systematic review and meta-analysis was registered on PROSPERO, CRD42020170906.

FINDINGS

Of 8492 records retrieved and screened, we included 11 RCTs involving 822 participants, six of which were fully or partly funded by industry. For the majority of the outcomes for which meta-analyses were possible (11/12), Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) assessments suggested that the evidence was of very low certainty. Results suggested that ONS might have a slightly positive effect on energy (kcal) intake (standardised mean difference 1·02 [95% CI 0·15 to 1·88]; I²=87%; four studies), protein intake (standardised mean difference 1·67 [-0·03 to 3·37; I²=97%; four studies), and mobility (mean difference 0·03 [0·02 to 0·04]; I²=0%; four studies), compared with standard care. Narrative syntheses suggested that the effect of ONS on quality of life, compared with standard care, was mixed. In the identified studies, there was very little information related to active components, determinants, or acceptability of interventions. One economic evaluation, done in a care home setting, showed that ONS could be cost-effective.

INTERPRETATION

We found little evidence of ONS reducing malnutrition or its associated adverse outcomes in older people who are frail. High-quality, non-industry-funded, adequately powered studies reporting on short-term and long-term health outcomes, determinants, and participant characteristics are needed.

FUNDING

UK National Institute of Health and Care Research (NIHR) Health Technology Assessment (NIHR128729).

FAIR data and metadata: GNSS precise positioning user perspective

The FAIR principles of Wilkinson et al. [1] are finding their way from research into application domains, one of which is the precise positioning with global satellite navigation systems (GNSS). Current GNSS users demand that data and services are findable online, accessible via open protocols (by both, machines and humans), interoperable with their legacy systems and reusable in various settings. Comprehensive metadata are essential in seamless communication between GNSS data and service providers and their users, and, for decades, geodetic and geospatial standards are efficiently implemented to support this. However, GNSS user community is transforming from precise positioning by highly specialised use by geodetic professionals to every-day precise positioning by autonomous vehicles or wellness obsessed citizens. Moreover, rapid technological developments allow alternative ways of offering data and services to their users. These transforming circumstances warrant a review whether metadata defined in generic geospatial and geodetic standards in use still support FAIR use of modern GNSS data and services across its novel user spectrum. This paper reports the results of current GNSS users' requirements in various application sectors on the way data, metadata and services are provided. We engaged with GNSS stakeholders to validate our findings and to gain understanding on their perception of the FAIR principles. Our results confirm that offering FAIR GNSS data and services is fundamental, but for a confident use of these, there is a need to review the way metadata are offered to the community. Defining standard compliant GNSS community metadata profile and providing relevant metadata with data on-demand, the approach outlined in this paper, is a way to manage current GNSS users' expectations and the way to improve FAIR GNSS data and service delivery for both humans and the machines.

First Measurement of High-Energy Reactor Antineutrinos at Daya Bay

This Letter reports the first measurement of high-energy reactor antineutrinos at Daya Bay, with nearly 9000 inverse beta decay candidates in the prompt energy region of 8-12 MeV observed over 1958 days of data collection. A multivariate analysis is used to separate 2500 signal events from background statistically. The hypothesis of no reactor antineutrinos with neutrino energy above 10 MeV is rejected with a significance of 6.2 standard deviations. A 29% antineutrino flux deficit in the prompt energy region of 8-11 MeV is observed compared to a recent model prediction. We provide the unfolded antineutrino spectrum above 7 MeV as a data-based reference for other experiments. This result provides the first direct observation of the production of antineutrinos from several high-Q_{β} isotopes in commercial reactors.

Scintillation light detection in the 6-m drift-length ProtoDUNE Dual Phase liquid argon TPC

DUNE is a dual-site experiment for long-baseline neutrino oscillation studies, neutrino astrophysics and nucleon decay searches. ProtoDUNE Dual Phase (DP) is a 6  ×  6  ×  6 m 3 liquid argon time-projection-chamber (LArTPC) that recorded cosmic-muon data at the CERN Neutrino Platform in 2019-2020 as a prototype of the DUNE Far Detector. Charged particles propagating through the LArTPC produce ionization and scintillation light. The scintillation light signal in these detectors can provide the trigger for non-beam events. In addition, it adds precise timing capabilities and improves the calorimetry measurements. In ProtoDUNE-DP, scintillation and electroluminescence light produced by cosmic muons in the LArTPC is collected by photomultiplier tubes placed up to 7 m away from the ionizing track. In this paper, the ProtoDUNE-DP photon detection system performance is evaluated with a particular focus on the different wavelength shifters, such as PEN and TPB, and the use of Xe-doped LAr, considering its future use in giant LArTPCs. The scintillation light production and propagation processes are analyzed and a comparison of simulation to data is performed, improving understanding of the liquid argon properties.

Using Natural Language Processing to Explore Mental Health Insights From UK Tweets During the COVID-19 Pandemic: Infodemiology Study

Background

There is need to consider the value of soft intelligence, leveraged using accessible natural language processing (NLP) tools, as a source of analyzed evidence to support public health research outputs and decision-making.

Objective

The aim of this study was to explore the value of soft intelligence analyzed using NLP. As a case study, we selected and used a commercially available NLP platform to identify, collect, and interrogate a large collection of UK tweets relating to mental health during the COVID-19 pandemic.

Methods

A search strategy comprised of a list of terms related to mental health, COVID-19, and lockdown restrictions was developed to prospectively collate relevant tweets via Twitter’s advanced search application programming interface over a 24-week period. We deployed a readily and commercially available NLP platform to explore tweet frequency and sentiment across the United Kingdom and identify key topics of discussion. A series of keyword filters were used to clean the initial data retrieved and also set up to track specific mental health problems. All collated tweets were anonymized.

Results

We identified and analyzed 286,902 tweets posted from UK user accounts from July 23, 2020 to January 6, 2021. The average sentiment score was 50%, suggesting overall neutral sentiment across all tweets over the study period. Major fluctuations in volume (between 12,622 and 51,340) and sentiment (between 25% and 49%) appeared to coincide with key changes to any local and/or national social distancing measures. Tweets around mental health were polarizing, discussed with both positive and negative sentiment. Key topics of consistent discussion over the study period included the impact of the pandemic on people’s mental health (both positively and negatively), fear and anxiety over lockdowns, and anger and mistrust toward the government.

Conclusions

Using an NLP platform, we were able to rapidly mine and analyze emerging health-related insights from UK tweets into how the pandemic may be impacting people’s mental health and well-being. This type of real-time analyzed evidence could act as a useful intelligence source that agencies, local leaders, and health care decision makers can potentially draw from, particularly during a health crisis.

multi-patient dose synthesis of [18F]Flumazenil via a copper-mediated 18F-fluorination

Background

Flumazenil (FMZ) is a functionally silent imidazobenzodiazepine which binds to the benzodiazepine binding site of approximately 75% of the brain γ-aminobutyric acid-A receptors (GABA_ARs). Positron Emission Tomography (PET) imaging of the GABAARs with [¹¹C]FMZ has been used to evidence alterations in neuronal density, to assess target engagement of novel pharmacological agents, and to study disorders such as epilepsy and Huntington’s disease. Despite the potential of FMZ PET imaging the short half-life (t_1/2) of carbon-11 (20 min) has limited the more widespread clinical use of [¹¹C]FMZ. The fluorine-18 (¹⁸F) isotopologue with a longer t_1/2 (110 min) is ideally suited to address this drawback. However, the majority of current radiochemical methods for the synthesis of [¹⁸F]FMZ are non-trivial and low yielding. We report a robust, automated protocol that is good manufacturing practice (GMP) compatible, and yields multi-patient doses of [¹⁸F]FMZ.

Results

The fully automated synthesis was developed on the Trasis AllinOne (AIO) platform using a single-use cassette. [¹⁸F]FMZ was synthesized in a one-step procedure from [¹⁸F]fluoride, via a copper-mediated ¹⁸F-fluorination of a boronate ester precursor. Purification was performed by semi-preparative radio-HPLC and the collected fraction formulated directly into the final product vial. The overall process from start of synthesis to delivery of product is approximately 55 min. Starting with an initial activity of 23.6 ± 5.8 GBq (n = 3) activity yields of [¹⁸F]FMZ were 8.0 ± 1 GBq (n = 3). The synthesis was successfully reproduced at two independent sites, where the product passed quality control release criteria in line with the European Pharmacopoeia standards and ICH Q3D(R1) guidelines to be suitable for human use.

Conclusion

Reported is a fully automated cassette-based synthesis of [¹⁸F]FMZ that is Good Manufacturing Practice (GMP) compatible and produces multi-patient doses of [¹⁸F]FMZ.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41181-022-00158-z.

Joint Determination of Reactor Antineutrino Spectra from ^{235}U and ^{239}Pu Fission by Daya Bay and PROSPECT

A joint determination of the reactor antineutrino spectra resulting from the fission of ^{235}U and ^{239}Pu has been carried out by the Daya Bay and PROSPECT Collaborations. This Letter reports the level of consistency of ^{235}U spectrum measurements from the two experiments and presents new results from a joint analysis of both data sets. The measurements are found to be consistent. The combined analysis reduces the degeneracy between the dominant ^{235}U and ^{239}Pu isotopes and improves the uncertainty of the ^{235}U spectral shape to about 3%. The ^{235}U and ^{239}Pu antineutrino energy spectra are unfolded from the jointly deconvolved reactor spectra using the Wiener-SVD unfolding method, providing a data-based reference for other reactor antineutrino experiments and other applications. This is the first measurement of the ^{235}U and ^{239}Pu spectra based on the combination of experiments at low- and highly enriched uranium reactors.

Initial multicenter experience using a novel endoscopic tack and suture system for challenging GI defect closure and stent fixation (with video)

BACKGROUND AND AIMS

Closure of endoscopic resection defects can be achieved with through-the-scope clips, over-the-scope clips, or endoscopic suturing. However, these devices are often limited by their inability to close large, irregular, and difficult-to-reach defects. Thus, we aimed to assess the feasibility and safety of a novel through-the-scope, suture-based closure system developed to overcome these limitations.

METHODS

This was a retrospective multicenter study involving 8 centers in the United States. Primary outcomes were feasibility and safety of early use of the device. Secondary outcomes were assessment of need for additional closure devices, prolonged procedure time, and technical feasibility of performing the procedure with an alternative device(s).

RESULTS

Ninety-three patients (48.4% women) with mean age 63.6 ± 13.1 years were included. Technical success was achieved in 83 patients (89.2%), and supplemental closure was required in 24.7% of patients (n = 23) with a mean defect size of 41.6 ± 19.4 mm. Closure with an alternative device was determined to be impossible in 24.7% of patients because of location, size, or shape of the defect. The use of the tack and suture device prolonged the procedure in 8.6% of cases but was considered acceptable. Adverse events occurred in 2 patients (2.2%) over a duration of follow-up of 34 days (interquartile range, 13-93.5) and were mild and moderate in severity. No serious adverse events or procedure-related deaths occurred.

CONCLUSIONS

The novel endoscopic through-the-scope tack and suture system is safe, efficient, and permits closure of large and irregularly shaped defects that were not possible with established devices.

COVID-19 Vaccine Hesitancy: Analysing Twitter to Identify Barriers to Vaccination in a Low Uptake Region of the UK

To facilitate effective targeted COVID-19 vaccination strategies, it is important to understand reasons for vaccine hesitancy where uptake is low. Artificial intelligence (AI) techniques offer an opportunity for real-time analysis of public attitudes, sentiments, and key discussion topics from sources of soft-intelligence, including social media data. In this work, we explore the value of soft-intelligence, leveraged using AI, as an evidence source to support public health research. As a case study, we deployed a natural language processing (NLP) platform to rapidly identify and analyse key barriers to vaccine uptake from a collection of geo-located tweets from London, UK. We developed a search strategy to capture COVID-19 vaccine related tweets, identifying 91,473 tweets between 30 November 2020 and 15 August 2021. The platform's algorithm clustered tweets according to their topic and sentiment, from which we extracted 913 tweets from the top 12 negative sentiment topic clusters. These tweets were extracted for further qualitative analysis. We identified safety concerns; mistrust of government and pharmaceutical companies; and accessibility issues as key barriers limiting vaccine uptake. Our analysis also revealed widespread sharing of vaccine misinformation amongst Twitter users. This study further demonstrates that there is promising utility for using off-the-shelf NLP tools to leverage insights from social media data to support public health research. Future work to examine where this type of work might be integrated as part of a mixed-methods research approach to support local and national decision making is suggested.

Survey of the perceived treatment gap in status epilepticus care across Sub-Saharan countries from the perspective of healthcare providers

BACKGROUND

Status epilepticus (SE) is a serious condition disproportionately affecting Sub-Saharan African (SSA) countries. Little is known about healthcare provider experiences. This study investigated the healthcare provider perspective of SE care.

METHODS

A pilot questionnaire was developed for healthcare professionals in SSA countries. It was distributed online at a conference concerning epilepsy care and local coordinators distributed the questionnaire in their networks. It was available online between 16th Jan and 1st Feb 2021. The unvalidated questionnaire questioned practitioner demographics, experience, confidence in SE care, common etiologies encountered, anticipated prognosis in their setting, available treatments, and barriers to care. We assessed practitioner perceptions not their knowledge base around SE care. Thematic analysis was used for open-ended questions.

RESULTS

Fifty nine responses were received from 11 countries. Respondents (44% nurses, 46% doctors) reported poor level of adequate SE training (mean self-reported confidence in training 2.9/10 (0/10 very inadequate and 10/10 very adequate training). Delays in arriving at hospital were common with 15 (32%) taking three or more hours and 28 (62%) proposing transport issues and distance were the main reasons for delay. Urban location was significantly associated with clinician confidence. Less than 20% used prehospital benzodiazepine treatment. 46 (78%) stated benzodiazepines were first-line hospital drug management, and 52 (88%) indicated alternative second-line hospital treatments were available.

CONCLUSION

A substantial perceived treatment gap in the management of SE in SSA is identified by staff working in SSA. Key issues are around staff training, patient education, medication access, and compliance.

Frontal Fibrosing Alopecia survey of severity assessment methods in routine clinical practice and validation of the IFFACG measurement guidance

BACKGROUND

Lack of validated and responsive outcome measures in the management of Frontal Fibrosing Alopecia (FFA) significantly limits our ability to assess disease progression and treatment response over time.

OBJECTIVES

The aim of this study was to understand how FFA extent and progression is currently assessed in UK specialist centres, validate components of the International FFA Cooperative Group (IFFACG) statement on FFA assessment, and identify pragmatic advice to improve FFA management in clinic.

METHODS

Consultant Dermatologists with a specialist interest in hair loss (n=17) were invited to take part. Preferred FFA assessment methods were explored using questionnaires and clinical scenarios. Participants were asked to identify and mark the current hairline in 10 frontal and 10 temporal hairline images, with assessment repeated 3 months later (to assess intra-individual variability) and 12 months later (to test whether inter-individual accuracy could be improved with simple instruction).

RESULTS

All 17 clinicians (100%) completed the questionnaire at each time interval. We identified a wide variation in assessment techniques between our experts. Measurements were perceived as the most accurate method of assessing frontal recession whereas photography was preferred for temporal recession. Inter-rater reliability between clinicians measuring the frontal hairline scenarios indicated a moderate strength of agreement (ICC 0.613; 95% CI: 0.398 to 0.848), yet intra-rater reliability was found to be poor with wide limits of agreement (-8.71mm to 9.92mm) on follow-up. Importantly, when clear guidance was provided on how the hairline should be identified (questionnaire 3), inter-rater reliability improved significantly, with an ICC 0.702 suggesting moderate agreement (95% CI: 0.508 to 0.890; p<0.001). A similar pattern was seen with temporal hairline measurements, which again improved in accuracy with instruction.

CONCLUSION

We show that accuracy of measurements in FFA can be improved with simple instruction and validate components of the IFFACG measurement recommendations.

Novel dilation technique and stent selection to reduce periprocedural adverse events in left hepaticogastrostomy

Video 1Video demonstration of left hepaticogastrostomy with the assistance of an angioplasty balloon.

519 Outcomes of Management with Ilizarov Frames in Bone Infection: An Observational Study

Aim

The successful treatment and eradication of bone infection requires a multifaceted approach and may recur even after excision if resultant bone void is not managed effectively. This paper aims to review the clinical effectiveness of antibiotic-impregnated bone void filler and current empirical antibiotic guidelines.

Method

We report a retrospective study of 18 patients with chronic osteomyelitis following injury or surgery managed via Ilizarov Ring Fixator (IRF). All patients were managed by IRF stabilisation procedures with debridement, microbiological sampling, and bone void filling with antibiotic-impregnated biocomposite material, in addition to culture-specific systemic antimicrobial therapy.

Results

Patients were followed up for a mean of 15.9 months. Infection was eradicated in 94.1% of patients in a grossly comorbid demographic. Comorbidities associated with increased risk of osteomyelitis were noted in 72.2% of patients. Anaerobic bacteria were identified in culture for four (22.2%) of the 18 patients.

Conclusions

We detected a higher than suspected growth of anaerobes in our samples, suggesting the need for metronidazole in empirical antibiotic treatment. This study would suggest that the use of STIMULAN® may be preferable in this National Health Service from a cost-effect perspective, as our results are comparable to those using other bone void fillers.

1323 Assessment of The Appropriate Use of Imaging and Reporting in Acute Pancreatitis in A Secondary Care Setting

Aim

Acute pancreatitis is the world's most common gastrointestinal disease requiring hospital admission. Our audit aim was to assess the timeframe within which Abdominal Ultrasound Scans (USS) and Computerised Tomography (CT) were performed, reported indications for CT and the prognostic factors noted in imaging reports.

Method

A retrospective search included admissions with acute pancreatitis between 01/09/19 to 30/11/19, collecting demographics, admission time & date, time and date of both radiological investigations and imaging reports. Patients under the age of 18 were excluded.

Results

This search identified 75 patients (M:F, 40:35) with a median age of 53 (18-95) years. USS were performed within 24 hours of admission in 40.0% (n = 30) of cases. Out of the patients (n = 44) who received a CT scan, 15.9% (n = 7) were scanned after more than 72 hours of onset of symptoms and 84.1% (n = 37) were scanned within less than 72 hours. Furthermore, 88.6%(n = 39) of CT request indications were in keeping with our standards. The average length of hospital stay was 6.1 days when scanned within 72 hours and 11.8 days when scanned after more than 72 hours.

Conclusions

Only 17.3% (n = 13) of the patients audited met all our standards and were managed according to the guidelines. The average length of hospital stay was half in those who had a CT scan after more than 72 hours of admission and this was also used to monitor disease progression/regression.

Use of a novel helical tack system for the management of challenging upper gastrointestinal defects

Background and Aims

Methods

Results

Conclusions

A comparative analysis: international variation in PET-CT service provision in oncology-an International Cancer Benchmarking Partnership study

Objective

To explore differences in position emission tomography-computed tomography (PET-CT) service provision internationally to further understand the impact variation may have upon cancer services. To identify areas of further exploration for researchers and policymakers to optimize PET-CT services and improve the quality of cancer services.

Design

Comparative analysis using data based on pre-defined PET-CT service metrics from PET-CT stakeholders across seven countries. This was further informed via document analysis of clinical indication guidance and expert consensus through round-table discussions of relevant PET-CT stakeholders. Descriptive comparative analyses were produced on use, capacity and indication guidance for PET-CT services between jurisdictions.

Setting

PET-CT services across 21 jurisdictions in seven countries (Australia, Denmark, Canada, Ireland, New Zealand, Norway and the UK).

Participants

None.

Intervention(s)

None.

Main Outcome Measure(s)

None.

Results

PET-CT service provision has grown over the period 2006–2017, but scale of increase in capacity and demand is variable. Clinical indication guidance varied across countries, particularly for small-cell lung cancer staging and the specific acknowledgement of gastric cancer within oesophagogastric cancers. There is limited and inconsistent data capture, coding, accessibility and availability of PET-CT activity across countries studied.

Conclusions

Variation in PET-CT scanner quantity, acquisition over time and guidance upon use exists internationally. There is a lack of routinely captured and accessible PET-CT data across the International Cancer Benchmarking Partnership countries due to inconsistent data definitions, data linkage issues, uncertain coverage of data and lack of specific coding. This is a barrier in improving the quality of PET-CT services globally. There needs to be greater, richer data capture of diagnostic and staging tools to facilitate learning of best practice and optimize cancer services.

Impacts on staff after implementation of a respiratory protection program in a Victorian public hospital

BACKGROUND

In October 2020, the Royal Melbourne Hospital implemented a Respiratory Protection Program (RPP), which was initiated by the Victorian Government. This study was to evaluate the effectiveness of the program.

METHODS

A cohort of 158 employees, who were identified as high risk to respiratory biohazard exposure, were invited to participate in the RPP. We provided a bundle of interventions, which included an online training package, and mandatory quantitative fit testing. The main outcomes included the participants' knowledge and attitude toward respiratory protection equipment (RPE), which were assessed via an online survey. Their donning and doffing skills, and user seal check techniques on four different types of N95 respirators were also assessed by an observer using a pre-determined marking sheet. We compared these outcomes before and after participation in the program.

RESULTS

There was a total of 125 participants, all of whom completed the knowledge and attitude assessment, and 69 completed the skill assessment before and after the program. There was a statistically significant improvement in their knowledge scores, donning and doffing skills, and user seal check techniques after participation in the RPP. Participants also reported significant increased level of confidence in their RPE knowledge, training and skills; and workplace safety.

CONCLUSION

This initial report of the implementation of a novel RPP in a Victorian major tertiary hospital provides guidance on the benefits to respiratory protection, staff knowledge, skills, confidence and morale that can be acquired from a scalable online training package combined with mandatory quantitative fit testing.

Prospects for beyond the Standard Model physics searches at the Deep Underground Neutrino Experiment: DUNE Collaboration

The Deep Underground Neutrino Experiment (DUNE) will be a powerful tool for a variety of physics topics. The high-intensity proton beams provide a large neutrino flux, sampled by a near detector system consisting of a combination of capable precision detectors, and by the massive far detector system located deep underground. This configuration sets up DUNE as a machine for discovery, as it enables opportunities not only to perform precision neutrino measurements that may uncover deviations from the present three-flavor mixing paradigm, but also to discover new particles and unveil new interactions and symmetries beyond those predicted in the Standard Model (SM). Of the many potential beyond the Standard Model (BSM) topics DUNE will probe, this paper presents a selection of studies quantifying DUNE's sensitivities to sterile neutrino mixing, heavy neutral leptons, non-standard interactions, CPT symmetry violation, Lorentz invariance violation, neutrino trident production, dark matter from both beam induced and cosmogenic sources, baryon number violation, and other new physics topics that complement those at high-energy colliders and significantly extend the present reach.

Tokophobia and fear of birth: a workshop consensus statement on current issues and recommendations for future research

Objective: To discuss and develop a statement on the current state of the evidence and opinion in Fear of Childbirth (FoC) and Tokophobia (Tocophobia), and to provide recommendations. Background: A group met in 2019 to discuss the state of clinical and academic knowledge relating to FoC/Tokophobia. Five key areas were agreed as the focus of the meeting. Methods: 12 internationally acknowledged experts, in this or a closely related area (e.g. PTSD) met to discuss their understanding of the evidence for FoC/ Tokophobia and current practice. The consensus described in this paper constitutes the expression of the general opinion of the participants and does not necessarily imply unanimity. Keys points: Work focussed on tokophobia is recent and there remains a wide range of issues, which were addressed in the workshop including complexity in defining prevalence, a theoretical lack of understanding, which creates challenge for robust assessment and the identification of risk factors. An improved aetiological and developmental understanding of the tokophobia is required to underpin appropriate, effective and evidence-based interventions. Evaluation of pathways of care and relevant interventions, should be a focus of future research. Conclusion: Significant gaps remain within the FoC/tokophobia knowledge base. Further research is necessary.

Maternal immunization with adjuvanted RSV prefusion F protein effectively protects offspring from RSV challenge and alters innate and T cell immunity

Respiratory syncytial virus (RSV) commonly causes severe respiratory tract infections in infants, peaking between 2 and 6 months of age; an age at which direct vaccination is unlikely to be effective. Maternal immunization can deliver high levels of antibodies to newborns, providing immediate protection. Following natural infection, antibodies targeting the prefusion conformation of RSV F protein (PreF) have the greatest neutralizing capacity and thus, may provide infants with a high degree of RSV protection when acquired through maternal vaccination. However, the influence of anti-PreF maternal antibodies on infant immunity following RSV exposure has not been elucidated. To address this knowledge gap, offspring born to dams immunized with a RSV PreF vaccine formulation were challenged with RSV and their immune responses were analyzed over time. These studies demonstrated safety and efficacy for RSV-challenged, maternally-immunized offspring but high and waning maternal antibody levels were associated with differential innate and T cell immunity.

Myeloid Sarcoma Involving the Central Nervous System Without Evidence of Preexisting Hematologic Disease: A Case Report

Introduction/Objective

Myeloid sarcoma within the central nervous system is a rare presentation of an infiltrative mass of immature myeloid cells. It is typically found in association with myeloid dysplastic syndrome, myeloproliferative disorder, or acute myeloid leukemia. Rarely, it can occur in the absence of these diseases.

Methods

We present the case of 68-year-old female with worsening nausea and headaches. Brain MRI showed diffuse pachymeningeal enhancement with numerous nodular enhancing extra-axial masses overlying both cerebral hemispheres.

Results

Open biopsy of these masses showed gelatinous, hemorrhagic, brown tissue measuring 3.0 x 2.0 x 0.7 cm. Histologically, the specimen shows a diffuse polymorphous atypical myeloid proliferation consisting of all three cell lineages. There are nodules composed predominantly of large blastoid cells with 1 to 2 prominent oblong nucleoli, consistent with erythroblasts and early erythroid precursors. In between the nodules there are myeloid cells in different stages of maturation, including numerous eosinophilic precursors. Scattered megakaryocytes are also identified.

Immunohistochemistry shows positivity for E-cadherin, CD235a and spectrin which highlight the immature erythroid cells. MPO, muramidase, and CD33 are positive in myeloid elements. Eosinophilic peroxidase highlights numerous eosinophilic precursors. CD34 is positive in the endothelial cells and very rare hematopoietic cells. CD20 and PAX 5 highlights B-cells, CD3 highlights T-cells, and CD4 highlights monocytic precursors, monocytes, histiocytes and a subset of T-cells.

Conclusion

Additional work up at the time of biopsy including FLOW cytometry and bone marrow biopsies showed no evidence of hematologic pathology. In summary the histologic and immunohistochemical findings demonstrate a tumor composed of proliferating immature myeloid cells most consistent with myeloid sarcoma without any evidence of hematological disease.

Absolute standardisation and determination of the half-life and gamma emission intensities of 89Zr

An absolute standardisation of ⁸⁹Zr was performed alongside determination of gamma emission intensities and half-life. The collected data were evaluated alongside complementary works from previous publications and new recommended nuclear data values are presented including a new evaluated T_1/2 = 78.361(25) h and new absolute intensities for gamma transitions resulting from its decay to ⁸⁹Y. Dial settings for commercially available radionuclide calibrators are also presented and show a relative difference of approximately 3% compared to previously published values.

Improved Constraints on Sterile Neutrino Mixing from Disappearance Searches in the MINOS, MINOS+, Daya Bay, and Bugey-3 Experiments

Searches for electron antineutrino, muon neutrino, and muon antineutrino disappearance driven by sterile neutrino mixing have been carried out by the Daya Bay and MINOS+ collaborations. This Letter presents the combined results of these searches, along with exclusion results from the Bugey-3 reactor experiment, framed in a minimally extended four-neutrino scenario. Significantly improved constraints on the θ_{μe} mixing angle are derived that constitute the most constraining limits to date over five orders of magnitude in the mass-squared splitting Δm_{41}^{2}, excluding the 90% C.L. sterile-neutrino parameter space allowed by the LSND and MiniBooNE observations at 90% CL_{s} for Δm_{41}^{2}<13  eV^{2}. Furthermore, the LSND and MiniBooNE 99% C.L. allowed regions are excluded at 99% CL_{s} for Δm_{41}^{2}<1.6 eV^{2}.

BNST transient activity associates with approach behavior in a stressful environment and is modulated by the parabrachial nucleus

Studies demonstrate a role for the bed nucleus of the stria terminalis (BNST) in modulating affective behavior and stress-reward integration. To explore the dynamic nature of in vivo BNST activity associated with anxiety-like behavior in a stress-inducing context, we utilized fiber photometry and detected BNST calcium transients in mice during the novelty-suppressed feeding task (NSFT). Phasic BNST activity emerged time-locked to novel object or food pellet approach during NSFT. The parabrachial nucleus (PBN) has a large input to the BNST and is thought to function as a danger signal, in arousal responses and in feeding behavior. To explore a potential role for the PBN as a contributor to BNST activity in NSFT, we investigated whether chemogenetic regulation of PBN activity altered the dynamic BNST response synchronized to NSFT approach behavior. We found that activation of the hM3D(G_q) DREADD in the PBN enhanced the observed transient signal in the BNST synchronized to the consummatory food approach, and was associated at the behavioral level with increased latency to consume food. Because the PBN has multiple efferent pathways, we next used a transsynaptic anterograde AAV-based strategy to express hM3D(G_q) specifically in PBN-innervated BNST (BNST^PBN) neurons in male and female mice. Activation of hM3D(G_q) in these BNST^PBN neurons increased latency to consume food in female, but not male mice. To further explore the population of BNST neurons contributing to phasic BNST activity associated with NSFT, we turned to PKCδ neurons in BNST. BNST(PKCδ) neurons are implicated in stress and food-related behavior, and we previously found that the expression of this kinase is regulated in the BNST by stress in a sex-dependent manner. Here, we demonstrate close apposition of CGRP, a marker of PBN terminals, adjacent to BNST(PKCδ) cells. Finally, we find that PKCδ-expressing BNST cells exhibit a large transient signal synchronized to the consummatory food approach similar to that seen with bulk BNST activity measures. Taken together these data demonstrate phasic BNST activity at a global and cell-specific level that is driven in part by PBN activity at the time of NSFT consummatory approach behavior.

Extended Treatment with Glial Cell Line-Derived Neurotrophic Factor in Parkinson's Disease

Background:

Intraputamenal glial cell line-derived neurotrophic factor (GDNF), administered every 4 weeks to patients with moderately advanced Parkinson’s disease, did not show significant clinical improvements against placebo at 40 weeks, although it significantly increased [¹⁸F]DOPA uptake throughout the entire putamen.

Objective:

This open-label extension study explored the effects of continued (prior GDNF patients) or new (prior placebo patients) exposure to GDNF for another 40 weeks.

Methods:

Using the infusion protocol of the parent study, all patients received GDNF without disclosing prior treatment allocations (GDNF or placebo). The primary outcome was the percentage change from baseline to Week 80 in the OFF state Unified Parkinson’s Disease Rating Scale (UPDRS) motor score.

Results:

All 41 parent study participants were enrolled. The primary outcome decreased by 26.7±20.7% in patients on GDNF for 80 weeks (GDNF/GDNF; N = 21) and 27.6±23.6% in patients on placebo for 40 weeks followed by GDNF for 40 weeks (placebo/GDNF, N = 20; least squares mean difference: 0.4%, 95% CI: –13.9, 14.6, p = 0.96). Secondary endpoints did not show significant differences between the groups at Week 80 either. Prespecified comparisons between GDNF/GDNF at Week 80 and placebo/GDNF at Week 40 showed significant differences for mean OFF state UPDRS motor (–9.6±6.7 vs. –3.8±4.2 points, p = 0.0108) and activities of daily living score (–6.9±5.5 vs. –1.0±3.7 points, p = 0.0003). No treatment-emergent safety concerns were identified.

Conclusions:

The aggregate study results, from the parent and open-label extension suggest that future testing with GDNF will likely require an 80- rather than a 40-week randomized treatment period and/or a higher dose.

Viscous placebo and carbohydrate breakfasts similarly decrease appetite and increase resistance exercise performance compared with a control breakfast in trained males

Given the common view that pre-exercise nutrition/breakfast is important for performance, the present study investigated whether breakfast influences resistance exercise performance via a physiological or psychological effect. Twenty-two resistance-trained, breakfast-consuming men completed three experimental trials, consuming water-only (WAT), or semi-solid breakfasts containing 0 g/kg (PLA) or 1·5 g/kg (CHO) maltodextrin. PLA and CHO meals contained xanthan gum and low-energy flavouring (approximately 122 kJ), and subjects were told both 'contained energy'. At 2 h post-meal, subjects completed four sets of back squat and bench press to failure at 90 % ten repetition maximum. Blood samples were taken pre-meal, 45 min and 105 min post-meal to measure serum/plasma glucose, insulin, ghrelin, glucagon-like peptide-1 and peptide tyrosine-tyrosine concentrations. Subjective hunger/fullness was also measured. Total back squat repetitions were greater in CHO (44 (sd 10) repetitions) and PLA (43 (sd 10) repetitions) than WAT (38 (sd 10) repetitions; P < 0·001). Total bench press repetitions were similar between trials (WAT 37 (sd 7) repetitions; CHO 39 (sd 7) repetitions; PLA 38 (sd 7) repetitions; P = 0·130). Performance was similar between CHO and PLA trials. Hunger was suppressed and fullness increased similarly in PLA and CHO, relative to WAT (P < 0·001). During CHO, plasma glucose was elevated at 45 min (P < 0·05), whilst serum insulin was elevated (P < 0·05) and plasma ghrelin suppressed at 45 and 105 min (P < 0·05). These results suggest that breakfast/pre-exercise nutrition enhances resistance exercise performance via a psychological effect, although a potential mediating role of hunger cannot be discounted.

Radiosynthesis of [18F]-Labelled Pro-Nucleotides (ProTides)

Phosphoramidate pro-nucleotides (ProTides) have revolutionized the field of anti-viral and anti-cancer nucleoside therapy, overcoming the major limitations of nucleoside therapies and achieving clinical and commercial success. Despite the translation of ProTide technology into the clinic, there remain unresolved in vivo pharmacokinetic and pharmacodynamic questions. Positron Emission Tomography (PET) imaging using [18F]-labelled model ProTides could directly address key mechanistic questions and predict response to ProTide therapy. Here we report the first radiochemical synthesis of [18F]ProTides as novel probes for PET imaging. As a proof of concept, two chemically distinct radiolabelled ProTides have been synthesized as models of 3'- and 2'-fluorinated ProTides following different radiosynthetic approaches. The 3'-[18F]FLT ProTide was obtained via a late stage [18F]fluorination in radiochemical yields (RCY) of 15-30% (n = 5, decay-corrected from end of bombardment (EoB)), with high radiochemical purities (97%) and molar activities of 56 GBq/μmol (total synthesis time of 130 min.). The 2'-[18F]FIAU ProTide was obtained via an early stage [18F]fluorination approach with an RCY of 1-5% (n = 7, decay-corrected from EoB), with high radiochemical purities (98%) and molar activities of 53 GBq/μmol (total synthesis time of 240 min).

Minimal Compared With Standard Monitoring During Sofosbuvir-Based Hepatitis C Treatment: A Randomized Controlled Trial

Background

Oral direct-acting antiviral agents (DAAs) for hepatitis C virus (HCV) became government subsidized in Australia in March 2016, bringing the interferon era to a close. The ideal monitoring schedule for patients receiving DAAs is unclear.

Methods

This study is a randomized controlled trial comparing standard with minimal monitoring in adults receiving sofosbuvir-based therapy for HCV genotypes 1 or 3. Exclusion criteria were cirrhosis or predicted poor adherence. Standard monitoring included blood tests and face-to-face clinic visits at treatment weeks 4 and 12 and 12 weeks after treatment completion. Minimal monitoring included a phone call at weeks 4 and 12 and one set of blood tests plus a clinic visit 12 weeks after treatment completion. The coprimary outcomes were as follows: (1) proportion of participants with sustained virological response; (2) staff time spent on patient support; and (3) patient satisfaction on a 10-point Likert scale.

Results

Thirty-six patients were randomized to standard monitoring and 38 to minimal monitoring. Sustained virological response at 12 weeks after the end of treatment was documented in 32 of 36 (89%) in the standard versus 37 of 38 (97%) in the minimal monitoring group. Staff time was nonsignificantly longer in the standard group (median 69 [interquartile range {IQR}, 54–80] versus 52 [IQR, 40–75] minutes). Patient satisfaction scores were not different (mean 9.8 of 10 standard versus 9.6 of 10 minimal group). There was no difference in adverse events or unplanned hospital visits; mean per-patient blood test costs were higher in the standard monitoring group ($432 versus $123, P < .001).

Conclusions

On-treatment monitoring with blood tests and clinic visits may not be necessary during sofosbuvir-based HCV treatment in selected patients.

AutoMicrobic System for Biochemical Identification of Listeria Species Isolated From Foods: Collaborative Study

A collaborative study was conducted to evaluate the performance of the AutoMicrobic System Gram- Positive Identification (GPI) and Gram-Negative Identification (GNI) test kits to biochemically characterize Listeria spp. Thirteen laboratories each tested 97 food and environmental isolates, representing the 7 species of Listeria, as well as 11 additional genera of Gram-positive rods. Each collaborator inoculated both a GPI and a GNI card with a pure culture of each organism. The AutoMicrobic System identified the isolates and printed out the biochemical results. The GPI card is used to obtain a species identification and a mannitol reaction result, and the GNI card is used to obtain rhamnose and xylose reaction results. Organisms are classified into species groups and can be further distinguished on the basis of hemolysis or nitrate reduction tests. The AutoMicrobic System method correctly classified 90.8% of the Listeria spp. isolates and 100% of the non-Listeria isolates. The AutoMicrobic System method was adopted first action by AOAC International for the biochemical characterization of Listeria spp. isolated from food and environmental sources.