The Unique Lived Experiences of LGBQ Athletes: A Collegiate Women's Rugby Club Team as an Inclusive & Empowering Community

There is ongoing debate regarding the culture of competitive women's sports. On one hand, women who participate in sports are viewed as adhering to and reinforcing heteronormative stereotypes and hegemonic masculinity. Conversely, women's sports are viewed as an inherently supportive environment for those involved. The current study explored the latter phenomena, specifically related to factors that promote an inclusive and empowering community for LGBTQ+ women. Eleven individual semi-structured interviews and one follow-up focus group with six participants were conducted with women from a collegiate women's rugby club team. All participants described their sexual identities as Lesbian, Gay, Bisexual, and/or Queer (LGBQ). A reflexive thematic analysis was used to analyze the data collectively. Participants described their collegiate rugby team as being one of their first encounters with a safe and inclusive LGBTQ+ environment. Membership on the team also was viewed as an important experience that helped participants come to terms with their sexual identity. Specifically, findings indicate the supportive actions of teammates, an inclusive team culture, and unique factors related to the sport of rugby helped promote an inclusive and empowering community for LGBTQ+ women. Indeed, from a critical positive youth development perspective, social justice life skills (e.g., allyship) provided actionable behaviors that promote an inclusive and empowering community for LGBTQ+ women. However, future research must seek to understand the lived experiences of all women's rugby participants, particularly transgender and athletes of color.

Survey of rectal cancer MRI technique and reporting tumour descriptors in the UK: a multi-centre British Society of Gastrointestinal and Abdominal Radiology (BSGAR) audit

AIM

To evaluate variation in magnetic resonance imaging (MRI) technique and reporting of rectal cancer staging examinations across the UK.

MATERIALS AND METHODS

A retrospective, multi-centre audit was undertaken of imaging protocols and information documented within consecutive MRI rectal cancer reports between March 2020 and August 2021, which were compared against American and European guidelines. Inclusion criteria included histologically proven rectal adenocarcinoma and baseline staging MRI rectum only.

RESULTS

Fully anonymised data from 924 MRI reports by 78 radiologists at 24 centres were evaluated. Thirty-two per cent of radiologists used template reporting, but these reports offered superior documentation of 13 out of 18 key tumour features compared to free-text reports including T-stage, relation to peritoneal reflection and mesorectal fascia (MRF), nodal status, and presence of extramural venous invasion (EMVI; p<0.027 in each). There was no significant differences in the remaining five features. Across all tumour locations, the tumour relationship to the MRF, the presence of EMVI, and the presence of tumour deposits were reported in 79.5%, 85.6%, and 44% of cases, respectively, and tumour, nodal, and distant metastatic stage documented in 94.4%, 97.7%, and 78.3%. In low rectal tumours, the relationship to the anal sphincter complex was reported in only 54.6%.

CONCLUSION

Considerable variation exists in rectal cancer MRI acquisition and reporting in this sample of UK centres. Inclusion of key radiological features in reports must be improved for risk stratification and treatment decisions. Template reporting is superior to free-text reporting. Routine adoption of standardised radiology practices should now be considered to improve standards to facilitate personalised precision treatment for patients to improve outcomes.

Oxalate nephropathy and chronic turmeric supplementation: a case report

We present a case of a 69-year-old man who presented for routine check-up and was incidentally found to have kidney failure with an initially unrevealing history and bland urinary sediment. He was diagnosed with oxalate nephropathy in the setting of chronic turmeric supplementation and chronic antibiotic therapy with associated diarrhea. Our case provides several key insights into oxalate nephropathy. First, the diagnosis requires a high index of clinical suspicion. It is uncommonly suspected clinically unless there is an obvious clue in the history such as Roux-en-Y gastric bypass or ethylene glycol poisoning. Diagnosis can be confirmed by histopathologic findings and corroborated by serum levels of oxalate and 24-hour urinary excretion. Second, the diagnosis can often be missed by the pathologist because of the characteristics of the crystals unless the renal pathologist has made it a rule to examine routinely all H&E sections under polarized light. This must be done on H&E, as the other stains dissolve the crystals. Third, one oxalate crystal in a routine needle biopsy is considered pathologic and potentially contributing to the AKI or to the CKD in an important way. Fourth, secondary oxalosis can be largely mitigated or prevented in many cases, especially iatrogenic cases. This can come through the surgeon or the gastroenterologist providing proper instructions to patients on an oxalate-restricted diet or other specific dietary measures. Lastly, this case highlights the success that results from cooperation and communication between the pathologist and the treating physician.

Multiorgan MRI findings after hospitalisation with COVID-19 in the UK (C-MORE): a prospective, multicentre, observational cohort study

INTRODUCTION

The multiorgan impact of moderate to severe coronavirus infections in the post-acute phase is still poorly understood. We aimed to evaluate the excess burden of multiorgan abnormalities after hospitalisation with COVID-19, evaluate their determinants, and explore associations with patient-related outcome measures.

METHODS

In a prospective, UK-wide, multicentre MRI follow-up study (C-MORE), adults (aged ≥18 years) discharged from hospital following COVID-19 who were included in Tier 2 of the Post-hospitalisation COVID-19 study (PHOSP-COVID) and contemporary controls with no evidence of previous COVID-19 (SARS-CoV-2 nucleocapsid antibody negative) underwent multiorgan MRI (lungs, heart, brain, liver, and kidneys) with quantitative and qualitative assessment of images and clinical adjudication when relevant. Individuals with end-stage renal failure or contraindications to MRI were excluded. Participants also underwent detailed recording of symptoms, and physiological and biochemical tests. The primary outcome was the excess burden of multiorgan abnormalities (two or more organs) relative to controls, with further adjustments for potential confounders. The C-MORE study is ongoing and is registered with ClinicalTrials.gov, NCT04510025.

FINDINGS

Of 2710 participants in Tier 2 of PHOSP-COVID, 531 were recruited across 13 UK-wide C-MORE sites. After exclusions, 259 C-MORE patients (mean age 57 years [SD 12]; 158 [61%] male and 101 [39%] female) who were discharged from hospital with PCR-confirmed or clinically diagnosed COVID-19 between March 1, 2020, and Nov 1, 2021, and 52 non-COVID-19 controls from the community (mean age 49 years [SD 14]; 30 [58%] male and 22 [42%] female) were included in the analysis. Patients were assessed at a median of 5·0 months (IQR 4·2-6·3) after hospital discharge. Compared with non-COVID-19 controls, patients were older, living with more obesity, and had more comorbidities. Multiorgan abnormalities on MRI were more frequent in patients than in controls (157 [61%] of 259 vs 14 [27%] of 52; p<0·0001) and independently associated with COVID-19 status (odds ratio [OR] 2·9 [95% CI 1·5-5·8]; padjusted=0·0023) after adjusting for relevant confounders. Compared with controls, patients were more likely to have MRI evidence of lung abnormalities (p=0·0001; parenchymal abnormalities), brain abnormalities (p<0·0001; more white matter hyperintensities and regional brain volume reduction), and kidney abnormalities (p=0·014; lower medullary T1 and loss of corticomedullary differentiation), whereas cardiac and liver MRI abnormalities were similar between patients and controls. Patients with multiorgan abnormalities were older (difference in mean age 7 years [95% CI 4-10]; mean age of 59·8 years [SD 11·7] with multiorgan abnormalities vs mean age of 52·8 years [11·9] without multiorgan abnormalities; p<0·0001), more likely to have three or more comorbidities (OR 2·47 [1·32-4·82]; padjusted=0·0059), and more likely to have a more severe acute infection (acute CRP >5mg/L, OR 3·55 [1·23-11·88]; padjusted=0·025) than those without multiorgan abnormalities. Presence of lung MRI abnormalities was associated with a two-fold higher risk of chest tightness, and multiorgan MRI abnormalities were associated with severe and very severe persistent physical and mental health impairment (PHOSP-COVID symptom clusters) after hospitalisation.

INTERPRETATION

After hospitalisation for COVID-19, people are at risk of multiorgan abnormalities in the medium term. Our findings emphasise the need for proactive multidisciplinary care pathways, with the potential for imaging to guide surveillance frequency and therapeutic stratification.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Toward Burnout Prevention: Can One Short Virtual Reality Relaxation and Mindfulness Training Session for Staff and Patients Decrease Stress and Improve Subjective Sense of Wellbeing?

PURPOSE/OBJECTIVE(S)

Mental wellness of healthcare workers has deteriorated recently, increasing burnout rates. Cancer patients are also often highly distressed, reporting fear, pain, and fatigue. Relaxation and mindfulness training have been shown to decrease stress and anxiety. Currently, the use of virtual reality (VR) for relaxation and mindfulness for cancer patients and oncology clinical staff is an ongoing area of research. We aimed to test the preliminary efficacy of incorporating an innovative digital therapeutic (DTx) we developed at our center in this population.

MATERIALS/METHODS

Cancer patients and clinic staff from one institution's Gastrointestinal and Radiation Oncology departments participated in the immersive VR-enhanced relaxation and mindfulness experience for this IRB-exempt study. Users completed a pre-VR survey via iPad assessing baseline knowledge and practice of stress reduction techniques, baseline stress, and familiarity with VR. In the VR app deployed on an Oculus Quest 2, users chose a relaxing water scene (e.g., stream, beach) and optional soothing background music. Users could also choose a relaxation or mindfulness training audio track. A post-VR survey assessed whether the experience affected their subjective stress and sense of wellbeing ("Yes" or "No") as well as the feasibility of using the app. A binomial test on a single proportion was used to test whether more participants (>50%) indicated their stress was reduced following the VR training than did not. Post-VR qualitative verbal feedback was also collected to identify future changes to the VR app.

RESULTS

Six patients, a patient's son, and forty-three employees used the VR app. Users were aged ≤ 30 years old (18%), 30-50 years (60%), and 50-70 years (22%). Users completed the VR experience in a median of 14 min (IQR: 11-19 min). In the pre-survey, most (78%) reported they felt stress at this point in their lives. In the post-survey, significantly more than the expected proportion of participants (>50%) reported feeling less stressed after using the VR app (88%, n = 44, p <0.001). Most (90%) reported that the VR app improved their subjective sense of wellbeing. All (100%) users reported it was easy to learn the VR controls. Nearly all (96%) reported they would be interested in using this VR app again, including 30% and 38% who reported they would be "extremely likely" and "very likely," respectively, to use the app again.

CONCLUSION

These findings suggest our VR relaxation and mindfulness training was well accepted and could be integrated into the hospital setting in short sessions. Further work should be done based on participant feedback to expand the offerings of this VR app to offer a wider range of relaxation experiences and gamified psychological interventions that can help de-stress, recharge, and build resiliency.

Patient Empowerment Among Transgender and Gender Diverse Youth

Purpose: Patient empowerment is becoming increasingly important as health care moves toward more collaborative models of care. The goal of this study was to evaluate and characterize patient empowerment in a sample of transgender/gender-diverse/nonbinary (TGDNB) youth aged 14-24 who have had at least one conversation with a medical health care provider about gender-affirming care. Methods: We adapted a health care empowerment scale for use with TGDNB young people and collected patient empowerment and sociodemographic data among TGDNB youth in the United States over an 8-week period in the spring of 2022. Overall and domain-specific empowerment (including knowledge and understanding, control, identity, decision-making, and supporting others) were assessed on a four-point scale from a low of 1 to a high of 4. Results: A total of 177 youth completed the survey. Mean age was 18.4 ± 3.0 years, the sample was 39.5% gender-diverse/nonbinary, 16.4% transfemme, 44.1% transmasc, and 81.9% White. Average empowerment was 0.22 points higher in youth with supportive caregivers than those without (99% confidence interval [CI] 0.05-0.38, p < 0.001) and 0.20 points higher in youth who sought gender-affirming mental health support (99% CI 0.04-0.36, p = 0.001). Caregiver support increased youths' sense of control over their health/health care (estimated increase 0.29, 99% CI 0.09-0.50, p < 0.001), and mental health support increased youths' decision-making agency by 0.30 points (99% CI 0.06-0.53, p = 0.001). Conclusions: This is the first study to assess patient empowerment in TGDNB youth. Several sociodemographic factors were significantly associated with overall and domain-level empowerment. Further work in this area, both longitudinal and in larger samples, is warranted.

Successful surgical cricothyroidotomy following an obstetric "can't oxygenate" scenario: a narrative of enabling factors

The airway management of a patient requiring emergency caesarean delivery for fetal distress and pre-eclampsia with severe features is described. A difficult obstetric airway was anticipated prior to induction and managed with the use of decision-support guidelines and cognitive aids. Failed tracheal intubation later progressed to a "can't oxygenate" scenario necessitating front-of-neck-access via surgical cricothyroidotomy. We discuss the factors which facilitated the preparation and implementation of interventions required to successfully execute this high-acuity task.

Pharmacologic Treatments in Upper Extremity Complex Regional Pain Syndrome: A Review and Analysis of Quality of Evidence

BACKGROUND

The purpose of this study was to assess the quality of evidence informing on common pharmacologic modalities used in upper extremity complex regional pain syndrome (CRPS).

METHODS

A literature search was performed for primary prospective trials that reported on the pharmacologic treatment of CRPS type I and II specific to the upper extremity. Thirty-one trials were included and evaluated by 2 independent reviewers according to the Oxford Levels of Evidence (LOE), modified Coleman Methodology Score, and the revised Consolidated Standards of Reporting Trials (CONSORT) score. Cohen's kappa coefficient was calculated to measure interrater reliability.

RESULTS

Twenty-two Oxford LOE I and 9 level II trials met the inclusion criteria. Overall, there was high interrater reliability in the Oxford LOE (100% agreement), modified Coleman Methodology Score (87% agreement), and CONSORT score (94% agreement). The pharmacologic interventions with the highest quality of evidence supporting use in treatment of upper extremity CRPS were bisphosphonates and ketamine. Interventions that lack high-quality evidence are tricyclic antidepressants (TCAs) and topical dimethyl sulfoxide (DMSO). Pharmacologic agents that remain inconclusive are calcitonin, gabapentin, mycophenolate, probiotics, steroids, nonsteroidal anti-inflammatory drugs, vitamin C, and N-acetylcysteine. Agents with limited benefit are mannitol, isosorbide dinitrate, guanethidine, and morphine.

CONCLUSIONS

Based on the evidence evaluated in this study, bisphosphonates should be considered as a first-line medication in the treatment of CRPS. In patients presenting with chronic or refractory CRPS, strong consideration should be given for the use of ketamine. Adjunct treatment in the acute setting should include TCAs and/or topical DMSO.

The relationship between meniscal pathologies, cartilage loss, joint replacement and pain in knee osteoarthritis: a systematic review

OBJECTIVE

We conducted a systematic review in order to understand the relationship between imaging-visualised meniscus pathologies, hyaline cartilage, joint replacement and pain in knee osteoarthritis (OA).

DESIGN

A search of the Medline, Excerpta Medica database (EMBASE) and Cochrane library databases was performed for original publications reporting association between imaging-detected meniscal pathology (extrusion or tear/damage) and longitudinal and cross-sectional assessments of hyaline articular cartilage loss [assessed on magnetic resonance imaging (MRI)], incident joint replacement and pain (longitudinal and cross-sectional) in knee OA. Each association was qualitatively characterised by a synthesis of data from each analysis, based upon study design and quality scoring (including risk of bias assessment and adequacy of covariate adjustment using Cochrane recommended methodology).

RESULTS

In total 4,878 abstracts were screened and 82 publications were included (comprising 72 longitudinal analyses and 49 cross-sectional). Using high quality, well-adjusted data, meniscal extrusion and meniscal tear/damage were associated with longitudinal progression of cartilage loss, cross-sectional cartilage loss severity and joint replacement, independently of age, sex and body mass index (BMI). Medial and lateral meniscal tears were associated with cartilage loss when they occurred in the body and posterior horns, but not the anterior horns. There was a lack of high quality, well-adjusted meniscal pathology and pain publications and no clear independent association between meniscal extrusion or tear/damage with pain severity, progression in pain or incident frequent knee symptoms.

CONCLUSION

Meniscal features have strong associations with cartilage loss and joint replacement in knee OA, but weak associations with knee pain. Systematic review PROSPERO registration number: CRD 42020210910.

Early effect of the COVID-19 pandemic on the North American cardiothoracic surgery job market

Background

The present study aims to report the early effect of the coronavirus disease 2019 (COVID-19) pandemic on the cardiothoracic surgery job market in North America.

Methods

The Cardiothoracic Surgery Network (CTSNet) job market database was queried, and patterns from January to May for 2019 versus January to May 2020 were compared for trends in job postings and job seekers.

Results

Our study is comprised of 395 cardiothoracic surgery job postings, of which 98% were positions located in North America and 63% were academic. The negative impact of the pandemic on the cardiothoracic surgery job market was greatest in the cardiothoracic/cardiovascular combined subspecialty, followed by congenital and adult cardiac surgery, whereas general thoracic surgery experienced an increase in proportion of jobs available. Despite an increase in views per job posted in 2020 vs. 2019 (532 vs. 290), employer views of job seeker curriculum vitae declined over the same time period in 2020 (January, 380 views/month to May, 3 views/month) compared to 2019 (January, 100 views/month to May, 54 views/month).

Conclusions

An analysis of job postings from CTSNet suggests a decline in job availability in the North American cardiothoracic surgical job market following declaration of the pandemic with acknowledgement that there is month to month variability and a supply-demand mismatch. The COVID-19 pandemic has had an unprecedented impact on our field, and the ultimate consequences remain unknown.

Impact of Cover Crop Planting and Termination Dates on Arthropod Activity in the Following Corn

Relative to fallow-cash crop rotations, the addition of a cover crop can contribute to greater plant diversity and has the potential to conserve predatory arthropods. The transition of arthropods from a cover crop to a subsequent cash crop depends on several factors, such as cover crop biomass production and weather conditions. Information about the effect of cover crop planting and termination dates on arthropods in a subsequent corn system is limited. A two-year field study was conducted in Nebraska in 2018/2019 and 2019/2020 to evaluate the impact of cover crop planting and termination dates as a source for arthropods in the subsequent corn. A total of 38,074 and 50,626 arthropods were collected in the first and second year, respectively. In both years, adding a grass cover crop increased predatory arthropods but reduced yield in follow corn crop. Of the arthropods collected, Carabidae and Araneae had greater activity with cover crop biomass increments, whereas Collembola and Acari activity only increased in treatments with little or no cover crop biomass. Insect pest pressure was not significant in any treatment for either year. A cover crop planted in mid- or late-September and terminated at corn planting was identified as the best management strategy to maximize cover crop biomass, increase predator activity, and modify predator-prey dynamics. The results of this study provide growers with a cover crop management strategy to maximize cover crop biomass, beneficial arthropod activity, and potentially minimize insect pest problems; however, corn Zea Mays (L.) grain yield was reduced as cover crop biomass increased.

Clinical characteristics with inflammation profiling of long COVID and association with 1-year recovery following hospitalisation in the UK: a prospective observational study

BACKGROUND

No effective pharmacological or non-pharmacological interventions exist for patients with long COVID. We aimed to describe recovery 1 year after hospital discharge for COVID-19, identify factors associated with patient-perceived recovery, and identify potential therapeutic targets by describing the underlying inflammatory profiles of the previously described recovery clusters at 5 months after hospital discharge.

METHODS

The Post-hospitalisation COVID-19 study (PHOSP-COVID) is a prospective, longitudinal cohort study recruiting adults (aged ≥18 years) discharged from hospital with COVID-19 across the UK. Recovery was assessed using patient-reported outcome measures, physical performance, and organ function at 5 months and 1 year after hospital discharge, and stratified by both patient-perceived recovery and recovery cluster. Hierarchical logistic regression modelling was performed for patient-perceived recovery at 1 year. Cluster analysis was done using the clustering large applications k-medoids approach using clinical outcomes at 5 months. Inflammatory protein profiling was analysed from plasma at the 5-month visit. This study is registered on the ISRCTN Registry, ISRCTN10980107, and recruitment is ongoing.

FINDINGS

2320 participants discharged from hospital between March 7, 2020, and April 18, 2021, were assessed at 5 months after discharge and 807 (32·7%) participants completed both the 5-month and 1-year visits. 279 (35·6%) of these 807 patients were women and 505 (64·4%) were men, with a mean age of 58·7 (SD 12·5) years, and 224 (27·8%) had received invasive mechanical ventilation (WHO class 7-9). The proportion of patients reporting full recovery was unchanged between 5 months (501 [25·5%] of 1965) and 1 year (232 [28·9%] of 804). Factors associated with being less likely to report full recovery at 1 year were female sex (odds ratio 0·68 [95% CI 0·46-0·99]), obesity (0·50 [0·34-0·74]) and invasive mechanical ventilation (0·42 [0·23-0·76]). Cluster analysis (n=1636) corroborated the previously reported four clusters: very severe, severe, moderate with cognitive impairment, and mild, relating to the severity of physical health, mental health, and cognitive impairment at 5 months. We found increased inflammatory mediators of tissue damage and repair in both the very severe and the moderate with cognitive impairment clusters compared with the mild cluster, including IL-6 concentration, which was increased in both comparisons (n=626 participants). We found a substantial deficit in median EQ-5D-5L utility index from before COVID-19 (retrospective assessment; 0·88 [IQR 0·74-1·00]), at 5 months (0·74 [0·64-0·88]) to 1 year (0·75 [0·62-0·88]), with minimal improvements across all outcome measures at 1 year after discharge in the whole cohort and within each of the four clusters.

INTERPRETATION

The sequelae of a hospital admission with COVID-19 were substantial 1 year after discharge across a range of health domains, with the minority in our cohort feeling fully recovered. Patient-perceived health-related quality of life was reduced at 1 year compared with before hospital admission. Systematic inflammation and obesity are potential treatable traits that warrant further investigation in clinical trials.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Time-effectiveness and convenience of transvaginal ultrasound probe disinfection using ultraviolet vs chlorine dioxide multistep wipe system: prospective survey study

OBJECTIVES

To compare the efficiency, ease of use and user satisfaction of two methods of transvaginal ultrasound probe high-level disinfection: ultraviolet-C radiation (UV-C) and a chlorine dioxide multistep wipe system.

METHODS

This was a prospective survey study. UV-C units were introduced into a busy early pregnancy assessment service and compared with a multiwipe system for disinfection. Before seeing each patient, healthcare professionals (HCPs) measured with a stopwatch the time taken to complete a cycle of disinfection using either UV-C or chlorine dioxide multistep wipes and responded to a quick-response (QR) code-linked survey. Additional essential tasks that could be completed before seeing the next patient during probe disinfection were also documented. Using another QR code-linked survey, data on ease of use, satisfaction with the system used and preferred system were collected. The ease of use and satisfaction with the system were rated on a 0 to 10 Likert scale (0 poor, 10 excellent). A free-text section for comments was then completed.

RESULTS

Disinfection using UV-C (n = 331) was 60% faster than the chlorine dioxide multiwipe system (n = 332) (101 vs 250 s; P < 0.0001). A greater number of tasks were completed during probe disinfection when using UV-C, saving a further 74 s per patient (P < 0.0001). The HCPs using UV-C (n = 71) reported greater ease of use (median Likert score, 10 vs 3; P < 0.0001) and satisfaction (median Likert score, 10 vs 2; P < 0.0001) compared with those using the multiwipe system (n = 43). HCPs reported that the chlorine dioxide system was time-consuming and environmentally unfriendly, while the UV-C system was efficient and easy to use. Overall, 98% of the HCPs preferred using the UV-C system.

CONCLUSIONS

UV-C technology is more time-efficient and allows more essential tasks to be completed during disinfection. For a 4-h ultrasound list of 15 patients, the use of UV-C would save 55 min 45 s. HCPs found UV-C preferable and easier to use. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Is resting-state functional connectivity altered in regular cannabis users? A systematic review of the literature

RATIONALE

Regular cannabis use has been associated with brain functional alterations within frontal, temporal, and striatal pathways assessed during various cognitive tasks. Whether such alterations are consistently reported in the absence of overt task performance needs to be elucidated to uncover the core neurobiological mechanisms of regular cannabis use.

OBJECTIVES

We aim to systematically review findings from studies that examine spontaneous fluctuations of brain function using functional Magnetic Resonance Imaging (fMRI) resting-state functional connectivity (rsFC) in cannabis users versus controls, and the association between rsFC and cannabis use chronicity, mental health symptoms, and cognitive performance.

METHODS

We conducted a PROSPERO registered systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and searched eight databases.

RESULTS

Twenty-one studies were included for review. Samples comprised 1396 participants aged 16 to 42 years, of which 737 were cannabis users and 659 were controls. Most studies found greater positive rsFC in cannabis users compared to controls between frontal-frontal, fronto-striatal, and fronto-temporal region pairings. The same region pairings were found to be preliminarily associated with varying measures of cannabis exposure.

CONCLUSIONS

The evidence to date shows that regular cannabis exposure is consistently associated with alteration of spontaneous changes in Blood Oxygenation Level-Dependent signal without any explicit cognitive input or output. These findings have implications for interpreting results from task-based fMRI studies of cannabis users, which may additionally tax overlapping networks. Future longitudinal rsFC fMRI studies are required to determine the clinical relevance of the findings and their link to the chronicity of use, mental health, and cognitive performance.

Controlled Study of Decision-Making Algorithms for Kidney Replacement Therapy Initiation in Acute Kidney Injury

BACKGROUND AND OBJECTIVES

AKI requiring KRT is associated with high mortality and utilization. We evaluated the use of an AKI Standardized Clinical Assessment and Management Plan (SCAMP) on patient outcomes, including mortality, hospital length of stay, and intensive care unit length of stay.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We conducted a 12-month controlled study in the intensive care units of a large academic tertiary medical center. We alternated use of the AKI-SCAMP with use of a "sham" control form in 4- to 6-week blocks. The primary outcome was risk of inpatient mortality. Prespecified secondary outcomes included 30- and 60-day mortality, hospital length of stay, and intensive care unit length of stay. Generalized estimating equations were used to estimate the effect of the AKI-SCAMP on mortality and length of stay.

RESULTS

There were 122 patients in the AKI-SCAMP group and 102 patients in the control group. There was no significant difference in inpatient mortality associated with AKI-SCAMP use (41% versus 47% control). AKI-SCAMP use was associated with significantly reduced intensive care unit length of stay (mean, 8; 95% confidence interval, 8 to 9 days versus mean, 12; 95% confidence interval, 10 to 13 days; P<0.001) and hospital length of stay (mean, 25; 95% confidence interval, 22 to 29 days versus mean, 30; 95% confidence interval, 27 to 34 days; P=0.02). Patients in the AKI-SCAMP group were less likely to receive KRT in the context of physician-perceived treatment futility than those in the control group (2% versus 7%; P=0.003).

CONCLUSIONS

Use of the AKI-SCAMP tool for AKI KRT was not significantly associated with inpatient mortality, but was associated with reduced intensive care unit length of stay, hospital length of stay, and use of KRT in cases of physician-perceived treatment futility.

CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER

Acute Kidney Injury Standardized Clinical Assessment and Management Plan for Renal Replacement Initiation, NCT03368183.

PODCAST

This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2022_02_07_CJN02060221.mp3.

Complications associated with early cranioplasty for patients with traumatic brain injury: a 25-year single-center analysis

OBJECTIVE

Cranioplasty is a technically simple procedure, although one with potentially high rates of complications. The ideal timing of cranioplasty should minimize the risk of complications, but research investigating cranioplasty timing and risk of complications has generated diverse findings. Previous studies have included mixed populations of patients undergoing cranioplasty following decompression for traumatic, vascular, and other cerebral insults, making results challenging to interpret. The objective of the current study was to examine rates of complications associated with cranioplasty, specifically for patients with traumatic brain injury (TBI) receiving this procedure at the authors' high-volume level 1 trauma center over a 25-year time period.

METHODS

A single-institution retrospective review was conducted of patients undergoing cranioplasty after decompression for trauma. Patients were identified and clinical and demographic variables obtained from 2 neurotrauma databases. Patients were categorized into 3 groups based on timing of cranioplasty: early (≤ 90 days after craniectomy), intermediate (91-180 days after craniectomy), and late (> 180 days after craniectomy). In addition, a subgroup analysis of complications in patients with TBI associated with ultra-early cranioplasty (< 42 days, or 6 weeks, after craniectomy) was performed.

RESULTS

Of 435 patients identified, 141 patients underwent early cranioplasty, 187 patients received intermediate cranioplasty, and 107 patients underwent late cranioplasty. A total of 54 patients underwent ultra-early cranioplasty. Among the total cohort, the mean rate of postoperative hydrocephalus was 2.8%, the rate of seizure was 4.6%, the rate of postoperative hematoma was 3.4%, and the rate of infection was 6.0%. The total complication rate for the entire population was 16.8%. There was no significant difference in complications between any of the 3 groups. No significant differences in postoperative complications were found comparing the ultra-early cranioplasty group with all other patients combined.

CONCLUSIONS

In this cohort of patients with TBI, early cranioplasty, including ultra-early procedures, was not associated with higher rates of complications. Early cranioplasty may confer benefits such as shorter or fewer hospitalizations, decreased financial burden, and overall improved recovery, and should be considered based on patient-specific factors.

A System for In Vitro Generation of Mature Murine Plasma Cells Uncovers Differential Blimp-1/Prdm1 Promoter Usage

Upon encounter with Ag, B cells undergo a sequential process of differentiation to become Ab-secreting plasma cells. Although the key drivers of differentiation have been identified, research has been limited by the lack of in vitro models recapitulating the full process for murine B cells. In this study, we describe methodology using BCR or TLR ligation to obtain plasma cells that are phenotypically mature, have exited cell cycle and express a gene signature concordant with long-lived plasma cells. Dependent on the initial stimuli, the transcriptomes also show variation including the enhanced expression of matrisome components after BCR stimulation, suggestive of unique functional properties for the resultant plasma cells. Moreover, using the new culture conditions we demonstrate that alternative promoter choice regulating the expression of the master transcription factor Blimp-1/Prdm1 can be observed; when the canonical B cell promoter for Prdm1 is deleted, differentiating B cells exhibit flexibility in the choice of promoter, dictated by the initiating stimulus, with preferential maintenance of expression following exposure to TLR ligation. Thus our system provides a readily tractable model for furthering our understanding of plasma cell biology.

Ultrasound characteristics, serum biochemistry and outcome of ectopic pregnancies presenting during COVID-19 pandemic

OBJECTIVE

To describe and compare the characteristics of ectopic pregnancies (EPs) in the year prior to vs during the coronavirus disease 2019 (COVID-19) pandemic.

METHODS

This was a retrospective analysis of women diagnosed with an EP on transvaginal sonography conducted at a center in London, UK, providing early-pregnancy assessment, between 1 January 2019 and 31 December 2020. Women were identified via the Astraia ultrasound reporting system using coded and non-coded outcomes of EP or pregnancy outside the uterine cavity. Data related to predefined outcomes were collected using Astraia and Cerner electronic reporting systems. Main outcome measures included clinical, ultrasound and biochemical features of EP, in addition to reported complications and management.

RESULTS

There were 22 683 consultations over the 2-year period. Following consultation, a similar number and proportion of EPs were diagnosed in 2019 (141/12 657 (1%)) and 2020 (134/10 026 (1%)). Both cohorts were comparable in age, ethnicity, weight and method of conception. Gestational age at the first transvaginal sonography scan and at diagnosis were similar, and no difference in location, size or morphology of EP was found between the two cohorts. Serum human chorionic gonadotropin (hCG) levels at the time of EP diagnosis were higher in 2020 than in 2019 (1005 IU/L vs 665 IU/L; P = 0.03). The proportions of women according to type of final EP management were similar, but the rate of failed first-line management was higher during vs before the pandemic (16% vs 6%; P = 0.01). The rates of blood detected in the pelvis (hemoperitoneum) on ultrasound (23% vs 26%; P = 0.58) and of ruptured EP confirmed surgically (9% vs 3%; P = 0.07) were similar in 2019 vs 2020.

CONCLUSIONS

No difference was observed in the location, size, morphology or gestational age at the first ultrasound examination or at diagnosis of EP between women diagnosed before vs during the COVID-19 pandemic. Complication rates and final management strategy were also unchanged. However, hCG levels and the failure rate of first-line conservative management measures were higher during the pandemic. Our findings suggest that women continued to access appropriate care for EP during the COVID-19 pandemic, with no evidence of diagnostic delay or an increase in adverse outcome in our population. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

EP.WE.429Surgery during the COVID-19 pandemic: Are we obtaining informed consent?

Background

It was estimated that 1 in 4 inpatients with COVID-19 acquired the virus whilst admitted in December 2020. Surgical patients that contract COVID-19 have poor outcomes, with mortality rates as high as 24% and risk of pulmonary complications as high as 50%. The Royal College of Surgeons of England published COVID-19 consenting guidelines in June 2020.

Aims

To identify the proportion of surgical patients who were informed of the risk of acquiring COVID-19 during the consenting process at two District General Hospitals.

Methods

The consent forms of 220 surgical patients who had either elective or emergency surgery during the second COVID-19 lockdown were reviewed retrospectively (1/11/2020-20/11/2020). This included General Surgery, Trauma and Orthopaedics and Urology. Patients with incomplete notes or who lacked capacity were excluded.

Results

In total, 193 patients were included. We found that 41.5% of patients were consented for the risk of acquiring COVID-19 peri-operatively. This did not vary significantly between elective and non-elective patients.

Conclusions

Our study shows that current practice does not meet national recommendations. In order to provide informed consent, surgeons must engage in emerging research regarding the local prevalence of COVID-19 and the implications of infection during the peri-operative period. Only with this knowledge, will surgeons be able to balance the risks and benefits on a case by case basis, to provide the patient with necessary information for consent. We recommend that trusts adopt a COVID-19 consenting policy, as part of the pre-operative assessment.

Impact of surgeon rhBMP-2 cost awareness on complication rates and health system costs for spinal arthrodesis

OBJECTIVE

Recombinant human bone morphogenetic protein-2 (rhBMP-2) is used in spinal arthrodesis procedures to enhance bony fusion. Research has suggested that it is the most cost-effective fusion enhancer, but there are significant upfront costs for the healthcare system. The primary objective of this study was to determine whether intraoperative dosing and corresponding costs changed with surgeon cost awareness. The secondary objective was to describe surgical complications before and after surgeon awareness of rhBMP-2 cost.

METHODS

A retrospective medical record review was conducted to identify patients who underwent spinal arthrodesis procedures performed by a single surgeon, supplemented with rhBMP-2, from June 2016 to June 2018. Collected data included rhBMP-2 dosage, rhBMP-2 list price, and surgical complications. Expected Medicare reimbursement was calculated. Data were analyzed before and after surgeon awareness of rhBMP-2 cost.

RESULTS

Forty-eight procedures were performed using rhBMP-2, 16 before and 32 after surgeon cost awareness. Prior to cost awareness, the most frequent rhBMP-2 dosage level was x-small (38.9%, n = 7), followed by large (27.8%, n = 5) and small (22.2%, n = 4). After cost awareness, the most frequent rhBMP-2 dosage was xx-small (56.8%, n = 21), followed by x-small (21.6%, n = 8) and large (13.5%, n = 5). The rhBMP-2 average cost per surgery was $4116.56 prior to surgeon cost awareness versus $2268.38 after. Two complications were observed in the pre-cost awareness surgical group; 2 complications were observed in the post-cost awareness surgical group.

CONCLUSIONS

Surgeon awareness of rhBMP-2 cost resulted in use of smaller rhBMP-2 doses, decreased rhBMP-2 cost per surgery, and decreased overall hospital admission charges, without a detectable increase in surgical complications.

FENETRE study: quality-assured follow-up of quiescent neovascular age-related macular degeneration by non-medical practitioners: study protocol and statistical analysis plan for a randomised controlled trial

OBJECTIVE

Management of age-related macular degeneration (AMD) places a high demand on already constrained hospital-based eye services. This study aims to assess the safety and quality of follow-up within the community led by suitably trained non-medical practitioners for the management of quiescent neovascular AMD (QnAMD).

METHODS/DESIGN

This is a prospective, multisite, randomised clinical trial. 742 participants with QnAMD will be recruited and randomised to either continue hospital-based secondary care or to receive follow-up within a community setting. Participants in both groups will be monitored for disease reactivation over the course of 12 months and referred for treatment as necessary. Outcomes measures will assess the non-inferiority of primary care follow-up accounting for accuracy of the identification of disease reactivation, patient loss to follow-up and accrued costs and the budget impact to the National Health Service.

ETHICS AND DISSEMINATION

Research ethics approval was obtained from the London Bloomsbury Ethics Committee. The results of this study will be disseminated through academic peer-reviewed publications, conferences and collaborations with eye charities to insure the findings reach the appropriate patient populations.

TRIAL REGISTRATION NUMBER

NCT03893474.

INPP5K and SIL1 associated pathologies with overlapping clinical phenotypes converge through dysregulation of PHGDH

Marinesco-Sjögren syndrome (MSS) is a rare human disorder caused by biallelic mutations in SIL1 characterized by cataracts in infancy, myopathy and ataxia, symptoms that are also associated with a novel disorder caused by mutations in INPP5K. While these phenotypic similarities may suggest commonalties at a molecular level, an overlapping pathomechanism has not been established yet. In this study, we present six new INPP5K patients and expand the current mutational and phenotypical spectrum of the disease showing the clinical overlap between MSS and the INPP5K-phenotype. We applied unbiased proteomic profiling on cells derived from MSS- and INPP5K-patients and identified alterations in D-3-phosphoglycerate dehydrogenase as a common molecular feature. D-3-phosphoglycerate dehydrogenase modulates the production of L-serine and mutations in this enzyme were previously associated with a neurological phenotype, which clinically overlaps with MSS and INPP5K-disease. As, L-serine administration represents a promising therapeutic strategy for D-3-phosphoglycerate dehydrogenase patients, we tested the effect of L-serine in generated sil1, phgdh and inpp5k a + b zebrafish models which showed an improvement in their neuronal phenotype. Thus our study defines a core phenotypical feature underpinning a key common molecular mechanism in three rare diseases and reveals a common and novel therapeutic target for these patients.

Results from a prospective longitudinal survey of employment and work outcomes in newly diagnosed cancer patients during and after curative-intent chemotherapy: A Wisconsin Oncology Network study

BACKGROUND

Postcancer work limitations may affect a substantial proportion of patients and contribute to the "financial toxicity" of cancer treatment. The degree and nature of work limitations and employment outcomes are poorly understood for cancer patients, particularly in the immediate period of transition after active treatment. We prospectively examined employment, work ability, and work limitations during and after treatment.

METHODS

A total of 120 patients receiving curative therapy who were employed prior to their cancer diagnosis and who intended to work during or after end of treatment (EOT) completed surveys at baseline (pretreatment), EOT, and 3, 6, and 12 months after EOT. Surveys included measures of employment, work ability, and work limitations. Descriptive statistics (frequencies, percentages, means with standard deviations) were calculated.

RESULTS

A total of 111 participants completed the baseline survey. On average, participants were 48 years of age and were mostly white (95%) and female (82%) with a diagnosis of breast cancer (69%). Full-time employment decreased during therapy (from 88% to 50%) and returned to near prediagnosis levels by 12-month follow-up (78%). Work-related productivity loss due to health was high during treatment.

CONCLUSIONS

This study is the first to report the effects of curative intent cancer therapy on employment, work ability, and work limitations both during and after treatment. Perceived work ability was generally high overall 12 months after EOT, although a minority reported persistent difficulty. A prospective analysis of factors (eg, job type, education, symptoms) most associated with work limitations is underway to assist in identifying at-risk patients.

Faecal microbiota transplant to ERadicate gastrointestinal carriage of Antibiotic Resistant Organisms (FERARO): a prospective, randomised placebo-controlled feasibility trial

INTRODUCTION

Antimicrobial resistance is rising, largely due to the indiscriminate use of antimicrobials. The human gut is the largest reservoir of antibiotic resistant bacteria (ARB). Individuals colonised with ARB have the potential to spread these organisms both in the community and hospital settings. Infections with ARB such as extended spectrum beta-lactamase producing enterobacteriales (ESBL-E) and carbapenemase producing enterobacteriales (CPE) are more difficult to treat and are associated with an increased morbidity and mortality. Presently, there is no effective decolonisation strategy for these ARB. Faecal microbiota transplant (FMT) has emerged as a potential strategy for decolonisation of ARB from the human gut, however there is significant uncertainty about the feasibility, effectiveness and safety of using this approach.

METHODS AND ANALYSIS

Prospective, randomised, patient-blinded, placebo-controlled feasibility trial of FMT to eradicate gastrointestinal carriage of ARB. Eighty patients with a recent history of invasive infection secondary to ESBL-E or CPE and persistent gastrointestinal carriage will be randomised 1:1 to receive encapsulated FMT or placebo. The primary outcome measure is consent rate (as a proportion of patients who fulfil inclusion/exclusion criteria); this will be used to determine if a substantive trial is feasible. Participants will be followed up at 1 week, 1 month, 3 months and 6 months and monitored for adverse events as well as gastrointestinal carriage rates of ARB after intervention.

ETHICS AND DISSEMINATION

Research ethics approval was obtained by London-City and East Research Ethics Committee (ref 20/LO/0117). Trial results will be published in a peer-reviewed journal and presented at international conferences.

TRIAL REGISTRATION NUMBER

ISRCTN registration number 34 467 677 and EudraCT number 2019-001618-41.

Surveillance of dengue: evolution of surveillance strategies during a large outbreak, Réunion, France

Issue

After a period of low-level circulation of a few cases per week during 2017, La Réunion experienced an outbreak of dengue in 2018 followed by a second and ongoing larger epidemic wave in 2019. Various surveillance systems have been progressively implemented to monitor and characterize the outbreak.

Methods

All laboratory diagnoses of dengue are routinely notified to the regional health authority (RHA) for investigation. With the outbreak onset additional programmes were implemented including the monitoring of presentations to emergency departments (EDs) and hospitalisations of dengue cases. In addition, all death notifications to the RHA which cite dengue are reviewed by an expert committee and the cause of death classified as directly, indirectly or unrelated to dengue. Finally, weekly data from a sentinel network of general practitioners is used to estimate the number of community consultations with dengue-like illness across the island.

Results

In 2017, 97 dengue cases were notified, with low level circulation continuing through the austral winter. In 2018, 6,679 cases (exclusively serotype 2) were notified. Western and southern regions of the island were most affected. The supplementary surveillance identified over 500 ED presentations for dengue-like illness and 160 hospitalisations. Three deaths were determined to be directly due to dengue, while 3 were indirectly related. Finally, there was an estimated 26,000 consultations for dengue-like illness in the community. After a second winter of persistent circulation, a second epidemic wave commenced in December 2018, and is still ongoing.

Lessons

The implementation of additional surveillance systems enabled a better understanding of the magnitude and impact of the outbreak. The use of sentinel network allowed the estimation of the number of people affected in the community without a laboratory diagnosis. The ongoing viral circulation since 2017 suggests a high risk of endemisation of dengue on the island.

Key messages

The outbreak has had a significant impact of health and community health services, and on the wider population. The second consecutive austral winter with interrupted transmission suggest a high risk of endemisation.

Detecting autoreactive B cells in the peripheral blood of people with type 1 diabetes using ELISpot

Type 1 diabetes mellitus (T1D) is an autoimmune disorder where T lymphocytes damage the islet beta cells but B lymphocytes also play an important role. Although changes in peripheral B cell phenotype have been observed, little is known about the B cells that secrete the autoantibodies. We developed a sensitive B cell enzyme-linked immunospot assay (ELISpot assay) to detect individual B cell antibody responses to glutamic acid decarboxylase (GAD) and islet antigen-2 (IA-2). We found that even healthy donors have B cells that secrete antibodies in response to GAD and IA-2 in the ELISpot. There was increased B cell reactivity to autoantigens in the peripheral blood of individuals with newly-diagnosed, but not long-standing, type 1 diabetes. However, no correlation with serum autoantibody levels was found, indicating that additional factors such as antigen affinity or exposure to antigens in vivo are required for antibody secretion, and that even healthy donors have potentially autoreactive B cells.

Abstract 34: Implementation of a Novel Fast-Track Extubation Protocol after Routine and Complex Adult Cardiovascular Operations

Background: The Society of Thoracic Surgeons (STS) defines early extubation after cardiac operations as endotracheal extubation and separation from mechanical ventilation in less than 6 hours of surgery, which is associated with improved postoperative outcomes.

Objectives: 1. To improve rates of early extubation in post-operative cardiac surgery patients. 2. To evaluate implementation of a multidisciplinary fast-track extubation (FTE) protocol on the duration of mechanical ventilation after adult cardiac surgery as compared to historical unmatched-controls.

Methods: After IRB approval, prospective data were collected on 101 consecutive patients identified by the operating surgeon as appropriate for early extubation based on standard protocols (Control Cohort). Our multidisciplinary stakeholder group evaluated barriers to early extubation and developed a sustainable FTE protocol. Post-implementation data was collected for 3 months (FTE Cohort). A structural framework to alter culture and behavior was utilized for long-term adoption of our protocol.

Results: The study included 312 patients (Control Cohort N=101 / FTE Cohort N=211). Patient and procedural demographics were similar between the groups. Extubation occurred within 6 hours in 48% (N=48) in the control cohort versus 73% (N=153) in the FTE cohort (p <0.001) (Figure 1). Following implementation of the FTE protocol, patients with more complex surgeries, not meeting original inclusion criteria, were also safely extubated using the protocol.

Conclusion: Our FTE protocol safely improved the rate of early extubation after routine and complex cardiac surgery. A behavioral change framework was instrumental in establishing and maintaining staff engagement.

Short-term exercise training reduces glycaemic variability and lowers circulating endothelial microparticles in overweight and obese women at elevated risk of type 2 diabetes

Exercise is recognized as a frontline therapy for the prevention and treatment of type 2 diabetes (T2D) but the optimal type of exercise is not yet determined. We compared the effects of high-intensity interval training (HIIT) with moderate-intensity continuous training (MICT) for improvement of continuous glucose monitoring (CGM)-derived markers of glycaemic variability, and biomarkers of endothelial cell damage (CD31+ and CD62+ endothelial microparticles (EMPs)) within a population at elevated risk of developing T2D. Fifteen inactive overweight or obese women were randomized to 2 weeks (10-sessions) of progressive HIIT (n = 8, 4-10X 1-min @ ∼90% peak heart rate, 1-min rest periods) or MICT (n = 7, 20-50 min of continuous activity at ∼65% peak heart rate). Prior and three days post-training, fasting blood samples were collected. Both HIIT and MICT improved glycaemic variability as measured by CGM standard deviation (HIIT: 0.82 ± 0.39 vs. 0.72 ± 0.33 mmol/L; MICT: 0.82 ± 0.19 vs. 0.62 ± 0.16 mmol/L, pre vs. post) and mean amplitude of glycaemic excursions (MAGE; HIIT: 1.98 ± 0.81 vs. 1.41 ± 0.90; MICT; 1.98 ± 0.43 vs. 1.65 ± 0.48, pre vs. post) with no difference between groups. CD62+ EMPs were lower following HIIT (187.7 ± 65 vs. 174.9 ± 55, pre vs. post) and MICT (170 ± 60 vs. 160.3 ± 59, pre vs. post) with no difference between groups. There was no change in 24-h mean glucose or CD31+ EMPs. Two weeks of both HIIT or MICT similarly decreased glycaemic variability and CD62+ EMPs in overweight/obese women at elevated risk of T2D.

Comparison of Forced-air Warming and Radiant Heating during Transurethral Prostatic Resection under Spinal Anaesthesia

Forced-air warming is commonly used to warm patients intraoperatively, but may not achieve normothermia during a short procedure. Comparative trials of a new radiant warming device in general anaesthesia (Suntouch™, Fisher and Paykel, Auckland, New Zealand) have had conflicting results. We conducted a randomized controlled trial to compare the efficacy and thermal comfort of the Suntouch™ radiant warmer and forced-air warming in patients at high risk of hypothermia during neuraxial blockade. With ethics committee approval, 60 patients having transurethral resection of the prostate under spinal were randomized to either radiant warming or forced-air warming. All intravenous and irrigation fluids were warmed but pre-warming was not used. The final intraoperative rectal temperatures for the radiant warming and forced-air warming groups were 36.1°C and 36.4°C respectively (P=0.03). A large proportion of patients in both groups (46% and 33% respectively, P=0.3) were hypothermic (<36°C) on arrival in the post-anaesthesia care unit. No other patient variables were significantly different. Neither warming device reliably prevented hypothermia, although forced-air warming was slightly superior.

Innovating public engagement and patient involvement through strategic collaboration and practice

BACKGROUND

Patient and public involvement and engagement is an important and expected component of health-related research activity in the UK. Specifically within the health research sphere, public engagement (usually defined as raising awareness of research) and patient involvement (usually defined as actively involving people in research) have traditionally been seen as separate but have much to gain from working together towards a common goal of better health outcomes for all.

METHODS

This paper describes a unique approach taken by the Public Programmes Team: a small interdisciplinary team of public engagement specialists, with backgrounds in science, community development, public engagement and involvement, policy, ethics, communications, industry, museums and creative practice, embedded within translational research infrastructure and delivery in Manchester in the North West of England. We propose a new model of professional practice - a 'cycle' of engagement and involvement - innovating across the complementary fields of public engagement and patient involvement, and working inclusively and in partnership with people in health research. Further, our approach capitalises on strategic collaboration offering economies of scale and a joined up way of working. Our ambition is to boldly experiment, learn and reflect, responsibly and based on evidence and partnerships, using methods of engagement that address issues of social justice.

RESULTS

Here, we report on preliminary case studies exemplifying the impact of our approach, and data relating to achievements and learning between April 2017 and March 2018. Informed by our findings, we propose that our approach has the potential to be replicated elsewhere.

CONCLUSIONS

Our practice and the beginning of its evaluation lead us to believe that our way of working and model of professional practice - the 'cycle' of engagement and involvement - is effective in: addressing our vision of making health research relevant and inclusive for everyone; and embedding and joining up public involvement in a busy and fertile translational health research ecosystem.

Site-1 protease function is essential for the generation of antibody secreting cells and reprogramming for secretory activity

The unfolded protein response (UPR) and activation of XBP1 is necessary for high secretory efficiency and functional differentiation of antibody secreting cells (ASCs). The UPR additionally includes a branch in which membrane-bound transcription factors, exemplified by ATF6, undergo intramembrane-proteolysis by the sequential action of site-1 (MBTPS1/S1P) and site-2 proteases (MBTPS2/S2P) and release of the cytoplasmic domain as an active transcription factor. Such regulation is shared with a family of CREB3-related transcription factors and sterol regulatory element-binding proteins (SREBPs). Of these, we identify that the CREB3 family member CREB3L2 is strongly induced and activated during the transition from B-cell to plasma cell state. Inhibition of site-1 protease leads to a profound reduction in plasmablast number linked to induction of autophagy. Plasmablasts generated in the presence of site-1 protease inhibitor segregated into CD38high and CD38low populations, the latter characterized by a marked reduction in the capacity to secrete IgG. Site-1 protease inhibition is accompanied by a distinctive change in gene expression associated with amino acid, steroid and fatty acid synthesis pathways. These results demonstrate that transcriptional control of metabolic programs necessary for secretory activity can be targeted via site-1 protease inhibition during ASC differentiation.

Evaluating the impact of Marie Stopes International's digital family planning counselling application on the uptake of long-acting and permanent methods of contraception in Vietnam and Ethiopia: a study protocol for a multi-country cluster randomised controlled trial

Background

Maintaining quality of care in family planning (FP) counselling in low-resource settings is challenging. Job aids can help providers give more accurate and client-specific advice but require a provider to use them effectively and consistently. Marie Stopes International (MSI) have designed the tablet-computer based Digital Counselling Application (DCA), which prompts structured, supportive, client-specific and unbiased FP counselling. We hypothesise that a systematic exploration of clients’ fertility intentions, medical eligibility and preferences will increase their uptake of long acting and permanent methods of contraception (LAPMs).

Methods/design

We will conduct a two-armed, parallel, cluster randomised control trial across all MSI clinics (clusters) in Ethiopia (24) and Vietnam (11), randomising 18 clinics to the intervention group and 17 to the control group. Intervention providers will attend a two-day DCA-use training programme, and use DCA in their FP counselling sessions. Usual care providers will counsel clients as before. We aim to recruit 75 clients who have had FP counselling per clinic (2625 total), following them up via two telephone interviews, initially within 2 days and then at 4 months. The primary outcome is defined as the proportion of clients who report choosing a LAPM following FP counselling and will include switchers (FP counselling clients who switch from using any other FP method) and adopters (FP counselling clients who adopt any FP method having not previously been using one). We will also collect secondary outcomes at the initial follow-up (including the proportion of clients reporting being recommended a LAPM by a provider and a range of measures of client experience and satisfaction) and at the 4-month follow-up (including a range of measures of continuation rates for different FP method types). In the intervention arm, we will also conduct mixed-methods sampling to assess how providers use DCA (using an observational survey of provider–client interactions), and understand users’ experiences of receiving and giving DCA-based FP counselling (through in-depth interviews).

Discussion

This trial will provide novel information on the feasibility and acceptability of health worker delivered FP counselling using DCA, with robust evidence on its effectiveness at increasing the uptake of LAPMs in low-resource settings.

Trial registration

ISRCTN, ISRCTN11040557. Registered on 2 March 2017 (retrospectively registered).

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2815-0) contains supplementary material, which is available to authorized users.