Beyond regulatory compliance: evaluating radiology artificial intelligence applications in deployment

The implementation of artificial intelligence (AI) applications in routine practice, following regulatory approval, is currently limited by practical concerns around reliability, accountability, trust, safety, and governance, in addition to factors such as cost-effectiveness and institutional information technology support. When a technology is new and relatively untested in a field, professional confidence is lacking and there is a sense of the need to go above the baseline level of validation and compliance. In this article, we propose an approach that goes beyond standard regulatory compliance for AI apps that are approved for marketing, including independent benchmarking in the lab as well as clinical audit in practice, with the aims of increasing trust and preventing harm.

Measurement of Electron-Neutrino Charged-Current Cross Sections on ^{127}I with the COHERENT NaIνE Detector

Using an 185-kg NaI[Tl] array, COHERENT has measured the inclusive electron-neutrino charged-current cross section on ^{127}I with pion decay-at-rest neutrinos produced by the Spallation Neutron Source at Oak Ridge National Laboratory. Iodine is one the heaviest targets for which low-energy (≤50  MeV) inelastic neutrino-nucleus processes have been measured, and this is the first measurement of its inclusive cross section. After a five-year detector exposure, COHERENT reports a flux-averaged cross section for electron neutrinos of 9.2_{-1.8}^{+2.1}×10^{-40}  cm^{2}. This corresponds to a value that is ∼41% lower than predicted using the MARLEY event generator with a measured Gamow-Teller strength distribution. In addition, the observed visible spectrum from charged-current scattering on ^{127}I has been measured between 10 and 55 MeV, and the exclusive zero-neutron and one-or-more-neutron emission cross sections are measured to be 5.2_{-3.1}^{+3.4}×10^{-40} and 2.2_{-0.5}^{+0.4}×10^{-40}  cm^{2}, respectively.

Investigating the DSM-5 and the ICD-11 PTSD symptoms using network analysis across two distinct samples

OBJECTIVE

Posttraumatic stress disorder (PTSD) has long been debated with a recent focus on the consequences of having two different diagnostic descriptions of PTSD (i.e., the Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition [DSM-5] and the International Classification of Diseases-11th Edition [ICD-11]). Research has modeled PTSD as a network of interacting symptoms according to both diagnostic systems, but the relations between the two systems remain unclear regarding which symptoms are more central or interconnected. To answer this question, the present study is the first study to investigate the combined network structure of PTSD symptoms according to both systems using validated measurements (i.e., the International Trauma Questionnaire [ITQ] and the Posttraumatic Stress Disorder Checklist 5 [PCL-5] across two distinct trauma samples [a community sample, N = 2,367], and a military sample, N = 657).

METHOD

We estimated two Gaussian Graphical Models of the combined ICD-11 and DSM-5 PTSD symptoms across the two samples.

RESULTS

Five of the six most central symptoms were the same across both samples.

CONCLUSIONS

The results underline that a combination of five symptoms representing both diagnostic systems may hold central positions and potentially be important for treatment. However, the implications depend on if the different diagnostic descriptions can be reconciled in an indexical rather than constitutive perspective. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

The impact of COVID-19 on palliative care social work: An online survey by a European Association of Palliative Care Task Force

BACKGROUND

The SARS-Cov-2 (COVID-19) pandemic affected the delivery of health and social care services globally. However, little is known about how palliative care social work services were impacted.

AIM

The aim of this study was to capture and analyse data from palliative care social workers who provided professional support in a range of settings across 21 countries during the COVID-19 pandemic.

DESIGN

A cross-sectional survey-based design was used for this empirical study and this paper primarily focuses on the quantitative responses.

SETTING/PARTICIPANTS

Participants, palliative care social workers, were drawn internationally via members of the EAPC Social Work Task Force and the World Hospice Palliative Care Social Work network.

RESULTS

We received 362 survey responses from 21 countries. Most (79%) respondents worked with adults in in-patient units or hospitals. The number of referrals during COVID-19 increased more in non-European countries, compared to European countries. The full range of social work services could no longer be delivered, existing services changed and 65.3% of participants reported higher levels of pressure during the pandemic, which was linked to higher levels of staff absence and additional duties. For many respondents (40.8%), this included facilitating online communication between patients and their families.

CONCLUSIONS

Our findings indicate that restrictions to limit the spread of COVID-19 resulted in adaptations to service delivery, increased pressure on staff and moral distress, like other health and social care professions. All members of the palliative team need support and supervision to ensure effective interdisciplinary working and team cohesion.

First Probe of Sub-GeV Dark Matter beyond the Cosmological Expectation with the COHERENT CsI Detector at the SNS

The COHERENT Collaboration searched for scalar dark matter particles produced at the Spallation Neutron Source with masses between 1 and 220  MeV/c^{2} using a CsI[Na] scintillation detector sensitive to nuclear recoils above 9  keV_{nr}. No evidence for dark matter is found and we thus place limits on allowed parameter space. With this low-threshold detector, we are sensitive to coherent elastic scattering between dark matter and nuclei. The cross section for this process is orders of magnitude higher than for other processes historically used for accelerator-based direct-detection searches so that our small, 14.6 kg detector significantly improves on past constraints. At peak sensitivity, we reject the flux consistent with the cosmologically observed dark-matter concentration for all coupling constants α_{D}<0.64, assuming a scalar dark-matter particle. We also calculate the sensitivity of future COHERENT detectors to dark-matter signals which will ambitiously test multiple dark-matter spin scenarios.

The time is now: making the case for a UK registry of deployment of radiology artificial intelligence applications

Artificial intelligence (AI)-based healthcare applications (apps) are rapidly evolving, and radiology is a target specialty for their implementation. In this paper, we put the case for a national deployment registry to track the spread of AI apps into clinical use in radiology in the UK. By gathering data on the specific locations, purposes, and people associated with AI app deployment, such a registry would provide greater transparency on their spread in the radiology field. In combination with other regulatory and audit mechanisms, it would provide radiologists and patients with greater confidence and trust in AI apps. At the same time, coordination of this information would reduce costs for the National Health Service (NHS) by preventing duplication of piloting activities. This commentary discusses the need for a UK-wide registry for such apps, its benefits and risks, and critical success factors for its establishment. We conclude by noting that a critical window of opportunity has opened up for the development of a deployment registry, before the current pattern of localised clusters of activity turns into the widespread proliferation of AI apps across clinical practice.

Understanding the tool influence function during sub-aperture belt-on-wheel glass polishing

The tool influence function (TIF) during sub-aperture belt-on-wheel polishing has been evaluated as a function of various process conditions (belt use/wear, dwell time, displacement, belt velocity, and wheel modulus and diameter) on fused silica glass workpieces using C e O ₂ polishing media. TIF spots are circular or elliptical in shape with a largely flat bottom character. The volumetric removal rate varies significantly with belt use (or wear), stabilizing after ∼15m i n of use. A modified Preston model, where the pressure dependence is adjusted using a different scaling of the wheel modulus (E w0.5), largely predicts the volumetric removal rate over the range of process conditions evaluated. The relatively high volumetric removal rate of 30-60m m ³/h using a fixed C e O ₂-in-resin-host belt offers a rapid, and hence, more economical, initial polish of aspheric and freeform optics.

Energetic and myocellular pathways in cardiac and skeletal muscle following anthracycline chemotherapy

Background

Anthracycline-related cardiac dysfunction is a recognised consequence of cancer therapies. Here we assess resting cardiac and skeletal muscle energic status as an early mechanistic pathway of myocyte derangement and explore molecular targets of skeletal myocyte metabolism, protein synthesis/degradation and mitochondrial biogenesis signalling.

Methods

We conducted a prospective, mechanistic, observational, longitudinal study of chemotherapy-naive breast cancer patients undergoing anthracycline-based chemotherapy, compared to a healthy control group. 31P-Magnetic Resonance spectroscopy in cardiac and skeletal muscle (phosphocreatine/gamma adenosine triphosphate (PCr/yATP) and inorganic phosphate/phosphocreatine (Pi/PCr) ratios respectively), cardiac magnetic resonance (CMR) imaging inclusive of T1 and T2 mapping, echocardiography-derived global longitudinal strain function, serum NT-pro-BNP and skeletal muscle biopsies from the right vastus lateralis were assessed before and after 3 cycles of Flurouracil, Epirubicin and Cyclophosphamide followed by 3 cycles of Docetaxel. Statistical significance was set at p&lt;0.05.

Results

Twenty-five female breast cancer patients (median age 53 years, range 32–74 years) receiving a mean epirubicin dose 307 mg/m2) and twenty-eight controls (median age 44 years, range 23–65) were recruited. All study assessments in breast cancer patients at pre-chemotherapy stage were comparable to the matched healthy controls. However, following chemotherapy, breast cancer patients demonstrated a small but significant reduction in cardiac function (global longitudinal strain −22.9±3.9 vs −19.1±3.3%, p=0.01 and CMR-derived ejection fraction 65±5 vs 62±4%, p=0.047), a mild increase in CMR-derived indexed left ventricular volumes (end diastolic 65±10 vs 74±11 ml/m2, p=0.014 and end systolic 23±5 vs 28±5 ml/m2, p=0.01) as well as an increase in left ventricular T1 and T2-mapping (1289±29 vs 1321±31 ms, p=0.004 and 50±4 vs 55±7 ms, p=0.027, respectively) and serum NT-Pro-BNP (49±25 vs 108±84 pg/m, p=0.008). After epirubicin, there was significant reduction in cardiac PCr/yATP ratio (2.0±0.7 vs 1.2±0.6, p=0.007) and a significant increase in skeletal muscle Pi/PCr ratio (0.13±0.04 vs 0.22±0.2, p=0.008) – Figure 1.

Following chemotherapy, there was significant upregulation of skeletal myocyte protein synthesis (mammalian target of rapamycin, 0.44±0.4 vs 0.53±0.2, p&lt;0.001) and degradation (Calcium/calmodulin dependent protein kinase II, 1.4±0.7 vs 2.7±1.1, p&lt;0.001), metabolism (peroxisome proliferator-activated receptor gamma, 0.35±0.2 vs 0.60±0.1, p&lt;0.001) and muscle mass regulator myostatin-2 (0.16±0.1 vs 0.24±0.1, p&lt;0.001).

Conclusion

Contemporary doses of epirubicin for breast cancer result in significant reduction of cardiac and skeletal muscle high energy 31P-metabolism alongside skeletal myocellular alterations of protein synthesis and metabolic regulation pathways.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Tenovus ScotlandNHS Grampian Endowment fund

Measurement of the Coherent Elastic Neutrino-Nucleus Scattering Cross Section on CsI by COHERENT

We measured the cross section of coherent elastic neutrino-nucleus scattering (CEvNS) using a CsI[Na] scintillating crystal in a high flux of neutrinos produced at the Spallation Neutron Source at Oak Ridge National Laboratory. New data collected before detector decommissioning have more than doubled the dataset since the first observation of CEvNS, achieved with this detector. Systematic uncertainties have also been reduced with an updated quenching model, allowing for improved precision. With these analysis improvements, the COHERENT Collaboration determined the cross section to be (165_{-25}^{+30})×10^{-40}  cm^{2}, consistent with the standard model, giving the most precise measurement of CEvNS yet. The timing structure of the neutrino beam has been exploited to compare the CEvNS cross section from scattering of different neutrino flavors. This result places leading constraints on neutrino nonstandard interactions while testing lepton flavor universality and measures the weak mixing angle as sin^{2}θ_{W}=0.220_{-0.026}^{+0.028} at Q^{2}≈(50  MeV)^{2}.

Residual neuromuscular blockade in the ICU: a prospective observational study and national survey

Residual neuromuscular blockade is associated with significant morbidity. It has been widely studied in anaesthesia; however, the incidence of residual neuromuscular blockade in patients managed in the ICU is unknown. We conducted a prospective observational study in a tertiary ICU to determine the incidence of residual neuromuscular blockade using quantitative accelerographic monitoring. We tested for residual neuromuscular blockade (defined as a train-of-four ratio < 0.9) before cessation of sedation in anticipation of tracheal extubation. We also surveyed 16 other ICUs in New Zealand to determine their use of neuromuscular monitoring. A total of 191 patients were included in the final analysis. The incidence (95%CI) of residual neuromuscular blockade was 43% (36-50%), with a similar incidence observed in non-postoperative and postoperative patients. There was a lower risk of residual neuromuscular blockade with atracurium than rocuronium (risk ratio (95%CI) of 0.39 (0.12-0.78)) and a higher risk with pancuronium than rocuronium (1.59 (1.06-2.49)). Our survey shows that, in New Zealand ICUs, monitoring of neuromuscular function is rarely carried out before tracheal extubation. When neuromuscular monitoring is undertaken, it is based on individual clinician suspicion and performed using qualitative measurements. No ICU reported using a quantitative monitor or a clinical guideline. The results demonstrate a high incidence of residual neuromuscular blockade in our ICU patients and identify the type of neuromuscular blocking drug as a possible risk factor. Monitoring neuromuscular function before tracheal extubation is not currently the standard of care in New Zealand ICUs. These data suggest that residual neuromuscular blockade may be an under-recognised problem in ICU practice.

A highly virulent variant of HIV-1 circulating in the Netherlands

We discovered a highly virulent variant of subtype-B HIV-1 in the Netherlands. One hundred nine individuals with this variant had a 0.54 to 0.74 log₁₀ increase (i.e., a ~3.5-fold to 5.5-fold increase) in viral load compared with, and exhibited CD4 cell decline twice as fast as, 6604 individuals with other subtype-B strains. Without treatment, advanced HIV-CD4 cell counts below 350 cells per cubic millimeter, with long-term clinical consequences-is expected to be reached, on average, 9 months after diagnosis for individuals in their thirties with this variant. Age, sex, suspected mode of transmission, and place of birth for the aforementioned 109 individuals were typical for HIV-positive people in the Netherlands, which suggests that the increased virulence is attributable to the viral strain. Genetic sequence analysis suggests that this variant arose in the 1990s from de novo mutation, not recombination, with increased transmissibility and an unfamiliar molecular mechanism of virulence.

Disentangling the Symptom-Level Nuances in Comorbid Posttraumatic Stress Disorder and Problematic Alcohol Use in Northern Irish Military Veterans: A Network Analysis

Posttraumatic stress disorder (PTSD) and alcohol use are highly prevalent among military veteran populations. Several theories have been proposed to account for the comorbidity between PTSD and problematic alcohol use, but research examining the symptom-level associations between the two is limited. The current study used network analysis to examine the associations between PTSD and problematic alcohol use. Data were collected through a cross-sectional survey of veterans of the United Kingdom Armed Forces living in Northern Ireland. The sample comprised 511 (91.2% male) veterans with a history of trauma exposure and current alcohol use. A network consisting of PTSD symptoms from the PTSD Checklist for DSM-5 (PCL-5) and items from the Alcohol Use Disorders Identification Test (AUDIT) was constructed, and the bridge centrality of all items was estimated to identify items with the highest number of associations and the strongest associations between the two constructs. The PTSD symptom "reckless behavior" (2.43) had the highest bridge centrality values and thus the strongest connections and most connections to the alcohol use items. For the alcohol use items, "not being able to stop drinking" (2.31) and "number of drinks" (1.24) demonstrated the strongest bridge connections to the PTSD items. These results highlight the role of specific PTSD symptoms involved in the interaction between PTSD and problematic alcohol use.

The risk of miscarriage following surgical treatment of heterotopic extrauterine pregnancies

STUDY QUESTION

What is the risk of loss of a live normally sited (eutopic) pregnancy following surgical treatment of the concomitant extrauterine ectopic pregnancy?

SUMMARY ANSWER

In women diagnosed with heterotopic pregnancies, minimally invasive surgery to treat the extrauterine ectopic pregnancy does not increase the risk of miscarriage of the concomitant live eutopic pregnancy.

WHAT IS KNOWN ALREADY

Previous studies have indicated that surgical treatment of the concomitant ectopic pregnancy in women with live eutopic pregnancies could be associated with an increased risk of miscarriage. The findings of our study did not confirm that.

STUDY DESIGN, SIZE, DURATION

A retrospective observational case–control study of 52 women diagnosed with live eutopic and concomitant extrauterine pregnancies matched to 156 women with live normally sited singleton pregnancies. The study was carried out in three London early pregnancy units (EPUs) covering a 20-year period between April 2000 and November 2019.

PARTICIPANTS/MATERIALS, SETTING, METHODS

All women attended EPUs because of suspected early pregnancy complications. The diagnosis of heterotopic pregnancy was made on ultrasound scan and women were subsequently offered surgical or expectant management.

There were three controls per each case who were randomly selected from our clinical database and were matched for maternal age, mode of conception and gestational age at presentation.

MAIN RESULTS AND THE ROLE OF CHANCE

In the study group 49/52 (94%) women had surgery and 3/52 (6%) were managed expectantly. There were 9/52 (17%, 95% CI 8.2–30.3) miscarriages <12 weeks’ gestation and 9/49 (18%, 95% CI 8.7–32) miscarriages in those treated surgically. In the control group, there were 28/156 (18%, 95% CI 12.2–24.8) miscarriages <12 weeks’ gestation, which was not significantly different from heterotopic pregnancies who were treated surgically [odds ratio (OR) 1.03 95% CI 0.44–2.36]. There was a further second trimester miscarriage in the study group and one in the control group. The live birth rate in the study group was 41/51 (80%, 95% CI 66.9–90.2) and 38/48 (79%, 95% CI 65–89.5) for those who were treated surgically. These results were similar to 127/156 (81%, 95% CI 74.4–87.2) live births in the control group (OR 0.87, 95% CI 0.39–1.94).

LIMITATIONS, REASONS FOR CAUTION

This study is retrospective, and the number of patients is relatively small, which reflects the rarity of heterotopic pregnancies. Heterotopic pregnancies without a known outcome were excluded from analysis.

WIDER IMPLICATIONS OF THE FINDINGS

This study demonstrates that in women diagnosed with heterotopic pregnancies, minimally invasive surgery to treat the extrauterine pregnancy does not increase the risk of miscarriage of the concomitant live eutopic pregnancy. This finding will be helpful to women and their clinicians when discussing the options for treating heterotopic pregnancies.

STUDY FUNDING/COMPETING INTEREST(S)

This work did not receive any funding. None of the authors has any conflict of interest to declare.

TRIAL REGISTRATION NUMBER

Research Registry: researchregistry6430.

Exploring complex-PTSD comorbidity in trauma-exposed Northern Ireland veterans

BACKGROUND

Complex posttraumatic stress disorder (CPTSD) describes the results of complex, prolonged, and/or inescapable trauma, and is typified by avoidance, re-experiencing, sense of threat, affect dysregulation, negative self-concept, and interpersonal disturbances. Additionally, CPTSD is highly comorbid with other common psychopathologies.

OBJECTIVES

A study was conducted in a trauma-exposed UK Armed Forces Veteran population resident in Northern Ireland (N = 638, NI) to determine the prevalence of CPTSD and comorbid associations.

METHODS

Data from the Northern Ireland Veterans Health and Wellbeing Study (NIVHWS), including self-report data describing traumatic stress, depression, anxiety, and suicidality, were used in a latent class analysis to identify distinct profiles of symptomology in the sample, and in a multinomial logistic regression to identify comorbidities associated with class membership.

RESULTS

Three distinct classes emerged: a low endorsement 'baseline' class (36%), a 'Moderate Symptomatic' class (27%), and a high endorsement 'Probable CPTSD' class (37%). Both the Moderate Symptomatic and CPTSD classes were predicted by cumulative trauma exposure. Depression was highly comorbid (OR = 23.06 in CPTSD), as was anxiety (OR = 22.05 in CPTSD) and suicidal ideation (OR = 4.32 in CPTSD), with suicidal attempt associated with the CPTSD class (OR = 2.51).

CONCLUSIONS

Cases of probable CPTSD were more prevalent than cases of probable posttraumatic stress disorder (PTSD) without Difficulties in Self-Organisation (DSO) symptoms in a UK Armed Forces veteran sample, were associated with repeated/cumulative trauma, and were highly comorbid across a range of psychopathologies. Findings validate previous literature on CPTSD and indicate considerable distress and thus need for support in UK Armed Forces veterans resident in NI.

Mental well-being and quality of working life in UK social workers before and during the COVID-19 pandemic: A propensity score matching study

During the COVID-19 pandemic interest into its potential impact on mental well-being has intensified. Within the social care sector, the pandemic has increased job demands and prolonged stress taking a disproportionate toll on the workforce, particularly social workers. This article compares the mental well-being and quality of working life of social workers in the United Kingdom (UK) before and during the pandemic. Data were collected in 2018 (N = 1,195) and 2020 (N = 1,024) using two cross-sectional surveys. To account for the differences between the datasets, propensity score matching was employed prior to effect estimation, utilising demographic and work-related variables common to both datasets. The differences between the two time-points were estimated using multiple regressions. Both mental well-being and quality of working life were significantly higher during the COVID-19 pandemic in 2020 compared to 2018. This suggests that during the highpoint of the pandemic in the UK, increased support, and changes to working practices, such as reprioritisation of work and other initiatives, may be responsible for increased mental well-being and quality of working life. While acknowledging the known pressures on UK social workers during the COVID-19 pandemic this evidence suggests a mixed picture of the pandemic with lessons for managers and employers.

The Mediating Role of Distress Tolerance in the Relationship Between Childhood Maltreatment and Mental Health Outcomes Among University Students

A wealth of empirical literature has documented that the experience of childhood maltreatment is related to an increased risk for the development of psychopathologies in adulthood. Empirical studies examining the factors that could possibly explain this relationship, however, remain sparse. The emerging literature on distress tolerance (DT) suggests that it could possibly act as an explanatory or mediating factor within this relationship. The current study, therefore, examined the mediating role of DT in the relationship between childhood maltreatment and psychopathology (posttraumatic stress disorder, depression, anxiety, and alcohol use) in adulthood in a university student population sample (N = 642). Results showed that childhood maltreatment was positively associated with caseness for all mental health outcomes under investigation. It was also found that individuals with higher levels of DT were less likely to experience adverse mental health outcomes. The results of the mediation analysis indicated that the exposure to childhood maltreatment remained associated with elevated risk for being in the symptomatic group across mental health outcomes, and that DT significantly mediated this relationship. These results provide insight into the relationship between childhood maltreatment and mental ill-health later in life, highlighting the importance of considering DT as a potential risk and resilience factor in this relationship.

2021 European Guideline on the management of proctitis, proctocolitis and enteritis caused by sexually transmissible pathogens

This guideline intents to offer guidance on the diagnosis and management of patients with gastrointestinal symptoms and a suspected sexually transmitted cause. Proctitis is defined as an inflammatory syndrome of the anal canal and/or the rectum. Infectious proctitis can be sexually transmitted via genital-anal mucosal contact, but some also via digital contact and toys. Neisseria gonorrhoeae, Chlamydia trachomatis (including lymphogranuloma venereum), Treponema pallidum and herpes simplex virus are the most common sexually transmitted anorectal pathogens. Shigellosis can be transferred via oral-anal contact and may lead to proctocolitis or enteritis. Although most studies on these infections have concentrated on men who have sex with men (MSM), women having anal intercourse may also be at risk. A presumptive clinical diagnosis of proctitis can be made when there are symptoms and signs, and a definitive diagnosis when the results of laboratory tests are available. The symptoms of proctitis include anorectal itching, pain, tenesmus, bleeding, constipation and discharge in and around the anal canal. The majority of rectal chlamydia and gonococcal infections are asymptomatic and can only be detected by laboratory tests. Therefore, especially when there is a history of receptive anal contact, exclusion of anorectal infections is generally indicated as part of standard screening for sexually transmitted infections (STIs). Condom use does not guarantee protection from STIs, which are often spread without penile penetration. New in this updated guideline is: (i) lymphogranuloma venereum proctitis is increasingly found in HIV-negative MSM, (ii) anorectal Mycoplasma genitalium infection should be considered in patients with symptomatic proctitis after exclusion of other common causations such N. gonorrhoeae, C. trachomatis, syphilis and herpes, (iii) intestinal spirochetosis incidentally found in colonic biopsies should not be confused with syphilis, and (iv) traumatic causes of proctitis should be considered in sexually active patients.

Cost-effectiveness of mifepristone and misoprostol versus misoprostol alone for the management of missed miscarriage: an economic evaluation based on the MifeMiso trial

OBJECTIVE

To assess the cost-effectiveness of mifepristone and misoprostol (MifeMiso) compared with misoprostol only for the medical management of a missed miscarriage.

DESIGN

Within-trial economic evaluation and model-based analysis to set the findings in the context of the wider economic evidence for a range of comparators. Incremental costs and outcomes were calculated using nonparametric bootstrapping and reported using cost-effectiveness acceptability curves. Analyses were performed from the perspective of the UK's National Health Service (NHS).

SETTING

Twenty-eight UK NHS early pregnancy units.

SAMPLE

A cohort of 711 women aged 16-39 years with ultrasound evidence of a missed miscarriage.

METHODS

Treatment with mifepristone and misoprostol or with matched placebo and misoprostol tablets.

MAIN OUTCOME MEASURES

Cost per additional successfully managed miscarriage and quality-adjusted life years (QALYs).

RESULTS

For the within-trial analysis, MifeMiso intervention resulted in an absolute effect difference of 6.6% (95% CI 0.7-12.5%) per successfully managed miscarriage and a QALYs difference of 0.04% (95% CI -0.01 to 0.1%). The average cost per successfully managed miscarriage was lower in the MifeMiso arm than in the placebo and misoprostol arm, with a cost saving of £182 (95% CI £26-£338). Hence, the MifeMiso intervention dominated the use of misoprostol alone. The model-based analysis showed that the MifeMiso intervention is preferable, compared with expectant management, and this is the current medical management strategy. However, the model-based evidence suggests that the intervention is a less effective but less costly strategy than surgical management.

CONCLUSIONS

The within-trial analysis found that based on cost-effectiveness grounds, the MifeMiso intervention is likely to be recommended by decision makers for the medical management of women presenting with a missed miscarriage.

TWEETABLE ABSTRACT

The combination of mifepristone and misoprostol is more effective and less costly than misoprostol alone for the management of missed miscarriages.

2019 IUSTI-Europe guideline for the management of anogenital warts

This guideline is an update of the 2011 European Guideline for the Management of Anogenital Warts. It is intended to support best practice in the care of patients with anogenital warts by including evidence-based recommendations on diagnosis, treatment, follow-up and advice to patients. It is intended for use by healthcare professionals in sexual healthcare or dermato-venereology clinics in Europe but may be adapted for use in other settings where the management of anogenital warts is undertaken. As a European guideline, recommendations should be adapted according to national circumstances and healthcare systems. Despite the availability of vaccine to prevent HPV types 6 and 11, the cause of >95% anogenital warts, they remain an important and frequent health problem. The previous systematic review of randomized controlled trials for anogenital warts was updated. The changes in the present guideline include the following: Updated background information on the prevalence, natural history and transmission of human papillomavirus (HPV) infection and anogenital warts. Key recommendations for diagnosis and treatment have been graded according to the strength of the recommendation and the quality of supporting evidence. 5-fluorouracil, local interferon and photodynamic therapy have been evaluated and included as potential second-line treatment options. Evidence of the impact of HPV vaccination on the incidence of anogenital warts has been updated.

Exploring overcrowding trends in an inner city emergence department in the UK before and during COVID-19 epidemic

Background

The COVID-19 pandemic and the associated lockdowns have caused significant disruptions across society, including changes in the number of emergency department (ED) visits. This study aims to investigate the impact of three pre-COVID-19 interventions and of the COVID-19 UK-epidemic and the first UK national lockdown on overcrowding within University College London Hospital Emergency Department (UCLH ED). The three interventions: target the influx of patients at ED (A), reduce the pressure on in-patients’ beds (B) and improve ED processes to improve the flow of patents out from ED (C).

Methods

We collected overcrowding metrics (daily attendances, the proportion of people leaving within 4 h of arrival (four-hours target) and the reduction in overall waiting time) during 01/04/2017–31/05/2020. We then performed three different analyses, considering three different timeframes. The first analysis used data 01/04/2017–31/12–2019 to calculate changes over a period of 6 months before and after the start of interventions A-C. The second and third analyses focused on evaluating the impact of the COVID-19 epidemic, comparing the first 10 months in 2020 and 2019, and of the first national lockdown (23/03/2020–31/05/2020).

Results

Pre-COVID-19 all interventions led to small reductions in waiting time (17%, p < 0.001 for A and C; an 9%, p = 0.322 for B) but also to a small decrease in the number of patients leaving within 4 h of arrival (6.6,7.4,6.2% respectively A-C,p < 0.001).

In presence of the COVID-19 pandemic, attendance and waiting time were reduced (40% and 8%; p < 0.001), and the number of people leaving within 4 h of arrival was increased (6%,p < 0.001). During the first lockdown, there was 65% reduction in attendance, 22% reduction in waiting time and 8% increase in number of people leaving within 4 h of arrival (p < 0.001). Crucially, when the lockdown was lifted, there was an increase (6.5%,p < 0.001) in the percentage of people leaving within 4 h, together with a larger (12.5%,p < 0.001) decrease in waiting time. This occurred despite the increase of 49.6%(p < 0.001) in attendance after lockdown ended.

Conclusions

The mixed results pre-COVID-19 (significant improvements in waiting time with some interventions but not improvement in the four-hours target), may be due to indirect impacts of these interventions, where increasing pressure on one part of the ED system affected other parts. This underlines the need for multifaceted interventions and a system-wide approach to improve the pathway of flow through the ED system is necessary.

During 2020 and in presence of the COVID-19 epidemic, a shift in public behaviour with anxiety over attending hospitals and higher use of virtual consultations, led to notable drop in UCLH ED attendance and consequential curbing of overcrowding.

Importantly, once the lockdown was lifted, although there was an increase in arrivals at UCLH ED, overcrowding metrics were reduced. Thus, the combination of shifted public behaviour and the restructuring changes during COVID-19 epidemic, maybe be able to curb future ED overcrowding, but longer timeframe analysis is required to confirm this.

Art boxes supporting parents and infants to share creative interactions at home: an art-based response to improve well-being during COVID-19 restrictions

OBJECTIVES

This article seeks to demonstrate the impact of distributing boxes of art resources and guided activities for vulnerable parents and infants to do together at home.

STUDY DESIGN

Designed in conjunction with the local arts centre and the psychology team at the University of Dundee, the art boxes were a response to planned face-to-face art interventions with families being cancelled due to COVID-19 restrictions. The aim of the art boxes is to encourage parents to make art together with their infants, fostering connection through playful, creative shared experiences. This research is currently being expanded to reach out to new families through referrals from health visitors, family nurses, and charity partners.

METHODS

Data is being collected on how the art boxes are experienced by families using a mixed-methods approach. Families complete feedback cards (online, or using the stamped addressed card included in the box) rating their experience on quantitative scales and providing open comments. Visual data are gathered through parents sharing images with us on social media. An initial sample of 10 participants has been interviewed using semistructured interviews, allowing more in-depth qualitative understanding of their experiences. These preliminary findings are discussed here.

RESULTS

The thematic analysis of initial interviews provided a rich picture of the disconnection families experienced during lockdown, why art boxes may be beneficial to parental well-being, and the mechanisms by which the boxes may help to develop connections for the parent and infant together.

CONCLUSIONS

Preliminary findings show parents reporting feeling more confident and undertaking new activities which they plan to continue. This was of particular importance during lockdown where parents report opportunities for different experiences being more limited. Parent's describe positive playful interactions and reported improvements to their own well-being from doing creative activities together with their child. Analysis of these initial interviews gives a framework of barriers and supports to connection which highlights how art boxes can facilitate connectedness between dyads with the potential to strengthen attachments.

Assessing the Mediating Role of Social Support in Childhood Maltreatment and Psychopathology Among College Students in Northern Ireland

The detrimental impact of early trauma, particularly childhood maltreatment, on mental health is well documented. Although it is understood that social support can act as a protective factor toward mental health for children who experience such adversity, few studies have addressed the experience of childhood maltreatment and the important function of social support in adulthood. The current study aimed to assess the mediating role of social support in the relationship between childhood experiences of maltreatment and mental health outcomes including anxiety, depression, posttraumatic stress disorder (PTSD), and problematic alcohol use in a sample of university students (N = 640) from Northern Ireland. Results of binary logistic regression analyses indicated that those reporting experiences of childhood maltreatment were at increased odds of mental health outcomes of PTSD, anxiety, and depression, but not alcohol use. Those reporting greater social support were significantly less likely to report on these mental health outcomes. In addition, the indirect paths from childhood maltreatment through social support to PTSD, depression, and anxiety were all significant, suggesting that social support, particularly family support, is a significant mediator of these relationships. Such findings have important implications for the social care response to children experiencing maltreatment and future support for such children as they transition to adolescence and adulthood.

The Role of Coping in the Wellbeing and Work-Related Quality of Life of UK Health and Social Care Workers during COVID-19

The coronavirus disease 2019 (COVID-19) was declared a global pandemic in early 2020. Due to the rapid spread of the virus and limited availability of effective treatments, health and social care systems worldwide quickly became overwhelmed. Such stressful circumstances are likely to have negative impacts on health and social care workers' wellbeing. The current study examined the relationship between coping strategies and wellbeing and quality of working life in nurses, midwives, allied health professionals, social care workers and social workers who worked in health and social care in the UK during its first wave of COVID-19. Data were collected using an anonymous online survey (N = 3425), and regression analyses were used to examine the associations of coping strategies and demographic characteristics with staff wellbeing and quality of working life. The results showed that positive coping strategies, particularly active coping and help-seeking, were associated with higher wellbeing and better quality of working life. Negative coping strategies, such as avoidance, were risk factors for low wellbeing and worse quality of working life. The results point to the importance of organizational and management support during stressful times, which could include psycho-education and training about active coping and might take the form of workshops designed to equip staff with better coping skills.

Factor structure of the International Trauma Questionnaire in UK Armed Forces veterans residing in Northern Ireland

Background: Complex Posttraumatic Stress Disorder (C-PTSD) was recently included in the revised International Classification of Diseases (ICD-11) by the World Health Organization (WHO, 2018). C-PTSD is a new trauma related disorder which may develop after prolonged and multiple exposures to trauma. It is a sister disorder of PTSD and is further characterized by symptomatology of disorganized self-organization (DSO). To qualify for the diagnosis, individuals must first meet the diagnostic criteria for PTSD, then report DSO symptoms and functional impairment. A body of work is emerging which has focused on the underlying dimensionality of C-PTSD across both adult and more recently adolescent populations from differing index trauma groups and from across several nations and cultures. However, few studies have been conducted in populations exposed to combat trauma despite the obvious prolonged and multiple nature of their trauma histories. Objective: To contribute to emerging evidence of the factor structure of ICD-11 C-PTSD in a novel population. Methods: This is the first factor analytic study to explore C-PTSD in a sample of UK Armed Forces veterans residing in Northern Ireland (N = 732). C-PTSD was measured via the ITQ and we utilized CFA to assess the fit of 7 competing models. Results: Based on established CFA fit indices, a correlated, first order, 6-factor model of C-PTSD, representing 3 PTSD and 3 DSO symptom groupings, was deemed to provide superior fit to the data compared to 6 alternative C-PTSD models. The superiority of the model was further supported by statistical comparisons of competing C-PTSD models. All factor loadings (0.866-0.998) and inter-factor correlations (.746-.975) of the optimally fitting model were statistically significant and high. Conclusion: These results provide support for the construct validity of ICD-11 C-PTSD in a unique sample of Armed Forces veterans residing in Northern Ireland.

Association of body mass index with immune recovery, virological failure and cardiovascular disease risk among people living with HIV

OBJECTIVES

We conducted a longitudinal cohort analysis to evaluate the association of pre-treatment body mass index (BMI) with CD4 recovery, virological failure (VF) and cardiovascular risk disease (CVD) markers among people living with HIV (PLHIV).

METHODS

Participants who were enrolled between January 2003 and March 2019 in a regional Asia HIV cohort with weight and height measurements prior to antiretroviral therapy (ART) initiation were included. Factors associated with mean CD4 increase were analysed using repeated-measures linear regression. Time to first VF after 6 months on ART and time to first development of CVD risk markers were analysed using Cox regression models. Sensitivity analyses were done adjusting for Asian BMI thresholds.

RESULTS

Of 4993 PLHIV (66% male), 62% had pre-treatment BMI in the normal range (18.5-25.0 kg/m² ), while 26%, 10% and 2% were underweight (< 18.5 kg/m² ), overweight (25-30 kg/m2) and obese (> 30 kg/m² ), respectively. Both higher baseline and time-updated BMI were associated with larger CD4 gains compared with normal BMI. After adjusting for Asian BMI thresholds, higher baseline BMIs of 23-27.5 and > 27.5 kg/m² were associated with larger CD4 increases of 15.6 cells/µL [95% confidence interval (CI): 2.9-28.3] and 28.8 cells/µL (95% CI: 6.6-50.9), respectively, compared with normal BMI (18.5-23 kg/m² ). PLHIV with BMIs of 25-30 and > 30 kg/m² were 1.27 times (95% CI: 1.10-1.47) and 1.61 times (95% CI: 1.13-2.24) more likely to develop CVD risk factors. No relationship between pre-treatment BMI and VF was observed.

CONCLUSIONS

High pre-treatment BMI was associated with better immune reconstitution and CVD risk factor development in an Asian PLHIV cohort.

Virological failure and HIV drug resistance among adults living with HIV on second-line antiretroviral therapy in the Asia-Pacific

OBJECTIVES

To assess second-line antiretroviral therapy (ART) virological failure and HIV drug resistance-associated mutations (RAMs), in support of third-line regimen planning in Asia.

METHODS

Adults > 18 years of age on second-line ART for ≥ 6 months were eligible. Cross-sectional data on HIV viral load (VL) and genotypic resistance testing were collected or testing was conducted between July 2015 and May 2017 at 12 Asia-Pacific sites. Virological failure (VF) was defined as VL > 1000 copies/mL with a second VL > 1000 copies/mL within 3-6 months. FASTA files were submitted to Stanford University HIV Drug Resistance Database and RAMs were compared against the IAS-USA 2019 mutations list. VF risk factors were analysed using logistic regression.

RESULTS

Of 1378 patients, 74% were male and 70% acquired HIV through heterosexual exposure. At second-line switch, median [interquartile range (IQR)] age was 37 (32-42) years and median (IQR) CD4 count was 103 (43.5-229.5) cells/µL; 93% received regimens with boosted protease inhibitors (PIs). Median duration on second line was 3 years. Among 101 patients (7%) with VF, CD4 count > 200 cells/µL at switch [odds ratio (OR) = 0.36, 95% confidence interval (CI): 0.17-0.77 vs. CD4 ≤ 50) and HIV exposure through male-male sex (OR = 0.32, 95% CI: 0.17-0.64 vs. heterosexual) or injecting drug use (OR = 0.24, 95% CI: 0.12-0.49) were associated with reduced VF. Of 41 (41%) patients with resistance data, 80% had at least one RAM to nonnucleoside reverse transcriptase inhibitors (NNRTIs), 63% to NRTIs, and 35% to PIs. Of those with PI RAMs, 71% had two or more.

CONCLUSIONS

There were low proportions with VF and significant RAMs in our cohort, reflecting the durability of current second-line regimens.

Making the transition: How finding a good job is a risky business for military Veterans in Northern Ireland

Veterans transitioning from the military to civilian life may encounter difficulties in different domains of functioning. Most research in this area comes from the US and Israel, with Veterans in Northern Ireland (NI) in the United Kingdom, remaining an understudied population. This qualitative study aimed to examine the nature of transition experiences of NI Veterans by analyzing responses (N = 252) to an open-ended question related to the transition process, in a self-report survey. Thematic analysis highlighted both positive and negative experiences across high-level themes. These were related to (1a) how good the military life had been, (1b) the transition had been easy for some Veterans, and (1c) the skills gained in the military have been valuable; (2) it was hard to adjust to civilian life/still adjusting; (3) negative employment experiences; (4) lack of trust; (5) transitioning is hard in NI; and (6) inadequate support, post-service. The findings highlight that NI Veterans share some of the same challenges as other Veterans; however, the challenges in NI are compounded by ongoing security concerns and political tensions, which means living under the radar is a reality for many, making finding meaningful work and community integration difficult. The findings indicate that preparation for civilian life and the acculturation process needs to start many months before discharge. Perhaps more crucially, regiments should work closely with and support civilian employers to equip them to recognize and value the skills ex-Services Veterans can offer, and find a good fit for their skills within their organizations.

Predictors of not working among treatment-seeking UK veterans: a cross-sectional study

INTRODUCTION

Many veterans do well reintegrating to civilian life following military service. Yet, many face difficulties in finding and securing work. Veterans are more likely than civilians to experience work difficulties, but there remains little research investigating contributing factors, particularly among samples of treatment-seeking veterans. As such, the study examines predictors of not working among UK treatment-seeking veterans.

DESIGN

The study employed a cross-sectional design.

METHODS

Of 667 treatment-seeking UK veterans, 403 (M_age =50.94) provided information on a range of demographic variables, military-related experiences, the total number of physical health conditions and mental health outcomes. Work status was categorised as not working due to illness (M_age =48.15), not working due to other reasons (M_age =61.92) and currently working (M_age = 46.13).

RESULTS

Prevalence rates of not working was 69%. Not working was predicted by a greater number of physical health problems as well as more years since leaving the military. Not working due to poor health was independently predicted by symptoms of post-traumatic stress disorder (PTSD) and younger age, while not working due to other reasons was predicted by older age.

CONCLUSIONS

The study revealed that treatment-seeking veterans of younger age with a high number of physical health difficulties, symptoms of PTSD and more years since leaving the military are most at risk of not working due to ill health. The findings have important implications for identifying veterans most at risk of not working and offer the opportunity to tailor rehabilitation programmes to promote successful veteran reintegration into civilian life.

Childhood adversities in UK treatment-seeking military veterans

Introduction

The long-term consequences of adverse childhood experiences (ACEs) on adult physical and mental health are well documented in the literature. The current study sought to examine this relationship in a sample of UK treatment-seeking military veterans.

Methods

The data were collected through a cross-sectional self-report survey from military veterans who have sought help for mental health difficulties from a veteran-specific UK-based charity. The response rate was 67.2% (n=403) and the effective sample for this study consisted of 386 male veterans. Participants’ history of ACEs and current mental/physical health difficulties were assessed. A latent class analysis was conducted to categorise participants into subgroups based on their ACEs and the relationship of these to the mental and physical health outcomes was examined.

Results

Five classes of veterans with different combinations of ACEs were identified. A total of 97% reported at least one ACE. There were minimal differences between the classes on mental and physical health outcomes, but the total number of ACEs was related to aggression, common mental health problems and post-traumatic stress disorder (PTSD).

Conclusions

No combination of ACEs was specifically predictive of adverse mental/physical health difficulties in our sample. Instead, those with a higher number of ACEs may be more prone to developing problems with aggression, common mental health problems and PTSD. Assessing the history of childhood adversities in military veterans is therefore important when veterans are seeking help for mental health difficulties, as some of these may be related to childhood adversities and may need to be addressed in treatment.

The chondrogenic differentiation potential of dental pulp stem cells

Dental pulp stem cells (DPSCs) are particularly promising for tissue engineering (TE) due to the ease of their isolation procedure, great expansion potential and capability to differentiate towards several cell types of the mesodermal, ectodermal and endodermal lineages. Although several studies hint that DPSCs exhibit potential for cartilage tissue formation, the chondrogenic potential of DPSCs has only been marginally explored. Thus, the aim of the present study was to closely investigate the chondrogenic differentiation capacity of DPSCs for TE applications. More specifically, the potential of DPSCs for engineering hyaline and fibrous cartilage was determined. DPSCs obtained from 7 human molars were expanded and chondrogenically differentiated in a 3D pellet culture model. After 21 d of differentiation with chondrogenic stimuli, DPSCs displayed glycosaminoglycan, aggrecan and limited collagen type II deposition. Cells presented an elongated morphology and produced a collagen-rich extracellular matrix, with a predominance of collagen type I in most of the samples, a characteristic of fibrous cartilage tissue. Variations in the administration periods of several chondro-inductive growth factors, including transforming growth factor beta 3, bone morphogenetic protein-2, -6, -7 and insulin-like growth factor-1, did not increase glycosaminoglycan or collagen type II deposition, typical markers of hyaline cartilage tissue. Furthermore, DPSCs could not be stimulated to go into hypertrophic chondrogenesis. These results indicated that under a large variety of chondro-inductive culture conditions, DPSCs could form fibrocartilaginous tissues but not hyaline cartilage. Thus, DPSCs represent a valuable cell source for the regeneration of fibrocartilage in joints.

Atherosclerotic cardiovascular disease screening and management protocols among adult HIV clinics in Asia

OBJECTIVES

Integration of HIV and non-communicable disease services improves the quality and efficiency of care in low- and middle-income countries (LMICs). We aimed to describe current practices for the screening and management of atherosclerotic cardiovascular disease (ASCVD) among adult HIV clinics in Asia.

METHODS

Sixteen LMIC sites included in the International Epidemiology Databases to Evaluate AIDS - Asia-Pacific network were surveyed.

RESULTS

Sites were mostly (81%) based in urban public referral hospitals. Half had protocols to assess tobacco and alcohol use. Protocols for assessing physical inactivity and obesity were in place at 31% and 38% of sites, respectively. Most sites provided educational material on ASCVD risk factors (between 56% and 75% depending on risk factors). A total of 94% reported performing routine screening for hypertension, 100% for hyperlipidaemia and 88% for diabetes. Routine ASCVD risk assessment was reported by 94% of sites. Protocols for the management of hypertension, hyperlipidaemia, diabetes, high ASCVD risk and chronic ischaemic stroke were in place at 50%, 69%, 56%, 19% and 38% of sites, respectively. Blood pressure monitoring was free for patients at 69% of sites; however, most required patients to pay some or all the costs for other ASCVD-related procedures. Medications available in the clinic or within the same facility included angiotensin-converting enzyme inhibitors (81%), statins (94%) and sulphonylureas (94%).

CONCLUSION

The consistent availability of clinical screening, diagnostic testing and procedures and the availability of ASCVD medications in the Asian LMIC clinics surveyed are strengths that should be leveraged to improve the implementation of cardiovascular care protocols.

Posttraumatic Stress Disorder Symptoms and Reckless Behaviors: A Network Analysis Approach

Existing literature indicates a theoretical and empirical relation between engagement in reckless behaviors and posttraumatic stress disorder (PTSD). Thus, the DSM-5 revision of the PTSD nosology added a new "reckless or self-destructive behavior" (RSDB) symptom (Criterion E2). The current study applied a network analytic approach to examine the item-level relations among a range of reckless behaviors and PTSD symptom clusters. Participants were recruited from Amazon's Mechanical Turk (N = 417), and network analysis was conducted with 20 variables: six PTSD symptom clusters, corresponding to the hybrid model of PTSD (Armour et al., 2015) and excluding the externalizing behavior cluster (Community 1), and 14 items related to reckless behavior (Community 2). The results showed that the network associations were strongest within each construct (i.e., within PTSD and within reckless behaviors), although several bridge connections (i.e., between PTSD clusters and reckless behaviors) were identified. Most reckless behavior items had direct associations with one or more PTSD symptom clusters. The present findings support the existence of close relations between a variety of reckless behaviors and PTSD symptom clusters beyond their relations with DSM Criterion E2. The results provide testable hypotheses about the associations between specific reckless behaviors and PTSD symptom clusters, which may inform future research.

The cost-effectiveness of progesterone in preventing miscarriages in women with early pregnancy bleeding: an economic evaluation based on the PRISM trial

OBJECTIVES

To assess the cost-effectiveness of progesterone compared with placebo in preventing pregnancy loss in women with early pregnancy vaginal bleeding.

DESIGN

Economic evaluation alongside a large multi-centre randomised placebo-controlled trial.

SETTING

Forty-eight UK NHS early pregnancy units.

POPULATION

Four thousand one hundred and fifty-three women aged 16-39 years with bleeding in early pregnancy and ultrasound evidence of an intrauterine sac.

METHODS

An incremental cost-effectiveness analysis was performed from National Health Service (NHS) and NHS and Personal Social Services perspectives. Subgroup analyses were carried out on women with one or more and three or more previous miscarriages.

MAIN OUTCOME MEASURES

Cost per additional live birth at ≥34 weeks of gestation.

RESULTS

Progesterone intervention led to an effect difference of 0.022 (95% CI -0.004 to 0.050) in the trial. The mean cost per woman in the progesterone group was £76 (95% CI -£559 to £711) more than the mean cost in the placebo group. The incremental cost-effectiveness ratio for progesterone compared with placebo was £3305 per additional live birth. For women with at least one previous miscarriage, progesterone was more effective than placebo with an effect difference of 0.055 (95% CI 0.014-0.096) and this was associated with a cost saving of £322 (95% CI -£1318 to £673).

CONCLUSIONS

The results suggest that progesterone is associated with a small positive impact and a small additional cost. Both subgroup analyses were more favourable, especially for women who had one or more previous miscarriages. Given available evidence, progesterone is likely to be a cost-effective intervention, particularly for women with previous miscarriage(s).

TWEETABLE ABSTRACT

Progesterone treatment is likely to be cost-effective in women with early pregnancy bleeding and a history of miscarriage.