New Collaborative Research on Suicide Prevention, Practice, and Policy With American Indian and Alaska Native Communities Holds Promise for All Peoples

Youth suicide is increasing in the United States, with deaths among younger people of color driving this upward trend. For more than four decades, American Indian and Alaska Native (AIAN) communities have suffered disproportionate rates of youth suicide and years of productive life lost compared to other U.S. Races. The National Institute of Mental Health (NIMH) recently funded three regional Collaborative Hubs to carry out suicide prevention research, practice, and policy development with AIAN communities in Alaska and rural and urban areas of the Southwestern United States. The Hub partnerships are supporting a diverse array of tribally-driven studies, approaches, and policies with immediate value for increasing empirically driven public health strategies to address youth suicide. We discuss unique features of the cross-Hub work, including: (a) long-standing Community-Based Participatory Research processes that led to the Hubs' innovative designs and novel approaches to suicide prevention and evaluation, (b) comprehensive ecological theoretical approaches that contextualize individual risk and protective factors in multilevel social contexts; (c) unique task-shifting and systems of care approaches to increase reach and impact on youth suicide in low-resource settings; and (d) prioritization of strengths-based approaches. The work of the Collaborative Hubs for AIAN youth suicide prevention is generating specific and substantive implications for practice, policy, and research presented in this article at a time when youth suicide prevention is a dire national priority. Approaches also have relevance for historically marginalized communities worldwide.

Effect of trans-cinnamaldehyde nanoemulsion wash on chicken embryo development in fertilized eggs

Cleanliness of eggs is critical in successful hatching egg operations. The objective of this study was to investigate the effect of trans-cinnamaldehyde nanoemulsion (TCNE) wash treatments, as a sanitation strategy, on embryonic development in fertilized eggs. Trans-cinnamaldehyde is a generally recognized as safe status phytochemical obtained from cinnamon bark. TCNE were prepared with emulsifiers Tween 80 (Tw.80) or gum Arabic and lecithin (GAL) by sonication. Day-old fertilized eggs were subjected to TCNE wash treatments at 34°C for 5 min, followed by 18 d of incubation at 37.7°C. Washing of fertilized eggs with TCNE-Tw.80 or GAL at 0.48% concentration did not significantly alter the egg weight at d 18 of incubation, as compared to baseline and control (P > 0.05). The egg weight loss (calculated as percentage) did not differ significantly between eggs subjected to nanoemulsion wash treatments and control eggs (P > 0.05). In case of embryo fertility and mortality, for baseline and control, ∼ 95% fertility rate was achieved, with combined early and midterm mortality at 16%. Likewise, TCNE-Tw.80 or TCNE-GAL resulted in 95% fertility (P > 0.05), with 11% and 17% combined early and midterm mortality, respectively. Furthermore, TCNE wash treatments did not differ significantly in yolk sac and embryo weight (as compared to control) and did not affect the length of the d 18 embryo (P > 0.05). Moreover, TCNE wash treatments did not alter tibia weight and length (P > 0.05). Results suggest that TCNE could potentially be used as a natural antimicrobial for fertilized egg sanitation. Further studies in industry settings are warranted.

First Direct Measurement Constraining the ^{34}Ar(α,p)^{37}K Reaction Cross Section for Mixed Hydrogen and Helium Burning in Accreting Neutron Stars

The rate of the final step in the astrophysical αp process, the ^{34}Ar(α,p)^{37}K reaction, suffers from large uncertainties due to a lack of experimental data, despite having a considerable impact on the observable light curves of x-ray bursts and the composition of the ashes of hydrogen and helium burning on accreting neutron stars. We present the first direct measurement constraining the ^{34}Ar(α,p)^{37}K reaction cross section, using the Jet Experiments in Nuclear Structure and Astrophysics gas jet target. The combined cross section for the ^{34}Ar,Cl(α,p)^{37}K,Ar reaction is found to agree well with Hauser-Feshbach predictions. The ^{34}Ar(α,2p)^{36}Ar cross section, which can be exclusively attributed to the ^{34}Ar beam component, also agrees to within the typical uncertainties quoted for statistical models. This indicates the applicability of the statistical model for predicting astrophysical (α,p) reaction rates in this part of the αp process, in contrast to earlier findings from indirect reaction studies indicating orders-of-magnitude discrepancies. This removes a significant uncertainty in models of hydrogen and helium burning on accreting neutron stars.

Trans-cinnamaldehyde nanoemulsion wash inactivates Salmonella Enteritidis on shelled eggs without affecting egg color

Salmonella Enteritidis is a major foodborne pathogen that causes enteric illnesses in humans, primarily through the consumption of contaminated poultry meat and eggs. Despite implementation of traditional disinfection approaches to reduce S. Enteritidis contamination, egg-borne outbreaks continue to occur, raising public health concerns and adversely affecting the popularity and profitability for the poultry industry. Generally Recognized as Safe (GRAS) status phytochemicals such as Trans-cinnamaldehyde (TC) have previously shown to exhibit anti-Salmonella efficacy, however, the low solubility of TC is a major hurdle in its adoption as an egg wash treatment. Therefore, the present study investigated the efficacy of Trans-cinnamaldehyde nanoemulsions (TCNE) prepared with emulsifiers Tween 80 (Tw.80) or Gum Arabic and lecithin (GAL) as dip treatments, at 34°C, for reducing S. Enteritidis on shelled eggs in presence or absence of 5% chicken litter. In addition, the efficacy of TCNE dip treatments in reducing trans-shell migration of S. Enteritidis across shell barrier was investigated. The effect of wash treatments on shell color were evaluated on d 0, 1, 7, and 14 of refrigerated storage. TCNE-Tw.80 or GAL treatments (0.06, 0.12, 0.24, 0.48%) were effective in inactivating S. Enteritidis by at least 2 to 2.5 log cfu/egg as early as 1 min of washing time (P < 0.05). In presence of organic matter, nanoemulsions (0.48%) reduced S. Enteritidis counts by ∼ 2 to 2.5 log cfu/egg as early as 1 min, (P < 0.05). Nanoemulsion wash also inhibited trans-shell migration of S. Enteritidis, as compared to control (P < 0.05). The nanoemulsion wash treatments did not affect shell color (P > 0.05). Results suggest that TCNE could potentially be used as an antimicrobial wash to reduce S. Enteritidis on shelled eggs, although further studies investigating the effect of TCNE wash treatments on organoleptic properties of eggs are necessary.

Implementation and Clinical Adoption of Precision Oncology Workflows Across a Healthcare Network

BACKGROUND

Precision oncology relies on molecular diagnostics, and the value-proposition of modern healthcare networks promises a higher standard of care across partner sites. We present the results of a clinical pilot to standardize precision oncology workflows.

METHODS

Workflows are defined as the development, roll-out, and updating of disease-specific molecular order sets. We tracked the timeline, composition, and effort of consensus meetings to define the combination of molecular tests. To assess clinical impact, we examined order set adoption over a two-year period (before and after roll-out) across all gastrointestinal and hepatopancreatobiliary (GI) malignancies, and by provider location within the network.

RESULTS

Development of 12 disease center-specific order sets took ~9 months, and the average number of tests per indication changed from 2.9 to 2.8 (P = .74). After roll-out, we identified significant increases in requests for GI patients (17%; P < .001), compliance with testing recommendations (9%; P < .001), and the fraction of "abnormal" results (6%; P < .001). Of 1088 GI patients, only 3 received targeted agents based on findings derived from non-recommended orders (1 before and 2 after roll-out); indicating that our practice did not negatively affect patient treatments. Preliminary analysis showed 99% compliance by providers in network sites, confirming the adoption of the order sets across the network.

CONCLUSION

Our study details the effort of establishing precision oncology workflows, the adoption pattern, and the absence of harm from the reduction of non-recommended orders. Establishing a modifiable communication tool for molecular testing is an essential component to optimize patient care via precision oncology.

Waning of SARS-CoV-2 IgG antibodies after vaccination: first results from the CoMoLo follow-up 2021

Background

In 2020, the study “Corona-Monitoring Lokal” (CoMoLo) assessed seroprevalences of SARS-CoV-2 IgG antibodies in four study locations that were particularly affected by outbreaks in the early stages of the pandemic in Germany. One of the objectives of the 2021 follow-up was to examine the development of immunological parameters over time, including the extent of IgG antibody waning after vaccination.

Methods

Venous blood specimens were collected from a sample of initial study participants over a 2-week period between May and October 2021, with an oversampling of seropositive or previously infected individuals. Levels of IgG antibodies to the SARS-CoV-2 spike protein were measured from serum using Anti-SARS-CoV-2-QuantiVac-ELISA (IgG) tests by Euroimmun. Information on SARS-CoV-2 vaccinations or known infections was collected via online questionnaires or telephone interviews.

Results

A total of 3328 participants (74% response) gave blood specimens for this follow-up study, with questionnaire information available for 2843 (85%) of these. Preliminary analyses suggest that in participants who had received two doses of a vaccine more than 3 weeks before giving blood (n = 1583), IgG levels decreased exponentially by about 9.8% (95%CI 9.1% - 10.4%) with each additional week since the last dose, when controlling for age, sex, and type of vaccine. There was evidence of this waning effect differing by vaccine type. Antibody levels also appear to decline with increasing age, according to preliminary results. Final results of the linear model used to assess the dynamics and predictive factors of antibody levels will be reported.

Conclusions

This follow-up study will add evidence to an improved understanding of antibody waning after SARS-CoV-2 vaccination. Preliminary results are in line with international studies and may be helpful for discussions on potential benefits of further vaccinations in Germany.

Key messages

• Antibodies induced by COVID-19 vaccination wane over time. The magnitude of this effect differs by vaccine type. Antibodies also decreased with increasing age.

• Our results may be helpful for discussions on potential benefits of further COVID-19 vaccinations in Germany.

International Horizon Scanning the impact of Covid-19 on increasing the health gap and vulnerability

 

The COVID-19 pandemic has caused unprecedented challenges for populations, health systems and governments worldwide, which have resulted in lasting economic, social and health impacts. The results of such have been felt disproportionately throughout society and existing vulnerabilities have been highlighted and heightened. A clear understanding of the extent of these vulnerabilities is needed in order to fully address the problem. The World Health Organization Collaborating Centre on Investment for Health and Well-being (WHOCC), Public Health Wales has developed a summary report focusing on the existing and emerging inequalities resulting from the pandemic, as identified through international evidence and learning from the International Horizon Scanning Reports. These reports, undertaken between May 2020 - August 2021, are based upon rapid evidence synthesis reviews of international literature. The summary report focuses on global learning and best practices in order to better understand and address the unequal impacts of the pandemic. The information has been categorised according to the five essential conditions required to enable a healthy life as presented within the WHO health equity conditions framework. The report provides evidence on groups most vulnerable to both direct and indirect impacts of the pandemic as well as promising practice to address the resulting inequity. Inequalities and related factors explored within the report include but are not limited to, level of deprivation and education. Taking a global perspective, this report summarises international evidence to support inclusive, sustainable, and equitable solutions, such as protecting economic well-being and taking an intergenerational lens in both response and recovery. To address and mitigate the impact of the pandemic upon vulnerable groups, collating and sharing international evidence and best practice has proven to support equitable long-term socio-economic and environmental recovery.

Key messages

• International learning provides vital insights to support recovery in Wales and beyond.

• Responses to the pandemic should address the needs of the vulnerable to reduce existing health gaps.

Aligning tumor mutational burden (TMB) quantification across diagnostic platforms: phase II of the Friends of Cancer Research TMB Harmonization Project

BACKGROUND

Tumor mutational burden (TMB) measurements aid in identifying patients who are likely to benefit from immunotherapy; however, there is empirical variability across panel assays and factors contributing to this variability have not been comprehensively investigated. Identifying sources of variability can help facilitate comparability across different panel assays, which may aid in broader adoption of panel assays and development of clinical applications.

MATERIALS AND METHODS

Twenty-nine tumor samples and 10 human-derived cell lines were processed and distributed to 16 laboratories; each used their own bioinformatics pipelines to calculate TMB and compare to whole exome results. Additionally, theoretical positive percent agreement (PPA) and negative percent agreement (NPA) of TMB were estimated. The impact of filtering pathogenic and germline variants on TMB estimates was assessed. Calibration curves specific to each panel assay were developed to facilitate translation of panel TMB values to whole exome sequencing (WES) TMB values.

RESULTS

Panel sizes >667 Kb are necessary to maintain adequate PPA and NPA for calling TMB high versus TMB low across the range of cut-offs used in practice. Failure to filter out pathogenic variants when estimating panel TMB resulted in overestimating TMB relative to WES for all assays. Filtering out potential germline variants at >0% population minor allele frequency resulted in the strongest correlation to WES TMB. Application of a calibration approach derived from The Cancer Genome Atlas data, tailored to each panel assay, reduced the spread of panel TMB values around the WES TMB as reflected in lower root mean squared error (RMSE) for 26/29 (90%) of the clinical samples.

CONCLUSIONS

Estimation of TMB varies across different panels, with panel size, gene content, and bioinformatics pipelines contributing to empirical variability. Statistical calibration can achieve more consistent results across panels and allows for comparison of TMB values across various panel assays. To promote reproducibility and comparability across assays, a software tool was developed and made publicly available.

Sustaining suicide prevention programs in American Indian and Alaska Native communities and Tribal health centers

Background:

Research on sustaining community-based interventions is limited. This is particularly true for suicide prevention programs and in American Indian and Alaska Native (AIAN) settings. Aiming to inform research in this area, this paper sought to identify factors and strategies that are key to sustain suicide prevention efforts in AIAN communities.

Methods:

We used a modified Nominal Group Technique with a purposeful sample of N = 35 suicide prevention research experts, program implementors and AIAN community leaders to develop a list of prioritized factors and sustainability strategies. We then compared this list with the Public Health Program Capacity for Sustainability Framework (PHPCSF) to examine the extent the factors identified aligned with the existing literature.

Results:

Major factors identified included cultural fit of intervention approaches, buy in from local communities, importance of leadership and policy making, and demonstrated program success. Strategies to promote these factors included partnership building, continuous growth of leadership, policy development, and ongoing strategic planning and advocacy. All domains of the PHPCF were representative, but additional factors and strategies were identified that emerged as important in AIAN settings.

Conclusions:

Sustaining effective and culturally informed suicide prevention efforts is of paramount importance to prevent suicide and save lives. Future research will focus on generating empirical evidence of these strategies and their effectiveness at promoting program sustainability in AIAN communities.

Intracranial germ cell tumors in Adolescents and Young Adults: European and North American consensus review, current management and future development

The incidence of intracranial germ cell tumors (iGCT) is much lower in European and North American (E&NA) than in Asian population. However, E&NA cooperative groups have simultaneously developed with success treatment strategies with specific attention paid to long-term sequelae. Neurological sequelae may be reduced by establishing a diagnosis with an endoscopic biopsy and/or cerebrospinal fluid (CSF) and/or serum analysis, deferring the need to perform a radical surgery. Depending on markers and/or histological characteristics, patients are treated as either germinoma or non-germinomatous germ cell tumors (NGGCT). Metastatic disease is defined by a positive CSF cytology and/or distant drops in craniospinal MRI. The combination of surgery and/or chemotherapy and radiation therapy is tailored according to grouping and staging. With more than 90% 5-year event-free survival (EFS), localized germinomas can be managed without aggressive surgery, and benefit from chemotherapy followed by whole ventricular irradiation with local boost. Bifocal germinomas are treated as non-metastatic entities. Metastatic germinomas may be cured with craniospinal irradiation. With a 5-year EFS over 70%, NGGCT benefit from chemotherapy followed by delayed surgery in case of residual disease, and some form of radiotherapy. Future strategies will aim at decreasing long-term side effects while preserving high cure rates.

Blurred boundaries between Pro-Anorexia and Fitspiration media? Diverging cognitive and emotional effects

Social media is an emerging source of body-focused messages affecting young women. This research investigated the diverging cognitive and emotional effects of Pro-Anorexia (Pro-Ana) and Fitspiration content using linguistic analysis. Undergraduate college women (N = 129) viewed one of six experimentally-created blogs: text or images of Fitspiration, Pro-Ana, or control (Home Décor) and completed an open-ended prompt with their reaction. Linguistic analysis on post-exposure writing suggested Fitspiration blogs produced positive emotions and social comparison processes; Pro-Ana blogs produced negative and anxious emotions. Participants' history of past disordered eating behavior qualified affective (positive emotion and anxiety), but not cognitive (social comparison) outcomes. Given the cognitive and emotional impact of viewing such media, findings speak to the need for specific content of social media sites to be addressed and discussed in the treatment and prevention of eating disorders.

A critique of measures of emotion and empathy in First Peoples' cultural safety in nursing education: A systematic literature review

BACKGROUND

In Australia, undertaking cultural safety education often evokes strong emotional responses by health students. Despite the potential for emotion to drive transformative learning in this space, measures of emotion are uncommon.

AIM

To review existing tools that intend to measure emotional components of learning in relation to cultural safety education.

METHODS

Articles published in English from January 2005 to January 2020; reported studies from Australia, New Zealand, Canada and United States of America; and measured an emotional construct/s after an education intervention offered to university students enrolled in a health programme were included. Studies were assessed for quality according to the Critical Appraisals Skills Programme criteria.

RESULTS

Eight articles were reviewed; five conducted in the United States of America, and three in Australia. Intervention type, measures, methodological rigour and outcomes varied. Studies predominately measured empathy, guilt and/or fear.

CONCLUSIONS

Although students' emotional responses were measured, processes for students to reflect upon these reactions were not incorporated in the classroom. The review has implications for future research and curricula through developments in measuring and acting upon emotion in cultural safety education for nursing students in Australia.

Forecasting the economic consequences of COVID-19 on longstanding illnesses in Wales

Introduction

The unemployment rate following the COVID-19 pandemic in Wales is increasing and there is a positive link between unemployment and longstanding illnesses. This study aimed to project the percentage of adults with longstanding illnesses and chronic health conditions following COVID-19 associated with the economic consequences.

Methods

We retrieved historical data on the unemployment rates and status of longstanding illnesses among adults from the Office for National Statistics (ONS) and National Survey for Wales (NSW), and used time-series models to project the unemployment rates and percentage of adults with longstanding illnesses and chronic health conditions over a three year period (2020/21 - 2022/23).

Results

Without reparative interventions, the unemployment rate is expected to increase sharply from 3.8% in 2019 to about 7% in 2020 following COVID-19 and then gradually increase over the projected period. With increased unemployment, longstanding illness (LSI) would be expected to increase gradually following COVID-19, with an estimated increase of around or exceeding 4% over three years depending on the LSI measure. There would be a higher increment in the percentage of adults with limiting LSI compared with adults with any LSI, suggesting implications for wider health and social care services. With current unemployment predictions, the percentage of adults with chronic health conditions is projected to increase following the COVID-19 pandemic over the projected period, with a higher increment for mental health and endocrine/metabolic conditions

Conclusions

The longstanding illnesses and chronic health conditions are expected to increase in the coming years following COVID-19 pandemic. Therefore, preventative measures for longstanding illnesses and chronic health conditions should be a priority for a sustainable recovery from the COVID-19.

Key messages

Without reparative interventions, the unemployment rate is expected to increase following the COVID-19 pandemic. The projected prevalence of limiting longstanding illness in adults following COVID-19 suggests implications for wider health and social care services.

COVID-19 impact on financial security: evidence from the National Public Engagement Survey in Wales

Background

A nationally representative COVID-19 Public Engagement Survey for Wales, led by the World Health Organization Collaborating Centre on Investment for Health and Well-being at Public Health Wales, has been ongoing from April 2020, helping to inform a sustainable recovery from the COVID-19 pandemic. A data analysis was performed as part of the Welsh Health Equity Status Report initiative focusing on income and job security, which influences living conditions and lifestyle behaviours.

Methods

A Generalized Linear Model was used to calculate the predicted probability of response for variables of interest, e.g. whether an individual reported being in a worse financial situation due to the pandemic, across the life course, socio-economic gradient and sex. Data collected via telephone between 03 April - 25 July 2020 produced a sample ranging between approx. 2,500 - 7,500 participants. The sample was weighted according to deprivation quintile (using the Welsh Index of Multiple Deprivation), age group and sex.

Results

A significantly higher proportion of survey respondents (18 - 24 years of age) reported being worried about losing their job or not being able to find one, than any other age group. A significantly higher proportion of survey respondents in the most deprived population fifth (33.7%) reported being in a worse financial situation as a result of the restrictions, compared to the least deprived fifth (21.7%).

Conclusions

COVID-19 has had a major impact on people's lives and livelihoods in Wales, hitting the most deprived and vulnerable the most. It has increased job insecurity, especially among younger/working age people. The government has taken unprecedented financial and other measures to address inequities; nevertheless, most are temporary and not specifically targeted to support specific (vulnerable) groups. Measures to promote sustainable economic recovery, job security and safeguarding due to the COVID-19 pandemic need continuity and consistency

Key messages

COVID-19 has had a significant impact on income and job security in Wales, disproportionately affecting the most deprived. To mitigate COVID-19 harms, a continuous and consistent focus on equity is essential to promote sustainable economic recovery.

COVID-19 International Horizon Scanning – informing a response and recovery in Wales and beyond

Issue

The rapidly evolving nature and uncertainties of the COVID-19 pandemic have led to unprecedented challenges for health systems, as well as to wellbeing, social and economic impacts for individuals and communities across the globe. Effective, dynamic, innovative and evidence-based solutions are needed to address these challenges.

Description of Problem

The World Health Organization (WHO) Collaborating Centre on Investment for Health and Well-being, Public Health Wales, has initiated and continues to perform International Horizon Scanning work to inform the evolving COVID-19 public health response and recovery plans in Wales by learning from best practices from other countries. The learning and intelligence is systematically synthesized in rapid regular reports published every week/two weeks. The focus and scope vary, depending on the COVID-19 situation and public health and policy needs.

Results

The work stream has provided Welsh Government, the National Health Service (NHS), Public Health Wales and other key stakeholders with continuous and timely learning from the experience of other countries along with emerging evidence and guidance, provided by key international organisations. This includes international evidence, epidemiological data, experience, measures and recovery approaches, to understand and explore solutions. Reports have given a consistent overview of approaches across countries such as a comparative analysis of the vaccine roll-out or a systematic overview of the R-value and measures implemented accordingly.

Lessons

To understand, mitigate and address the impacts of the pandemic in Wales and beyond, a timely, dynamic and evidence-informed actionable intelligence has proven to be essential to inform and support decision-making on government and health system level to address the pandemic and mitigate harms from COVID-19.

Key messages

International learning has and continues to inform the evolving COVID-19 public health response in Wales.

Public Health Wales is contributing to an evidence-informed inclusive recovery from the pandemic in Wales and beyond.

182 Treating Distal Femur Fractures Without Fluoroscopy: Comparison of Implants Used in a Rural Hospital in Tanzania

Introduction

SIGN is a charity providing implants for hospitals with limited resources. There are two nails that can be inserted without fluoroscopy - the standard SIGN nail and the Fin nail. We aimed to evaluate the effectiveness of these implants in treating distal femur fractures.

Method

Retrospective analysis of SIGN database at Nkoaranga Hospital, Tanzania between July 2017 and January 2019. 28 patients (20 male, 8 female) with distal femur fractures had a standard nail (n = 14) or a Fin nail (n = 14). Inclusion criteria: distal femur fractures treated with intramedullary nail. Exclusion criteria: age&lt;16, open injury, antegrade approach, no follow-up at 4 weeks.

Results

Mean age was 41.4 (18-81). Average time from injury to surgery was 29 days. Average first follow-up was 14 weeks (4-73). Painless weight-bearing was achieved in 93% (13/14) of standard nails and 100% (14/14) of Fin nails. Knee flexion &gt;30° was 64% (9/14) in standard nails and 50% (7/14) in Fin nails. Screw loosening was seen in 7% (1/14) in standard nails and no patients with Fin nails. There were no instances of implant breakage, clinical deformity, or infection.

Conclusions

Patients had variable follow-up and presented late causing delayed treatment. Both nails can achieve excellent results. A larger sample size is required.

O61: TEXTBOOK SURGICAL OUTCOMES IN OESOPHAGO-GASTRIC CANCER: THE INFLUENCE OF NATIONAL KEY PERFORMANCE INDICATORS

Introduction

High quality surgery remains the cornerstone of treating oesophago-gastric malignancy. Recent work from the Dutch Upper-gastrointestinal Cancer Audit (DUCA) have defined ten surgical and perioperative ‘textbook’ parameters that correlate with improved overall survival. The aim of this project was to examine the proportion of patients attaining ‘textbook’ outcomes for oesophagectomy and gastrectomy in our unit before and after the introduction of national key performance indicators (KPIs).

Method

A retrospective review of all oesophagectomies and gastrectomies from January 2010 until June 2019 was performed. Clinical, pathological, perioperative, morbidity and mortality outcomes were recorded. 10 ‘textbook’ parameters were studied pre- and post-KPI introduction.

Result

269 and 284 patients underwent oesophagectomy and gastrectomy respectively, 167 pre-KPI and 386 post-KPI. There were no significant differences in age (67.6 vs 66.4 years, p=0.6), gender (71% male, 29% female vs 68% male, 22% female, p=0.48), ASA grade (p=0.6) or tumour stage (p=0.37) pre- and post-KPI. In the pre-KPI era, 28/167 (17%) patients achieved all ten textbook parameters, compared with 157/386, (41%, p=0.001) post-KPI. This compares favourably to DUCA ‘textbook’ data. There was an improvement in adequate lymphadenectomy (56% vs 83%, p=0.002), a reduction in margin positivity (21% vs 7%, p= 0.001) and peri-operative mortality (6% vs 2%, p=0.03) post-KPI.

Conclusion

There has been a significant improvement in perioperative outcomes in esophagectomy following the introduction of national KPIs in our unit. The number of patients achieving ‘textbook’ outcomes is comparable with international standards. The identification of textbook parameters allows further focus for future quality improvement initiatives.

Take-home message

National KPIs improve peri-operative outcomes in oesophago-gastric cancer.

Circulating Tumor DNA Predicts Pathologic and Clinical Outcomes Following Neoadjuvant Chemoradiation and Surgery for Patients With Locally Advanced Rectal Cancer

PURPOSE

This study was designed to assess the ability of perioperative circulating tumor DNA (ctDNA) to predict surgical outcome and recurrence following neoadjuvant chemoradiation for locally advanced rectal cancer (LARC).

MATERIALS AND METHODS

Twenty-nine patients with newly diagnosed LARC treated between January 2014 and February 2018 were enrolled. Patients received long-course neoadjuvant chemoradiation prior to surgery. Plasma ctDNA was collected at baseline, preoperatively, and postoperatively. Next-generation sequencing was used to identify mutations in the primary tumor, and mutation-specific droplet digital polymerase chain reaction was used to assess mutation fraction in ctDNA.

RESULTS

The median age was 54 years. The overall margin-negative, node-negative resection rate was 73% and was significantly higher among patients with undetectable preoperative ctDNA (n = 17, 88%) versus patients with detectable preoperative ctDNA (n = 9, 44%; P = .028). Undetectable ctDNA was also associated with more favorable neoadjuvant rectal scores (univariate linear regression, P = .029). Recurrence-free survival (RFS) was calculated for the subset (n = 19) who both underwent surgery and had postoperative ctDNA available. At a median follow-up of 20 months, patients with detectable postoperative ctDNA experienced poorer RFS (hazard ratio, 11.56; P = .007). All patients (4 of 4) with detectable postoperative ctDNA recurred (positive predictive value = 100%), whereas only 2 of 15 patients with undetectable ctDNA recurred (negative predictive value = 87%).

CONCLUSION

Among patients treated with neoadjuvant chemoradiation for LARC, patients with undetectable preoperative ctDNA were more likely to have a favorable surgical outcome as measured by the rate of margin-negative, node-negative resections and neoadjuvant rectal score. Furthermore, we have confirmed prior reports indicating that detectable postoperative ctDNA is associated with worse RFS. Future prospective study is needed to assess the potential for ctDNA to assist with personalizing treatment for LARC.

Descriptive examination of secure messaging in a longitudinal cohort of diabetes patients in the ECLIPPSE study

The substantial expansion of secure messaging (SM) via the patient portal in the last decade suggests that it is becoming a standard of care, but few have examined SM use longitudinally. We examined SM patterns among a diverse cohort of patients with diabetes (N = 19 921) and the providers they exchanged messages with within a large, integrated health system over 10 years (2006-2015), linking patient demographics to SM use. We found a 10-fold increase in messaging volume. There were dramatic increases overall and for patient subgroups, with a majority of patients (including patients with lower income or with self-reported limited health literacy) messaging by 2015. Although more physicians than nurses and other providers messaged throughout the study, the distribution of health professions using SM changed over time. Given this rapid increase in SM, deeper understanding of optimizing the value of patient and provider engagement, while managing workflow and training challenges, is crucial.

Effect of High-Dose vs Standard-Dose Vitamin D3 Supplementation on Body Composition among Patients with Advanced or Metastatic Colorectal Cancer: A Randomized Trial

Simple Summary

Skeletal muscle and adipose tissue express the vitamin D receptor and may be a mechanism through which vitamin D supplementation slows cancer progression and reduces cancer death. It is unknown if high-dose vitamin D₃ impacts skeletal muscle and adipose tissue, as compared with standard-dose vitamin D₃, in patients with advanced or metastatic colorectal cancer. In this exploratory analysis of a phase II randomized trial, high-dose vitamin D₃ did not lead to changes of body weight, body mass index, muscle area, muscle attenuation, visceral adipose tissue area, or subcutaneous adipose tissue area, as compared with standard-dose vitamin D₃. High-dose vitamin D₃ did not change body composition in patients receiving chemotherapy for advanced or metastatic colorectal cancer.

Abstract

Skeletal muscle and adipose tissue express the vitamin D receptor and may be a mechanism through which vitamin D supplementation slows cancer progression and reduces cancer death. In this exploratory analysis of a double-blind, multicenter, randomized phase II clinical trial, 105 patients with advanced or metastatic colorectal cancer who were receiving chemotherapy were randomized to either high-dose vitamin D₃ (4000 IU) or standard-dose (400 IU) vitamin D₃. Body composition was measured with abdominal computed tomography at enrollment (baseline) and after cycle 8 of chemotherapy (16 weeks). As compared with standard-dose vitamin D₃, high-dose vitamin D₃ did not significantly change body weight [−0.7 kg; (95% CI: −3.5, 2.0)], body mass index [−0.2 kg/m²; (95% CI: −1.2, 0.7)], muscle area [−1.7 cm²; (95% CI: −9.6, 6.3)], muscle attenuation [−0.4 HU; (95% CI: −4.2, 3.2)], visceral adipose tissue area [−7.5 cm²; (95% CI: −24.5, 9.6)], or subcutaneous adipose tissue area [−8.3 cm²; (95% CI: −35.5, 18.9)] over the first 8 cycles of chemotherapy. Among patients with advanced or metastatic colorectal cancer, the addition of high-dose vitamin D₃, vs standard-dose vitamin D₃, to standard chemotherapy did not result in any changes in body composition.

Diel cycles of carbon, nutrient and metal in humic lakes of permafrost peatlands

Despite the importance of surface waters of permafrost landscapes in carbon (C) emission and dissolved C and metal storage and export, the majority of available observations in high latitude aquatic systems deal with punctual or seasonal sampling without accounting for diurnal variations in temperature and primary productivity-respiration cycles. Towards providing comprehensive understanding of diel variations in CO₂ emission, organic C and element concentrations in lakes of frozen peatlands, we monitored, each 2 h over 2 days, the water temperature, pH, CO₂ fluxes, CO₂, CH₄, dissolved organic and inorganic carbon (DOC and DIC, respectively), nutrients, carboxylic acids, bacterial number, and major and trace elements in two acidic (pH = 3.6 and 4.0) and humic (DOC = 15 and 35 mg L^-1) thermokarst lakes of discontinuous permafrost zone in Western Siberia. We discovered a factor of 2 to 3 higher CO₂ concentrations and fluxes during the night compared to daytime in the high-DOC lake. The emission fluxes in the low-DOC lake increased from zero to negative values during the day to highly positive values during the end of night and early morning. The methane concentration varied within a factor of 5 without any link to the diurnal cycle. The bulk of dissolved (< 0.45 μm) hydrochemical parameters remained highly stable with ±10% variation in concentration over 2 days of observation (DOC, DIC, SUVA_254nm, carboxylates (formate, oxalate, puryvate and glutarate), Mn, Fe, Al, other trace elements). Concentrations of Si, P, K, Cu varied within ±20% whereas those of Zn and Ni ranged by a factor of 2 to 4 without any link to diurnal pattern. Overall, the impact of diel cycle on CH₄, DOC, nutrient and metal concentration was below 10%. However, neglecting night-time period may underestimate net CO₂ emission by ca. 30 to 50% in small organic-rich thaw ponds and switch the CO₂ exchange from uptake/zero to net emission in larger thermokarst lakes. Given the dominance of large lakes in permafrost regions, the global underestimation of the emission flux may be quite high. As such, monitoring CO₂ concentrations and fluxes in thermokarst lakes during months of extended night time (August to October) is mandatory for assessing the net emissions from lentic waters of frozen peatlands.

Dissipation of electron-beam-driven plasma wakes

Metre-scale plasma wakefield accelerators have imparted energy gain approaching 10 gigaelectronvolts to single nano-Coulomb electron bunches. To reach useful average currents, however, the enormous energy density that the driver deposits into the wake must be removed efficiently between shots. Yet mechanisms by which wakes dissipate their energy into surrounding plasma remain poorly understood. Here, we report picosecond-time-resolved, grazing-angle optical shadowgraphic measurements and large-scale particle-in-cell simulations of ion channels emerging from broken wakes that electron bunches from the SLAC linac generate in tenuous lithium plasma. Measurements show the channel boundary expands radially at 1 million metres-per-second for over a nanosecond. Simulations show that ions and electrons that the original wake propels outward, carrying 90 percent of its energy, drive this expansion by impact-ionizing surrounding neutral lithium. The results provide a basis for understanding global thermodynamics of multi-GeV plasma accelerators, which underlie their viability for applications demanding high average beam current.

Revisiting MET: Clinical Characteristics and Treatment Outcomes of Patients with Locally Advanced or Metastatic, MET-Amplified Esophagogastric Cancers

BACKGROUND

Metastatic esophagogastric cancers (EGCs) have a poor prognosis with an approximately 5% 5-year survival. Additional treatment approaches are needed. c-MET gene-amplified tumors are an uncommon but potentially targetable subset of EGC. Clinical characteristics and outcomes were evaluated in patients with MET-amplified EGC and compared with those without MET amplification to facilitate identification of these patients and possible treatment approaches.

PATIENTS AND METHODS

Patients with locally advanced or metastatic MET-amplified EGC at Massachusetts General Hospital (MGH) were identified using fluorescent in situ hybridization analysis, with a gene-to-control ratio of ≥2.2 defined as positive. Non-MET-amplified patients identified during the same time period who had undergone tumor genotyping and treatment at MGH were evaluated as a comparison group.

RESULTS

We identified 233 patients evaluated for MET amplification from 2002 to 2019. MET amplification was seen in 28 (12%) patients versus 205 (88%) patients without amplification. Most MET-amplified tumors occurred in either the distal esophagus (n = 9; 32%) or gastroesophageal junction (n = 10; 36%). Of MET-amplified patients, 16 (57%) had a TP53 mutation, 5(18%) had HER2 co-amplification, 2 (7.0%) had EGFR co-amplification, and 1 (3.5%) had FGFR2 co-amplification. MET-amplified tumors more frequently had poorly differentiated histology (19/28, 68.0% vs. 66/205, 32%; p = .02). Progression-free survival to initial treatment was substantially shorter for all MET-amplified patients (5.6 vs. 8.8 months, p = .026) and for those with metastatic disease at presentation (4.0 vs. 7.6 months, p = .01). Overall, patients with MET amplification had shorter overall survival (19.3 vs. 24.6 months, p = .049). No difference in survival was seen between low MET-amplified tumors (≥2.2 and <25 MET copy number) compared with highly amplified tumors (≥25 MET copy number).

CONCLUSION

MET-amplified EGC represents a distinct clinical entity characterized by rapid progression and short survival. Ideally, the identification of these patients will provide opportunities to participate in clinical trials in an attempt to improve outcomes.

IMPLICATIONS FOR PRACTICE

This article describes 233 patients who received MET amplification testing and reports (a) a positivity rate of 12%, similar to the rate of HER2 positivity in this data set; (b) the clinical characteristics of poorly differentiated tumors and nodal metastases; and (c) markedly shorter progression-free survival and overall survival in MET-amplified tumors. Favorable outcomes are reported for patients treated with MET inhibitors. Given the lack of published data in MET-amplified esophagogastric cancers and the urgent clinical importance of identifying patients with MET amplification for MET-directed therapy, this large series is a valuable addition to the literature and will have an impact on future practice.

A double-blinded randomised controlled study to investigate the effect of intraperitoneal levobupivacaine on post laparoscopic pain

BACKGROUND

Laparoscopic surgery is the cornerstone of modern gynaecological surgery, with shorter hospital stays and a quicker return to normal activities. However postoperative pain remains problematic. No strategy to reduce phrenic nerve irritation, including heating or humidifying the insufflating gas, alternatives to CO₂, and intraperitoneal analgesics, has shown superiority.

METHODS

100 women undergoing laparoscopic surgery were randomly allocated, having either 40ml of 0.25% levobupivacaine or 40ml 0.9% sodium chloride solution administered into the peritoneal cavity following surgery. The patients and the main researcher were blinded. All women received standardised anaesthetic and laparoscopic technique, and postoperative pain control including nursing position and nature of analgesia. Postoperative pain was assessed 3 hours, 8 hours, day 1 and day 4/5 postoperatively.

RESULTS

100 patients were recruited undergoing surgery for benign causes aged 19-73(mean 40.3±13). There was no difference between the groups for age(p=0.64) or length of operation(p=0.56). There were no adverse events related to use of intraperitoneal instillation. There was a significant reduction in shoulder-tip pain scores in the levobupivacaine group at 3 hours(p=0.04). Furthermore, there was a significant reduction in wound-pain scores in the levobupivacaine group at 8hrs(p=0.04) and at day 4(p=0.04). No difference was found in pelvic pain between the two groups. No significant difference was found in the use of post-operative analgesia.

CONCLUSIONS

Intraperitoneal instillation of 40ml of levobupivacaine has some benefit in reducing postoperative pain and need for analgesia in the initial hours following gynaecological surgery. However, further well-designed randomised control trials are required to decide the optimum route and concentration of administering local anaesthetic.

Innovative data analysis approach informing policy action to improve wellbeing and health equity

Wales is leading the way as one of the first countries supporting the World Health Organization to take forward the work of the Health Equity Status Report Initiative (HESRi) at a national level. The Welsh Health Equity Status Report Initiative (WHESRi) has been established to strengthen this global wellbeing and health equity agenda, applying a cutting-edge HESRi methodology first in Wales, providing valuable lessons and experience, which can enable other countries to take action to address health inequity. WHESRi includes three research streams: a) Health equity data analysis; b) Policy analysis and c) Health economic analysis.

The National Survey for Wales (NSW) (cross-sectional study design) is used to 'decompose' the gap in a health outcome using the Blinder-Oaxaca decomposition methodology. The analysis breaks down contributions to the inequitable health outcomes observed between different population groups, by factors that differ systematically between the groups. Factors, which align to the five HESRi health equity conditions (Health Services, Income Security & Social Protection, Living Conditions, Social & Human Capital and Employment & Working Conditions).

The work is also exploring how different health outcomes e.g. mental health and life satisfaction, result in different relative contributions to inequities in those outcomes from the five conditions.

Analysis of the 2016-17 NSW shows that the prevalence of good health is significantly higher in those who are not materially deprived (75.6% CI 74.5% to 76.6%) compared to those who are (55.3% CI 52.3% to 58.4%). Preliminary data suggests that when decomposing the gap in self-reported health between those who are materially deprived and those who are not, the largest contributing factor to the inequity is systematic differences in the degree of Income Security and Social Protection (39%).

The analysis identifies priority policy areas for action and further analysis.

Key messages

The health gap can be stratified and explained by five essential health equity conditions. Explaining the health gap informs cross-sector policy action and investment prioritisation towards healthy prosperous lives for all.

Learning from regret

BACKGROUND

Death after surgery is infrequent but can be devastating for the surgeon. Surgeons may experience intense emotional reactions after a patient's death, reflecting on their part in the death and the patient's loss of life. Excessive rumination or feelings of regret may have lasting negative consequences, but these reactions may also facilitate learning for future decision-making. This qualitative study analysed surgeons' reflections on what might have been done differently before a patient's death and explored non-technical (cognitive and interpersonal) aspects of care as potential targets for improvement.

METHODS

In Australia's Queensland Audit of Surgical Mortality, surgeons reflect on factors surrounding the death of patients in their care and respond to the open-ended question: in retrospect, would you have done anything differently? Framework analysis was applied to surgeons' responses to identify themes relating to non-technical aspects of care.

RESULTS

Responses from 1214 surgeons were analysed. Two main themes were identified. Dilemmas and difficult decisions confirmed the uncertainty, complexity and situational pressures that often precede a surgical death; regret and empathy for patients featured in some responses. In the second main theme, communication matters, surgeons cited better communication, with patients, families, colleagues and at handover, as a source of reflective change to improve decision-making and reduce regret.

CONCLUSION

Surgical decision-making involves uncertainty, and regret may occur after a patient's death. Enhancing the quality of communication with patients and peers in comprehensive assessment of the surgical patient may mitigate postdecision regret among surgeons.

Infrared thermography and ulcer prevention in the high-risk diabetic foot: data from a single-blind multicentre controlled clinical trial

AIM

To assess the usefulness of monthly thermography and standard foot care to reduce diabetic foot ulcer recurrence.

METHODS

People with diabetes (n = 110), neuropathy and history of ≥ 1 foot ulcer participated in a single-blind multicentre clinical trial. Feet were imaged with a novel thermal imaging device (Diabetic Foot Ulcer Prevention System). Participants were randomized to intervention (active thermography + standard foot care) or control (blinded thermography + standard foot care) and were followed up monthly until ulcer recurrence or for 12 months. Foot thermograms of participants from the intervention group were assessed for hot spots (areas with temperature ≥ 2.2°C higher than the corresponding contralateral site) and acted upon as per local standards.

RESULTS

After 12 months, 62% of participants were ulcer-free in the intervention group and 56% in the control group. The odds ratios of ulcer recurrence (intervention vs control) were 0.82 (95% CI 0.38, 1.8; P = 0.62) and 0.55 (95% CI 0.21, 1.4; P = 0.22) in univariate and multivariate logistic regression analyses, respectively. The hazard ratios for the time to ulcer recurrence (intervention vs control) were 0.84 (95% CI 0.45, 1.6; P = 0.58) and 0.67 (95% CI 0.34, 1.3; P = 0.24) in univariate and multivariate Cox regression analyses, respectively.

CONCLUSIONS

Monthly intervention with thermal imaging did not result in a significant reduction in ulcer recurrence rate or increased ulcer-free survival in this cohort at high risk of foot ulcers. This trial has, however, informed the design of a refined study with longer follow-up and group stratification, further aiming to assess the efficacy of thermography to reduce ulcer recurrence.