Variation in the mu-opioid receptor gene (OPRM1) moderates the influence of maternal sensitivity on child attachment

The endogenous opioid system is thought to play an important role in mother-infant attachment. In infant rhesus macaques, variation in the μ-opioid receptor gene (OPRM1) is related to differences in attachment behavior that emerges following repeated separation from the mother; specifically, infants carrying at least one copy of the minor G allele of the OPRM1 C77G polymorphism show heightened and more persistent separation distress, as well as a pattern of increased contact-seeking behavior directed towards the mother during reunions (at the expense of affiliation with other group members). Research in adult humans has also linked the minor G allele of the analogous OPRM1 A118G polymorphism with greater interpersonal sensitivity. Adopting an interactionist approach, we examined whether OPRM1 A118G genotype and maternal (in)sensitivity are associated with child attachment style, predicting that children carrying the G allele may be more likely to develop an ambivalent attachment pattern in response to less sensitive maternal care. The sample consisted of 191 mothers participating with their children (n = 223) in the Maternal Adversity, Vulnerability and Neurodevelopment (MAVAN) project, a community-based, birth cohort study of Canadian mothers and their children assessed longitudinally across the child's development. Maternal sensitivity was coded from at-home mother-child interactions videotaped when the child was 18 months of age. Child attachment was assessed at 36 months using the Strange Situation paradigm. As predicted, G allele carriers, but not AA homozygotes, showed increasing odds of being classified as ambivalently attached with decreasing levels of maternal sensitivity. Paralleling earlier non-human animal research, this work provides support for the theory that endogenous opioids contribute to the expression of attachment behaviors in humans.

Crowdsourced cycling data applications to estimate noise pollution exposure during urban cycling

This research demonstrates a methodology to integrate freely available datasets to understand the relationship between road traffic noise and cycling experiences in a medium sized city. An illustrative example of the methodology was drawn from data for Dublin, Ireland. We aggregate local environmental data with 81,403 Strava cycle trips, contextualised by feedback from 335 cyclists to estimate exposure levels and infer impacts on experiences and behaviours. Results demonstrate that cyclists recognise that they are subjected to increased noise levels and experience negative psychophysical consequences as a result, but they tend to downplay the impact of noise as merely a minor annoyance. Noise also impacts behaviour, most noticeably through temporal and spatial detours. Geospatial mapping was used to visualise the relationship between noise pollution and cycling activity. Estimating traffic noise levels across two cycle routes, direct vs popular detour, revealed a +10 dB(A) increase in exposure for a saving of approximately 4 min on the direct route compared to the detour. Spatial inequities in exposure levels may have serious health consequences for cyclists in a city such as Dublin. The methodology is demonstrated as suitable for policy level interventions and planning purposes.

Utilisation of WhatsApp for Emergency Medical Services in Garissa, Kenya

Garissa county, Kenya is a geographically large county with a mobile pastoralist population that has developed a method for emergency medical services (EMS) coordination using the WhatsApp communication platform. This work was based on a site visit, to better understand and describe the current operations, strengths, and weaknesses of the EMS communication system in Garissa. The use of WhatsApp in Garissa county seems to work well in the local context and has the potential to serve as a cost-effective solution for other EMS systems in Kenya, Africa, and other LMICs.

Cardiovascular Imaging in Women

Multimodality cardiovascular imaging is a cornerstone diagnostic tool in the diagnosis, risk stratification, and management of cardiovascular diseases, whether those involving the coronary tree, myocardial, or pericardial diseases in general and particularly in women. This manuscript aims to shed some light and summarize the very features of cardiovascular disease in women, explore their unique characteristics and discuss the role of cardiovascular imaging in ischemic heart disease and cardiomyopathies. The role of four imaging modalities will be discussed including nuclear medicine, echocardiography, noninvasive coronary angiography, and cardiac magnetic resonance.

Prognostic value of pre-operative mean corpuscular volume (MCV) in colorectal cancer

BACKGROUND

Mean corpuscular volume (MCV) has been shown to have some correlation to oncological outcomes in oesophageal cancer, with high pre-operative MCV associated with disease recurrence. A similar association has previously been reported in colorectal cancer.

AIMS

This study is aimed at investigating whether high MCV bears similar relation to post-operative outcome and disease recurrence in colorectal cancer (CRC).

METHODS

Patients undergoing elective CRC resection with curative intent between January 2008 and December 2019 were identified from our prospective database. Review of patient demographic details, American Society of Anaesthesiologists (ASA) grade, smoking and alcohol intake were performed. In addition, tumour location and staging, operation performed, pre-operative laboratory data and oncological management of each patient were noted. Post-operative morbidity (Clavien-Dindo (CD) score > 2), 30-day mortality, in-hospital mortality and cancer recurrence were examined and multivariable regression analysis was performed to predict these outcomes.

RESULTS

A total of 1,293 CRCs were resected, with 1,159 patients (89.7%) experiencing a hospital course without major morbidity (CD < 3). 30-day mortality rate was less than 1% (12/1293). There were 176 patients (13.6%) with recurrence at follow-up. When multivariable regression analysis was performed, high pre-operative MCV did not predict negative post-operative or oncological outcomes.

CONCLUSION

MCV does not appear to be an independent prognostic factor for outcomes following elective CRC resection.

Limited Effect of Prevention Strategies on Incidence of Clinically Detectable Venous Thromboembolism After Lung Transplantation

BACKGROUND

Thromboembolic complications are common post-lung transplant, leading to significant morbidity. We instituted multiple interventions because of an observed 36.8% incidence of venous thromboembolism (VTE) (Incidence rate (IR) 5.74/1000 pt days) in our recipients.

METHODS

Our initiative commenced January 2015 with enoxaparin initiation within 6-8 hours of intensive care unit arrival and continuation for 4-6 weeks. We evaluated the IR of VTE in lung transplant recipients within 90 days of transplant. In 2017, the protocol was modified to extend the time to initiation of prophylaxis to within 72 hours of ICU arrival. In 2019, we further amended our intraoperative vascular access strategy.

RESULTS

Eighteen of 26 lung transplant recipients (LTR) met inclusion criteria in the 2015 cohort. Six of 18 (33.3%) developed VTE, 50% of which were upper extremity (UE), line associated. Fifty two of 75 LTR were eligible for enoxaparin prophylaxis in the 2017 cohort. Fifteen of 52 subjects (28.8%) developed VTE, 77.8% of which were UE and line associated. Despite improved adherence in 2017, there was little change in VTE IR (3.90/1000 pt days compared with 3.85/1000 pt days). Twenty six of 43 LTR met protocol inclusion criteria in the 2019 cohort. Ten subjects (38.5%) developed VTE, 67% of which were UE and line associated (IR 5.18/1000 pt days).

CONCLUSION

Our prospective study found that LTR remain at high risk for VTE despite aggressive prophylaxis with 4-6 weeks of enoxaparin and adjustment of vascular access approach. Alternative interventions should be investigated to minimize VTE development in this vulnerable population.

Longitudinal Care Patterns and Utilization Among Patients With New-Onset Neck Pain by Initial Provider Specialty

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To compare utilization patterns for patients with new-onset neck pain by initial provider specialty.

SUMMARY OF BACKGROUND DATA

Initial provider specialty has been associated with distinct care patterns among patients with acute back pain; little is known about care patterns among patients with acute neck pain.

METHODS

De-identified administrative claims and electronic health record data were derived from the Optum Labs Data Warehouse, which contains longitudinal health information on over 200M enrollees and patients representing a mixture of ages and geographical regions across the United States. Patients had outpatient visits for new-onset neck pain from October 1, 2016 to September 30, 2019, classified by initial provider specialty. Utilization was assessed during a 180-day follow-up period, including subsequent neck pain visits, diagnostic imaging, and therapeutic interventions.

RESULTS

The cohort included 770,326 patients with new-onset neck pain visits. The most common initial provider specialty was chiropractor (45.2%), followed by primary care (33.4%). Initial provider specialty was strongly associated with the receipt of subsequent neck pain visits with the same provider specialty. Rates and types of diagnostic imaging and therapeutic interventions during follow-up also varied widely by initial provider specialty. While uncommon after initial visits with chiropractors (≤2%), CT, or MRI scans occurred in over 30% of patients with initial visits with emergency physicians, orthopedists, or neurologists. Similarly, 6.8% and 3.4% of patients initially seen by orthopedists received therapeutic injections and major surgery, respectively, compared with 0.4% and 0.1% of patients initially seen by a chiropractor.

CONCLUSION

Within a large national cohort, chiropractors were the initial provider for a plurality of patients with new-onset neck pain. Compared with patients initially seen by physician providers, patients treated initially by chiropractors or therapists received fewer and less costly imaging services and were less likely to receive invasive therapeutic interventions during follow-up.

LEVEL OF EVIDENCE

3.

Healthcare use attributable to COVID-19: a propensity-matched national electronic health records cohort study of 249,390 people in Wales, UK

BACKGROUND

To determine the extent and nature of changes associated with COVID-19 infection in terms of healthcare utilisation, this study observed healthcare contact 1 to 4 and 5 to 24 weeks following a COVID-19 diagnosis compared to propensity-matched controls.

METHODS

Two hundred forty nine thousand three hundred ninety Welsh individuals with a positive reverse transcription-polymerase chain reaction (RT-PCR) test were identified from data from national PCR test results. After elimination criteria, 98,600 positive individuals were matched to test negative and never tested controls using propensity matching. Cohorts were split on test location. Tests could be taken in either the hospital or community. Controls were those who had tested negative in their respective environments. Survival analysis was utilised for first clinical outcomes which are grouped into primary and secondary. Primary outcomes include post-viral-illness and fatigue as an indication of long-COVID. Secondary outcomes include clinical terminology concepts for embolism, respiratory conditions, mental health conditions, fit notes, or hospital attendance. Increased instantaneous risk for positive individuals was quantified using hazard ratios (HR) from Cox regression, while absolute risk (AR) and relative risk were quantified using life table analysis.

RESULTS

Analysis was conducted using all individuals and stratified by test location. Cases are compared to controls from the same test location. Fatigue (HR: 1.77, 95% CI: 1.34-2.25, p =  < 0.001) and embolism (HR: 1.50, 95% CI: 1.15-1.97, p = 0.003) were more likely to occur in all positive individuals in the first 4 weeks; however, anxiety and depression (HR: 0.83, 95% CI: 0.73-0.95, p = 0.007) were less likely. Positive individuals continued to be more at risk of fatigue (HR: 1.47, 95% CI: 1.24-1.75, p =  < 0.001) and embolism (HR: 1.51, 95% CI: 1.13-2.02, p = 0.005) after 4 weeks. All positive individuals are also at greater risk of post-viral illness (HR: 4.57, 95% CI: 1.77-11.80, p = 0.002). Despite statistical association between testing positive and several conditions, life table analysis shows that only a small minority of the study population were affected.

CONCLUSIONS

Community COVID-19 disease is associated with increased risks of post-viral-illness, fatigue, embolism, and respiratory conditions. Despite elevated risks, the absolute healthcare burden is low. Subsequently, either very small proportions of people experience adverse outcomes following COVID-19 or they are not presenting to healthcare.

Room Temperature Ion Beam Synthesis of Ultra-Fine Molybdenum Carbide Nanoparticles: Toward a Scalable Fabrication Route for Earth-Abundant Electrodes

Molybdenum carbides are promising low-cost electrocatalysts for electrolyzers, fuel cells, and batteries. However, synthesis of ultrafine, phase-pure carbide nanoparticles (diameter < 5 nm) with large surface areas remains challenging due to uncontrollable agglomeration that occurs during traditional high temperature syntheses. This work presents a scalable, physical approach to synthesize molybdenum carbide nanoparticles at room temperature by ion implantation. By tuning the implantation conditions, various molybdenum carbide phases, stoichiometries, and nanoparticle sizes can be accessed. For instance, molybdenum ion implantation into glassy carbon at 30 keV energy and to a fluence of 9 × 10¹⁶ at cm^-2 yields a surface η-Mo₃ C₂ with a particle diameter of (10 ± 1) nm. Molybdenum implantation into glassy carbon at 60 keV to a fluence of 6 × 10¹⁶ at cm^-2 yields a buried layer of ultrafine γ'-MoC/η-MoC nanoparticles. Carbon ion implantation at 20 keV into a molybdenum thin film produces a 40 nm thick layer primarily composed of β-Mo₂ C. The formation of nanoparticles in each molybdenum carbide phase is explained based on the Mo-C phase diagram and Monte-Carlo simulations of ion-solid interactions invoking the thermal spike model. The approaches presented are widely applicable for synthesis of other transition metal carbide nanoparticles as well.

Discriminating Mild Traumatic Brain Injury and Posttraumatic Stress Disorder Using Latent Neuroimaging and Neuropsychological Profiles in Active-Duty Military Service Members

OBJECTIVE

Mild traumatic brain injury (mTBI) and posttraumatic stress disorder (PTSD) commonly occur among military Service Members and Veterans and have heterogenous, but also overlapping symptom presentations, which often complicate the diagnoses of underlying impairments and development of effective treatment plans. Thus, we sought to examine whether the combination of whole brain gray matter (GM) and white matter (WM) structural measures with neuropsychological performance can aid in the classification of military personnel with mTBI and PTSD.

METHODS

Active-Duty US Service Members ( n = 156; 87.8% male) with a history of mTBI, PTSD, combined mTBI+PTSD, or orthopedic injury completed a neuropsychological battery and T1- and diffusion-weighted structural neuroimaging. Cortical, subcortical, ventricular, and WM volumes and whole brain fractional anisotropy (FA), mean diffusivity (MD), radial diffusivity (RD), and axial diffusivity (AD) were calculated. Latent profile analyses were performed to determine how the GM and WM indicators, together with neuropsychological indicators, classified individuals.

RESULTS

For both GM and WM, respectively, a 4-profile model was the best fit. The GM model identified greater ventricular volumes in Service Members with cognitive symptoms, including those with a diagnosis of mTBI, either alone or with PTSD. The WM model identified reduced FA and elevated RD in those with psychological symptoms, including those with PTSD or mTBI and comorbid PTSD. However, contrary to expectation, a global neural signature unique to those with comorbid mTBI and PTSD was not identified.

CONCLUSIONS

The findings demonstrate that neuropsychological performance alone is more robust in differentiating Active-Duty Service Members with mTBI and PTSD, whereas global neuroimaging measures do not reliably differentiate between these groups.

Farmland practices are driving bird population decline across Europe

Declines in European bird populations are reported for decades but the direct effect of major anthropogenic pressures on such declines remains unquantified. Causal relationships between pressures and bird population responses are difficult to identify as pressures interact at different spatial scales and responses vary among species. Here, we uncover direct relationships between population time-series of 170 common bird species, monitored at more than 20,000 sites in 28 European countries, over 37 y, and four widespread anthropogenic pressures: agricultural intensification, change in forest cover, urbanisation and temperature change over the last decades. We quantify the influence of each pressure on population time-series and its importance relative to other pressures, and we identify traits of most affected species. We find that agricultural intensification, in particular pesticides and fertiliser use, is the main pressure for most bird population declines, especially for invertebrate feeders. Responses to changes in forest cover, urbanisation and temperature are more species-specific. Specifically, forest cover is associated with a positive effect and growing urbanisation with a negative effect on population dynamics, while temperature change has an effect on the dynamics of a large number of bird populations, the magnitude and direction of which depend on species' thermal preferences. Our results not only confirm the pervasive and strong effects of anthropogenic pressures on common breeding birds, but quantify the relative strength of these effects stressing the urgent need for transformative changes in the way of inhabiting the world in European countries, if bird populations shall have a chance of recovering.

Shaping Perpendicular Magnetic Anisotropy of Co2MnGa Heusler Alloy Using Ion Irradiation for Magnetic Sensor Applications

Magnetic sensors are key elements in many industrial, security, military, and biomedical applications. Heusler alloys are promising materials for magnetic sensor applications due to their high spin polarization and tunable magnetic properties. The dynamic field range of magnetic sensors is strongly related to the perpendicular magnetic anisotropy (PMA). By tuning the PMA, it is possible to modify the sensing direction, sensitivity and even the accuracy of the magnetic sensors. Here, we report the tuning of PMA in a Co₂MnGa Heusler alloy film via argon (Ar) ion irradiation. MgO/Co₂MnGa/Pd films with an initial PMA were irradiated with 30 keV ⁴⁰Ar⁺ ions with fluences (ions·cm^-2) between 1 × 10¹³ and 1 × 10¹⁵ Ar·cm^-2, which corresponds to displacement per atom values between 0.17 and 17, estimated from Monte-Carlo-based simulations. The magneto optical and magnetization results showed that the effective anisotropy energy (K_eff) decreased from ~153 kJ·m^-3 for the un-irradiated film to ~14 kJ·m^-3 for the 1 × 10¹⁴ Ar·cm^-2 irradiated film. The reduced K_eff and PMA are attributed to ion-irradiation-induced interface intermixing that decreased the interfacial anisotropy. These results demonstrate that ion irradiation is a promising technique for shaping the PMA of Co₂MnGa Heusler alloy for magnetic sensor applications.

Detection of Hemodialysis Venous Needle Dislodgment Using Venous Access Pressure Measurements: A Simulation Study

Key Points

Hemodialysis machine pressure alarms may not detect venous needle dislodgment when patients have changes in venous pressure. A cross-sectional analysis of hemodialysis treatment data identified the occurrences of venous pressure changes that would make it hard to trigger a machine alarm. A proof-of-concept use of a data analytic–derived algorithm for the detection of venous needle dislodgments was demonstrated.

Background:

In rare instances, hemodialysis venous needles may become dislodged, and when left undetected, this can lead to severe injury or death. Although dialysis machines have alarms to detect venous needle dislodgment (VND), their range of detection is limited. An understanding of the clinical conditions that may lead to missed needle dislodgments is needed for the development of more robust detection systems.

Methods:

We created a sham dialysis circuit with a Fresenius 2008K dialysis machine for in vitro simulation testing of machine alarm behavior under variable conditions. The circuit used a blood substitute and mimicked a patient's venous access site. We varied blood flow rate, venous pressure (VP), and upward drift in VP and analyzed the time to alarm for the machine and an improved alarm algorithm. We also performed a cross-sectional retrospective study to identify the clinical occurrence of VP upward drift between September 1, 2016, and November 1, 2016, in patients on hemodialysis with an arteriovenous fistula.

Results:

Of 43,390 VP readings for 147 patients on hemodialysis, 16,594 (38%) showed an upward drift in VP (range 20–79 mmHg), with a mean±SD increase of 11±18 mm Hg within 20±14 minutes. A total of 19 VND simulations under different VP and blood flow parameters resulted in 19 (100%) algorithm alarm activations. Only eight simulations (42%) activated a machine alarm, and machine alarm activation time was longer than the algorithm activation time for all eight machine alarms (range 1–13 seconds).

Conclusions:

Patients can experience changes in VP during hemodialysis which may not trigger a machine alarm in the case of a VND. Our simulations showed that current dialysis machine alarm systems may not compensate for upward drift in VP, and improved algorithms for detecting needle dislodgment during hemodialysis are needed.

Ex vivo expansion of circulating tumour cells (CTCs)

Circulating tumour cells (CTCs) are a critical intermediate step in the process of cancer metastasis. The reliability of CTC isolation/purification has limited both the potential to report on metastatic progression and the development of CTCs as targets for therapeutic intervention. Here we report a new methodology, which optimises the culture conditions for CTCs using primary cancer cells as a model system. We exploited the known biology that CTCs thrive in hypoxic conditions, with their survival and proliferation being reliant on the activation of hypoxia-inducible factor 1 alpha (HIF-1α). We isolated epithelial-like and quasi-mesenchymal CTC phenotypes from the blood of a cancer patient and successfully cultured these cells for more than 8 weeks. The presence of CTC clusters was required to establish and maintain long-term cultures. This novel methodology for the long-term culture of CTCs will aid in the development of downstream applications, including CTC theranostics.

Abstract P1-11-09: Five year follow up of a randomized phase II comparison of neo-adjuvant docetaxel, carboplatin, trastuzumab with or without lapatinib in HER-2 positive breast cancer

Background: The addition of trastuzumab (H) to pre-operative chemotherapy in HER2+ breast cancer (H+BC) increases the rate of pathological complete response (pCR). TCH is a widely used adjuvant regimen in early stage H+BC. Lapatinib (L) is a small molecule HER2 antagonist that produces responses following H failure, and has been reported to augment H activity in combination in vitro. We compared neo-adjuvant docetaxel, carboplatin (TC) + H v TCL v TCHL in pts with H+BC.

Methods: Pts with stages Ic–III H+BC were randomized to receive neo-adjuvant TCH, TCL or TCHL (ICORG/CTRIAL-IE 10-05, NCT01485926 www.clinicaltrials.gov). Pts subsequently underwent surgery and received H post-operatively for 1 year from the first dose of H. The primary endpoint of the trial was pCR. Secondary objectives were overall survival (OS) and relapse-free survival (RFS) and molecular and pharmacological markers of response. This study was supported by GSK, Novartis, The Cancer Clinical Research Trust and The Caroline Foundation.

Results: When the NCIC CTG MA.31 trial reported inferior outcomes for L compared to H, we discontinued the TCL arm. This abstract reports data on the 76 pts recruited to the TCH and TCHL arms only, who included stage II (69.7%; n=53) or stage III disease (21.1%; n=16, with stage unknown for 9.2% (n=7). The final analysis set numbered 75 pts. Clinicopathological characteristics were well balanced between arms. The pCR rate of the two arms TCHL and TCH were virtually identical at 51.6% and 52.8% respectively (Fisher’s test p-value: 1.000). TCHL pts had significantly superior 5 year relapse-free survival (relative risk (RR) 0.171, 95% CI 0.041 – 0.713; log-rank test p-value = 0.009). OS was comparable between the TCH and TCHL groups (RR 0.205, 95% CI 0.025 – 1.675); log-rank test p-value = 0.2). Median RFS and OS were not reached. The most frequent serious adverse event was diarrhoea which occurred in 21.3% (n=16/75) pts (Grade 3 diarrhoea 13/16). One pt (TCH arm) who did not have protocol-mandated prophylactic G-CSF had a Grade 5 toxicity. One TCHL pt had a self-limiting diverticular perforation. There was a significantly higher frequency of severe diarrhoea in pts who received the TCHL regimen (Grade 3+, 32.4% vs 10.5%, p=0.038). The use of prophylactic loperamide reduced the frequency of diarrhoea in both the TCHL arm (86.2% vs 44.4%, p=0.004) and in the TCH arm (58.8% vs 24%, p=0.009). A post lock audit with minimum 9-year follow-up showed relapse rates of 15% TCHL vs 33% TCH.

Conclusions: The study did not meet its primary pCR endpoint possibly due to a high TCH pCR rate, and small numbers. TCHL produced a statistically significant improvement in RFS compared to TCH. TCHL produced a higher rate of gastro-intestinal toxicity, but the use of loperamide significantly reduced the frequency of diarrhoea. These data suggest that anti-HER2 TKIs merit further investigation in the neo-adjuvant treatment of early stage H+BC.

Table 1. pCR rates, 5 year RFS and OS results for ICORG/CTRIAL-IE 10-05 (NCT01485926) study pts. * significant, p&lt;0.05.

Citation Format: John Crown, Denis M. Collins, Alex J. Eustace, Maccon Keane, Linda Coate, John Kennedy, Seamus O’Reilly, Catherine Kelly, Miriam O’Connor, Michael J. Martin, Conleth Murphy, Karen Duffy, Janice Walshe, Thamir Mahgoub, Giuseppe Gullo, Brian Moulton, Alberto Alvarez-Iglesias, Imelda Parker, Bryan Hennessy. Five year follow up of a randomized phase II comparison of neo-adjuvant docetaxel, carboplatin, trastuzumab with or without lapatinib in HER-2 positive breast cancer [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P1-11-09.

Left atrial vorticity is independently associated with embolic brain infarcts and represents a promising imaging biomarker of cardioembolism in sinus rhythm and atrial fibrillation

Background

Atrial fibrillation (AF) is associated with embolic stroke, but risk scores such as CHA2DS2-VASc perform only modestly (C statistics 0.6–0.7). Meanwhile, up to 25% of embolic strokes in patients without AF have no identifiable cause, and occult left atrial (LA) thromboembolism may be a relevant mechanism in such cases.

Purpose

We hypothesised that imaging of left atrial blood flow could improve embolic risk prediction in patients with and without AF. We used 4D flow magnetic resonance imaging (MRI) to identify a biomarker that is: (a) independently associated with embolic brain infarction by brain MRI, (b) able to stratify blood flow characteristics both during AF and in sinus rhythm (SR), and (c) reproducible.

Methods

We recruited 3 patient cohorts to respectively address each aim. Firstly, to assess the association between LA flow parameters and embolic brain infarcts, we recruited cohort A, consisting of 134 patients (41% female; age 70±9 years) with a history of ischaemic stroke (N=44) or no history of stroke but with CHA2DS2VASc score ≥1 (N=90). Next, the sensitivity of 4D flow parameters to rhythm change was assessed in cohort B: 37 patients with persistent AF studied before and after cardioversion, whose results were compared with those of 23 healthy controls in SR [CHA2DS2-VASc = 0.0 (0.0–0.0)]. Finally, scan-rescan coefficients of variation (CV) and interval-scan CV at 30 days were determined in Cohort C (86 subjects; 64 in SR, 22 in AF). Brain MRI was used to identify large non-cortical or cortical brain infarcts (LNCCI) – i.e. infarcts likely to be embolic in origin.

Results

At least one LNCCI was present in 39 of 134 patients in cohort A. Lower LA vorticity was significantly associated with higher risk of prevalent LNCCIs (Figure 1), after adjustment for AF, age, and CHA2DS2VASc score [OR=2.10 (95% CI 1.12–3.92) per SD, P=0.02]. This association remained significant after further adjustment for other cardiac parameters (all P&lt;0.05, Figure 1). By contrast, there was no significant association between peak velocity and LNCCIs (P=0.21).

LA vorticity was sensitive to rhythm change, improving significantly in patients in cohort B in SR at ≥4 weeks after cardioversion (CV) of persistent AF (Figure 2A, paired P&lt;0.001 vs pre-CV), but remained impaired compared to healthy controls (Figure 2B, P&lt;0.01).

Finally, reproducibility studies in cohort C showed that LA vorticity had a same-day scan-rescan CV of 7% without significant differences between SR and AF subjects (P&gt;0.05), and also showed no significant temporal variability on interval scanning (P&gt;0.05).

Conclusions

LA vorticity is reproducible, sensitive to changes in heart rhythm, and independently associated with embolic brain infarcts, suggesting a promising imaging biomarker of cardioembolism in SR and AF. LA blood flow imaging could improve stroke prediction and the personalisation of decisions about anticoagulation, regardless of heart rhythm.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Oxford BRC, BHF

Impact of first UK COVID-19 lockdown on hospital admissions: Interrupted time series study of 32 million people

Background

Uncontrolled infection and lockdown measures introduced in response have resulted in an unprecedented challenge for health systems internationally. Whether such unprecedented impact was due to lockdown itself and recedes when such measures are lifted is unclear. We assessed the short- and medium-term impacts of the first lockdown measures on hospital care for tracer non-COVID-19 conditions in England, Scotland and Wales across diseases, sexes, and socioeconomic and ethnic groups.

Methods

We used OpenSAFELY (for England), EAVEII (Scotland), and SAIL Databank (Wales) to extract weekly hospital admission rates for cancer, cardiovascular and respiratory conditions (excluding COVID-19) from the pre-pandemic period until 25/10/2020 and conducted a controlled interrupted time series analysis. We undertook stratified analyses and assessed admission rates over seven months during which lockdown restrictions were gradually lifted.

Findings

Our combined dataset included 32 million people who contributed over 74 million person-years. Admission rates for all three conditions fell by 34.2% (Confidence Interval (CI): -43.0, -25.3) in England, 20.9% (CI: -27.8, -14.1) in Scotland, and 24.7% (CI: -36.7, -12.7) in Wales, with falls across every stratum considered. In all three nations, cancer-related admissions fell the most while respiratory-related admissions fell the least (e.g., rates fell by 40.5% (CI: -47.4, -33.6), 21.9% (CI: -35.4, -8.4), and 19.0% (CI: -30.6, -7.4) in England for cancer, cardiovascular-related, and respiratory-related admissions respectively). Unscheduled admissions rates fell more in the most than the least deprived quintile across all three nations. Some ethnic minority groups experienced greater falls in admissions (e.g., in England, unscheduled admissions fell by 9.5% (CI: -20.2, 1.2) for Whites, but 44.3% (CI: -71.0, -17.6), 34.6% (CI: -63.8, -5.3), and 25.6% (CI: -45.0, -6.3) for Mixed, Other and Black ethnic groups respectively). Despite easing of restrictions, the overall admission rates remained lower in England, Scotland, and Wales by 20.8%, 21.6%, and 22.0%, respectively when compared to the same period (August-September) during the pre-pandemic years. This corresponds to a reduction of 26.2, 23.8 and 30.2 admissions per 100,000 people in England, Scotland, and Wales respectively.

Interpretation

Hospital care for non-COVID diseases fell substantially across England, Scotland, and Wales during the first lockdown, with reductions persisting for at least six months. The most deprived and minority ethnic groups were impacted more severely.

Funding

This work was funded by the Medical Research Council as part of the Lifelong Health and Wellbeing study as part of National Core Studies (MC_PC_20030). SVK acknowledges funding from the Medical Research Council (MC_UU_00022/2), and the Scottish Government Chief Scientist Office (SPHSU17). EAVE II is funded by the Medical Research Council (MR/R008345/1) with the support of BREATHE - The Health Data Research Hub for Respiratory Health (MC_PC_19004), which is funded through the UK Research and Innovation Industrial Strategy Challenge Fund and delivered through Health Data Research UK. BG has received research funding from the NHS National Institute for Health Research (NIHR), the Wellcome Trust, Health Data Research UK, Asthma UK, the British Lung Foundation, and the Longitudinal Health and Wellbeing strand of the National Core Studies programme.

Economic Costs of Violence Against Women and Girls in Low- and Middle-Income Countries: A Pilot Study on Management's Outlook

BACKGROUND

In low and middle-income countries (LMICs), violence against women and girls (VAWG) is rampant, primarily due to patriarchy. However, there is little understanding of its ripple effect in the workplace in LMICs. While recent studies in LMICs have attempted to understand the effects of VAWG on productivity using data collected from colleagues, survivors, or perpetrators, there is limited research on the employers' perspective of the impact of VAWG on productivity.

METHODS

A survey, developed by the investigators, based on previous research in Peru and Vietnam, was administered to 74 senior management executives in Ghana, Pakistan, and South Sudan. Based on female employees' absenteeism, tardiness, and presenteeism, this study provides the management's perspective on the invisible costs of VAWG.

FINDINGS

The results show that 25% and 36% of senior executives have witnessed intimate partner violence and non-partner sexual violence, respectively, against their female colleagues. One (32%) in three managers also acknowledged the impact of VAWG on productivity and day-to-day operations.

CONCLUSIONS

This study provides evidence that there is a need for the development of employee assistance programs (EAPs) in LMICs. Due to significant increase in employees' productivity in the absence of VAWG, investing in occupational health services needs to be viewed as an investment, not cost. As many international companies in developed countries do business in LMICs, their occupational health departments need to be more aware of VAWG. Occupational health practitioners can assist in the needs assessment for EAPs as well as provide appropriate referrals and counseling to impacted employees.

Reproducibility and long-term stability of Sn doped MnO2 nanostructures: Practical photocatalytic systems and wastewater treatment applications

Sn-doped MnO₂ were synthesized as an oxidant, a mediator of maleic acid (C₄H₄O₄) and SnCl₂ as doping ingredient via a basic sol-gel reaction with KMnO₄. XRD study signposts that tetragonal crystal structure of MnO₂ (ICDD#44-0141) with a plane group of 12/m (87) for both pure and Sn doped MnO₂ nanostructures. The photocatalyst synthesized has mesoporosity, allowing to the N₂ adsorption/desorption experiments. The geometry of the materials varies from spherical shape in pristine MnO₂ to a rod-like shape in Sn-MnO₂, as observed in the SEM and TEM pictures. To examine optic properties and energy bandgaps topologies, UV-visible diffuse reflectance spectroscopy was applied. In visible spectrum, overall catalytic performance of Sn-doped MnO₂ was tested using methyl orange and phenol as dyes. The results suggest that the optimized Sn doped MnO₂ (10 wt.%) catalyst showed higher degradation efficiency (98.5%), apparent constant (0.7841 min^-1) and long term permanence. For this improved charge extraction efficiency, a potential photocatalytic mechanism was proposed.

Effect of Ag doped MnO2 nanostructures suitable for wastewater treatment and other environmental pollutant applications

A modest sol-gel method has been employed to prepare the pure and Ag doped MnO₂ nanoparticles and methodologically studied their physical, morphological, and photosensitive properties through XRD, TEM, EDAX, Raman, UV, PL and N₂ adsorption - desorption study. Tetragonal crystalline arrangement with spherical nanoparticles was found out through XRD and TEM studies. The EDAX studies further supported that formation Ag in the MnO₂ crystal matrix. The bandgap energy of Ag doped MnO₂ was absorbed through UV spectra. Photo -generated recombination process and surface related defects were further recognized by PL spectra. Through visible light irradiation, the photo - degradation of methyl orange (MO) and phenol dye solutions were observed. The optimum condition of (10 wt% of Ag) Ag doped MnO₂ catalyst showed tremendous photocatalytic efficiency towards MO than phenol under same experimental study.

Does Federalism Prevent Democratic Accountability? Assigning Responsibility for Rates of COVID-19 Testing

Does federalism prevent citizens from holding governments accountable for their actions? The pandemic represents the ideal scenario for testing the effects of federalism on democratic accountability because citizens are highly motivated to hold governments accountable for preventing or failing to prevent the rapid transmission of the virus. Previous research suggests that a number of institutional and political factors complicate the accountability function in federal systems. We add to this literature by assessing the effect of one political factor, exclusivity (measured in terms of policy variation at one level), on accountability. The coronavirus pandemic provides a unique opportunity to assess this factor given the high levels of issue saliency, media attention, and low levels of intergovernmental and interparty conflict it has generated. Drawing on original data from the May 2020 Democratic Checkup Survey and public data from the Canadian National Microbiology Laboratory, our preliminary findings suggest that interprovincial policy variation with respect to coronavirus testing is not correlated with public assessments of the adequacy of provincial testing, and so it seems that Canadians are not able to assign responsibility to the correct level of government despite ideal conditions for doing so.

Quantitative SPECT/CT for dosimetry of peptide receptor radionuclide therapy

Neuroendocrine tumors (NETs) are uncommon malignancies of increasing incidence and prevalence. As these slow growing tumors usually overexpress somatostatin receptors (SSTRs), the use of ⁶⁸Ga-DOTA-peptides (gallium-68 chelated with dodecane tetra-acetic acid to somatostatin), which bind to the SSTRs, allows for PET based imaging and selection of patients for peptide receptor radionuclide therapy (PRRT). PRRT with radiolabeled somatostatin analogues such as ¹⁷⁷Lu-DOTATATE (lutetium-177-[DOTA,Tyr³]-octreotate), is mainly used for the treatment of metastatic or inoperable NETs. However, PRRT is generally administered at a fixed injected activity in order not to exceed dose limits in critical organs, which is suboptimal given the variability in radiopharmaceutical uptake among patients. Advances in SPECT (single photon emission computed tomography) imaging enable the absolute quantitative measure of the true radiopharmaceutical distribution providing for PRRT dosimetry in each patient. Personalized PRRT based on patient-specific dosimetry could improve therapeutic efficacy by optimizing effective tumor absorbed dose while limiting treatment related radiotoxicity.

Successful Implementation of an All-or-None Diabetes Measure in 10 U.S. Health Systems

Type 2 diabetes mellitus (T2DM) affects 31.5 million adults in the United States and is commonly treated in primary care settings. One promising approach to comprehensive care is to focus on an all-or-none diabetes bundle measure, which ensures each patient meets a set of guideline-recommended measures. This requires a practice-level coordinated strategy. The purpose of this initiative was to help health care organizations (HCOs) improve the care and outcomes of patients with T2DM using an all-or-none bundle measure. This observational study was carried out in the context of a national best practices learning Collaborative that implemented targeted interventions in primary care settings and measured success using an all-or-none bundle measure. Ten AMGA member-HCOs, across 8 states, treating nearly 300,000 adult patients with T2DM in primary care participated. The primary measure, the Together 2 Goal^® Core Bundle, included hemoglobin A1c (A1c) control (<8%), blood pressure (BP) control (<140/90 mmHg), lipid management (prescribed a statin), and medical attention for nephropathy. All 10 HCOs improved the Core Bundle measure during the 12-month Collaborative. The rate for the Core Bundle improved from 40.2% to 42.8%, an absolute increase of 2.6% (P < 0.001). In addition, 9 HCOs improved BP control, 8 improved lipid management, 6 improved attention to nephropathy, and 4 improved A1c control. Implementing interventions in primary care settings was successful in achieving comprehensive care for an estimated additional 7700 people living with T2DM who met all 4 components of the bundle measure during the 12-month intervention period.

Development and validation of a risk score to prioritize patients for evaluation of access stenosis

Background

Access flow dysfunction, often associated with stenosis, is a common problem in hemodialysis access and may result in progression to thrombosis. Timely identification of accesses in need of evaluation is critical to preserving a functioning access. We hypothesized that a risk score using measurements obtained from the Vasc‐Alert surveillance device could be used to predict subsequent interventions.

Methods

Measurement of five factors over the preceding 28 days from 1.46 million hemodialysis treatments (6163 patients) were used to develop a score associated with interventions over the subsequent 60 days. The score was validated in a separate dataset of 298,620 treatments (2641 patients).

Results

Interventions in arteriovenous fistulae (AVF; n = 4125) were much more common in those with the highest score (36.2%) than in those with the lowest score (11.0). The score also was strongly associated with interventions in patients with an arteriovenous graft (AVG; n = 2,038; 43.2% vs. 21.1%). There was excellent agreement in the Validation datasets for AVF (OR = 2.67 comparing the highest to lowest score) and good agreement for AVG (OR = 1.92).

Conclusions

This simple risk score based on surveillance data may be useful for prioritizing patients for physical examination and potentially early referral for intervention.

1082 Are Trauma and Orthopaedics Consultant Posts Decreasing in Frequency and Increasing in Subspecialisation?

Aim

Changes to the configuration of the NHS Trauma Services in T&O and the level of subspecialisation are changing and could impact training and the number of consultant posts available at CCT. The aim of this study was to review the number of T&O Consultant posts and determine the frequency of the subspecialist requirements of these posts from 2011 to 2020, to assess the perceived reduction in advertised numbers and the increasing sub specialisation as a whole.

Method

451 volumes of the BMJ were reviewed over Jan 2011 - April 2020. The total number of jobs advertised were recorded. Additionally, for each post, sub-specialism, regional analysis and substansive or locum tenure were recorded.

Results

1141 jobs were advertised during this period. There has been a decreasing trend in the total number of advertised posts of 13% per annum. Proportion of specialty jobs remain constant yearly. However, jobs listing Trauma clearly decreased after 2012, when trauma centres were initiated. Clear decreases were present in North-west and Scotland in number of jobs. There has also been an increasing trend of advertisement of substantive posts, with locum posts forming less than 13% of total advertisements.

Conclusions

We found no significant increase in job specialism contradicting previous research. Overall, the total number of Consultant jobs in Trauma and Orthopaedics is decreasing, especially in the north-west and Scotland, two of the biggest employers. Questions must be asked for the future of training in T&O to meet service needs.

An ensemble reconstruction of global monthly sea surface temperature and sea ice concentration 1000-1849

This paper describes a global monthly gridded Sea Surface Temperature (SST) and Sea Ice Concentration (SIC) dataset for the period 1000-1849, which can be used as boundary conditions for atmospheric model simulations. The reconstruction is based on existing coarse-resolution annual temperature ensemble reconstructions, which are then augmented with intra-annual and sub-grid scale variability. The intra-annual component of HadISST.2.0 and oceanic indices estimated from the reconstructed annual mean are used to develop grid-based linear regressions in a monthly stratified approach. Similarly, we reconstruct SIC using analog resampling of HadISST.2.0 SIC (1941-2000), for both hemispheres. Analogs are pooled in four seasons, comprising of 3-months each. The best analogs are selected based on the correlation between each member of the reconstructed SST and its target. For the period 1780 to 1849, We assimilate historical observations of SST and night-time marine air temperature from the ICOADS dataset into our reconstruction using an offline Ensemble Kalman Filter approach. The resulting dataset is physically consistent with information from models, proxies, and observations.

Ironsand (Titanomagnetite-Titanohematite): Chemistry, Magnetic Properties and Direct Applications for Wireless Power Transfer

Ironsand is an abundant and inexpensive magnetic mineral resource. However, the magnetic properties of unprocessed ironsand are often inadequate for any practical applications. In this work, the applicability of ironsand for use as a component in a soft magnetic composite for large-scale inductive power transfer applications was investigated. After magnetic separation, the chemical, structural and magnetic properties of ironsand sourced from different locations were compared. Differences observed in the DC magnetic properties were consistent with changes in the chemical compositions obtained from X-ray Absorption Near-Edge Spectroscopy (XANES), which suggests varying the titanohematite to titanomagnetite content. Increased content in titanomagnetite and magnetic permeability correlated well with the total Fe content in the materials. The best-performing ironsand with the highest permeability and lowest core losses was used alongside Mn,Zn-Ferrite particles (ranging from ∼100 μm to 2 mm) to fabricate toroid cores with varying magnetic material loading. It was shown that ironsand can be used to replace up to 15 wt.% of the magnetic materials with minimal impact on the composite magnetic performance, thus reducing the cost. Ironsand was also used as a supporting material in a single-rail wireless power transfer system, effectively increasing the power transfer, demonstrating potential applications to reduce flux leakage.

Ion Beam Analysis of Proton-Induced X-ray Emission (PIXE) Techniques for Elemental Investigation of Young Stage Neem Leaf of Southern India, Tamil Nadu

Young stage neem leaf (Azadirachta indica) was collected at Thiruvallur district in Tamil Nadu, South India. Multi-elemental analysis of neem leaf was carried out using non-destructive techniques (NDT) of proton-induced X-ray emission (PIXE, 2.5 MeV) which is one of the well-known surface chemical sophisticated analytical methods of ion beam analyses (IBA). From the emitted X-ray output of the target specimen specimen fingerprint multi-elements such as, aluminium (Al), silicon (Si), phosphorus (P), sulphur (S), chloride (Cl), potassium (K), calcium (Ca), titanium (Ti), manganese (Mn), iron (Fe), copper (Cu), zinc (Zn) and strontium (Sr) are found to be present in the leaf in different ppm levels. Among the elements, silicon (Si, 42034 + 1198.0 ppm) and potassium (K, 28985 + 747.8 ppm) showed the highest concentration. Minor elements (Mn, Sr, Fe, Zn, Cu and Ti) are observed in the neem plant. The variation in elemental concentration in the leaf may be due to soil, water, etc. However, there are no toxic elements observed like arsenic and lead in the leaf. Further, though the presence of different medicinal values in the target specimen chemical multi-elements observed in ppm level. However, there are more chemical analysis to be required for the functionalization of active biomedical applications for these kinds of medicinal species.

[IS MYOCARDIAL PERFUSION IMAGING INTERPRETATION HARDER WITH X-RAY BEAM HARDENING ARTIFACT?]

Myocardial perfusion imaging (MPI) is a well-established imaging modality for the diagnosis of coronary artery disease and for prognostication. In recent years, the management of heart failure has developed tremendously including implantation of defibrillators for prevention of malignant tachyarrhythmias and resynchronizing therapy for the improvement of clinical symptoms and left ventricular function. Cardiac magnetic resonance and computed tomography are imaging modalities that are negatively affected by the presence of metallic devices. MPI is a hybrid study combining computed tomography for attenuation correction and nuclear imaging. This case shows that a metal device has no effect on the interpretation of MPI.

Scaling of oscillatory kinematics and Froude efficiency in baleen whales

High efficiency lunate-tail swimming with high-aspect-ratio lifting surfaces has evolved in many vertebrate lineages, from fish to cetaceans. Baleen whales (Mysticeti) are the largest swimming animals that exhibit this locomotor strategy, and present an ideal study system to examine how morphology and the kinematics of swimming scale to the largest body sizes. We used data from whale-borne inertial sensors coupled with morphometric measurements from aerial drones to calculate the hydrodynamic performance of oscillatory swimming in six baleen whale species ranging in body length from 5 to 25 m (fin whale, Balaenoptera physalus; Bryde's whale, Balaenoptera edeni; sei whale, Balaenoptera borealis; Antarctic minke whale, Balaenoptera bonaerensis; humpback whale, Megaptera novaeangliae; and blue whale, Balaenoptera musculus). We found that mass-specific thrust increased with both swimming speed and body size. Froude efficiency, defined as the ratio of useful power output to the rate of energy input ( Sloop, 1978), generally increased with swimming speed but decreased on average with increasing body size. This finding is contrary to previous results in smaller animals, where Froude efficiency increased with body size. Although our empirically parameterized estimates for swimming baleen whale drag were higher than those of a simple gliding model, oscillatory locomotion at this scale exhibits generally high Froude efficiency as in other adept swimmers. Our results quantify the fine-scale kinematics and estimate the hydrodynamics of routine and energetically expensive swimming modes at the largest scale.

Building Successful Models in Primary Care to Improve the Management of Adult Patients with Obesity

Although several obesity clinical practice guidelines are available and relevant for primary care, a practical and effective medical model for treating obesity is necessary. The aim of this study was to develop and implement a holistic population health-based framework with components to support primary care-based obesity management in US health care organizations. The Obesity Care Model Collaborative (OCMC) was conducted with guidance and expertise of an advisory committee, which selected participating health care organizations based on prespecified criteria. A committee comprising obesity and quality improvement specialists and representatives from each organization developed and refined the obesity care framework for testing and implementing guideline-based practical interventions targeting obesity. These interventions were tracked over time, from an established baseline to 18 months post implementation. Ten geographically diverse organizations, treating patients with diverse demographics, insurance coverage, and health status, participated in the collaborative. The key interventions identified for managing obesity in primary care were applicable across the 4 OCMC framework domains: community, health care organization, care team, and patient/family. Care model components were developed within each domain to guide the primary care of obesity based on each organization's structure, resources, and culture. Key interventions included development of quality monitoring systems, training of leadership and staff, identifying clinical champions, patient education, electronic health record best practice alerts, and establishment of community partnerships, including the identification of external resources. This article describes the interventions developed based on the framework, with a focus on implementation of the model and lessons learned.

Abstract PS4-23: An analysis of the clinical and economic impact of the 21-gene recurrence score (RS) in invasive lobular early-stage breast cancer (ESBC) in Ireland

Background: The use of the 21-gene recurrence score assay (RS) has reduced chemotherapy (CT) administration in patients with hormone receptor (HR)-positive, HER-2 negative, lymph-node negative, early stage breast cancer (ESBC). Invasive lobular carcinoma (ILC) accounts for up to 15% of all breast cancers. This study uses real world data to assess (1) the effect of RS testing on treatment decision making in patients with ILC and (2) the economic benefit of testing in this subgroup.

Methods: From October 2011 to February 2019, a retrospective, cross-sectional, observational study was conducted on HR+, HER-2 negative, lymph-node negative, ESBC patients with ILC who had RS testing in Ireland. For the decision impact analysis, a survey of Irish breast medical oncologists presumed that, without RS testing, CT would be recommended to patients with histological grade (G) 2 and 3 tumours and not for G1 tumours. In accordance with TAILOR-x results, patients were classified overall as low risk (RS≤25) and high risk (RS&gt;25) and patients ≤50 years old were low risk (RS 0-15), intermediate risk (RS 16-25), and high risk (RS&gt;25). Data were collected from electronic patient records. Descriptive statistics were used. Cost data were obtained from the National Healthcare Pricing Regulatory Authority. The economic analysis was adjusted for changing treatment and assay costs over the study period.

Results: 166 patients with ILC were identified. Mean age was 59 years. Mean tumour size was 2.3cm (range 0.7-5.8). The majority had G2 tumors (n=152, 92%) with a small number of G3 (n=7, 4%) and G1 (n=7,4%). Overall, 153 patients (92.2%) had a low RS (≤25), 12 (7.2%) had high RS (&gt;25), and 1(0.6%) was unknown. All 12 patients with RS&gt;25 had G2 tumours, 6/12 (50%) had tumour size &gt;3cm, 4(33.3%) were PR+ and 8(66.7%) were PR negative. In 29/166 (17.5%) patients, aged ≤50 at diagnosis, RS was ≤15 in 16(55%), 16-20 in 6(21%), 21-25 in 5(17%), &gt;25 in 1(3.5%) and unknown in 1(3.5%). The majority of these patients (27, 93%) had G2 tumours, 1 had G1 and 1 had G3. Post RS testing 124 patients (74.5%) had a change in CT recommendation; all from CT to hormone therapy. In total, only 35 patients (21%) received CT. In this group, RS was 0-15 in 3(9%), RS 16-25 in 19(54%), RS &gt;25 in 12 (34%) and unknown in 1(3%). Eight of 35 patients (23%) were aged ≤50. The most common CT regimen administered was docetaxel plus cyclophosphamide (TC). RS testing achieved a 78% reduction in chemotherapy use. This resulted in savings of €900,000 in treatment costs. With the incorporation of the assay cost, the net savings totalled approximately €400,000.

Conclusions: Ireland was the first public health care system to reimburse the 21-gene recurrence score assay in Europe. There is limited evidence demonstrating the benefits of RS in ILC. In our study, the use of the test has resulted in a 78% reduction in chemotherapy use in an Irish ILC patient population and a substantial cost saving (greater than €400,000) to the Irish Healthcare System.

Citation Format: Mehala Tharmabala, Lynda McSorley, Fathiya Al Rahbi, Evoy Denis, James G Geraghty, Rothwell Jane, Damian McCartan, Enda McDermott, Maccon M Keane, John Kennedy, Seamus O'Reilly, Steve Millen, John Crown, Lilian Mary Smyth, Catherine Margaret Kelly, Prichard Ruth, Cecily Quinn, Janice M Walshe. An analysis of the clinical and economic impact of the 21-gene recurrence score (RS) in invasive lobular early-stage breast cancer (ESBC) in Ireland [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS4-23.

TGFβ drives NK cell metabolic dysfunction in human metastatic breast cancer

Background

Natural killer (NK) cells provide important immune protection from cancer and are a key requirement for particular immunotherapies. There is accumulating evidence that NK cells become dysfunctional during cancer. Overcoming NK cell exhaustion would be an important step to allow them to function optimally in a range of NK cell therapies, including those that depend on autologos circulating NK cells. We have previously demonstrated that NK cells undergo a normal metabolic reprogramming in response to cytokine activation and that this is required for optimal function. The objective of this work was to investigate if cellular metabolism of circulating NK cells is dysregulated in patients with metastatic breast cancer and if so, to gain insights into potential mechanisms underpinning this. Such discoveries would provide important insights into how to unleash the full activity of NK cells for maximum immunotherapy output.

Methods

Single-cell analysis, metabolic flux and confocal analysis of NK cells from patients with metastatic breast cancer and healthy controls

Results

In addition to reduced interferon-γ production and cytotoxicity, peripheral blood NK cells from patients had clear metabolic deficits including reduced glycolysis and oxidative phosphorylation. There were also distinct morphologically alterations in the mitochondria with increased mitochondrial fragmentation observed. Transforminggrowth factor-β (TGFβ) was identified as a key driver of this phenotype as blocking its activity reversed many metabolic and functional readouts. Expression of glycoprotein-A repetitions predominant (GARP) and latency associated peptide (LAP), which are involved with a novel TGFβ processing pathway, was increased on NK cells from some patients. Blocking the GARP–TGFβ axis recapitulated the effects of TGFβ neutralization, highlighting GARP as a novel NK cell immunotherapy target for the first time.

Conclusions

TGFβ contributes to metabolic dysfunction of circulating NK cells in patients with metastatic breast cancer. Blocking TGFβ and/or GARP can restore NK cell metabolism and function and is an important target for improving NK cell-based immunotherapies.

Examining the effectiveness of telemonitoring with routinely acquired blood pressure data in primary care: challenges in the statistical analysis

Background

Scale-up BP was a quasi-experimental implementation study, following a successful randomised controlled trial of the roll-out of telemonitoring in primary care across Lothian, Scotland. Our primary objective was to assess the effect of telemonitoring on blood pressure (BP) control using routinely collected data. Telemonitored systolic and diastolic BP were compared with surgery BP measurements from patients not using telemonitoring (comparator patients). The statistical analysis and interpretation of findings was challenging due to the broad range of biases potentially influencing the results, including differences in the frequency of readings, ‘white coat effect’, end digit preference, and missing data.

Methods

Four different statistical methods were employed in order to minimise the impact of these biases on the comparison between telemonitoring and comparator groups. These methods were “standardisation with stratification”, “standardisation with matching”, “regression adjustment for propensity score” and “random coefficient modelling”. The first three methods standardised the groups so that all participants provided exactly two measurements at baseline and 6–12 months follow-up prior to analysis. The fourth analysis used linear mixed modelling based on all available data.

Results

The standardisation with stratification analysis showed a significantly lower systolic BP in telemonitoring patients at 6–12 months follow-up (-4.06, 95% CI -6.30 to -1.82, p < 0.001) for patients with systolic BP below 135 at baseline. For the standardisation with matching and regression adjustment for propensity score analyses, systolic BP was significantly lower overall (− 5.96, 95% CI -8.36 to − 3.55 , p < 0.001) and (− 3.73, 95% CI− 5.34 to − 2.13, p < 0.001) respectively, even after assuming that − 5 of the difference was due to ‘white coat effect’. For the random coefficient modelling, the improvement in systolic BP was estimated to be -3.37 (95% CI -5.41 to -1.33 , p < 0.001) after 1 year.

Conclusions

The four analyses provide additional evidence for the effectiveness of telemonitoring in controlling BP in routine primary care. The random coefficient analysis is particularly recommended due to its ability to utilise all available data. However, adjusting for the complex array of biases was difficult. Researchers should appreciate the potential for bias in implementation studies and seek to acquire a detailed understanding of the study context in order to design appropriate analytical approaches.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12874-021-01219-8.

Colossal Magnetization and Giant Coercivity in Ion-Implanted (Nb and Co) MoS2 Crystals

Colossal saturation magnetization and giant coercivity are realized in MoS₂ single crystals doped with Nb and/or Co using an ion implantation method. Magnetic measurements have demonstrated that codoping with 2 at % Nb and 4 at % Co invoked a "giant" coercivity, as high as 9 kOe at 100 K. Doping solely with 5 at % Nb induces a "colossal" magnetization of 1800 emu/cm³ at 5 K, which is higher than that of metallic Co. The high magnetization is due to the formation of Nb-rich defect complexes, as confirmed by first-principles calculations. It is proposed that the high coercivity is due to the combined effects of strong directional exchange coupling induced by the Nb and Co doping and pinning effects from defects within the layered structure. This high magnetization mechanism is also applicable to 2D materials with bilayers or few layers of thickness, as indicated by first-principles calculations. Hence, this work opens a potential pathway for the development of 2D high-performance magnetic materials.

The feasibility of implementing an exercise programme for deconditioned cancer survivors in a national cancer centre: FIXCAS Study

Introduction: As both the number of cancer survivors and the length of survival time are increasing, long-term health issues related to cancer and its treatment are becoming more prevalent. Research suggests that exercise can mitigate several negative health consequences in cancer survivors and improve physical function and quality of life. Multi-modal exercise interventions have been proposed as a cornerstone for survivorship care. However, studies evaluating exercise programmes within the Irish population are lacking. Purpose: To evaluate the introduction, implementation and acceptability of a multi-modal exercise rehabilitation programme for deconditioned cancer survivors in a real-world, standard practice setting. Methods and analysis: In this single-arm prospective feasibility study, cancer survivors (n=40) will undergo a 10-week multi-modal exercise programme. The study population will comprise of cancer survivors attending outpatient services in an Irish national cancer centre. Participants will be aged 18 or older and have completed treatment with curative intent. Feasibility will be evaluated in terms of recruitment, adherence and compliance to the programme. Secondary outcomes will examine physical function and quality of life measures. In addition, the acceptability of the programme will be assessed through stakeholder feedback. Ethics and dissemination: Ethical approval through the St. James's Hospital and Tallaght University Hospital Research and Ethics Committee is currently pending. The study results will be used to optimise the intervention content and may serve as the foundation for a larger definitive trial. Results will be disseminated through peer-review journals, congresses and relevant clinical groups. Trial registration: ClinicalTrials.gov NCT04026659 (19/07/19).

Catalyst-free synthesis of copper oxide composites as solar radiative filters

Copper oxide composites were successfully synthesized by a catalyst-free method, plasma arc technology. The as-synthesized composites were characterized by x-ray diffraction, scanning electron microscopy, transmission electron microscopy, Raman spectroscopy, and x-ray photoelectron spectroscopy. The analysis revealed a mixture of crystalline copper oxide (CuO), cuprous oxide (Cu₂O) and copper (Cu) phases of the copper oxide composites constitute of irregularly spheroidal particlesµ with nanoparticles aggregate on the surface. Gas pressure during plasma arc process noticeably influences the composition and solar radiative properties of the composite materials. Among the samples studied, the composites synthesized with an arc current of 80 A and a pressure of 300 Torr exhibited the highest near infrared diffuse reflectance, providing a total solar reflectance of 22.96%. The mixed phase composition together with the nanostructures among the composites are considered to contribute to the excellent near infrared reflectance of copper oxide composites. Low reflectance in the visible region combined with high reflectance in the near infrared region make this composite material a good candidate for solar reflective coating which will demonstrate black appearance but keep a cool surface under solar irradiation.

High sensitivity of tropical precipitation to local sea surface temperature

Precipitation and atmospheric circulation are the coupled processes through which tropical ocean surface temperatures drive global weather and climate^1–5. Local ocean surface warming tends to increase precipitation, but this local control is hard to disentangle from remote effects of conditions elsewhere. Such remote effects occur, for example, from El Niño Southern Oscillation (ENSO) events in the equatorial Pacific, which alter precipitation across the tropics. Atmospheric circulations associated with tropical precipitation are predominantly deep, extending up to the tropopause. Shallow atmospheric circulations^6–8, impacting the lower troposphere, also occur, but the importance of their interaction with precipitation is unclear. Uncertainty in precipitation observations^9,10, and limited observations of shallow circulations¹¹, further obstruct understanding of the ocean’s influence on weather and climate. Despite decades of research, persistent biases remain in many numerical model simulations^12–18, including excessively-wide tropical rainbands^14,18, the ‘double-intertropical convergence zone (ITCZ) problem’^12,16,17 and too-weak responses to ENSO¹⁵. These demonstrate stubborn gaps in our understanding, reducing confidence in forecasts and projections. Here we show that the real world has a high sensitivity of seasonal tropical precipitation to local sea-surface temperature. Our best observational estimate is 80% precipitation change per g/kg change in the saturation specific humidity (itself a function of the ocean surface temperature). This observed sensitivity is higher than in 43 of the 47 climate models studied, and is associated with strong shallow circulations. Models with more realistic sensitivity have smaller biases across a wide range of metrics. Our results apply to both temporal and spatial variation, over regions where climatological precipitation is around 1 mm/day or greater. Novel analysis of multiple independent observations, physical constraints and model data, underpin these findings. The spread in model behaviour is further linked to differences in shallow convection, providing a focus for accelerated research, to improve seasonal forecasts through multidecadal climate projections.

Patient self-reported awareness of COVID: Overconfidence in knowledge, underestimation of risk

174

Background: Oncology patients have had to adapt to minimize the risks of contracting COVID-19. We assessed patient knowledge of COVID, and the impact of the pandemic on their behaviours, concerns and healthcare experience, to identify any further education/quality improvement needs. Methods: Following ethical approval, a 16 page survey was distributed to 120 oncology patients attending the day unit of a tertiary Irish cancer center for systemic anti-cancer therapy (May/June 2020). The Irish COVID rate during this period was 33.8 new cases/day (pop. 4.9 million). Results: 101 responses were received. Cancer types included breast (19%), gastrointestinal (29%), head and neck (11%), and lung (13%). 31% had been tested for COVID; just 1 patient was positive. 100% were aware of advice to “cocoon” and reported good understanding of this. 75% reported complete compliance, but of those, 73% were not social-distancing within their homes, 22% received visitors, and 36% continued to shop in-store; of these, 42% shopped as/more often than pre-COVID. Of the 51 patients regularly shopping, many were not using risk-reduction strategies e.g. social distancing (22%), mask-wearing (20%), using “priority shopping’ hours (31%), avoiding public transport (26%). 94% felt confident/very confident in recognizing COVID symptoms, but 66% did not recognize two or more key symptoms from a list of 10, most frequently aches/pains (58%), fatigue (55%), altered smell/taste (33%) and dyspnea (14%). The number recognized did not correlate with confidence (p = 0.9) or desire for more information about COVID (p = 0.9). 40% did not feel they were at higher risk of contracting COVID, while 15% thought they were no more likely to be very sick than an average person if infected. Many did not know that chemotherapy, steroids, radiation, and immunotherapy can impact morbidity/mortality in COVID (31%, 70%, 44% and 49% respectively). 46% were somewhat/very fearful of COVID, but this did not strongly predict for either protective (e.g. mask-wearing: OR 1.1, 95% CI 0.3-4.8 p = 0.9), or risk behaviors (e.g. continuing to shop frequently: OR 0.5, 95% CI 0.1-1.4 p = 0.2). 66% would like more cancer specific information, particularly about prevention (45%) and symptoms (33%), with a preference for written information (74%). Conclusions: Despite self-reported confidence in knowledge, patient’s self-assessments of their risk category and the preventative strategies they should use may be inaccurate. Increased education about risk, cocooning and symptom recognition is necessary.

Health and fertility of ICSI-conceived young men: study protocol

STUDY QUESTIONS

What are the long-term health and reproductive outcomes for young men conceived using ICSI whose fathers had spermatogenic failure (STF)? Are there epigenetic consequences of ICSI conception?

WHAT IS KNOWN ALREADY

Currently, little is known about the health of ICSI-conceived adults, and in particular the health and reproductive potential of ICSI-conceived men whose fathers had STF. Only one group to date has assessed semen parameters and reproductive hormones in ICSI-conceived men and suggested higher rates of impaired semen quality compared to spontaneously conceived (SC) peers. Metabolic parameters in this same cohort of men were mostly comparable. No study has yet evaluated other aspects of adult health.

STUDY DESIGN SIZE DURATION

This cohort study aims to evaluate the general health and development (aim 1), fertility and metabolic parameters (aim 2) and epigenetic signatures (aim 3) of ICSI-conceived sons whose fathers had STF (ICSI study group). There are three age-matched control groups: ICSI-conceived sons whose fathers had obstructive azoospermia (OAZ) and who will be recruited in this study, as well as IVF sons and SC sons, recruited from other studies. Of 1112 ICSI parents including fathers with STF and OAZ, 78% (n = 867) of mothers and 74% (n = 823) of fathers were traced and contacted. Recruitment of ICSI sons started in March 2017 and will finish in July 2020. Based on preliminary participation rates, we estimate the following sample size will be achieved for the ICSI study group: mothers n = 275, fathers n = 225, sons n = 115. Per aim, the sample sizes of OAZ-ICSI (estimated), IVF and SC controls are: Aim 1-OAZ-ICSI: 28 (maternal surveys)/12 (son surveys), IVF: 352 (maternal surveys)/244 (son surveys), SC: 428 (maternal surveys)/255 (son surveys); Aim 2-OAZ-ICSI: 12, IVF: 72 (metabolic data), SC: 391 (metabolic data)/365 (reproductive data); Aim 3-OAZ-ICSI: 12, IVF: 71, SC: 292.

PARTICIPANTS/MATERIALS SETTING METHODS

Eligible parents are those who underwent ICSI at one of two major infertility treatment centres in Victoria, Australia and gave birth to one or more males between January 1994 and January 2000. Eligible sons are those aged 18 years or older, whose fathers had STF or OAZ, and whose parents allow researchers to approach sons. IVF and SC controls are age-matched men derived from previous studies, some from the same source population. Participating ICSI parents and sons complete a questionnaire, the latter also undergoing a clinical assessment. Outcome measures include validated survey questions, physical examination (testicular volumes, BMI and resting blood pressure), reproductive hormones (testosterone, sex hormone-binding globulin, FSH, LH), serum metabolic parameters (fasting glucose, insulin, lipid profile, highly sensitive C-reactive protein) and semen analysis. For epigenetic and future genetic analyses, ICSI sons provide specimens of blood, saliva, sperm and seminal fluid while their parents provide a saliva sample. The primary outcomes of interest are the number of mother-reported hospitalisations of the son; son-reported quality of life; prevalence of moderate-severe oligozoospermia (sperm concentration <5 million/ml) and DNA methylation profile. For each outcome, differences between the ICSI study group and each control group will be investigated using multivariable linear and logistic regression for continuous and binary outcomes, respectively. Results will be presented as adjusted odds ratios and 95% CIs.

STUDY FUNDING/COMPETING INTERESTS

This study is funded by an Australian National Health and Medical Research Council Partnership Grant (NHMRC APP1140706) and was partially funded by the Monash IVF Research and Education Foundation. L.R. is a minority shareholder and the Group Medical Director for Monash IVF Group, and reports personal fees from Monash IVF group and Ferring Australia, honoraria from Ferring Australia, and travel fees from Merck Serono, MSD and Guerbet; R.J.H. is the Medical Director of Fertility Specialists of Western Australia and has equity in Western IVF; R.I.M. is a consultant for and a shareholder of Monash IVF Group and S.R.C. reports personal fees from Besins Healthcare and non-financial support from Merck outside of the submitted work. The remaining authors have no conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

Not applicable.

TRIAL REGISTRATION DATE

Not applicable.

DATE OF FIRST PATIENT’S ENROLMENT

Not applicable.