How Long Does Contouring Really Take? Results of the Royal College of Radiologists Contouring Surveys

AIMS

The success and safety of modern radiotherapy relies on accurate contouring. Understanding the time taken to complete radiotherapy contours is critical to informing workforce planning and, in the context of a workforce shortfall, advocating for investment in technology and multi-professional skills mix. We aimed to quantify the time taken to delineate target volumes for radical radiotherapy.

MATERIALS AND METHODS

The Royal College of Radiologists circulated two electronic surveys via email to all clinical oncology consultants in the UK. The individual case survey requested anonymous data regarding the next five patients contoured for radical radiotherapy. The second survey collected data on respondents' usual practice in radiotherapy contouring.

RESULTS

The median time to contour one radiotherapy case was 85 minutes (IQR = 50-131 minutes). Marked variability between and within tumour sites was evident: paediatric cancers took the most time (median = 210 minutes, IQR = 87.5 minutes), followed by head and neck and gynaecological cancers (median = 120 minutes, IQR = 71 and 72.5 minutes respectively). Breast cancer contouring required the least time (median = 43 minutes, IQR = 60 minutes). Radiotherapy technique, inclusion of nodes and 4D CT planning were associated with longer contouring times. A non-medical professional was involved in contouring in 65% of cases, but clinical oncology consultants were involved in target volume delineation in 90% of cases, and OARs in 74%. Peer review took place in 46% of cases with 56% of consultants reporting no time for peer review in their job plan.

CONCLUSION

Contouring for radical radiotherapy is complex and time-consuming, and despite increasing involvement of non-medical professionals, clinical oncology consultants remain the primary practitioners. Peer review practice is variable and time is often a limiting factor. Many factors influence the time required for contouring, and departments should take these factors and the need for peer-review into account when developing job plans.

Development and validation of the Chiropractic Professional Identity Embodiment Scale (CPIES)

BACKGROUND AND PURPOSE

Chiropractic professional identity (CPI) encompasses diverse values, beliefs, experiences, and philosophies about one's work, specific to the chiropractic profession. Yet currently, there is no instrument available to measure CPI. This study aimed to develop and validate the Chiropractic Professional Identity Embodiment Scale (CPIES).

MATERIALS AND METHODS

A mixed-methods sequential exploratory design was employed where qualitative inquiry preceded quantitative analysis of survey items conducted in New Zealand in 2022. Expert key informants provided feedback on candidate items via one-to-one cognitive interviews. Candidate items were administered to Board-registered chiropractors or chiropractic students through an online survey. The suitability of candidate items was evaluated using a variety of psychometric analyses including conceptually guided exploratory factor analysis (EFA) and reliability testing.

RESULTS

Based on relevant professional identity literature and feedback from 15 expert key informants, a draft survey instrument with 92 candidate items (across six domains) was rated by 231 participants. Using EFA, the number of items was reduced to 15. The CPIES sum score exhibited significant correlations with individuals' philosophical self-categorisation and five of the six optional subscales.

CONCLUSION

The 15-item CPIES, either as a unidimensional score or with six separate subscale scores, has been demonstrated to provide valid and reliable measurement of CPI. Future research could utilise the CPIES to investigate how CPI influences clinical practice, patient outcomes, career satisfaction, and public perception of the chiropractic profession, further advancing professionalisation and recognition within healthcare.

An Overview of Real-World Data Infrastructure for Cancer Research

AIMS

There is increasing interest in the opportunities offered by Real World Data (RWD) to provide evidence where clinical trial data does not exist, but access to appropriate data sources is frequently cited as a barrier to RWD research. This paper discusses current RWD resources and how they can be accessed for cancer research.

MATERIALS AND METHODS

There has been significant progress on facilitating RWD access in the last few years across a range of scales, from local hospital research databases, through regional care records and national repositories, to the impact of federated learning approaches on internationally collaborative studies. We use a series of case studies, principally from the UK, to illustrate how RWD can be accessed for research and healthcare improvement at each of these scales.

RESULTS

For each example we discuss infrastructure and governance requirements with the aim of encouraging further work in this space that will help to fill evidence gaps in oncology.

CONCLUSION

There are challenges, but real-world data research across a range of scales is already a reality. Taking advantage of the current generation of data sources requires researchers to carefully define their research question and the scale at which it would be best addressed.

CT vs. MRI: Which is More Accurate in Grading Rectal Wall Infiltration after Hydrogel Spacer Placement for Prostate Cancer Patients?

PURPOSE/OBJECTIVE(S)

The purpose of this study was to evaluate the incidence and severity of rectal wall infiltration (RWI) in prostate cancer patients after rectal hydrogel spacer implantation, a commonly used procedure to minimize rectal radiation exposure during prostate radiotherapy. The study aimed to determine correlation of RWI using computed tomography (CT) scans and magnetic resonance imaging (MRI) scans in order to determine the optimal post-placement imaging modality.

MATERIALS/METHODS

This retrospective study was conducted on 370 patients diagnosed with localized prostate cancer who underwent rectal hydrogel spacer placement from 2020 to 2022. CT scans were performed on all patients, with a smaller subset also undergoing MRI scans. The images were independently evaluated by three radiation oncologists to grade RWI levels using a standardized scoring system based on CT and MRI images after hydrogel placement. The levels were categorized as 0 (no RWI), 1 (focal RWI), 2 (moderate RWI), and 3 (significant RWI).

RESULTS

Any grade of RWI was identified in 79.8% of men with the majority (41%) being RWI grade 1. The median time for CT scans was 9 days after hydrogel spacer placement and 14.5 days for MRI scans. For the subset of patients with both CT and MRI scans after spacer (mostly SpaceOAR Vue), RWI was detected in 58.33% of patients based on CT and 61.11% of patients based on MRI. Table 1 shows the mean percentage of patients with each score of RWI for each imaging modality. MRI was more likely to lead to a designation of RWI of any grade compared to CT and more often led to detection of RWI grades 2-3.

CONCLUSION

Our findings demonstrate that the incidence and severity of RWI may be higher than previously reported in clinical trials and that MRI may be a more sensitive imaging modality. Caution is needed in the utilization of rectal spacer gels given the potential for complications with misplacement prior to radiation therapy. Further study is warranted to determine the potential impact of low-grade RWI on the safety of subsequent treatment.

Internal and external workload in national and international netball competition

Differences in workload exist between netball playing positions and competition levels, but no research has compared workloads experienced by the same elite players during national and international competitions. This study collected internal (heart rate) and external (PlayerLoad·min-1) workload data per match quarter from 44 players during a national competition and 12 players during an international competition. Nine players played in both competitions. Linear mixed models compared percentage of match quarter in each heart rate zone and PlayerLoad·min-1 between competitions for each playing position. Workloads against low- and high-ranked international opponents were also compared. Internal workloads were greater in national compared to international competition for GD and WD positions. PlayerLoad·min-1 was significantly higher by 8-13% in the national competition for positions WD and C, and by 5-8% in the international competition for GD and GA. Positional differences may indicate a role of the team's tactical style of play. Workloads were generally greater against higher- rather than lower-ranked international opponents. These results indicate that tactical factors in combination with playing position and opposition characteristics should be considered when preparing physically for matches.

Health Services Research in Brachytherapy: Current Understanding and Future Challenges

Brachytherapy is an integral component of cancer care. Widespread concerns have been expressed though about the need for greater brachytherapy availability across many jurisdictions. Yet, health services research in brachytherapy has lagged behind that in external beam radiotherapy. Optimal brachytherapy utilisation, to help inform expected demand, have not been defined beyond the New South Wales region in Australia, with few studies having reported observed brachytherapy utilisation. There is also a relative lack of robust cost and cost-effectiveness studies, making investment decisions in brachytherapy even more uncertain and challenging to justify, despite its key role in cancer control. As the range of indications for brachytherapy expands, providing organ/function preservation for a wider range of diagnoses, there is an urgent need to redress this balance. By outlining the work undertaken in this area to date, we highlight its importance and explore where further study is required.

Defining chiropractic professional identity: A concept analysis

BACKGROUND

The concept of professional identity within chiropractic is often discussed and debated, however in the field to date, there is no formal definition of chiropractic professional identity (CPI). This article aims to create a coherent definition of CPI and to formalise the conceptual domains that may encompass it.

METHODS

Using the Walker and Avant (2005) process, a concept analysis methodology was employed to clarify the diffuse concept of CPI. This method initially involved selecting the concept (CPI), determining the aims and purpose of the analysis, identifying concept uses, and defining attributes. This was achieved from a critical literature review of professional identity across health disciplines. Chiropractic-related model, borderline and contrary cases were used to exemplify characteristics of CPI. The antecedents required to inform CPI, consequences of having, and ways to measure the concept of CPI were evaluated.

RESULTS

From the concept analysis data, CPI was found to encompass six broad attributes or domains: knowledge and understanding of professional ethics and standards of practice, chiropractic history, practice philosophy and motivations, the roles and expertise of a chiropractor, professional pride and attitude, and professional engagement and interaction behaviours. These domains were not mutually exclusive and may overlap.

CONCLUSION

A conceptual definition of CPI may bring together members and groups within the profession and promote intra-professional understanding across other disciplines. The CPI definition derived from this concept analysis is: 'A chiropractor's self-perception and ownership of their practice philosophies, roles and functions, and their pride, engagement, and knowledge of their profession'.

A global perspective on collision and non-collision match characteristics in male rugby union: Comparisons by age and playing standard

This study quantified and compared the collision and non-collision match characteristics across age categories (i.e. U12, U14, U16, U18, Senior) for both amateur and elite playing standards from Tier 1 rugby union nations (i.e. England, South Africa, New Zealand). Two-hundred and one male matches (5911 min ball-in-play) were coded using computerised notational analysis, including 193,708 match characteristics (e.g. 83,688 collisions, 33,052 tackles, 13,299 rucks, 1006 mauls, 2681 scrums, 2923 lineouts, 44,879 passes, 5568 kicks). Generalised linear mixed models with post-hoc comparisons and cluster analysis compared the match characteristics by age category and playing standard. Overall significant differences (p < 0.001) between age category and playing standard were found for the frequency of match characteristics, and tackle and ruck activity. The frequency of characteristics increased with age category and playing standard except for scrums and tries that were the lowest at the senior level. For the tackle, the percentage of successful tackles, frequency of active shoulder, sequential and simultaneous tackles increased with age and playing standard. For ruck activity, the number of attackers and defenders were lower in U18 and senior than younger age categories. Cluster analysis demonstrated clear differences in all and collision match characteristics and activity by age category and playing standard. These findings provide the most comprehensive quantification and comparison of collision and non-collision activity in rugby union demonstrating increased frequency and type of collision activity with increasing age and playing standard. These findings have implications for policy to ensure the safe development of rugby union players throughout the world.

Consensus on a netball video analysis framework of descriptors and definitions by the netball video analysis consensus group

Using an expert consensus-based approach, a netball video analysis consensus (NVAC) group of researchers and practitioners was formed to develop a video analysis framework of descriptors and definitions of physical, technical and contextual aspects for netball research. The framework aims to improve the consistency of language used within netball investigations. It also aims to guide injury mechanism reporting and identification of injury risk factors. The development of the framework involved a systematic review of the literature and a Delphi process. In conjunction with commercially used descriptors and definitions, 19 studies were used to create the initial framework of key descriptors and definitions in netball. In a two round Delphi method consensus, each expert rated their level of agreement with each of the descriptors and associated definition on a 5-point Likert scale (1-strongly disagree; 2-somewhat disagree; 3-neither agree nor disagree; 4-somewhat agree; 5-strongly agree). The median (IQR) rating of agreement was 5.0 (0.0), 5.0 (0.0) and 5.0 (0.0) for physical, technical and contextual aspects, respectively. The NVAC group recommends usage of the framework when conducting video analysis research in netball. The use of descriptors and definitions will be determined by the nature of the work and can be combined to incorporate further movements and actions used in netball. The framework can be linked with additional data, such as injury surveillance and microtechnology data.

Promoting a culture change in junior and youth sport in New Zealand

This paper provides insight into the evolution of a project designed to address longstanding adult attitudes and behavioural issues in junior and youth sport in New Zealand. The project was funded by Sport New Zealand (Sport NZ) and implemented by Aktive, a charitable trust that works with national and regional partners to fund and deliver community sport in Auckland. Aktive collaborated with a team of junior and youth sport researchers, adopting a pragmatic, mixed methods design-based research (DBR) approach to co-design an educational delivery framework aimed at influencing attitudes and assumptions underpinning coaches, parents, and community sport leaders' behaviours. Transformative learning principles informed the delivery framework with the project reaching 4,222 participants. Research evaluations included multiple case studies, surveys, semi-structured interviews, and focus groups, which confirmed awareness of problematic beliefs. The programme expanded to Regional Sport Organisations (RSOs) and National Sport Organisations (NSOs) culminating in a nationwide rollout. The study highlights the effectiveness of theoretically informed adult behaviour change programmes in junior and youth sport, the benefits of programmes being underpinned by a rigorous pedagogical approach, and the benefits of sport organisations and researchers collaborating to design and deliver sustainable change initiatives that address belief systems underpinning current issues.

Standards of Care for the Health of Transgender and Gender Diverse People, Version 8

Background: Transgender healthcare is a rapidly evolving interdisciplinary field. In the last decade, there has been an unprecedented increase in the number and visibility of transgender and gender diverse (TGD) people seeking support and gender-affirming medical treatment in parallel with a significant rise in the scientific literature in this area. The World Professional Association for Transgender Health (WPATH) is an international, multidisciplinary, professional association whose mission is to promote evidence-based care, education, research, public policy, and respect in transgender health. One of the main functions of WPATH is to promote the highest standards of health care for TGD people through the Standards of Care (SOC). The SOC was initially developed in 1979 and the last version (SOC-7) was published in 2012. In view of the increasing scientific evidence, WPATH commissioned a new version of the Standards of Care, the SOC-8. Aim: The overall goal of SOC-8 is to provide health care professionals (HCPs) with clinical guidance to assist TGD people in accessing safe and effective pathways to achieving lasting personal comfort with their gendered selves with the aim of optimizing their overall physical health, psychological well-being, and self-fulfillment. Methods: The SOC-8 is based on the best available science and expert professional consensus in transgender health. International professionals and stakeholders were selected to serve on the SOC-8 committee. Recommendation statements were developed based on data derived from independent systematic literature reviews, where available, background reviews and expert opinions. Grading of recommendations was based on the available evidence supporting interventions, a discussion of risks and harms, as well as the feasibility and acceptability within different contexts and country settings. Results: A total of 18 chapters were developed as part of the SOC-8. They contain recommendations for health care professionals who provide care and treatment for TGD people. Each of the recommendations is followed by explanatory text with relevant references. General areas related to transgender health are covered in the chapters Terminology, Global Applicability, Population Estimates, and Education. The chapters developed for the diverse population of TGD people include Assessment of Adults, Adolescents, Children, Nonbinary, Eunuchs, and Intersex Individuals, and people living in Institutional Environments. Finally, the chapters related to gender-affirming treatment are Hormone Therapy, Surgery and Postoperative Care, Voice and Communication, Primary Care, Reproductive Health, Sexual Health, and Mental Health. Conclusions: The SOC-8 guidelines are intended to be flexible to meet the diverse health care needs of TGD people globally. While adaptable, they offer standards for promoting optimal health care and guidance for the treatment of people experiencing gender incongruence. As in all previous versions of the SOC, the criteria set forth in this document for gender-affirming medical interventions are clinical guidelines; individual health care professionals and programs may modify these in consultation with the TGD person.

Real-world application of tumor mutational burden-high (TMB-high) and microsatellite instability (MSI) confirms their utility as immunotherapy biomarkers

Introduction

Microsatellite instability (MSI) testing and tumor mutational burden (TMB) are genomic biomarkers used to identify patients who are likely to benefit from immune checkpoint inhibitors. Pembrolizumab was recently approved by the Food and Drug Administration for use in TMB-high (TMB-H) tumors, regardless of histology, based on KEYNOTE-158. The primary objective of this retrospective study was real-world applicability and use of immunotherapy in TMB/MSI-high patients to lend credence to and refine this biomarker.

Methods

Charts of patients with advanced solid tumors who had MSI/TMB status determined by next generation sequencing (NGS) (FoundationOne CDx) were reviewed. Demographics, diagnosis, treatment history, and overall response rate (ORR) were abstracted. Progression-free survival (PFS) was determined from Kaplan–Meier curves. PFS1 (chemotherapy PFS) and PFS2 (immunotherapy PFS) were determined for patients who received immunotherapy after progressing on chemotherapy. The median PFS2/PFS1 ratio was recorded.

Results

MSI-high or TMB-H [≥20 mutations per megabase (mut/MB)] was detected in 157 adults with a total of 27 distinct tumor histologies. Median turnaround time for NGS was 73 days. ORR for most recent chemotherapy was 34.4%. ORR for immunotherapy was 55.9%. Median PFS for patients who received chemotherapy versus immunotherapy was 6.75 months (95% confidence interval, 3.9-10.9 months) and 24.2 months (95% confidence interval, 9.6 months to not reached), respectively (P = 0.042). Median PFS2/PFS1 ratio was 4.7 in favor of immunotherapy.

Conclusion

This real-world study reinforces the use of TMB as a predictive biomarker. Barriers exist to the timely implementation of NGS-based biomarkers and more data are needed to raise awareness about the clinical utility of TMB. Clinicians should consider treating TMB-H patients with immunotherapy regardless of their histology.

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This retrospective study examined the real-world use of immune checkpoint inhibitors (ICIs) in TMB/MSI-high patients with a diverse set of cancer types.

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TMB is an emerging tumor-agnostic biomarker for response to treatment with ICIs that may expand personalized cancer care.

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ICIs remain underutilized as a first-line therapy for TMB/MSI-H patients without specific histologic approval for ICIs.

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The PFS2 to PFS1 ratio was 4.7, favoring immunotherapy over chemotherapy even as a second-line therapy.

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Our study reinforces the real-world evidence that TMB is a valid surrogate marker for MSI and can predict response to ICIs.

Creating a Live and Flexible Normative Dataset for Netball

A previous research has identified large data and information sources which exist about netball performance and align with the discussion of coaches during the games. Normative data provides context to measures across many disciplines, such as fitness testing, physical conditioning, and body composition. These data are normally presented in the tables as representations of the population categorized for benchmarking. Normative data does not exist for benchmarking or contextualization in netball, yet the coaches and players use performance statistics. A systems design methodology was adopted for this study where a process for automating the organization, normalization, and contextualization of netball performance data was developed. To maintain good ecological validity, a case study utilized expert coach feedback on the understandability and usability of the visual representations of netball performance population data. This paper provides coaches with benchmarks for assessing the performances of players, across competition levels against the player positions for performance indicators. It also provides insights to a performance analyst around how to present these benchmarks in an automated “real-time” reporting tool.

948 Feasibility Study of a Drive-Through Influenza Vaccination Clinic for Patients-At-Risk & Their Contacts

Background

There are 3-5 million cases of severe influenza-like illness globally each year, and up to 650,000 related deaths. This high prevalence rate proves to be a heavy burden on the healthcare system with >3,000 hospitalisations and >150 ICU admissions annually. Immunisation is gold-standard for the prevention of influenza outbreaks. The HSE Influenza Immunisation Strategy allocates vaccines to be administered in primary care to patients at-risk and their contacts. However, due to the COVID-19 pandemic, this has become a logistical challenge. We aimed to design and test a drive-through influenza vaccine clinic at a large GP practice in Cork.

Method

We designed and implemented an online booking system for at-risk patients and their contacts. 1-minute drive-through time slots were available to book for up to 6 people per vehicle. The primary measurement was the number of patients vaccinated with a secondary measurement of time spent vaccinating these patients.

Results

The pilot clinic occurred on 10/10/2020 with over 600 patients-at-risk & their contacts receiving the influenza vaccination over a time period of 10 hours. The capacity of this clinic was limited by the supply of vaccines. We estimate that 1,800 people could be vaccinated over the same time period with adequate vaccine supply.

Conclusions

A drive-through influenza vaccination clinic can be efficiently run using an online booking system and serves as a safe, efficient, and convenient way for patients-at-risk & their contacts to receive vaccinations. This system can be rolled out efficiently each winter for influenza vaccination and could be expanded to deliver mass vaccination for SARS-CoV-2.

The Prognosis in Palliative care Study II (PiPS2): A prospective observational validation study of a prognostic tool with an embedded qualitative evaluation

Background

Prognosis in Palliative care Study (PiPS) models predict survival probabilities in advanced cancer. PiPS-A (clinical observations only) and PiPS-B (additionally requiring blood results) consist of 14- and 56-day models (PiPS-A14; PiPS-A56; PiPS-B14; PiPS-B56) to create survival risk categories: days, weeks, months. The primary aim was to compare PIPS-B risk categories against agreed multi-professional estimates of survival (AMPES) and to validate PiPS-A and PiPS-B. Secondary aims were to assess acceptability of PiPS to patients, caregivers and health professionals (HPs).

Methods and findings

A national, multi-centre, prospective, observational, cohort study with nested qualitative sub-study using interviews with patients, caregivers and HPs. Validation study participants were adults with incurable cancer; with or without capacity; recently referred to community, hospital and hospice palliative care services across England and Wales. Sub-study participants were patients, caregivers and HPs. 1833 participants were recruited. PiPS-B risk categories were as accurate as AMPES [PiPS-B accuracy (910/1484; 61%); AMPES (914/1484; 61%); p = 0.851]. PiPS-B14 discrimination (C-statistic 0.837) and PiPS-B56 (0.810) were excellent. PiPS-B14 predictions were too high in the 57–74% risk group (Calibration-in-the-large [CiL] -0.202; Calibration slope [CS] 0.840). PiPS-B56 was well-calibrated (CiL 0.152; CS 0.914). PiPS-A risk categories were less accurate than AMPES (p<0.001). PiPS-A14 (C-statistic 0.825; CiL -0.037; CS 0.981) and PiPS-A56 (C-statistic 0.776; CiL 0.109; CS 0.946) had excellent or reasonably good discrimination and calibration. Interviewed patients (n = 29) and caregivers (n = 20) wanted prognostic information and considered that PiPS may aid communication. HPs (n = 32) found PiPS user-friendly and considered risk categories potentially helpful for decision-making. The need for a blood test for PiPS-B was considered a limitation.

Conclusions

PiPS-B risk categories are as accurate as AMPES made by experienced doctors and nurses. PiPS-A categories are less accurate. Patients, carers and HPs regard PiPS as potentially helpful in clinical practice.

Study registration

ISRCTN13688211.

Prognostic tools or clinical predictions: Which are better in palliative care?

PURPOSE

The Palliative Prognostic (PaP) score; Palliative Prognostic Index (PPI); Feliu Prognostic Nomogram (FPN) and Palliative Performance Scale (PPS) have all been proposed as prognostic tools for palliative cancer care. However, clinical judgement remains the principal way by which palliative care professionals determine prognoses and it is important that the performance of prognostic tools is compared against clinical predictions of survival (CPS).

METHODS

This was a multi-centre, cohort validation study of prognostic tools. Study participants were adults with advanced cancer receiving palliative care, with or without capacity to consent. Key prognostic data were collected at baseline, shortly after referral to palliative care services. CPS were obtained independently from a doctor and a nurse.

RESULTS

Prognostic data were collected on 1833 participants. All prognostic tools showed acceptable discrimination and calibration, but none showed superiority to CPS. Both PaP and CPS were equally able to accurately categorise patients according to their risk of dying within 30 days. There was no difference in performance between CPS and FPN at stratifying patients according to their risk of dying at 15, 30 or 60 days. PPI was significantly (p<0.001) worse than CPS at predicting which patients would survive for 3 or 6 weeks. PPS and CPS were both able to discriminate palliative care patients into multiple iso-prognostic groups.

CONCLUSIONS

Although four commonly used prognostic algorithms for palliative care generally showed good discrimination and calibration, none of them demonstrated superiority to CPS. Prognostic tools which are less accurate than CPS are of no clinical use. However, prognostic tools which perform similarly to CPS may have other advantages to recommend them for use in clinical practice (e.g. being more objective, more reproducible, acting as a second opinion or as an educational tool). Future studies should therefore assess the impact of prognostic tools on clinical practice and decision-making.

Physical, physiological, and technical demands of national netball umpires at different competition levels

To compare demands of national netball umpires between levels of competition, 22 Netball New Zealand high-performance umpires participated in this investigation. These included from highest to lowest standard: 9 × semi-professional ANZ Championships (ANZC); 6 × National A Squad (NZA); and 7 × National Development Squad (DEV). Physical (global positioning system tri-axial accelerometry), physiological (heart rate) and technical (video analysis) demands were determined for 48 (16 per group) umpire match performances. Level of competition had no significant effect on physical or mean physiological demands. However, ANZC umpires spent a lower proportion of time at low heart rates compared to DEV, and a greater proportion of time at high, rather than moderate, heart rates compared to NZA. Compared to lower standard umpires, ANZC spent lesser proportions of time standing but greater proportions of time walking backwards and sideways, and turning to change direction. Furthermore, ANZC umpires spent lower proportions of time jogging, but greater proportions of time sprinting compared to DEV. Finally, ANZC umpires spent longer mean durations than DEV on the goal third side line. As such, the difference in demands experienced by national netball umpires between levels of competition is more technical than physical or physiological.

Neutron Diffraction Study of Macrostress and Microstress in Al-Al2O3-Based Corrosion Protection Coating Obtained by Cold Spray (Dynamic Metallization)

Protective coatings based on an Al-Al2O3 metal matrix composite (MMC) were sprayed using dynamic metallization (DM), a low-pressure cold spray variant. A series of samples approximately 1 mm in thickness were sprayed using different spray process parameters (temperature, velocity) and different feedstock powder compositions (Al, Zn, Al2O3). This resulted in MMCs of different phase compositions and slightly different physical conditions of coating formation. The through-thickness residual stresses that accumulate in coatings during the spray process were studied using neutron diffraction in all phases comprising the MMCs. The overall residual stress in the coating (macrostress) was compressive, which is in good agreement with the data on residual stress observed in other cold spray coatings, accumulating as a result of the peening process. However, due to the slightly elevated spray temperature characteristic of DM in comparison with other cold spray variants, thermal stresses are also present and play an equally important role in the accumulation of residual stress in each phase. Because of the multi-phase composition and thermal mismatch between the metal and ceramic components of the MMC, inter-phase microstresses also accumulate. A micro-mechanical explanation of the observed tensile microstress in Al/Zn versus compressive stress in Al2O3 is proposed.

Pravastatin for early-onset pre-eclampsia: a randomised, blinded, placebo-controlled trial

Objective

Women with pre‐eclampsia have elevated circulating levels of soluble fms‐like tyrosine kinase‐1 (sFlt‐1). Statins can reduce sFlt‐1 from cultured cells and improve pregnancy outcome in animals with a pre‐eclampsia‐like syndrome. We investigated the effect of pravastatin on plasma sFlt‐1 levels during pre‐eclampsia.

Design

Blinded (clinician and participant), proof of principle, placebo‐controlled trial.

Setting

Fifteen UK maternity units.

Population

We used a minimisation algorithm to assign 62 women with early‐onset pre‐eclampsia (24⁺⁰–31⁺⁶ weeks of gestation) to receive pravastatin 40 mg daily (n = 30) or matched placebo (n = 32), from randomisation to childbirth.

Primary outcome

Difference in mean plasma sFlt‐1 levels over the first 3 days following randomisation.

Results

The difference in the mean maternal plasma sFlt‐1 levels over the first 3 days after randomisation between the pravastatin (n = 27) and placebo (n = 29) groups was 292 pg/ml (95% CI −1175 to 592; P = 0.5), and over days 1–14 was 48 pg/ml (95% CI −1009 to 913; P = 0.9). Women who received pravastatin had a similar length of pregnancy following randomisation compared with those who received placebo (hazard ratio 0.84; 95% CI 0.50–1.40; P = 0.6). The median time from randomisation to childbirth was 9 days (interquartile range [IQR] 5–14 days) for the pravastatin group and 7 days (IQR 4–11 days) for the placebo group. There were three perinatal deaths in the placebo‐treated group and no deaths or serious adverse events attributable to pravastatin.

Conclusions

We found no evidence that pravastatin lowered maternal plasma sFlt‐1 levels once early‐onset pre‐eclampsia had developed. Pravastatin appears to have no adverse perinatal effects.

Tweetable abstract

Pravastatin does not improve maternal plasma sFlt‐1 or placental growth factor levels following a diagnosis of early preterm pre‐eclampsia #clinicaltrial finds.

Pravastatin does not improve maternal plasma sFlt‐1 or placental growth factor levels following a diagnosis of early preterm pre‐eclampsia #clinicaltrial finds.

Activity Profile of Elite Netball Umpires During Match Play

Spencer, KN, Paget, N, Farley, ORL, and Kilding, AE. Activity profile of elite netball umpires during match play. J Strength Cond Res 34(10): 2832-2839, 2020-The study aimed to determine activity profiles of officials in elite netball. Physical demands of Load·min (au) representing accumulated accelerations by triaxial accelerometers during matches and exercise-to-rest ratio were measured using global positioning systems (Catapult, MinimaxX S4). Physiological demands were quantified by estimated equivalent distance and heart rate (HR) (MeanHR, percentage HRpeak, and HRzones) and movement variables (frequency, mean time, and percentage of total time) were coded using Sportscode Elite (Version 10, Hudl, Lincoln, Nebraska). Differences were analyzed by periods (Q1-Q4). Load·min (au) (M = 407 ± 66) significantly varied with time (F [3, 55] = 3.42, p = 0.02) and the highest percentage of exercise-to-rest performed in Q1 (21 ± 5%). Estimated equivalent distance (3,839 ± 614 m) varied significantly with time (F [3, 56] = 3.18, p = 0.03), the umpires spent longest duration of time (35%) in HRzone 3 (75-85% of HRpeak). Mean HR significantly decreased with time (p < 0.01; Q1 [157 ± 13], quarter 2 [156 ± 12], and Q4 [153 ± 14]). Umpires spent 77% in rest-recovery ratio movements and 23% of time exercise-to-rest ratio. In summary, netball umpiring is characterized by intermittent, short, high-intensity activity (sprinting, sidestepping, and turn to change direction), with increasing periods of rest-recovery (walking and standing).

Hypofractionated Radiotherapy in Oesophageal Cancer for Patients Unfit for Systemic Therapy: A Retrospective Single-Centre Analysis

AIMS

Chemoradiotherapy (CRT) is established as a superior treatment option to definitive radiotherapy in the non-surgical management of oesophageal cancer. For patients precluded from CRT through choice or comorbidity there is little evidence to guide delivery of single-modality radiotherapy. In this study we outline outcomes for patients unfit for CRT who received a hypofractionated radiotherapy (HRT) regimen.

MATERIALS AND METHODS

A retrospective UK single-centre analysis of 61 consecutive patients with lower- or middle-third adenocarcinoma (OAC; 61%) or squamous cell carcinoma of the oesophagus managed using HRT with radical intent between April 2009 and 2014. Treatment consisted of 50 Gy in 16 fractions (n = 49, 80.3%) or 50-52.5 Gy in 20 fractions (n = 12, 19.7%). Outcomes were referenced against a contemporaneous comparator cohort of 80 (54% OAC) consecutive patients managed with conventionally fractionated CRT within the same centre.

RESULTS

Three-year and median overall survival were, respectively, 56.9% and 29 months with HRT compared with 55.5% and 26 months for CRT; adjusted hazard ratio 0.79 (95% confidence interval 0.48-1.28). Grade 3 and 4 toxicity rates were low at 16.4% (n = 10) for those receiving HRT and 40.2% (n = 32) for the CRT group. In patients with OAC, CRT delivered superior overall survival (hazard ratio 0.46; 95% confidence interval 0.25-0.85) and progression-free survival (hazard ratio 0.45; 95% confidence interval 0.23-0.88) when compared with HRT.

CONCLUSIONS

The HRT regimen described here was safe and tolerable in patients unable to receive CRT, and delivered promising survival outcomes. The use of HRT for the treatment of oesophageal cancer, both alone and as a sequential or concurrent treatment with chemotherapy, requires further study. New precision radiotherapy technologies may provide additional scope for improving outcomes in oesophageal cancer using HRT-based approaches and should be evaluated.