Balloon Rises Above: REBOA at Zone 1 May Be Superior to Resuscitative Thoracotomy

BACKGROUND

The use of Zone 1 REBOA for life-threatening trauma has increased dramatically.

STUDY DESIGN

The Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery database was queried for blunt and penetrating trauma between 2013 and 2021. Outcomes were examined both for mechanisms of injury combined and separately and for combinations of abdominal injury with and without traumatic brain injury and chest injuries (Abbreviated Injury Scale [AIS] score >2).

RESULTS

A total of 531 patients underwent REBOA (408 with blunt injury and 123 with penetrating injury) and 1,603 (595 with blunt injury and 1,008 with penetrating injury) underwent resuscitative thoracotomy (RT). Mean age was 38.5 ± 16 years and mean injury severity score was 34.5 ± 21; 57.7% had chest AIS score of more than 2, 21.8% had head AIS score of more than 2, and 37.3% had abdominal AIS score of more than 2. Admission Glasgow Coma Scale was 4.9 + 4, and systolic blood pressure at aortic occlusion (AO) was 22 + 40 mmHg. No differences in outcomes in REBOA or RT patients were identified between institutions (p > 0.5). After inverse probability weighting, Glasgow Coma Scale, age, injury severity score, systolic blood pressure at AO, CPR at AO, and blood product transfusion, REBOA was superior to RT in both blunt (odds ratio [OR] 4.7, 95% CI 1.9 to 11.7) and penetrating (OR 4.9, 95% CI 1.7 to 14) injuries, across all spectrums of injury (p < 0.01). Overall mortality was significantly higher for AO more than 90 minutes compared with less than 30 minutes in blunt (OR 4.6, 95% CI 1.5 to 15) and penetrating (OR 5.4, 95% CI 1.1 to 25) injuries. Duration of AO more than 60 minutes was significantly associated with mortality after penetrating abdominal injury (OR 5.1, 95% CI 1.1 to 22) and abdomen and head (OR 5.3, 95% CI 1.6 to 18).

CONCLUSIONS

In-hospital survival is higher for patients undergoing REBOA than RT for all injury patterns. Complete AO by REBOA or RT should be limited to less than 30 minutes. Neither hospital and procedure volume nor trauma verification level impacts outcomes for REBOA or RT.

Use of Tranexamic Acid With Resuscitative Endovascular Balloon Occlusion of the Aorta is Associated With Higher Distal Embolism Rates: Results From the American Association of Surgery for Trauma Aortic Occlusion and Resuscitation for Trauma and Acute Care Surgery Trial

INTRODUCTION

Tranexamic acid (TXA) use has been associated with thrombotic complications.

OBJECTIVE

We aim to investigate outcomes associated with TXA use in the setting of high- (HP) and low-profile (LP) introducer sheaths for resuscitative endovascular balloon occlusion of the aorta (REBOA).

PARTICIPANTS

The Aortic Occlusion and Resuscitation for Trauma and Acute Care Surgery (AORTA) database was queried for patients who underwent REBOA using a low-profile 7 French (LP) or high-profile, 11-14 French (HP) introducer sheaths between 2013 and 2022. Demographics, physiology, and outcomes were examined for patients who survived beyond the index operation.

RESULTS

574 patients underwent REBOA (503 LP, 71 HP); 77% were male, mean age was 44 ± 19 and mean injury severity score (ISS) was 35 ± 16. 212 patients received TXA (181 [36%] LP, 31 [43.7%] HP). There were no significant differences in admission vital signs, GCS, age, ISS, SBP at AO, CPR at AO, and duration of AO among LP and HP patients. Overall, mortality was significantly higher in the HP (67.6%) vs the LP group (54.9%; P = .043). Distal embolism was significantly higher in the HP group (20.4%) vs the LP group (3.9%; P < .001). Logistic regression demonstrated that TXA use was associated with a higher rate of distal embolism in both groups (OR = 2.92; P = .021). 2 LP patients (one who received TXA) required an amputation.

CONCLUSION

Patients who undergo REBOA are profoundly injured and physiologically devastated. Tranexamic acid was associated with a higher rate of distal embolism in those who received REBOA, regardless of access sheath size. For patients receiving TXA, REBOA placement should be accompanied by strict protocols for immediate diagnosis and treatment of thrombotic complications.

EPIDEEP: Using a Deep Learning Model to Predict In Vivo Electronic Portal Imaging Device (EPID) Transit Images

PURPOSE/OBJECTIVE(S)

To create a deep-learning model to predict in-vivo electronic portal imaging device (EPID) transit images for IMRT treatments. This model was created to predict in-vivo images to identify machine and patient-related errors that occur during beam delivery and are undetectable with current QA approaches. The deep-learning model can make image predictions much faster than Monte Carlo approaches, making image prediction feasible for application in online adaptive radiotherapy. Additionally, the model does not rely on any proprietary information and can be easily utilized by other clinics.

MATERIALS/METHODS

Our approach separates the primary and scatter components of in-vivo transit images. The attenuation of primary radiation reaching the EPID panel is modeled analytically, using attenuation measurements from phantoms of known thicknesses. The scatter component is estimated using a convolutional neural network (CNN). The CNN training uses information from the on-treatment cone-beam CTs (CBCTs), and a pretreatment EPID image with no patient in the beam. We acquired 193 IMRT fields/images from 118 patients previously treated on the Varian Halcyon. Treatment sites included the pelvis, abdomen, lungs, and extremities. CBCTs were collected immediately before treatment, to provide an accurate representation of the anatomy. A 3-channel input image was used, consisting of the pretreatment EPID image, a ray tracing projection through the CBCT to the EPID panel, and a projection to isocenter. Model training:validation:test set ratios were 133:20:40 images. The primary and scatter components are added together to give the predicted transit image. Prediction accuracy was assessed by comparing model-predicted and measured in-vivo EPID images with a 3%/3mm and 5%/3mm gamma pass rate.

RESULTS

The gamma pass rate for the patients in the training:validation:test was 91.5%:90.4%:92.1% for 3%/3mm and 96.7%:96.6%:97.0% for 5%/3mm. The model can make image predictions in 20 milliseconds. The poor passing rates of some images may be due to CBCT artifacts and patient motion that occurs between the time of CBCT and treatment.

CONCLUSION

This model can predict in-vivo EPID images with an average gamma pass rate greater than 90%. Image predictions from this model can be used to detect in-vivo treatment errors and changes in patient anatomy, providing an additional layer of patient-specific quality assurance. The speed of image predictions is 20 milliseconds, making use feasible for online adaptive treatments, which currently do not utilize patient-specific measurements of the delivered radiation. Upcoming studies will assess the model's ability in detecting clinically relevant errors and changes in patient anatomy that can adversely affect treatment. Future goals include acquiring more data to further improve the model and extending the model to make predictions for VMAT treatments.

Hair Collection for Cortisol Among Youth Experiencing Homelessness

BACKGROUND

Investigations of chronic physiological stress measured by hair cortisol are rapidly expanding among community samples of adolescents and adults. However, research examining physiological stress among youth experiencing homelessness is nascent despite the youth's increased risk for adverse exposures and subsequent impaired mental health.

OBJECTIVE

This article aimed to examine the feasibility of collecting hair for measuring cortisol among diverse youth experiencing homelessness and gain an understanding of variation in participation.

METHODS

Analysis of survey and hair participation data from three pilot studies among youth experiencing homelessness was conducted. Survey measures included sociodemographic characteristics (age, race and ethnicity, sex assigned at birth, and sexual orientation) and reasons for nonparticipation. Descriptive analysis examined participation rates in hair collection for cortisol measurement, including sociodemographic differences in participation.

RESULTS

Participation in the hair sampling for cortisol was high for the combined sample (88.4%), with some variation across the three pilot studies. Insufficient hair for cutting was the most common reason for not participating; Black and multiracial youth, as well as male youth, had a higher prevalence of nonparticipation.

DISCUSSION

The collection of hair for cortisol research among youth experiencing homelessness is feasible, and integration of physiological measures of stress into research with this vulnerable population should be considered, given their high risk for adversity and death by suicide and drug overdose. Methodological considerations and avenues for potential research are discussed.

An evaluation of the Compassion, Inclusion, and Engagement initiative: learning from PWLE and communities across British Columbia

BACKGROUND

The Compassion, Inclusion and Engagement initiative (CIE) was a social contact intervention that operated in British Columbia between 2015 and 2021. The primary objective of CIE was to increase the participation of people with lived experience of substance use (PWLE) in the planning, design, implementation, and evaluation of harm reduction supports and services.

CASE PRESENTATION

CIE used the developmental evaluation methodology outcome mapping to define and measure progress towards its goals. Developmental evaluation emphasizes learning in contrast to other forms of evaluation which are often more focused on determining the value or success of a project or programme based on predetermined criteria. Outcome mapping is a relational practice which acknowledges that change is achieved by an initiative's partners and the role of the initiative is to provide access to resources, ideas and opportunities that can facilitate and support change.

CONCLUSIONS

Through the implementation and evaluation of CIE, it became clear that directly supporting PWLE facilitated more meaningful and lasting change than solely working to improve the health and social services that supported them. The impacts of the CIE initiative extend far beyond the outcomes of any of the dialogues it facilitated and are largely the result of an increase in social capital. CIE engagements created the opportunity for change by inviting people most affected by the toxic drug supply together with those committed to supporting them, but their ability to bring about systemic change was limited. Both PWLE and service providers noted the lack of support to attend CIE engagements, lack of support for actions that came from those engagements, and lack of PWLE inclusion in decision-making by health authorities as limiting factors for systemic change. The lack of response at a systemic level often resulted in PWLE carrying the burden of responding to toxic drug poisonings, often without resources, support, or compensation.

Mental Health Professionals' Experiences of Adapting Mental Health Interventions for Autistic Adults: A Systematic Review and Thematic Synthesis

Autistic adults experience high rates of metal health difficulties and face significant barriers to accessing appropriate mental health care. Empirical research and recent professional guidelines emphasise the importance of modifying standard mental health interventions to best meet the needs of autistic adults. This systematic review explored mental health professionals' experiences of adapting mental health interventions for autistic adults. A systematic search was conducted on CINAHL, PsychINFO, PubMed, Scopus, and Web of Science in July 2022. The findings from 13 identified studies were synthesised using thematic synthesis. Three major analytical themes were generated, the unique experience of adapting interventions for autistic clients, factors which facilitate successful adaptations, and challenges to adapting interventions. Each theme contained a number of subsequent sub-themes. Professionals view the process of adapting interventions to be a highly individualised process. A range of personal traits, professional experiences, and systemic, service-based issues were identified in facilitating or challenging this individualised process. Further research regarding adaptations with different intervention models and increased supportive resources are required to enable professionals to successfully adapt interventions for autistic adult clients.

Evidence-based practice improves patient outcomes and healthcare system return on investment: Findings from a scoping review

BACKGROUND

Evidence-based practice and decision-making have been consistently linked to improved quality of care, patient safety, and many positive clinical outcomes in isolated reports throughout the literature. However, a comprehensive summary and review of the extent and type of evidence-based practices (EBPs) and their associated outcomes across clinical settings are lacking.

AIMS

The purpose of this scoping review was to provide a thorough summary of published literature on the implementation of EBPs on patient outcomes in healthcare settings.

METHODS

A comprehensive librarian-assisted search was done with three databases, and two reviewers independently performed title/abstract and full-text reviews within a systematic review software system. Extraction was performed by the eight review team members.

RESULTS

Of 8537 articles included in the review, 636 (7.5%) met the inclusion criteria. Most articles (63.3%) were published in the United States, and 90% took place in the acute care setting. There was substantial heterogeneity in project definitions, designs, and outcomes. Various EBPs were implemented, with just over a third including some aspect of infection prevention, and most (91.2%) linked to reimbursement. Only 19% measured return on investment (ROI); 94% showed a positive ROI, and none showed a negative ROI. The two most reported outcomes were length of stay (15%), followed by mortality (12%).

LINKING EVIDENCE TO ACTION

Findings indicate that EBPs improve patient outcomes and ROI for healthcare systems. Coordinated and consistent use of established nomenclature and methods to evaluate EBP and patient outcomes are needed to effectively increase the growth and impact of EBP across care settings. Leaders, clinicians, publishers, and educators all have a professional responsibility related to improving the current state of EBP. Several key actions are needed to mitigate confusion around EBP and to help clinicians understand the differences between quality improvement, implementation science, EBP, and research.

Mindfulness stress-buffering model of health: implications for successful aging

OBJECTIVES

Age-related variations in emotional, physical, and cognitive health are poorly understood. This multimethod study extends previous work by investigating mechanistic models by which trait mindfulness, perceived stress, and negative affect (NA) influence health outcomes in adults aged 57-87 years old.

METHOD

In this cross-sectional study, 119 adults completed clinical interviews, cognitive and gait assessments, the Mindful Attention and Awareness Scale, Positive and Negative Affect Schedule, and Perceived Stress Scale. Gait velocity and executive function (Flanker test of inhibitory control), which are important predictors of global health and functioning in older adults, served as objective health outcome measures.

RESULTS

Correlational analyses found that trait mindfulness is positively associated with age, gait velocity, and inhibitory control and negatively associated with NA and perceived stress. NA but not perceived stress was associated with slower gait velocity. PROCESS mediation analyses suggested that those higher in trait mindfulness showed lower NA as a result of less perceived stress, while moderation analyses indicated the relationship between gait velocity and age varied by levels of trait mindfulness.

CONCLUSION

Our findings are consistent with a mindfulness stress-buffering model of health. It is plausible that trait mindfulness, which has both mediating and moderating effects on health, might help to promote more successful aging and provide resilience to age-related declines in physical health.

O-125 Application of artificial intelligence using big data to devise and train a machine learning model on over 63,000 human embryos to automate time-lapse embryo annotation

Study question

Can a machine learning (ML) model, developed using modern neural network architecture produce comparable annotation data; utilisable for algorithmic outcome prediction, to manual time-lapse annotations?

Summary answer

The model automatically annotated unseen embryos with comparable results to manual methods, generating morphokinetic data to enable comparably predictive outputs from an embryo selection algorithm.

What is known already

The application of artificial intelligence across healthcare industries, including fertility, is increasing. Several ML models are available that seek to generate or analyse embryo images and morphokinetic data, and to determine embryo viability potential. Along with photographic images, the use of time-lapse in IVF laboratories has amassed numeric data, resulting predominantly from annotated manual assessment of images over time. Embryo annotation practice is variable in quality, can be subjective and is time-consuming; commonly taking several minutes per embryo. The development of rapid, accurate automatic annotation would represent a significant time-saving as well as an increase in reproducibility and accuracy.

Study design, size, duration

Multicentre quality assured annotation data from 63,383 time-lapse monitored embryos (EmbryoScope®), comprising over 400 million individual images, were used to train a ML model to automatically generate morphokinetic annotations. Data was derived from 8 UK clinics within a cohesive group between 2012-2021. Accuracy was assessed using 900 unseen embryos (with live birth outcome) by comparing the output of an established in-house, prospectively validated embryo selection model when the input was either ML-automated, or manual annotations.

Participants/materials, setting, methods

Multi-focal plane images were processed on the Azure cloud (Microsoft) and resampled to 300x300 pixels. A Laplacian-based focal stacking algorithm merged frames into a single image. The model consisted of an EfficientNetB4 Convolutional Neural Network classifier to extract features and classify the stage of embryo images. A Temporal Convolutional Network  interpreted a time-series of image features; producing annotations from pronuclear fading through to blastocyst. Soft localisation loss function used QA data to integrate annotation subjectivities.

Main results and the role of chance

The ML model rapidly and automatically generated annotations. Efficacy and comparability of the ML model to automate reliable, utilisable annotations was demonstrated by comparison with manual annotation data and the ML model’s ability to auto-generate annotations which could be used to predict live birth by providing annotation data to an established, validated in house embryo selection model. Live birth-predictive capability was measured, and benchmarked against manual annotation, using the area under the receiver operating characteristic curve (AUC).

When tested on time-lapse images, collected from pronuclear fading to full blastulation, representing 900 previously unseen, transferred blastocysts where live birth outcomes were blinded, the in-house developed auto-annotation ML model resulted in an AUC of 0.686 compared with 0.661 for manual annotations, for live birth prediction.

Auto annotation using the developed model took only milliseconds to complete per embryo. The developed auto-annotation model, built and tested on large data, is considered suitable for productionisation with the aim of being validated and integrated into an application to support IVF laboratory practice.

Limitations, reasons for caution

Whilst this model was trained to recognise key morphokinetic events, there are other morphokinetic variables that may be useful in the prediction of live birth and further improve embryo selection, or deselection, ability. Akin to manual interpretation, some embryos may fail to be annotated or need second opinion.

Wider implications of the findings

There is increasing evidence supporting the application of ML to utilise big data from time-lapse imaging and fertility care generally. Whilst promising benefits to IVF clinics and patients, responsible use of data is required alongside large high-quality datasets, and rigorous validation, to ensure safe and robust applications.

Trial registration number

N/A

O-306 LINZAGOLIX FOR ENDOMETRIOSIS-ASSOCIATED PAIN: SAFETY RESULTS FROM EDELWEISS 3, A PHASE 3, RANDOMIZED, DOUBLE-BLIND, PLACEBO-CONTROLLED TRIAL

Study question

Is once-daily linzagolix treatment for women with moderate to severe endometriosis-associated pain (EAP) safe for use for up to 6 months of treatment?

Summary answer

Both doses of linzagolix were well-tolerated with minimal BMD decrease and few TEAEs &gt;5% in either linzagolix arm.

What is known already

Linzagolix (LGX) is an investigational once-daily oral GnRH receptor antagonist that reduces serum estradiol in a dose-dependent manner and is being developed in two dosages for the treatment of endometriosis-associated pain (EAP): 75 mg, and 200 mg dose with hormonal add-back therapy (ABT). 

Study design, size, duration

EDELWEISS 3 is a randomized, double-blind, placebo-controlled, multicenter Phase 3 trial of linzagolix in women with moderate to severe EAP. The trial includes 3 treatment arms: 75 mg LGX, 200 mg LGX with ABT (E2 1 mg/ NETA 0.5 mg), or placebo. Here we present safety results up to 6 months (24 weeks) of treatment.

Participants/materials, setting, methods

Eligible reproductive-aged women with moderate-to-severe EAP were randomized and treated (n = 484) for 6 months with 75 mg LGX, 200 mg LGX with ABT (E2 1 mg/ NETA 0.5 mg), or placebo. Safety and tolerability objectives reported here include 6-month results for treatment emergent adverse events (TEAEs), assessment of mean percent change from baseline (CfB) in lumbar spine (LS) bone mineral density (BMD) and Z-scores.

The safety analysis set included 484 subjects across the 3 treatment groups.

Main results and the role of chance

The overall incidence of TEAEs was similar between the placebo and LGX 75 mg group (46.9%) and slightly higher (56.8%) in the LGX 200 mg + ABT group. There were few (3) serious TEAEs, and none were related to LGX. TEAEs that occurred in over 5% of patients in either active treatment arm included headache (10.5%, 8.1%, and 8.0%), hot flush (6.8%, 7.5%, and 2.5%), and fatigue (6.8%, 3.8%, and 2.5%) for the 200 mg LGX with ABT, 75 mg LGX, and placebo groups, respectively. Mean percent CfB (95% CI) in LS BMD was -0.79% (-1.15,  -0.43%), -0.89% (-1.31, -0.47%), and +0.78% (0.41, 1.15%) for the 200 mg LGX with ABT, 75 mg LGX, and placebo groups, respectively. Z-scores at 6 months remained within the same range as baseline in all groups.

Limitations, reasons for caution

Additional efficacy and safety results from the trial's 24 weeks (6 mo) extension phase are pending. (Edelweiss 6 protocol: NCT04335591)

Wider implications of the findings

These results support further development of ABT and non-ABT doses of linzagolix that have potential to provide flexibility and choice for women seeking treatment for EAP. A non-ABT option is important for women who have a contraindication to, are at increased risk for complications, or prefer not to use ABT.

Trial registration number

ClinicalTrials.gov: NCT02778399

A core outcome set for resuscitative endovascular balloon occlusion of the aorta: A consensus based approach using a modified Delphi method

BACKGROUND

The utilization of resuscitative endovascular balloon occlusion of the aorta (REBOA) in trauma has grown exponentially in recent years. However, inconsistency in reporting of outcome metrics related to this intervention has inhibited the development of evidence-based guidelines for REBOA application. This study sought to attain consensus on a core outcome set (COS) for REBOA.

METHODS

A review of "landmark" REBOA articles was performed, and panelists (first and senior authors) were contacted for participation in a modified Delphi study. In round 1, panelists provided a list of potential core outcomes. In round 2, using a Likert scale (1 [not important] to 9 [very important]), panelists scored the importance of each potential outcome. Consensus for core outcomes was defined a priori as greater than 70% of scores receiving 7 to 9 and less than 15% of scores receiving 1 to 3. Feedback was provided after round 2, and a third round was performed to reevaluate variables not achieving consensus and allow a final "write-in" round by the experts.

RESULTS

From 17 identified panelists, 12 participated. All panelists (12 of 12, 100%) participated in each subsequent round. Panelists initially identified 34 unique outcomes, with two outcomes later added upon write-in request after round 2. From 36 total potential outcomes, 20 achieved consensus as core outcomes, and this was endorsed by 100% of the participants.

CONCLUSION

Panelists successfully achieved consensus on a COS for REBOA-related research. This REBOA-COS is recommended for all clinical trials related to REBOA and should help enable higher-quality study designs, valid aggregation of published data, and development of evidence-based practice management guidelines.

LEVEL OF EVIDENCE

Diagnostic test or criteria, level V.

TRIAL REGISTRATION

Core Outcomes in Trauma Surgery: Development of a Core Outcome Set for Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) http://www.comet-initiative.org/Studies/Details/1709.

High resuscitative endovascular balloon occlusion of the aorta procedural volume is associated with improved outcomes: An analysis of the AORTA registry

BACKGROUND

The use of resuscitative endovascular balloon occlusion of the aorta (REBOA) is controversial. We hypothesize that REBOA outcomes are improved in centers with high REBOA utilization.

METHODS

We examined the Aortic Occlusion in Resuscitation for Trauma and Acute Care Surgery registry over a 5-year period (2014-2018). Resuscitative endovascular balloon occlusion of the aorta outcomes were analyzed by stratifying institutions into low-volume (<10), average-volume (11-30), and high-volume (>30) deployment centers. A multivariable model adjusting for volume group, mechanism of injury, signs of life, systolic blood pressure at initiation, operator level, device type, zone of placement, and hemodynamic response to aortic occlusion was created to analyze REBOA mortality and REBOA-related complications.

RESULTS

Four hundred ninety-five REBOA placements were included. High-volume centers accounted for 63%, while low accounted for 13%. High-volume institutions were more likely to place a REBOA in the emergency department (81% vs. 63% low volume, p = 0.003), had a lower mean systolic blood pressure at insertion (53 ± 38 vs. 64 ± 40, p = 0.001), and more Zone I deployments (64% vs. 55%, p = 0.002). Median time from admission to REBOA placement was significantly less in patients treated at high-volume centers (15 [7-30] minutes vs. 35 [20-65] minutes, p = 0.001). Resuscitative endovascular balloon occlusion of the aorta mortality was significantly higher at low-volume centers (67% vs. 57%; adjusted odds ratio, 1.29; adj p = 0.040), while average- and high-volume centers were similar. Resuscitative endovascular balloon occlusion of the aorta complications were less frequent at high-/average-volume centers, but did not reach statistical significance (adj p = 0.784).

CONCLUSION

Resuscitative endovascular balloon occlusion of the aorta survival is increased at high versus low utilization centers. Increased experience with REBOA may be associated with earlier deployment and subsequently improved patient outcomes.

LEVEL OF EVIDENCE

Therapeutic/Care Management, level IV.

Introduction to the complex intervention concept and the research perspectives

 

Few interventions are truly simple; complexity can arise from various sources, e.g.:

Aspects of the intervention itself, such as the number of intervention components, the number of groups targeted, how dynamic the intervention is permitted to be. The context in which the intervention is developed and delivered, such as the social, political, economic, and geographical context.

Complex intervention research should be approached with an awareness of these sources of complexity. Systems thinking can be helpful to understanding the dynamic interaction between interventions and their context. This presentation will introduce concepts of complex adaptive systems, e.g. feedback loops, adaptation, emergence, that should be considered when developing and evaluating complex interventions. It will then introduce participants to the research perspectives set out in the new framework: efficacy, effectiveness, theory-based, and systems perspectives. Each perspective is associated with a different type of research question, and therefore appropriate in different circumstances. The presentation will provide information to support participants to consider the research perspective(s) most suited to the research challenge that they are aiming to address.

Main messages

There are multiple sources of complexity, each of which can affect how the intervention works or contributes to change. Complex intervention research can take an efficacy, effectiveness, theory-based, or systems perspective, the choice of which is based on what is known already and what further evidence would be most useful.

The new Framework and the Core Elements of complex intervention research

 

The new framework will be presented. The main phases of intervention research: development or identification, feasibility, evaluation and implementation are connected to 6 core elements:

Context: any feature of the circumstances in which an intervention is conceived, developed, evaluated and implemented Programme theory: how an intervention is expected to lead to its effects and under what conditions. Programme theory should be tested and refined at all stages and used to guide the identification of uncertainties and research questions Stakeholders: those who are targeted by the intervention, involved in its development or delivery, or more broadly those whose personal or professional interests are affected, that is who have a stake in the topic. This includes patients, the public, and professionals Refinement: the process of ‘fine tuning' or making changes to the intervention once a preliminary version has been developed Uncertainties: identifying key uncertainties that exist given what is already known and what the programme theory, researchers and stakeholders identify as being most important to find out. These judgements inform the framing of research questions that, in turn, govern research perspective choice Economic considerations: exploring the comparative resource and outcome consequences of the interventions for those people and organisations affected

The presentation will discuss how to use the framework, highlighting that complex intervention research can be an iterative process. Repeating of phases is preferable to automatic progression to the next phase if uncertainties remain unresolved.

Main messages

Complex intervention research may begin at any phase, depending on what is appropriate for the intervention in question, and does not necessarily move sequentially through the phases. The core elements should be considered early and revisited continually throughout, as this will make it most likely that the intervention will be implementable in practice.

Global upper-atmospheric heating on Jupiter by the polar aurorae

Jupiter's upper atmosphere is considerably hotter than expected from the amount of sunlight that it receives1-3. Processes that couple the magnetosphere to the atmosphere give rise to intense auroral emissions and enormous deposition of energy in the magnetic polar regions, so it has been presumed that redistribution of this energy could heat the rest of the planet4-6. Instead, most thermospheric global circulation models demonstrate that auroral energy is trapped at high latitudes by the strong winds on this rapidly rotating planet3,5,7-10. Consequently, other possible heat sources have continued to be studied, such as heating by gravity waves and acoustic waves emanating from the lower atmosphere2,11-13. Each mechanism would imprint a unique signature on the global Jovian temperature gradients, thus revealing the dominant heat source, but a lack of planet-wide, high-resolution data has meant that these gradients have not been determined. Here we report infrared spectroscopy of Jupiter with a spatial resolution of 2 degrees in longitude and latitude, extending from pole to equator. We find that temperatures decrease steadily from the auroral polar regions to the equator. Furthermore, during a period of enhanced activity possibly driven by a solar wind compression, a high-temperature planetary-scale structure was observed that may be propagating from the aurora. These observations indicate that Jupiter's upper atmosphere is predominantly heated by the redistribution of auroral energy.

Influence of concomitant injuries on post-concussion symptoms after a mild traumatic brain injury - a prospective multicentre cohort study

Objectives: To compare post-concussion symptoms (PCS) and return to normal activities between mild Traumatic Brain Injury (mTBI) patients with or without concomitant injuries at 7-and 90 days post-mTBI.Methods: Design: Sub-analysis of a multicentre prospective cohort study.

PARTICIPANTS AND SETTING

patients with mTBI from 7 Canadian Emergency Departments.

PROCEDURE

Research assistants conducted telephone follow-ups using the Rivermead Postconcussion Symptoms Questionnaire (RPQ) at 7-, 30- and 90 days post-mTBI.

MAIN OUTCOME

Presence of PCS (RPQ: ≥3 symptoms) at 90 days.

SECONDARY OUTCOMES

RPQ score ≥21, prevalence of individual RPQ symptoms and patients' return to normal activities, at 7- and 90-days. Adjusted risk ratios (RR) were calculated.Results: 1725 mTBI patients were included and 1055 (61.1%) had concomitant injuries. Patients with concomitant injuries were at higher risk of having ≥3 symptoms on the RPQ (RR:1.26 [95% CI 1.01-1.58]) at 90 days. They were also at higher risk of experiencing specific symptoms (dizziness, fatigue, headaches and taking longer to think) and of non-return to their normal activities (RR:2.11 [95% CI 1.30-3.45]).Conclusion: Patients with concomitant injuries have slightly more PCS and seemed to be at higher risk of non-return to their normal activities 90 days, compared to patients without concomitant injuries.

Fatal and Nonfatal Injury Patterns of Stranded Motorists

Because nonfatal and fatal incidents for stranded motorists are not separated from vehicular accidents, little data are available on incident characteristics. To close this gap, data fields were inserted into databases at a medical examiner's office and two trauma centers to collect injury-related information. Forensic nurses and pathologists aided in forming a collaboration among the agencies involved and supported data collection efforts. Data collected over a 5-year period were examined for injury patterns to determine risk factors affecting these patterns. Of the total sample (N = 219), 24.7% had spinal injuries resulting in fatal injuries for 46 of 54 individuals. The odds were stranded motorists with spine-related injuries (C1-C7) had 9.13 times higher risk for a fatal outcome compared with those without spine-related injuries. Severe injuries (Abbreviated Injury Scale scores ≥ 4) noted for head/neck (29.7%) and chest (24.2%) were significantly associated with fatality. Of the 219 cases, 22.8% were inside of a stopped vehicle, and 77.2% were outside a vehicle at the time of injury. Outcomes illustrated the success of the interprofessional collaboration between trauma centers and a medicolegal death investigation agency that resulted in data useful for forensic nurses and pathologists documenting evidence, emergency and trauma responding personnel in patient priority stabilization, and injury prevention specialists for highway safety programs.

540 Point of Care Testing for Tetanus Immunity: A Systematic Review

Introduction

All patients presenting to emergency departments (EDs) with traumatic injuries require tetanus immunity assessments. Inaccurate tetanus vaccination history based on patient recall incurs unnecessary costs on the NHS. Point-of-care immunochromatographic tests (Tetanus Quick Sticks [TQS]) quickly identify tetanus immunity status. We aim to evaluate the diagnostic accuracy and cost-efficacy of TQS to assess their relevance in emergency care.

Method

The systematic review followed PRISMA guidelines. A retrospective search of MEDLINE, Embase, Global Health, HMIC and The Cochrane Library was conducted. Studies were eligible if sensitivity, specificity, or cost-efficacy of TQS were reported. At least two authors independently analysed the data from each study.

Results

12 studies were suitable for inclusion (n = 1,662,865 participants): one retrospective and 11 prospective observational cohort studies. Eight studies assessed diagnostic accuracy with the median sensitivity at 86% (55-100) and the median specificity at 97.5% (1-100). All six studies investigating cost-efficacy reported greater savings when using TQS instead of using vaccination history, due to a decrease in unnecessary tetanus vaccine and immunoglobulin administration.

Conclusions

TQS is a safe diagnostic tool, especially when used by trained operators. TQS widely reduces costs in comparison to traditional vaccination history. We recommend the use of TQS in Emergency Departments throughout the NHS.

The effect of ego depletion on challenge and threat evaluations during a potentially stressful public speaking task

It has been well established that challenge and threat evaluations affect the performance of potentially stressful tasks. However, the factors that influence these evaluations have rarely been examined. Objective: This study examined the effects of ego depletion on challenge and threat evaluations during a public speaking task. Method: 262 participants (150 males, 112 females; M_age = 20.5, SD = 4.3) were randomly assigned to either an ego depletion or control group. Participants then completed self-report measures of trait self-control. The ego depletion group performed a written transcription task requiring self-control, while the control group transcribed the text normally. Before the public speaking task, participant's challenge and threat evaluations and subjective ratings of performance were assessed via self-report items. Results: The results of independent t-tests supported the effectiveness of the self-control manipulation. There were no significant differences between the ego depletion and control groups in terms of challenge and threat evaluations or subjective performance. Additional correlation analyses revealed that trait measures of self-control were significantly and negatively related to challenge and threat evaluations and subjective performance. Conclusion: Findings suggest that ego depletion might not influence appraisals of potentially stressful tasks, and thus add to recent evidence questioning the ego-depletion phenomenon.

Size matters: first-in-human study of a novel 4 French REBOA device

Background

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an emerging technique used for non-compressible torso hemorrhage. However, its current use continues to be limited and there is a need for a simple, fast, and low profile REBOA device. Our objective was to evaluate the feasibility of a novel 4 French REBOA device called the COBRA-OS (Control of Bleeding, Resuscitation, Arterial Occlusion System).

Methods

This study is the first-in-human feasibility trial of the COBRA-OS. Due to the difficulty of trialing the device in the trauma setting, we performed a feasibility study using organ donors (due to the potential usefulness of the COBRA-OS for normothermic regional perfusion) after neurological determination of death (NDD) prior to organ retrieval. Bilateral 4 French introducer sheaths were placed in both femoral arteries and the COBRA-OS was advanced up the right side and deployed in the thoracic aorta (Zone 1). Once aortic occlusion was confirmed via the left-sided arterial line, the device was deflated, moved to the infrarenal aorta (Zone 3), and redeployed.

Results

A total of 7 NDD organ donors were entered into the study, 71% men, with a mean age 46.6 years (range 26 to 64). The COBRA-OS was able to occlude the aorta in Zones 1 and 3 in all patients. The mean time of placing a 4 French sheath was 47.7 seconds (n=13, range 28 to 66 seconds). The mean time from skin to Zone 1 aortic occlusion was 70.1 seconds (range 58 to 105 seconds); mean balloon volumes were 15 mL for Zone 1 (range 13 to 20 mL) and 9 mL for Zone 3 (range 6 to 15 mL); there were no complications and visual inspection of the aorta in all patients revealed no injury.

Discussion

The COBRA-OS is a novel 4 French REBOA device that has demonstrated fast and safe aortic occlusion in this first-in-human feasibility study.

Level of evidence

Level V, therapeutic.

Atmospheric implications of the lack of H3+ detection at Neptune

H3+ has been detected at all of the solar system giant planets aside from Neptune. Current observational upper limits imply that there is far less H3+ emission at Neptune than rudimentary modelling would suggest. Here, we explore via modelling a range of atmospheric conditions in order to find some that could be consistent with observational constraints. In particular, we consider that the upper atmosphere might be much cooler than it was during the 1989 Voyager 2 encounter, and we examine the impact of an enhanced influx of external material that could act to reduce H3+ density. Resulting ionosphere models that are consistent with existing H3+ observational constraints have an exospheric temperature of 450 K or less, 300 K lower than the Voyager 2 value. Alternatively, if a topside CO influx of 2 × 108 cm-2 s-1 is imposed, the upper atmospheric temperature can be higher, up to 550 K. The potential cooling of Neptune's atmosphere is relevant for poorly understood giant planet thermospheric energetics, and would also impact aerobreaking manoeuvers for any future spacecraft. Such a large CO influx, if present, could imply Triton is a very active moon with prominent atmospheric escape, and/or that Neptune's rings significantly modify its upper atmosphere, and the introduction of so much exogenic material would complicate interpretation of the origin of species observed in Neptune's lower atmosphere. This article is part a discussion meeting issue 'Future exploration of ice giant systems'.

Virtual Reality Meditation Among Youth Experiencing Homelessness: Pilot Randomized Controlled Trial of Feasibility

BACKGROUND

Homelessness among youth is devastating, with high rates of substance use disorders and mental health comorbidity. Mindfulness-based interventions that include meditation and mindfulness skills training reduce stress and symptoms of anxiety or depression. However, engaging high-risk youth in interventions is challenging. Virtual reality is a more flexible platform for delivering meditation and may be appealing to youth.

OBJECTIVE

The study objectives were to evaluate the feasibility of delivering virtual reality meditation and of collecting outcome measures, including anxiety and physiologic stress.

METHODS

A sample of 30 youth experiencing homelessness was enrolled in the study. Youth were randomized to receive 10 minutes of one of three interventions: (1) virtual reality meditation, (2) audio meditation (through a web-based platform), or (3) virtual reality imagery of historical pictures and text. Subjects who consented to the study attended two research visits. The first visit collected survey measures of demographics, mental health, and substance use, and oriented subjects to the intervention platforms. The second visit (1-3 days later) delivered the intervention and collected pre and post outcome measures of anxiety and physiologic stress (salivary cortisol). Changes in anxiety and cortisol at the second visit were compared across groups using a linear regression model in which the primary analysis compared virtual reality meditation to audio meditation and secondary analyses compared virtual reality meditation to virtual reality imagery.

RESULTS

Anxiety scores decreased in all groups, with a larger reduction among the virtual reality meditation group (difference=10.8) compared to the web-based meditation or virtual reality images groups (difference=5.8 and 5.0, respectively). After controlling for baseline values, there were no significant group differences in changes in anxiety scores or cortisol levels. In comparing virtual reality meditation and audio meditation, the effect size for anxiety was moderate (Cohen d=0.58) while the effect size for cortisol was small (Cohen d=0.08).

CONCLUSIONS

Preliminary results suggest that virtual reality meditation has a moderate benefit for anxiety but not physiologic stress. Future research is needed to confirm these results in a larger sample and to investigate whether the effects are sustained or increase with repeated use of virtual reality mediation. Virtual reality meditation appears feasible to deliver among homeless youth and merits further study.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04004520; https://clinicaltrials.gov/ct2/show/NCT04004520.

Angioleiomyoma of the Hand: A Case Series and Review of the Literature

Background

Angioleiomyomas are rare tumors arising from vascular tissue that can occasionally present in the hand. Reports of angioleiomyomas in this location are highly limited. Here, we describe the presentation and outcomes of a series of cases of angioleiomyomas.

Methods

A retrospective case review of five patients with angioleiomyomas arising in the hand was performed. Patients were identified via International Classification of Diseases, Ninth and Tenth Revision (ICD-9 and ICD-10) diagnosis codes and were reviewed through the electronic medical record for demographic information, tumor characteristics, management, and outcomes. A literature review was also conducted of angioleiomyomas.

Results

Five patients were diagnosed with angioleiomyoma at our institution between 1992 and 2015. Patients presented with a painful, slow-growing hand mass in all cases. The majority of patients were male and of middle-age. All of the patients were successfully treated with marginal excision and had full return to functional status without recurrence.

Conclusion

Angioleiomyomas are rare tumors that can arise in the hand and should be included in the differential diagnosis of a patient presenting with a painful hand mass. They can be successfully treated with marginal excision.

Regional variations in medical trainee diet and nutrition counseling competencies: Machine learning-augmented propensity score analysis of a prospective multi-site cohort study

BACKGROUND

Medical professionals and students are inadequately trained to respond to rising global obesity and nutrition-related chronic disease epidemics, primarily focusing on cardiovascular disease. Yet, there are no multi-site studies testing evidence-based nutrition education for medical students in preventive cardiology, let alone establishing student dietary and competency patterns.

METHODS

Cooking for Health Optimization with Patients (CHOP; NIH NCT03443635) was the first multi-national cohort study using hands-on cooking and nutrition education as preventive cardiology, monitoring and improving student diets and competencies in patient nutrition education. Propensity-score adjusted multivariable regression was augmented by 43 supervised machine learning algorithms to assess students outcomes from UT Health versus the remaining study sites.

RESULTS

3,248 medical trainees from 20 medical centers and colleges met study criteria from 1 August 2012 to 31 December 2017 with 60 (1.49%) being from UTHealth. Compared to the other study sites, trainees from UTHealth were more likely to consume vegetables daily (OR 1.82, 95%CI 1.04-3.17, p=0.035), strongly agree that nutrition assessment should be routine clinical practice (OR 2.43, 95%CI 1.45-4.05, p=0.001), and that providers can improve patients' health with nutrition education (OR 1.73, 95%CI 1.03-2.91, p=0.038). UTHealth trainees were more likely to have mastered 12 of the 25 competency topics, with the top three being moderate alcohol intake (OR 1.74, 95%CI 0.97-3.11, p=0.062), dietary fats (OR 1.26, 95%CI 0.57-2.80, p=0.568), and calories (OR 1.26, 95%CI 0.70-2.28, p=0.446).

CONCLUSION

This machine learning-augmented causal inference analysis provides the first results that compare medical students nationally in their diets and competencies in nutrition education, highlighting the results from UTHealth. Additional studies are required to determine which factors in the hands-on cooking and nutrition curriculum for UTHealth and other sites produce optimal student - and, eventually, preventive cardiology - outcomes when they educate patients in those classes.

Group Cognitive Behaviour Therapy for Depression - Does it Help Bipolar Patients Too?

Aims:

To compare the effectiveness of a manualised group cognitive behaviour therapy (CBT) programme for people with bipolar disorder (BPD) and major depressive disorder (MDD).

Method:

In addition to treatment as usual (TAU), 17 people with BPD and 17 matched controls with MDD completed 8 or 12 sessions of twice weekly group CBT, followed by 6 booster sessions, held at monthly intervals. Participants completed the Structured Clinical Interview for DSM-IV Axis 1 Disorders, Clinician Version (SCID-1) and the University of Rhode Island Change Assessment (URICA) prior to therapy. They completed the Beck Depression Inventory - II (BDI), the Beck Anxiety Inventory (BAI), the Clinical Outcomes in Routine Evaluation (CORE), the World Health Organisation Quality of Life Brief Version (WHOQoL - BREF) and the Dysfunctional Attitudes Scale (DAS) before and after therapy and at the final follow-up session. The BDI and BAI were also completed at each group session.

Results:

Both groups showed statistically and clinically significant improvement on the BDI and BAI after treatment and at follow-up. Both groups showed a significant improvement on the psychological health sub-scale on the WHOQoL-BREF.

Conclusions:

Manualised group CBT leads to a reduction in the symptoms of depression and anxiety in people with both BPD and MDD and helps improve their perceived quality of life.

Declaration of interest:

None.

Scalpel or Sheath? Outcomes Comparison Between Pre-Peritoneal Pelvic Packing and Angioembolization for Definitive Hemorrhage Control After REBOA

ABSTRACT Background: The role of angioembolization (AE) and pre-peritoneal pelvic packing (PPP) for pelvic hemorrhage control in the era of REBOA has not been well described. Our aim was to investigate outcomes of PPP and AE after REBOA. Methods: Patients who received aortic occlusion (AO) at Zone 3 (distal abdominal aorta) plus PPP and/or AE at 3 high-volume REBOA centers between February 2013 and December 2018 were identified. Outcomes were compared between 3 groups based on procedures performed: REBOA with PPP only (RPPP), REBOA with angioembolization only (RAE), and REBOA with PPP and AE (RPPPAE). Results: 58 patients underwent REBOA at Zone 3; 37 RPPP, 13 RAE, 8 RPPPAE. Mean age was 45±16 years, mean injury severity score (ISS) 35±13, mean SBP pre-AO was 71±19mmHg, and post-AO SBP was 110±34mmHg. In-hospital mortality was 28%, with the majority of deaths occurring in the intensive care unit (17%). Age, ISS, admission SBP, physiology on admission and at the time of AO, response to AO, admission hemoglobin, blood products transfused, and rate of local wound infections were not different between RPPP and RAE groups. Comparing RPPP to RAE groups, duration of AO was significantly lower in the RPPP group (45+34 vs 81+37 mins, p=0.012), while rates of AKI (14% vs 46%) and distal embolism (8% vs 31%) were higher in the RAE group (p=0.015, 0.04 respectively).There was no statistical difference in mortality between RPPP (22%) and RAE patients (39%), including on regression analysis controlling for duration of AO and ongoing CPR at the time of AO. Conclusion: Despite a longer duration of AO and higher rates of ongoing CPR at the time of AO in RAE patients, mortality rates are similar whether hemostasis is achieved after REBOA with pelvic packing or angioembolization. RPPP results in significantly lower systemic and local complication rates.

Trends of clinical outcomes in patients with a Traumatic Brain Injury (TBI) in Canada between 2006 and 2012

BACKGROUND

Traumatic brain injuries (TBI) are the leading cause of death for people aged <40 years. In Canada, the structure of trauma care has evolved independently across provinces during the last decade. However, little is known about the evolution of clinical outcomes. We aimed to compare trends in hospital mortality, unplanned readmission, hospital length of stay (LOS) and intensive care unit (ICU) LOS for TBI between 2006 and 2012 across Canadian provinces.

METHODS

We conducted a retrospective multicentre cohort study based on TBI admissions across Canadian level I and II trauma centres. Data were extracted from the National Trauma Registry linked to hospital discharge databases. All adults with an injury severity score ≥12 were included. Multilevel generalized linear models were used to evaluate trends in clinical outcomes.

RESULTS

Between 2006 and 2012, we observed a decrease in mortality in Canada (odd ratio [OR] = 0.95; 95% confidence intervals [CI] = 0.92-0.98) mostly driven by Ontario (OR = 0.95; 95% CI = 0.93-0.98). We observed a significant decrease in hospital length of stay in Canada (hazard ratio [HR]: hazard of being discharged alive from hospital = 1.02; 95% CI = 1.01-1.02) mostly driven by a decrease in Quebec (HR = 1.03; 95% CI = 1.01-1.04). We observed a decrease in ICU Length of stay only in Alberta (HR = 1.05; 95% CI = 1.01-1.09). No trend was observed for hospital readmissions.

CONCLUSION

We observed significant decreases in mortality, hospital and ICU length of stay for TBI in Canada between 2006 and 2012 but only in certain provinces. This study may represent the first step towards a better understanding of the influence of trauma system configuration on the burden of injuries in Canada.

A qualitative study of e-cigarette emergence and the potential for renormalisation of smoking in UK youth

Background

Growth of e-cigarette use among smokers has raised concerns over uptake by non-smokers, particularly young people. Legislative changes aimed in part at reducing youth exposure to e-cigarettes include the EU Tobacco Products Directive (TPD). A core justification for such measures is the belief that e-cigarettes can lead to tobacco smoking through mechanisms of renormalisation including: mimicking and normalizing the act of smoking; increasing product acceptability via marketing; nicotine exposure. These mechanisms are here explored in relation to findings from qualitative research.

Methods

This paper reports results from twenty-one group interviews with 14–15 year olds in Wales, England and Scotland, conducted as part of an ongoing evaluation of the impact of the TPD on youth smoking and e-cigarette use. Interviews were conducted around the end of the transitional period for TPD implementation, and explored perceptions of e-cigarettes and tobacco, as well as similarities and differences between them.

Results

Young people differentiated between tobacco and e-cigarettes, rejecting the term e-cigarette in favour of alternatives such as ‘vapes’. Experimental or occasional use was common and generally approved of where occurring within social activity with peers. However, regular use outside of this context was widely disapproved of, unless for the purpose of stopping smoking. Increased prevalence of e-cigarettes did not challenge strongly negative views of smoking or reduce perceived harms caused by it, with disapproval of smoking remaining high. Nicotine use was variable, with flavour a stronger driver for choice of e-liquid, and interest more generally.

Conclusion

The extent to which participants differentiated between vaping and smoking, including styles and reasons for use in adults and young people; absence of marketing awareness; and continued strong disapproval of smoking provides limited support for some of the potential mechanisms through which e-cigarettes may renormalise smoking. However caution over nicotine exposure is still necessary.

Intraoperative REBOA: an analysis of the American Association for the Surgery of Trauma AORTA registry

Background

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a less-invasive technique for aortic occlusion (AO). Commonly performed in the emergency department (ED), the role of intraoperative placement is less defined. We hypothesized that operating room (OR) placement is associated with increased in-hospital mortality.

Methods

The American Association for the Surgery of Trauma AORTA registry was used to identify patients undergoing REBOA. Injury characteristics and outcomes data were compared between OR and ED groups. The primary outcome was in-hospital mortality; secondary outcomes included total AO time, transfusion requirements, and acute kidney injury.

Results

Location and timing of catheter insertion were available for 305 of 321 (95%) subjects. 58 patients underwent REBOA in the OR (19%). There were no differences with respect to sex, admission lactate, and Injury Severity Score. The OR group was younger (33 years vs. 41 years, p=0.01) and with more penetrating injuries (36% vs. 15%, p<0.001). There were significant differences with respect to admission physiology. Time from admission to AO was longer in the OR group (75 minutes vs. 23 minutes, p<0.001) as was time to definitive hemostasis (116 minutes vs. 79 minutes, p=0.01). Unadjusted mortality was lower in the OR group (36.2% vs. 68.8%, p<0.001). There were no differences in secondary outcomes. After controlling for covariates, there was no association between insertion location and in-hospital mortality (OR 1.8, 95% CI 0.30 to 11.50).

Discussion

OR REBOA placement is common and generally employed in patients with more stable admission physiology. OR placement was not associated with increased in-hospital mortality despite longer times to AO and definite hemostasis when compared with catheters placed in the ED.

Level of evidence

IV; therapeutic/care management.

The H3+ ionosphere of Uranus: decades-long cooling and local-time morphology

The upper atmosphere of Uranus has been observed to be slowly cooling between 1993 and 2011. New analysis of near-infrared observations of emission from H3+ obtained between 2012 and 2018 reveals that this cooling trend has continued, showing that the upper atmosphere has cooled for 27 years, longer than the length of a nominal season of 21 years. The new observations have offered greater spatial resolution and higher sensitivity than previous ones, enabling the characterization of the H3+ intensity as a function of local time. These profiles peak between 13 and 15 h local time, later than models suggest. The NASA Infrared Telescope Facility iSHELL instrument also provides the detection of a bright H3+ signal on 16 October 2016, rotating into view from the dawn sector. This feature is consistent with an auroral signal, but is the only of its kind present in this comprehensive dataset. This article is part of a discussion meeting issue 'Advances in hydrogen molecular ions: H3+, H5+ and beyond'.

Modelling H3+ in planetary atmospheres: effects of vertical gradients on observed quantities

Since its detection in the aurorae of Jupiter approximately 30 years ago, the H3+ ion has served as an invaluable probe of giant planet upper atmospheres. However, the vast majority of monitoring of planetary H3+ radiation has followed from observations that rely on deriving parameters from column-integrated paths through the emitting layer. Here, we investigate the effects of density and temperature gradients along such paths on the measured H3+ spectrum and its resulting interpretation. In a non-isothermal atmosphere, H3+ column densities retrieved from such observations are found to represent a lower limit, reduced by 20% or more from the true atmospheric value. Global simulations of Uranus' ionosphere reveal that measured H3+ temperature variations are often attributable to well-understood solar zenith angle effects rather than indications of real atmospheric variability. Finally, based on these insights, a preliminary method of deriving vertical temperature structure is demonstrated at Jupiter using model reproductions of electron density and H3+ measurements. The sheer diversity and uncertainty of conditions in planetary atmospheres prohibits this work from providing blanket quantitative correction factors; nonetheless, we illustrate a few simple ways in which the already formidable utility of H3+ observations in understanding planetary atmospheres can be enhanced. This article is part of a discussion meeting issue 'Advances in hydrogen molecular ions: H3+, H5+ and beyond'.

Impact of a telephone-first consultation system in general practice

PURPOSE OF THE STUDY

Increasing pressure on general practice prompts innovative change in service organisation. This study sought to evaluate the impact of introducing a telephone-first consultation system in a socioeconomically deprived population.

STUDY DESIGN

An interrupted time series of preplanned outcomes for 2 years before and 1 year postintroduction of a telephone-first system was used to measure the volume and type of general practitioner (GP) consultations and the number of patients consulted per year. Emergency department (ED) and GP out-of-hours attendances, the number of outpatient referrals, and the number of requests for laboratory tests were measured as secondary outcomes.

RESULTS

The telephone-first system was associated with a 20% increase in total GP consultations (telephone and face-to-face, effect estimate at 12 months, p=0.001). Face-to-face consultations decreased by 39% (p<0.001), while telephone consultations increased by 131% (p<0.001). The volume of individual patient requests for a GP consultation and the number of treatment room nurse consultations did not change. Secondary outcome measures showed no change in hospital outpatient referrals, number of requests for laboratory tests, and ED or GP out-of-hours attendances.

CONCLUSIONS

A telephone-first system in a deprived urban general practice can decrease delays to GP-patient contacts. The number of patients seeking a medical intervention did not differ irrespective of the consultation system used. The telephone-first system did not affect GP out-of-hours, laboratory investigations or secondary care contacts.

The IBD Management Puzzle: Do We Have All the Pieces?

The management of inflammatory bowel disease (IBD) has entered an exciting era, with the optimisation of existing therapies, new strategies being explored that have the potential to further improve patient outcomes, and a growing recognition of the value of a personalised approach to treatment. This symposium explored optimal approaches to using biologic therapy, and the use of therapeutic drug monitoring (TDM) and biomarkers in treatment management. IBD shows a progressive immunopathogenesis, and a ‘window of opportunity’ exists whereby early intervention may alter the disease course. There is a convincing body of evidence supporting early intervention with anti-TNF-α therapies to improve patient outcomes. Cost is the major barrier to initiating and continuing treatment with biologic therapy. Biosimilars have the potential to reduce costs and increase patient access to biologic therapies, enabling more patients to receive biologic treatment earlier. The use of TDM in the treatment of IBD is increasing and offers benefits over standardised approaches to dosing, and it is likely that emerging dose optimisation tools will enable a personalised approach to treatment in the future. Many patients experience loss of response to anti-TNF-α therapy. Biomarkers currently used to monitor treatment response include C reactive protein (CRP), faecal calprotectin, and anti-drug antibodies (ADA). Although biomarker identification is still at an early stage for IBD, several genetic, serological, and microbiome markers have also shown promise in predicting response to anti-TNF-α therapy, while other biomarkers are also under investigation for use in diagnosis, predicting response to therapy, and treatment monitoring.

Migration, ethnicity and mental health: evidence from mothers participating in the Millennium Cohort Study

OBJECTIVES

Over a quarter of UK births are to women who were born outside of the UK. Black and Minority Ethnic (BME) women are disproportionately affected by poor mental health and inequitable access to mental health care in the perinatal period, yet the influence of the migrant status (mothers' UK vs. non-UK birth) is poorly understood. This study aimed to explore the relationship between ethnicity, migration and mental health indicators among mothers participating in a large nationally representative cohort study.

STUDY DESIGN

This is a secondary analysis of data from the Millennium Cohort Study.

METHODS

Logistic regression quantified the crude and adjusted effects of self-reported ethnicity and migrant status on prevalence of psychological distress and treatment for anxiety/depression at 9-month and 5-year postpartum.

RESULTS

We found substantial variation in the prevalence of distress according to ethnicity and migrant status, with Indian and Pakistani women at greatest risk. Despite equal or greater risk, BME and migrant women were less likely to report treatment for anxiety/depression. Mutually adjusted analyses showed ethnicity to be a stronger predictor of both outcomes than migrant status; however, at 5 years, being a migrant independently predicted lower odds of treatment, for a statistically similar level of distress.

CONCLUSIONS

Migrant women are likely to be at high risk of poor mental health in the perinatal period and beyond, yet may face significant barriers to accessing mental health care. A better understanding of ethnicity and migration as interrelated risk factors for perinatal mental ill-health is needed to help National Health Service organisations develop policy and practice that is flexible and responsive to diversity.

Performance of predictive tools to identify individuals at risk of non-traumatic fracture: a systematic review, meta-analysis, and meta-regression

There is no consensus on which tool is the most accurate to assess fracture risk. The results of this systematic review suggest that QFracture, Fracture Risk Assessment Tool (FRAX) with BMD, and Garvan with BMD are the tools with the best discriminative ability. More studies assessing the comparative performance of current tools are needed.

INTRODUCTION

Many tools exist to assess fracture risk. This review aims to determine which tools have the best predictive accuracy to identify individuals at high risk of non-traumatic fracture.

METHODS

Studies assessing the accuracy of tools for prediction of fracture were searched in MEDLINE, EMBASE, Evidence-Based Medicine Reviews, and Global Health. Studies were eligible if discrimination was assessed in a population independent of the derivation cohort. Meta-analyses and meta-regressions were performed on areas under the ROC curve (AUCs). Gender, mean age, age range, and study quality were used as adjustment variables.

RESULTS

We identified 53 validation studies assessing the discriminative ability of 14 tools. Given the small number of studies on some tools, only FRAX, Garvan, and QFracture were compared using meta-regression models. In the unadjusted analyses, QFracture had the best discriminative ability to predict hip fracture (AUC = 0.88). In the adjusted analysis, FRAX with BMD (AUC = 0.81) and Garvan with BMD (AUC = 0.79) had the highest AUCs. For prediction of major osteoporotic fracture, QFracture had the best discriminative ability (AUC = 0.77). For prediction of osteoporotic or any fracture, FRAX with BMD and Garvan with BMD had higher discriminative ability than their versions without BMD (FRAX: AUC = 0.72 vs 0.69, Garvan: AUC = 0.72 vs 0.65). A significant amount of heterogeneity was present in the analyses.

CONCLUSIONS

QFracture, FRAX with BMD, and Garvan with BMD have the highest discriminative performance for predicting fracture. Additional studies in which the performance of current tools is assessed in the same individuals may be performed to confirm this conclusion.

Correction: Safety and utility of image-guided research biopsies in relapsed high-grade serous ovarian carcinoma-experience of the BriTROC consortium

This article was originally published under a CC BY NC SA License, but has now been made available under a CC BY 4.0 License.

'Why us?' Causal attributions of childhood cancer survivors, survivors' parents and community comparisons - a mixed methods analysis

INTRODUCTION

Understanding the cause of their cancer is important for many cancer patients. Childhood cancer survivors'/survivors' parents' beliefs about cancer etiology are understudied. We aimed to assess survivors'/parents' beliefs about what causes childhood cancer, compared with beliefs in the community. We also investigated the influence of clinical and socio-demographic characteristics on the participants' beliefs about cancer etiology.

METHODS

This two-stage study investigated the participants' beliefs, by using questionnaires assessing causal attributions related to childhood cancer (stage 1) and then undertaking telephone interviews (stage 2; survivors/survivors' parents only) to get an in-depth understanding of survivors'/survivors' parents beliefs. We computed multivariable regressions to identify factors associated with the most commonly endorsed attributions: bad luck/chance, environmental factors and genetics. We analyzed interviews using thematic analysis.

RESULTS

Six hundred one individuals (64.6% survivors and 35.4% survivors' parents) and 510 community comparisons (53.1% community adults, 46.9% community parents) completed the question on causal attributions. We conducted 87 in-depth interviews. Survivors/survivors' parents (73.9%) were more likely to believe that chance/bad luck caused childhood cancer than community participants (42.4%). Community participants more frequently endorsed that genetics (75.3%) and environmental factors (65.3%) played a major role in childhood cancer etiology (versus survivors' and survivors' parents: genetics 20.6%, environmental factors: 19.3%). Community participants, participants with a first language other than English, and reporting a lower quality of life were less likely to attribute bad luck as a cause of childhood cancer. Community participants, all participants with a higher income and higher education were more likely to attribute childhood cancer etiology to environmental factors.

CONCLUSION

Causal attributions differed between survivors/survivors' parents and community participants. Most of the parents and survivors seem to understand that there is nothing they have done to cause the cancer. Understanding survivors' and survivors' parents' causal attributions may be crucial to address misconceptions, offer access to services and to adapt current and future health behaviors.