Improving hybrid image and structure-based deformable image registration for large internal deformations

Objective.Deformable image registration (DIR) is a widely used technique in radiotherapy. Complex deformations, resulting from large anatomical changes, are a regular challenge. DIR algorithms generally seek a balance between capturing large deformations and preserving a smooth deformation vector field (DVF). We propose a novel structure-based term that can enhance the registration efficacy while ensuring a smooth DVF.Approach.The proposed novel similarity metric for controlling structures was introduced as a new term into a commercially available algorithm. Its performance was compared to the original algorithm using a dataset of 46 patients who received pelvic re-irradiation, many of which exhibited complex deformations.Main results.The mean Dice Similarity Coefficient (DSC) under the improved algorithm was 0.96, 0.94, 0.76, and 0.91 for bladder, rectum, colon, and bone respectively, compared to 0.69, 0.89, 0.62, and 0.88 for the original algorithm. The improvement was more pronounced for complex deformations.Significance.With this work, we have demonstrated that the proposed term is able to improve registration accuracy for complex cases while maintaining realistic deformations.

Hitting the Target: Developing High-quality Evidence for Proton Beam Therapy Through Randomised Controlled Trials

The National Health Service strategy for the delivery of proton beam therapy (PBT) in the UK provides a unique opportunity to deliver high-quality evidence for PBT through randomised controlled trials (RCTs). We present a summary of three UK PBT RCTs in progress, including consideration of their key design characteristics and outcome assessments, to inform and support future PBT trial development. The first three UK multicentre phase III PBT RCTs (TORPEdO, PARABLE and APPROACH), will compare PBT with photon radiotherapy for oropharyngeal squamous cell carcinoma, breast cancer and oligodendroglioma, respectively. All three studies were designed by multidisciplinary teams, which combined expertise from clinicians, clinical trialists and scientists with strong patient advocacy and guidance from national radiotherapy research networks and international collaborators. Consistent across all three studies is a focus on the reduction of long-term radiotherapy-related toxicities and an evaluation of patient-reported outcomes and health-related quality of life, which will address key uncertainties regarding the clinical benefits of PBT. Innovative translational components will provide insights into mechanisms of toxicity and help to frame the key future research questions regarding PBT. The UK radiotherapy research community is developing and delivering an internationally impactful PBT research portfolio. The combination of data from RCTs with prospectively collected data from a national PBT outcomes registry will provide an innovative, high-quality repository for PBT research and the platform to design and deliver future trials of PBT.

Commentary on the published position statement regarding the pathogenesis of fetal basal ganglia- thalamic hypoxic-ischaemic injury

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Parental sensitivity to toddler's need for autonomy: An empirical study on mother-toddler and father-toddler interactions during feeding and play

During the second year of life, children's need for autonomy grows, and their behaviors become increasingly complex. Parental sensitivity to children's different cues is important in supporting adaptive psycho-emotional development. The present study assumes that mothers and fathers may respond with varying levels of sensitivity to the child's different cues, with particular attention to requests for greater autonomy. The study also examines the possible role played by interactive contexts (ie., play and feeding) and children's and parents' individual factors. The sample comprised N = 91 families with children aged between 12 and 24 months. Mother-toddler and father-toddler interactions were assessed during feeding and play. Parents completed questionnaires assessing children's temperament, psychopathological risk, and parenting stress. RESULTS: showed that toddlers' demands for autonomy were the most frequent cues in both play and feeding contexts, both with mothers and fathers. Furthermore, parents were more sensitive to toddlers' requests for cooperation than their requests for autonomy, in both interactive contexts. Moreover, mothers and fathers showed higher sensitivity to toddlers' demands for greater autonomy in the play context rather than in the feeding context. Mothers were more sensitive than fathers to toddlers' cues of resistance to parents' actions and to toddlers' requests for cooperation. Results showed differences and specificities in mother-toddler and father-toddler interactions in the two interactive contexts, showing associations between child negative emotionality, parental psychopathological risk and parenting stress, and maternal and paternal sensitivity to toddlers' demands for greater autonomy during play and feeding, respectively. These results confirm the initial hypotheses regarding parental sensitivity and its differential expression according to child cues. Implications are discussed.

Same but different - pseudo-pectin in the charophytic alga Chlorokybus atmophyticus

All land-plant cell walls possess hemicelluloses, cellulose and anionic pectin. The walls of their cousins, the charophytic algae, exhibit some similarities to land plants' but also major differences. Charophyte 'pectins' are extractable by conventional land-plant methods, although they differ significantly in composition. Here, we explore 'pectins' of an early-diverging charophyte, Chlorokybus atmophyticus, characterising the anionic polysaccharides that may be comparable to 'pectins' in other streptophytes. Chlorokybus 'pectin' was anionic and upon acid hydrolysis gave GlcA, GalA and sulphate, plus neutral sugars (Ara≈Glc>Gal>Xyl); Rha was undetectable. Most Gal was the l-enantiomer. A relatively acid-resistant disaccharide was characterised as β-d-GlcA-(1→4)-l-Gal. Two Chlorokybus 'pectin' fractions, separable by anion-exchange chromatography, had similar sugar compositions but different sulphate-ester contents. No sugars were released from Chlorokybus 'pectin' by several endo-hydrolases [(1,5)-α-l-arabinanase, (1,4)-β-d-galactanase, (1,4)-β-d-xylanase, endo-polygalacturonase] and exo-hydrolases [α- and β-d-galactosidases, α-(1,6)-d-xylosidase]. 'Driselase', which hydrolyses most land-plant cell wall polysaccharides to mono- and disaccharides, released no sugars except traces of starch-derived Glc. Thus, the Ara, Gal, Xyl and GalA of Chlorokybus 'pectin' were not non-reducing termini with configurations familiar from land-plant polysaccharides (α-l-Araf, α- and β-d-Galp, α- and β-d-Xylp and α-d-GalpA), nor mid-chain residues of α-(1→5)-l-arabinan, β-(1→4)-d-galactan, β-(1→4)-d-xylan or α-(1→4)-d-galacturonan. In conclusion, Chlorokybus possesses anionic 'pectic' polysaccharides, possibly fulfilling pectic roles but differing fundamentally from land-plant pectin. Thus, the evolution of land-plant pectin since the last common ancestor of Chlorokybus and land plants is a long and meandering path involving loss of sulphate, most l-Gal and most d-GlcA; re-configuration of Ara, Xyl and GalA; and gain of Rha.

Similarities and differences in the functional architecture of mother- infant communication in rhesus macaque and British mother-infant dyads

Similarly to humans, rhesus macaques engage in mother-infant face-to-face interactions. However, no previous studies have described the naturally occurring structure and development of mother-infant interactions in this population and used a comparative-developmental perspective to directly compare them to the ones reported in humans. Here, we investigate the development of infant communication, and maternal responsiveness in the two groups. We video-recorded mother-infant interactions in both groups in naturalistic settings and analysed them with the same micro-analytic coding scheme. Results show that infant social expressiveness and maternal responsiveness are similarly structured in humans and macaques. Both human and macaque mothers use specific mirroring responses to specific infant social behaviours (modified mirroring to communicative signals, enriched mirroring to affiliative gestures). However, important differences were identified in the development of infant social expressiveness, and in forms of maternal responsiveness, with vocal responses and marking behaviours being predominantly human. Results indicate a common functional architecture of mother-infant communication in humans and monkeys, and contribute to theories concerning the evolution of specific traits of human behaviour.

Use of Physical Activity Measures in Rehabilitation Interventions Following Lower Extremity Amputation

Purpose of Review

This systematic review aims to evaluate physical performance outcome tools that are used most frequently to assess rehabilitation interventions. The scope of this paper focused on outcomes used with established lower limb amputees when assessing interventions such as exercise programs or changes in prescription published in the last 5 years.

Recent Findings

The most recorded outcome measures used across all the papers were timed walk tests and the Activity Balance Confidence Scale. Many outcomes did not produce statistically significant results with established amputee cohorts. Understanding the minimal important clinical difference is key.

Summary

The use of outcome measures is essential. Training and education are likely to increase the use of outcome measures. Quality of life measures are important in conjunction with physical outcomes. Simple timed walk tests are commonly used. These are in general easy to administer requiring a small space, limited equipment, and a short time frame.

P15.04.B Serial18F-fluciclovine PET-CT and multiparametric MRI during chemoradiation for glioblastoma - an exploratory clinical study with pre-clinical correlation

Background

Positron emission tomography (PET) using anti-1-amino-3-18fluorine-fluorocyclobutane-1-carboxylic acid (18F-fluciclovine) shows preferential glioma cell uptake with low activity in normal brain. Dynamic contrast-enhanced (DCE) MRI may also be used to investigate regions of glioma that do not show gadolinium-enhancement on post-contrast T1-weighted MR sequences (Gd-T1) and may reflect tumour infiltration beyond the Gd-T1 enhancing margin. There is a paucity of data on how 18F-fluciclovine uptake correlates with Gd-T1 and DCE-MRI activity, how it correlates with tumour biology and whether significant changes in uptake occur during treatment. The aims of this pilot study were: 1 To compare 18F-fluciclovine PET, DCE-MRI and Gd-T1 in patients undergoing chemoradiotherapy for glioblastoma (GBM) 2 To investigate correlation between 18F-fluciclovine uptake, MRI findings, and tumour biology in a pre-clinical glioma model.

Material and Methods

18F-fluciclovine-PET-CT and MRI including DCE-MRI were acquired before, during and after adjuvant chemoradiotherapy (60 Gy in 30 fractions with temozolomide) in GBM patients. DCE-MRI and Gd-T1 volumes were manually contoured, and PET volumes defined using semi-automatic thresholding. Gd-T1 was subtracted from PET and DCE-MRI volumes to identify areas beyond the Gd-T1 volume boundary and similarity of the PET and DCE-MRI volumes outside the Gd-T1 volume boundary were measured using the Dice similarity coefficient (DSC). CT-2A tumour cells were stereotactically injected into the right striatum of 8 to 10-week-old C57BL6J mice and they underwent MRI and 18F-fluciclovine PET-CT. Post-mortem mice brains underwent immunohistochemistry staining for ASCT2 (amino acid transporter), nestin (stemness) and Ki-67 (proliferation) to assess for biologically active tumour.

Results

6 patients were recruited (GBM 1-6). For GBM 1-3: PET volumes were greater than DCE-MRI, in turn greater than Gd-T1. For GBM 4-6, Gd-T1 volumes were similar to DCE-MRI and both were greater than PET volumes. GBM 1-3 had lower overall survival than GBM 4-6: median 249 vs. 903 days. 18F-fluciclovine uptake and Gd uptake (on DCE-MRI) was seen beyond the margins of the standard Gd-T1 volume. Comparing these regions beyond the Gd-T1 margins, the PET and DCE-MRI had low DSC, suggesting distinct areas of fluciclovine and DCE-MRI uptake. Pre-clinical PET-CT demonstrated tumour-specific 18F-fluciclovine uptake which corresponded to biologically active tumour based on immunostaining for Ki-67, nestin and ASCT2.

Conclusion

Results from this joint pre-clinical and clinical pilot study suggest volumes of 18F-fluciclovine-PET activity beyond that depicted by MRI-DCE and Gd-T1 are associated with a poorer prognosis in patients undergoing chemoradiotherapy for GBM. The pre-clinical model confirmed 18F-fluciclovine uptake reflected biologically active tumour.

P08.05.B Communication in the context of glioblastoma treatment: what matters most to patients and caregivers

Background

Given the poor prognosis of glioblastoma, with short survival times regardless of treatment, it is critical that the benefits and risks of treatments are clearly discussed with patients and family caregivers. The respective value of quantity versus quality of life varies for each individual. Yet, effective communication can be complicated by emotional responses following diagnosis, patients’ neurocognitive deficits, and sometimes, lower health literacy. We aimed to investigate patient and caregiver experiences and preferences around glioblastoma treatment communication.

Material and Methods

Semi-structured qualitative interviews were conducted with adult glioblastoma patients and their caregivers, interviewed as dyads or individuals. Purposive sampling was used to capture views across the entire disease trajectory. Interviews were recorded, transcribed verbatim, and analysed for common themes. Analysis is ongoing and will be completed by June 2022, with preliminary findings described below.

Results

In total, 15 glioblastoma patients and 13 caregivers took part, 8 as dyads. Five main themes were found. 1) Communication experiences. A rush to get treatment underway can limit adequate communication. Patients and caregivers described that risks of treatment were clearly explained, but perceived it as ‘the only option’. 2) Communication preferences. Balanced and sensitive communication of prognostic information was desired, with uncertainty providing hope as well as being a burden. Patients and caregivers can have different information and support needs, requiring separate and proactive communication. 3) What matters most. Participants valued feeling involved, having clear and reliable information and support from the treatment team, and developing a personable relationship. In terms of treatment goals, they valued extending life with good quality of life. 4) Decision-making. Participants emphasised the importance of being involved in decisions, involving caregivers, and following treatment team advice. While faced with extremely limited treatment options, they valued having a sense of control over declining, pausing or stopping treatment. 5) Impact of Covid-19. In general, patients described limited impact of the measures taken during the pandemic (e.g., masks, telephone consultations), whilst caregivers highlighted specific issues around not being able to support patients in emergencies, expressing/reading nonverbal cues, or fully participating in telephone consultations.

Conclusion

Glioblastoma patients and caregivers value sensitive, comprehensive and comprehensible communication around treatment risks and benefits, and supportive care. Involving and supporting caregivers is critical.

P08.08.B Long-term survival and health-related quality of life in meningioma patients: a mixed-methods systematic review

Background

Meningiomas account for approximately 36% of all primary brain tumours. These tumours have a relatively favourable prognosis with approximately 92% of meningioma patients surviving >5 years after diagnosis. Yet, patients report high disease burden and survivorship issues even years after treatment, including cognitive issues and anxiety/depression affecting health-related quality of life (HRQOL). We aimed to systematically review the literature and synthesise evidence on HRQOL in meningioma patients across long-term survival, defined as >2 years post diagnosis.

Material and Methods

Systematic literature searches were carried out using Medline, EMBASE, CINAHL, PsycINFO, and Web of Science Core Collection up to November 2021. Two independent assessors carried out screening. Any published, peer reviewed article with primary quantitative or qualitative data covering the physical, mental, and/or social aspects of HRQOL were included. Quality was assessed using the Mixed Methods Appraisal Tool, before a data-based convergent synthesis design was used to interpret findings.

Results

The search returned 2252 articles. Following screening 12 papers were included in the review. The majority of studies used quantitative methods, with only one study reporting mixed-methodology. Two of these were articles from the same study. Most used cross-sectional assessments (n =10) with two reporting longitudinal assessments (n = 2). Included meningioma patient samples (n=2990 in total) represented a wide range of survival lengths (range: 24 months - 10 years). HRQOL was impacted predominantly through physical and mental issues, including persevering symptoms (e.g. headaches, fatigue, vision problems) and emotional difficulties (e.g. poorer mental and general health perceptions). Returning to work proved difficult for patients due to cognitive and social deficits (e.g. issues with concentration, procrastination and isolation). Factors including age and comorbidities, but also treatment type appears to affect patients’ satisfaction with their HRQOL.

Conclusion

While overall prognosis following a meningioma diagnosis is good, meningioma patients’ HRQOL appears affected throughout long-term survivorship. Findings from this review could be beneficial in addressing the HRQOL and supportive-care needs of patients across long-term survivorship.

UK 2022 Consensus on Normal Tissue Dose-Volume Constraints for Oligometastatic, Primary Lung and Hepatocellular Carcinoma Stereotactic Ablative Radiotherapy

The use of stereotactic ablative radiotherapy (SABR) in the UK has expanded over the past decade, in part as the result of several UK clinical trials and a recent NHS England Commissioning through Evaluation programme. A UK SABR Consortium consensus for normal tissue constraints for SABR was published in 2017, based on the existing literature at the time. The published literature regarding SABR has increased in volume over the past 5 years and multiple UK centres are currently working to develop new SABR services. A review and update of the previous consensus is therefore appropriate and timely. It is hoped that this document will provide a useful resource to facilitate safe and consistent SABR practice.

A treatment planning comparison of photon stereotactic ablative radiotherapy and proton beam therapy for the re-irradiation of pelvic cancer recurrence

BACKGROUND

Patients who experience a pelvic cancer recurrence in or near a region that received initial radiotherapy, typically have few options for treatment. Organs at risk (OAR) have often reached their dose constraint limits leaving minimal dose remaining for standard re-irradiation (reRT). However, photon based stereotactic ablative radiotherapy (SABR) has been utilised for reRT with promising initial results although meeting OAR constraints can be challenging. Proton beam therapy (PBT) could offer an advantage.

MATERIALS AND METHODS

SABR plans used for treatment for ten pelvic reRT patients were dosimetrically compared to PBT plans retrospectively planned using the same CT and contour data. PBT plans were created to match the CTV dose coverage of SABR treatment plans with V100% ≥95%. An 'as low as reasonably achievable' approach was taken to OAR tolerances with consideration of OAR dose from the initial radiation (using equivalent dose in 2 Gy fractions).

RESULTS

Dosimetric comparison of relevant OAR statistics showed a decrease in OAR dose using PBT over SABR in all patients, with equivalent target coverage. The largest statistically significant reduction was seen for the colon D0.5 cm3 with a median reduction from 13.1 Gy to 5.9 Gy. There were statistically significant dose reductions in the median dose to small bowel, sacral plexus and cauda equina.

CONCLUSION

PBT has the potential for significant dose reductions for OARs in the pelvic reRT setting compared to SABR. However, it remains unclear if the magnitude of these OAR dose reductions will translate into clinical benefit.

Food for all: designing sustainable and secure future seafood systems

Food from the sea can make a larger contribution to healthy and sustainable diets, and to addressing hunger and malnutrition, through improvements in production, distribution and equitable access to wild harvest and mariculture resources and products. The supply and consumption of seafood is influenced by a range of 'drivers' including ecosystem change and ocean regulation, the influence of corporations and evolving consumer demand, as well as the growing focus on the importance of seafood for meeting nutritional needs. These drivers need to be examined in a holistic way to develop an informed understanding of the needs, potential impacts and solutions that align seafood production and consumption with relevant 2030 Sustainable Development Goals (SDGs). This paper uses an evidence-based narrative approach to examine how the anticipated global trends for seafood might be experienced by people in different social, geographical and economic situations over the next ten years. Key drivers influencing seafood within the global food system are identified and used to construct a future scenario based on our current trajectory (Business-as-usual 2030). Descriptive pathways and actions are then presented for a more sustainable future scenario that strives towards achieving the SDGs as far as technically possible (More sustainable 2030). Prioritising actions that not only sustainably produce more seafood, but consider aspects of access and utilisation, particularly for people affected by food insecurity and malnutrition, is an essential part of designing sustainable and secure future seafood systems.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s11160-021-09663-x.

Food for all: designing sustainable and secure future seafood systems

Food from the sea can make a larger contribution to healthy and sustainable diets, and to addressing hunger and malnutrition, through improvements in production, distribution and equitable access to wild harvest and mariculture resources and products. The supply and consumption of seafood is influenced by a range of 'drivers' including ecosystem change and ocean regulation, the influence of corporations and evolving consumer demand, as well as the growing focus on the importance of seafood for meeting nutritional needs. These drivers need to be examined in a holistic way to develop an informed understanding of the needs, potential impacts and solutions that align seafood production and consumption with relevant 2030 Sustainable Development Goals (SDGs). This paper uses an evidence-based narrative approach to examine how the anticipated global trends for seafood might be experienced by people in different social, geographical and economic situations over the next ten years. Key drivers influencing seafood within the global food system are identified and used to construct a future scenario based on our current trajectory (Business-as-usual 2030). Descriptive pathways and actions are then presented for a more sustainable future scenario that strives towards achieving the SDGs as far as technically possible (More sustainable 2030). Prioritising actions that not only sustainably produce more seafood, but consider aspects of access and utilisation, particularly for people affected by food insecurity and malnutrition, is an essential part of designing sustainable and secure future seafood systems.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s11160-021-09663-x.

The Impact of Intra-thoracic Anatomical Changes upon the Delivery of Lung Stereotactic Ablative Radiotherapy

AIMS

So far, the impact of intra-thoracic anatomical changes (ITACs) on patients treated with stereotactic ablative radiotherapy (SABR) for early-stage non-small cell lung cancer is unknown. Studying these is important, as ITACs have the potential to impact the workflow and reduce treatment quality. The aim of this study was to assess and categorise ITACs, as detected on cone beam computed tomography scans (CBCT), and their subsequent impact upon treatment in lung cancer patients treated with SABR.

MATERIALS AND METHODS

CBCTs from 100 patients treated with SABR for early non-small cell lung cancer were retrospectively reviewed. The presence of the following ITACs was assessed: atelectasis, infiltrative change, pleural effusion, baseline shift and gross tumour volume (GTV) increase and decrease. ITACs were graded using a traffic light protocol. This was adapted from a tool previously developed to assesses potential target undercoverage or organ at risk overdose. The frequency of physics or clinician review was noted. A linear mixed effects model was used to assess the relationship between ITAC grade and set-up time (time from first CBCT to beam delivery).

RESULTS

ITACs were observed in 22% of patients. Twenty-one per cent of these were categorised as 'red', implying a risk of underdosage to the GTV. Most were 'yellow' (51%), indicating little impact upon planning target volume coverage of the GTV. Physics or clinician review was required in 10% of all treatment fractions overall. Three patients needed their treatment replanned. The mixed effect model analysis showed that ITACs cause a significant prolongation of set-up time (Χ2(3) = 9.22, P = 0.02).

CONCLUSION

Most ITACs were minor, but associated with unplanned physics or clinician review, representing a potentially significant resource burden. ITACs also had a significant impact upon set-up time, with consequences for the wider workflow and intra-fraction motion. Detailed guidance on the management of ITACs is needed to provide support for therapeutic radiographers delivering lung SABR.

P11.02 Long-term impact of primary brain tumour diagnosis on health-related quality of life: a systematic review

BACKGROUND

A primary brain tumour (PrBT) diagnosis can be devastating, and results in a wide range of symptoms. Relatively little is known about the long-term challenges these symptoms pose on HRQOL. The aim of this review is to identify the long-term HRQOL issues reported at least two years following diagnosis of a PrBT.

MATERIAL AND METHODS

Systematic literature searches were carried out using Medline, EMBASE, CINAHL, PsycINFO and Web of Science Core Collection. Searches were designed to identify a range of reported HRQOL aspects defined as physical, mental or social issues, in adult WHO grade II or III patients. To capture the full extent of patients’ experience, studies of any design reporting on primary data where patients had at least two years follow-up from diagnosis were included. WHO grade I and grade IV tumours were excluded due to their different prognoses and the expected nature of their disease trajectories. Quality assessment was conducted using the Mixed Methods Appraisal Tool (MMAT). Narrative synthesis was used to collate findings.

RESULTS

The search returned 8438 articles. 477 titles remained after title and abstract screening, with eighteen full text articles included in the final analysis. The majority of studies used quantitative methods, with only two articles reporting qualitative or mixed methodology. Articles were predominantly cross-sectional studies (n = 10), along with cohort studies (n = 3), clinical trials (n = 3) and pilot studies (n = 2). Results indicated that patients reported a variety of issues influencing their HRQOL, with emotional/psychological/cognitive changes being the most commonly reported. Physical complaints included problems with fatigue, seizures and maintaining daily activity. Social challenges included strained social relationships and issues managing finances. Patient coping strategies were found to significantly influence wellbeing and subsequent HRQOL.

CONCLUSION

PrBT patients’ long-term HRQOL and daily functioning can be impacted by their physical, mental and social wellbeing. Findings from this review lay the groundwork for efforts to improve patient HRQOL in long-term survivorship.

Fruit softening: evidence for pectate lyase action in vivo in date (Phoenix dactylifera) and rosaceous fruit cell walls

BACKGROUND AND AIMS

The programmed softening occurring during fruit development requires scission of cell wall polysaccharides, especially pectin. Proposed mechanisms include the action of wall enzymes or hydroxyl radicals. Enzyme activities found in fruit extracts include pectate lyase (PL) and endo-polygalacturonase (EPG), which, in vitro, cleave de-esterified homogalacturonan in mid-chain by β-elimination and hydrolysis, respectively. However, the important biological question of whether PL exhibits action in vivo had not been tested.

METHODS

We developed a method for specifically and sensitively detecting in-vivo PL products, based on Driselase digestion of cell wall polysaccharides and detection of the characteristic unsaturated product of PL action.

KEY RESULTS

In model in-vitro experiments, pectic homogalacturonan that had been partially cleaved by commercial PL was digested to completion with Driselase, releasing an unsaturated disaccharide ('ΔUA-GalA'), taken as diagnostic of PL action. ΔUA-GalA was separated from saturated oligogalacturonides (EPG products) by electrophoresis, then subjected to thin-layer chromatography (TLC), resolving ΔUA-GalA from higher homologues. The ΔUA-GalA was confirmed as 4-deoxy-β-l-threo-hex-4-enopyranuronosyl-(1→4)-d-galacturonic acid by NMR spectroscopy. Driselase digestion of cell walls from ripe fruits of date (Phoenix dactylifera), pear (Pyrus communis), rowan (Sorbus aucuparia) and apple (Malus pumila) yielded ΔUA-GalA, demonstrating that PL had been acting in vivo in these fruits prior to harvest. Date-derived ΔUA-GalA was verified by negative-mode mass spectrometry, including collision-induced dissociation (CID) fragmentation. The ΔUA-GalA:GalA ratio from ripe dates was roughly 1:20 (mol mol-1), indicating that approx. 5 % of the bonds in endogenous homogalacturonan had been cleaved by in-vivo PL action.

CONCLUSIONS

The results provide the first demonstration that PL, previously known from studies of fruit gene expression, proteomic studies and in-vitro enzyme activity, exhibits enzyme action in the walls of soft fruits and may thus be proposed to contribute to fruit softening.

Direct monitoring of biocatalytic deacetylation of amino acid substrates by 1H NMR reveals fine details of substrate specificity

Amino acids are key synthetic building blocks that can be prepared in an enantiopure form by biocatalytic methods. We show that the l-selective ornithine deacetylase ArgE catalyses hydrolysis of a wide-range of N-acyl-amino acid substrates. This activity was revealed by 1H NMR spectroscopy that monitored the appearance of the well resolved signal of the acetate product. Furthermore, the assay was used to probe the subtle structural selectivity of the biocatalyst using a substrate that could adopt different rotameric conformations.

Multicentre Investigation of Prognostic Factors Incorporating p16 and Tumour Infiltrating Lymphocytes for Anal Cancer After Chemoradiotherapy

AIMS

Anal squamous cell carcinomas (ASCC) are strongly associated with human papillomaviruses. Standard of care is chemoradiotherapy at uniform doses with no treatment stratification. Immunohistochemical staining for p16INK4A (p16), a surrogate for human papillomaviruses, is prognostic for outcomes. We investigated this alongside clinical-pathological factors, including tumour infiltrating lymphocyte (TIL) scores.

MATERIALS AND METHODS

Using an independent, multicentre cohort of 257 ASCC treated with chemoradiotherapy, pretreatment biopsies were stained and scored for p16 and TIL. Kaplan-Meier curves were derived for outcomes (disease-free survival [DFS], overall survival and cancer-specific survival), by stage, p16 and TIL scores and Log-rank tests were carried out to investigate prognostic effect. A multivariate analysis was carried out using Cox regression.

RESULTS

Stage, sex, p16 and TILs were independently prognostic. Hazard ratios for death (overall survival) were 2.51 (95% confidence interval 1.36-4.63) for p16 negative versus p16 positive, 2.17 (1.34-3.5) for T3/4 versus T1/2, 2.42 (1.52-3.8) for males versus females and 3.30 (1.52-7.14) for TIL1 versus TIL3 (all P < 0.05).

CONCLUSIONS

We have refined prognostic factors in ASCC. p16 adds to stratification by stage with respect to DFS in early disease and overall survival/DFS in locally advanced cancers. Our data support the role of the host immune response in mediating outcomes. These factors will be prospectively evaluated in PLATO (ISRCTN88455282).

Considerations for COVID-19 vaccination in pregnancy

Pregnant women are at greater risk of severe COVID-19 than non-pregnant women. Despite limited safety data on use of COVID-19 vaccines in pregnancy, many international societies have recommended their use when pregnant women are at particularly high risk of acquiring COVID-19, or have suggested that vaccines should not be withheld from pregnant women where no other contraindications to COVID-19 vaccination exist. A number of vaccines, including those against influenza, tetanus and pertussis, have been shown to reduce both maternal and infant morbidity and mortality when used antenatally. We explore the role of COVID-19 vaccination in the setting of pregnancy, discuss the limited data available, and summarise current international guidelines.

Oral cysteamine as an adjunct treatment in cystic fibrosis pulmonary exacerbations: An exploratory randomized clinical trial

BACKGROUND

Emerging data suggests a possible role for cysteamine as an adjunct treatment for pulmonary exacerbations of cystic fibrosis (CF) that continue to be a major clinical challenge. There are no studies investigating the use of cysteamine in pulmonary exacerbations of CF. This exploratory randomized clinical trial was conducted to answer the question: In future pivotal trials of cysteamine as an adjunct treatment in pulmonary exacerbations of CF, which candidate cysteamine dosing regimens should be tested and which are the most appropriate, clinically meaningful outcome measures to employ as endpoints?

METHODS AND FINDINGS

Multicentre double-blind randomized clinical trial. Adults experiencing a pulmonary exacerbation of CF being treated with standard care that included aminoglycoside therapy were randomized equally to a concomitant 14-day course of placebo, or one of 5 dosing regimens of cysteamine. Outcomes were recorded on days 0, 7, 14 and 21 and included sputum bacterial load and the patient reported outcome measures (PROMs): Chronic Respiratory Infection Symptom Score (CRISS), the Cystic Fibrosis Questionnaire-Revised (CFQ-R); FEV1, blood leukocyte count, and inflammatory markers. Eighty nine participants in fifteen US and EU centres were randomized, 78 completed the 14-day treatment period. Cysteamine had no significant effect on sputum bacterial load, however technical difficulties limited interpretation. The most consistent findings were for cysteamine 450mg twice daily that had effects additional to that observed with placebo, with improved symptoms, CRISS additional 9.85 points (95% CI 0.02, 19.7) p = 0.05, reduced blood leukocyte count by 2.46x109 /l (95% CI 0.11, 4.80), p = 0.041 and reduced CRP by geometric mean 2.57 nmol/l (95% CI 0.15, 0.99), p = 0.049.

CONCLUSION

In this exploratory study cysteamine appeared to be safe and well-tolerated. Future pivotal trials investigating the utility of cysteamine in pulmonary exacerbations of CF need to include the cysteamine 450mg doses and CRISS and blood leukocyte count as outcome measures.

CLINICAL TRIAL REGISTRATION

NCT03000348; www.clinicaltrials.gov.

Structural racism, socio-economic marginalization, and infant mortality

OBJECTIVES

We examine associations between infant mortality rates (IMRs) and measures of structural racism and socio-economic marginalization in Chicago, Illinois. Our purpose was to determine whether the Index of Concentration at the Extremes (ICE) was significantly related to community-level IMRs.

STUDY DESIGN

We use a cross-sectional ecological public health design to examine community-level factors related to IMRs in Chicago neighborhoods.

METHODS

We use data from the Chicago Department of Public Health and the American Community Survey to examine IMR inequities during the period 2012-2016. Calculations of the ICE for race and income were undertaken. In addition, we calculated racialized socio-economic status, which is the concentration of affluent Whites relative to poor Blacks in a community area. We present these ICE measures, as well as hardship, percent of births with inadequate prenatal care (PNC), and the percent of single-parent households as quintiles so that we can compare neighborhoods with the most disadvantage with neighborhoods with the least. Negative binomial regression was used to determine whether the ICE measures were independently related to community IMRs, net of hardship scores, PNC, and single-parent households.

RESULTS

Spearman correlation results indicate significant associations in Chicago communities between measures of racial segregation and economic marginalization and IMRs. Community areas with the lowest ICE_Race scores (those with the largest concentrations of Black residents, compared with White) had IMRs that were 3.63 times higher than those communities with the largest concentrations of White residents. Most associations between community IMRS and measures of structural racism and socioeconomic marginalization are accounted for in fully adjusted negative binomial regression models. Only ICERace remained significantly related to IMRs.

CONCLUSIONS

We show that structural racism as represented by the ICE is independently related to IMRs in Chicago; community areas with the largest concentrations of Blacks residents compared with Whites are those with the highest IMRs. This relationship persists even after controlling for socio-economic marginalization, hardship, household composition/family support, and healthcare access. Interventions to improve birth outcomes must address structural determinants of health inequities.

The stable component of maternal depressive symptoms predicts offspring emotional and behavioral symptoms: a 9-years longitudinal study

Background

Maternal sub-threshold and non-clinical depression and its possible outcomes on offspring internalizing/externalizing symptoms has received growing attention in recent years because of its significant worldwide prevalence.

Methods

Through a Latent State-Trait Analysis approach (LST), this longitudinal study aimed to identify a stable component of non-clinical maternal depression across a temporal interval of 6 years (measured through the Symptom Check-List-90/R) and to determine the effect of this component on children’s emotional and behavioral functioning (measured through the Child Behaviour Check-List) at age 12 years.

Results

LST analysis showed that maternal depressive symptoms tended to remain stable within individuals across 6 years of observation strongly contributing to children’s internalizing/externalizing and dysregulation symptoms.

Conclusions

The current longitudinal analysis of maternal and child data revealed that a stable component of maternal depressive symptoms reliably predicted a wide range of child emotional and behavioral symptoms at 12 years of age.

The Use of Physical Activity Outcomes in Rehabilitation Interventions for Lower Limb Amputees: a Systematic Review

BACKGROUND

Interventions which have focused on improving the physical activity of individuals with lower limb amputation can be mostly categorized into behavioural-based and prosthetic-based interventions. The aim of this review was to assess the quality of these interventions, and to identify the key gaps in research in this field.

METHODOLOGY

The databases of Scopus, Pubmed, Embase, Medline and Web of Science were searched between September and December of 2019 for articles relating to physical activity, amputees and interventions. Articles were assessed quantitively based on internal validity, external validity and intervention intensity.

FINDINGS

Sixteen articles (5 behavioural, 11 prosthetic) were assessed. Both approaches had comparable methodological quality and mixed efficacy for producing a significant change in physical activity outcomes. Almost all interventions used a simplistic measurement of activity as their outcome.

CONCLUSIONS

There is an insufficient amount of studies to assess the overall efficacy of behavioural interventions in regard to how they impact on physical activity behaviour. However, the increase of quality of the methodology in the more recent studies could indicate that future interventions will retain similar levels of quality. Prosthetic interventions have shown no major improvement in efficacy compared to similar reviews and may need to utilise more advanced prosthetic components to attain significant changes in physical activity. Activity outcomes should expand into more complex activity measurements to properly understand the physical activity profile of people with lower limb amputation.

Cardiovascular mortality and morbidity following radical radiotherapy for lung cancer: Is cardiovascular death under-reported?

BACKGROUND

Lung cancer is the most common malignancy worldwide. Radical radiotherapy is an essential treatment in the management of early and locally advanced lung cancer. Cardiac events are known to occur following radical radiotherapy for lung cancer. This study examines the burden of cardiac events post radiotherapy, and estimates the accuracy of death certification in patients who received radical radiotherapy for lung cancer.

METHODS

We conducted a retrospective observational cohort study for all patients receiving radical radiotherapy for non-small cell lung cancer (NSCLC) at a large cancer centre between 01/01/2010 to 31/12/2016. Baseline cardiovascular disease and cancer status and treatment data were collected, along with hospital admission data and documented cause of death from the national registry for a median follow-up period of 34 months.

RESULTS

Of 1224 patients included in the analysis, 378 (30.9%) patients had cardiovascular disease at baseline, including 140 (11.4%) with prior myocardial infarction. In the 846 patients without known cardiovascular disease, 451 (53.3%) had a QRISK2 predicted 10-year cardiovascular risk >20% over 10 years. During follow-up, 215 hospitalisations occurred (Incidence rate 6.2 per hundred patient years) which were classified as primarily cardiac, and 622 patients died (18 per 100 patient-years). However, death certificates stated a primary cardiac cause of death in only 33 cases (5.3% of deaths). Notably, 29% of patients dying out of hospital and certified as cancer death did not have documented cancer relapse prior to death, and 61% had no community palliative care input prior to death, implying these events may have been sudden and unexpected.

CONCLUSION

There is a high prevalence of baseline cardiovascular disease in people undergoing radiotherapy for NSCLC, accompanied by significant rates of post-radiotherapy cardiovascular hospitalisation. However, only a small proportion of deaths are attributed to cardiovascular disease, together with the large amount of sudden deaths observed, this suggests that cardiovascular death is greatly under-reported in official statistics.

The Impact of Paternal Depression in Infancy: A Mechanism for the Intergenerational Transmission of Risk

The adverse influence of parental psychopathology on child development has been the focus of intense research in recent years, yet we are only beginning to understand the factors that explain this intergenerational transmission. Depressive symptoms in fathers have received relatively little attention when compared to research on the impact of maternal depression on children's emotional and behavioural problems. Recent evidence suggests that paternal depressive symptoms in the postnatal period are associated with an increased risk of toddler behaviour problems, which persist in clinical significance into childhood. This research examines a model of ‘social-environmental transmission’ of paternal psychopathology. We compared patterns of parent-infant interactions among families with depressed and non-depressed fathers to address the following question: Are the early interactions of depressed fathers characterised by maladaptive affect, behaviour and cognitions? This study is part of an on-going longitudinal investigation, The Oxford Fathers Project (OFP) of families who are followed when infants are 3 months to 2 years of age. Paternal behaviours, including verbal comments and interactive behaviour were examined during free-play with their 3-month old infants. Father's behaviour was coded from Fiori-Cowley and Murray's (1996) Global Rating Scale and verbal transcripts were examined for cognitive and mentalizing statements.

Preliminary results suggest a higher proportion of infant directed negativity, in the verbal content of depressed fathers. Further analysis will be conducted and presented at the meeting. Discussion emphasises the importance of dysfunctional communication patterns in father-infant interactions that provide important clinical hypotheses as well as targets for identification and early intervention.

Characterisation of the non-oxidative degradation pathway of dehydroascorbic acid in slightly acidic aqueous solution

Although l-ascorbate (vitamin C) is an important biological antioxidant, its degradation pathways in vivo remain incompletely characterised. Ascorbate is oxidised to dehydroascorbic acid, which can be either hydrolysed to diketogulonate (DKG) or further oxidised. DKG can be further degraded, oxidatively or non-oxidatively. Here we characterise DKG products formed non-enzymically and non-oxidatively at 20 °C and at a slightly acidic pH typical of the plant apoplast. High-voltage electrophoresis revealed at least five products, including two novel CPLs (epimers of 2-carboxy-l-threo-pentonolactone), which slowly interconverted with CPA (2-carboxy-l-threo-pentonate). One of the two CPLs has an exceptionally low pK_a. The CPL structures were supported by MS [(C₆H₇O₇)^-] and by ¹H and ¹³C NMR spectroscopy. Xylonate and its lactone also appeared. Experiments with [1-¹⁴C]DKG showed that all five products (including the 5-carbon xylonate and its lactone) retained DKG's carbon-1; therefore, most xylonate arose by decarboxylation of CPLs or CPA, one of whose -COOH groups originates from C-2 or C-3 of DKG after a 'benzilic acid rearrangement'. Since CPLs appeared before CPA, a DKG lactone is probably the main species undergoing this rearrangement. CPA and CPL also form non-enzymically in vivo, where they may be useful to researchers as 'fingerprints', or to organisms as 'signals', indicating a non-oxidative, slightly acidic biological compartment.

Method Extension Study to Validate Applicability of AOAC Official Method 996.14 Assurance® Polyclonal Enzyme Immunoassay for Detection of Listeria monocytogenes and Related Listeria spp. from Environmental Surfaces: Collaborative Study

Test portions from 3 environmental surface types, representative of typical surfaces found in a food production facility, were analyzed by the Assurance®Listeria Polyclonal Enzyme Immunoassay (EIA) and the U.S. Department of Agriculture/Food Safety and Inspection Service (USDA/FSIS) culture method for Listeria monocytogenes and related Listeria species. In all cases, naturally contaminated environmental test samples were collected from an actual food production facility by sponge or swab. Test samples from concrete surfaces were collected by both swab and sponge; sponge test samples were collected from rubber surfaces, and swabs were used to sample steel surfaces. Test portions from each surface type were simultaneously analyzed by both methods. A total of 23 collaborators, representing government agencies, as well as private industry in both the United States and Canada, participated in the study. During this study, a total of 550 test portions and controls was analyzed and confirmed, of which 207 were positive and 336 were negative by both methods. Six test portions were positive by culture, but negative by the EIA. Three test portions were negative by culture, but positive by the EIA. Two test portions were negative by EIA and by culture, but confirmed positive when EIA enrichment broths were subcultured to selective agars. The data reported here indicate that the Assurance®Listeria EIA method and the USDA/FSIS culture method are statistically equivalent for detection of L. monocytogenes and related Listeria species from environmental surfaces taken by sponges or swabs.

Evaluation of the BAX® System for Detection of Salmonella in Selected Foods: Collaborative Study

A multilaboratory study was conducted to compare the automated BAX® System to the standard cultural methods for detection of Salmonella in selected foods. Five food types—frankfurters, raw ground beef, mozzarella cheese, raw frozen tilapia fish, and orange juice—at 3 inoculation levels, were analyzed by each method. A sixth food type, raw ground chicken, was tested using 3 naturally contaminated lots. A total of 16 laboratories representing government and industry participated. In this study, 1386 samples were analyzed, of which 1188 were paired samples and 198 were unpaired samples. Of the 1188 paired samples, 461 were positive by both methods and 404 were negative by both methods. Thirty-seven samples were positive by the BAX System but negative by the standard reference method, and 11 samples were positive by standard cultural method and negative by the BAX System. Of the 198 unpaired samples, 106 were positive by the BAX System and 60 were positive by the standard cultural method. A Chi square analysis of each of the 6 food types, at the 3 inoculation levels tested, was performed. For all foods, the BAX System demonstrated results comparable to those of the standard reference methods based on the Chi square results.

Method Extension Study to Validate Applicability of AOAC Official Method 997.03 Visual Immunoprecipitate Assay (VIP®) for Listeria monocytogenes and Related Listeria spp. from Environmental Surfaces: Collaborative Study

Test portions from 3 environmental surface types, representative of typical surfaces found in a food production facility, were analyzed by the Visual Immunoprecipitate assay (VIP®) and the U.S. Department of Agriculture/Food Safety and Inspection Service (USDA/FSIS) culture method for Listeria monocytogenes and related Listeria species. In all cases, naturally contaminated environmental test samples were collected from an actual food production facility by sponge or swab. Test samples from concrete surfaces were collected by both swab and sponge; sponge test samples were collected from rubber surfaces, and swabs were used to sample steel surfaces. Test portions from each surface type were simultaneously analyzed by both methods. A total of 27 laboratories, representing government agencies as well as private industry in both the United States and Canada, participated in the study. During this study, a total of 615 test portions and controls was analyzed and confirmed, of which 227 were positive and 378 were negative by both methods. Nine test portions were positive by culture, but negative by the VIP. Five test portions were negative by culture, but positive by the VIP. Four test portions were negative by VIP and by culture, but confirmed positive when VIP enrichment broths were subcultured to selective agars. The data reported here indicate that the VIP method and the USDA/FSIS culture method are statistically equivalent for detection of L. monocytogenes and related Listeria species from environmental surfaces taken by sponges or swabs.

Montbresides A-D: antibacterial p-coumaroyl esters of a new sucrose-based tetrasaccharide from Crocosmia × crocosmiiflora (montbretia) flowers

Crocosmia × crocosmiiflora (montbretia) flowers yielded four esters (montbresides A-D) of a new sucrose-based tetrasaccharide, 3-O-β-d-glucopyranosyl-4´-O-α-d-rhamnopyranosyl-sucrose [β-d-Glc-(1 → 3)-α-d-Glc-(1↔2)-β-d-Fru-(4 ← 1)-α-d-Rha]. All four possess O-p-coumaroyl residues on C-3 of fructose and C-4 of α-glucose, plus O-acetyl residues on C-2 and C-3 of rhamnose and C-6 of fructose. Montbresides A and B are additionally O-acetylated on C-1 of fructose. The p-coumaroyls are trans- in montbresides A and C and cis- in B and D. Elemental compositions were determined from MS data, and structures from 1D and 2D NMR spectra. Monosaccharide residues were identified from selective 1D TOCSY spectra and TLC, and acylation sites from 2D HMBC spectra. Enantiomers were distinguished by enzymic digestion. Montbretia flower extracts were cytotoxic against six human cancerous cell-lines, but purified montbresides lacked cytotoxicity. Each montbreside displayed antibacterial activity against Staphylococcus aureus (minimal inhibitory concentration ~6 μg/ml). Montbretia is a potential source of new cytotoxins and antibacterial agents.

P11.13 Radiotherapy combined with a multimodal imaging approach in a glioblastoma preclinical model

BACKGROUND

Glioblastoma multiforme (GBM) carries a poor prognosis, partly due to biological and anatomical heterogeneity. Although radiotherapy (RT) is effective, high doses damage surrounding healthy tissues. Multimodal imaging with Magnetic Resonance (MRI) and Positron Emission Tomography (PET) may represent a useful approach for identifying GBM heterogeneity and visualising metabolic tumour properties. PET radiotracer [18F]-fluciclovine is preferentially accumulated in gliomas compared to healthy brain tissue via the cellular transport systems, LAT1 and ASCT2. In this study the effect of fractionated RT using multimodal imaging including [18F]-fluciclovine uptake and immunohistochemistry (IHC) in a GBM preclinical model will be validated.

MATERIAL AND METHODS

Two C57BL/6J mice cohorts were injected intracranially (i.c.) with murine CT2A-luc cells and subsequently submitted to multiparametric MRI and [18F]-fluciclovine PET imaging during hemi-brain RT (3Gy on 2 days/each week) for maximum 25 days after i.c. injection. Brains were collected for IHC characterization including LAT1 and ASCT2 staining.

RESULTS

Preliminary data showed that both MRI and PET were effective modalities to track tumour growth in this model. PET data revealed up to greater than 3-fold increase in SUVmax from regions of interest around the tumour site compared to healthy brain tissue. Time activity curves showed a steady increase in tumour uptake over 90 minutes. MRI showed a 25% increase in T2 values in tumours relative to unaffected contralateral regions. Confirmation of treatment response through matched imaging and IHC are ongoing, from which changes in glioma cell biology as well as amino acid transporter protein levels will be analysed.

CONCLUSION

These preliminary results show that multimodal imaging presents novel data in the assessment of treatment response in this model and will permit parallel IHC analyses to better define GBM tumour heterogeneity aligned with imaging changes. These data will also inform an on-going clinical study using the same imaging modalities.

Work at authors’ labs are supported by an Investigator initiated project from Blue Earth Diagnostics (AS, SCS) and a University of Leeds Biswas studentship (SCS, DS). Daniela Salvatore is also supported by a Scholarship provided by Molecular and Translational Medicine Doctorate School of University of Milan (Italy).

Depression and change in occupational functioning in type 2 diabetes

BACKGROUND

The effect of depression on both employment and productivity in type 2 diabetes (T2D) is poorly understood.

AIMS

We tested whether depressive symptoms at diagnosis of T2D are associated with change in employment status and productivity over 2-year follow-up.

METHODS

In a prospective analysis of working-age (18-63 years) people with newly diagnosed T2D recruited from primary care, we tested the association between depressive symptoms at diagnosis of T2D (baseline) and employment rates over 2 years. Using the Patient Health Questionnaire-9, depressive symptoms were measured categorically (depression caseness score ≥10) and continuously. In those employed, we measured changes in presenteeism and absenteeism using the World Health Organization (WHO) Health and Work Performance Questionnaire in univariate and multivariate models, respectively, including and excluding part-time workers.

RESULTS

Of 1202 people aged 18-63 at baseline, 982 (82%) provided employment information; the mean age was 50.3 (SD 8.1) years, 44% were female, 59% of non-white ethnicity and 16% had depression. After adjustment for age, sex, ethnicity, socio-economic status, diabetes control and depression treatment, depression caseness was associated with worsening unemployment over 2 years only in full-time workers (odds ratio 0.43 (95% CI 0.20, 0.96), P < 0.05). In those employed full-time or part-time, total depressive symptoms were associated with worsening presenteeism over 2 years after full adjustment (β = -2.63 (95% CI -4.81, -0.45), P < 0.05), despite no association with worsening absenteeism.

CONCLUSIONS

In newly diagnosed T2D, depressive symptoms demonstrate an association with worsening employment rate and decline in work productivity over 2-year follow-up.

Scottish consensus statement on the role of FeNO in adult asthma

Fractional exhaled nitric oxide (FeNO) is the only available point of care test to assess type-2 inflammation in asthma. In making a diagnosis of asthma, FeNO should be used together with blood eosinophils and spirometry, alongside a history. Raised FeNO in conjunction with blood eosinophilia are treatable traits of type 2 inflammation in asthma, which in turn may guide personalised management. A FeNO suppression test can be used to assess adherence and device use with ICS therapy. Furthermore FeNO may be used to provide feedback to patients in response to ICS, especially when spirometry is normal. FeNO may facilitate appropriate referral to secondary care for more definitive specialist investigations. In summary, FeNO is cost effective in the diagnosis and management of asthma and should be incorporated into primary and secondary care as part of routine clinical practice.

Measuring implementation in global mental health: validation of a pragmatic implementation science measure in eastern Ukraine using an experimental vignette design

BACKGROUND

There is mounting evidence supporting the effectiveness of task-shifted mental health interventions in low- and middle-income countries (LMIC). However, there has been limited systematic scale-up or sustainability of these programs, indicating a need to study implementation. One barrier to progress is a lack of locally relevant and valid implementation measures. We adapted an existing brief dissemination and implementation (D&I) measure which includes scales for acceptability, appropriateness, feasibility and accessibility for local use and studied its validity and reliability among a sample of consumers in Ukraine.

METHODS

Local qualitative data informed adaptation of the measure and development of vignettes to test the reliability and validity. Participants were veterans and internally displaced persons (IDPs) recruited as part of a separate validity study of adapted mental health instruments. We examined internal consistency reliability, test-retest reliability, and construct and criterion validity for each scale on the measure. We randomly assigned half the participants to respond to a vignette depicting existing local psychiatric services which we knew were not well regarded, while the other half was randomized to a vignette describing a potentially more well-implemented mental health service. Criterion validity was assessed by comparing scores on each scale by vignette and by overall summary ratings of the programs described in the vignettes.

RESULTS

N = 169 participated in the qualitative study and N = 153 participated in the validity study. Qualitative findings suggested the addition of several items to the measure and indicated the importance of addressing professionalism/competency of providers in both the scales and the vignettes. Internal consistency reliabilities ranged from α = 0.85 for feasibility to α = 0.91 for appropriateness. Test-rest reliabilities were acceptable to good for all scales (rho: 0.61-0.79). All scales demonstrated substantial and significant differences in average scores by vignette assignment (ORs: 2.21-5.6) and overall ratings (ORs: 5.1-14.47), supporting criterion validity.

CONCLUSIONS

This study represents an innovative mixed-methods approach to testing an implementation science measure in contexts outside the United States. Results support the reliability and validity of most scales for consumers in Ukraine. Challenges included large amounts of missing data due to participants' difficulties responding to questions about a hypothetical program.