What works, how and in which contexts when supporting parents to implement intensive speech and language therapy at home for children with speech sound disorder? A protocol for a realist review

INTRODUCTION

Speech and language therapists (SLTs) worldwide report challenges with providing recommended, evidence-based intervention intensity for children with speech sound disorder (SSD). Challenges such as service constraints and/or family contexts impact on access to optimal therapy intensity. Existing research indicates that empowering and training parents to deliver intervention at home, alongside SLT support, offers one possible solution to increasing the intensity of intervention children with SSD receive. Digital health could increase accessibility to intensive home practice and help sustain engagement with therapy activities. Further exploration is needed around what makes parent-implemented interventions for children with SSD effective, for who and in which situations. This paper outlines the protocol for a realist review which aims to explore the active ingredients and contextual factors of effective digital parent-led interventions.

METHODS AND ANALYSIS

A realist review will explore the research question, following six stages. The scope of the review will be determined, and initial programme theories will be developed about what works in digital parent-implemented interventions for SSD, for whom, how, why and in what circumstances. Relevant secondary data, identified through a formal search strategy, will be selected, appraised, analysed and synthesised using realist principles to test and further refine the initial programme theories. This process will develop refined underpinning explanatory theories which capture the interaction between contexts, mechanisms and outcomes of the intervention. An expert steering group will provide insight to inform explanatory theories, searches, and dissemination.

ETHICS AND DISSEMINATION

Ethical approval is not required for this review. The refined programme theories from the review will inform the next stages of a wider study. A subsequent realist evaluation will test and further refine theories with key stakeholders. Following this, the underpinning programme theory will be used to coproduce a digital tool, to support parents to deliver home intervention alongside SLT support.

Comparing neoadjuvant therapy followed by local excision to total mesorectal excision in the treatment of early stage rectal cancer: a systematic review and meta-analysis of randomised clinical trials

INTRODUCTION

Total mesorectal excision (TME) is the standard-of-care in early, clinical stage (cT2-3 N0 M0) rectal cancer. Local excision (LE) may be an alternative after adequate response to neoadjuvant therapy (NAT), with either long-course chemoradiotherapy (nCRT) or short-course radiotherapy (SCRT), as a means of preserving the rectum and potentially obviating the morbidity of TME.

METHODS

A systematic review was performed according to PRISMA guidelines for studies that randomly assigned patients with cT2-3 N0 M0 rectal cancer to either NAT + LE or TME that reported radiologic, oncologic, surgical, and morbidity outcomes.

RESULTS

A total of 4 RCTs comprise 462 patients (232 patients receiving NAT + LE; nCRT n = 205; SCRT n = 27) and 230 undergoing TME, respectively. NAT compliance was 98.86%. The rate of early completion TME in the NAT + LE group was 22.3%, while the proportion of patients achieving durable organ preservation was 75.4% at mean follow-up of 5.6 years. There was no difference in disease-free survival (DFS) (HR [hazard ratio] 1.19; 95% CI 0.95, 1.49; p = 0.13) or overall survival (OS) (HR 0.94; 95% CI 0.72, 1.23; p = 0.63]) according to the assigned treatment arm. The local recurrence rate (LRR) (HR 1.22; 95% CI 0.5-3.02; p = 0.66) and distant metastases (HR 0.92; 95% CI 0.45, 1.90; p = 0.82) were also comparable between the groups. There was a significant reduction in major (OR 0.45; 95% CI 0.21, 0.95; p = 0.04) and minor morbidity (OR 0.45; 95% CI 0.24, 0.85; p = 0.01) for patients undergoing NAT + LE. Overall stoma formation was decreased in the NAT + LE group (OR 0.03; 95% CI 0.0, 0.23; p ≤ 0.00001).

CONCLUSION

NAT + LE reduces adverse effects of TME, without any compromise in oncological outcomes, and the potential for an organ preserving strategy should be discussed with patients with T2-3N0 rectal cancers prior to treatment.

Surgical management strategies for colorectal malignancies of the splenic flexure - A systematic review and network meta-analysis

BACKGROUND

Extended right hemicolectomy (ERHC) or left hemicolectomy (LHC) are accepted as the standard-of-care for colonic tumours of the splenic flexure. Lymphatic drainage at this site is poorly defined and subject to significant heterogeneity. Nevertheless, emerging evidence demonstrates the potential oncological safety of segmental splenic flexure colectomy (SFC).

AIM

To perform a systematic review and network meta-analysis (NMA) to compare outcomes following ERHC, LHC and SFC for splenic flexure tumours (SFTs).

METHODS

A systematic review was performed as per PRISMA guidelines. NMA was performed using R Shiny and Netmeta packages.

RESULTS

A total of 13 studies, involving 6176 patients (ERHC n = 785; LHC n = 1527; SFC n = 3864) were included in the NMA. There was no difference in overall survival (OS) (SFC vs LHC Hazard Ratio [HR] 1.0, 95% Credible Interval [CrI] 0.76,1.34; SFC vs ERHC HR 1.18, 95% CrI 0.85,1.58) between the groups. SFC had a shorter operation time (Mean 176.37 min; Mean Difference [MD] SFC vs LHC 20.34 min 95% CrI 10.9, 29.97; SFC vs ERHC MD 22.19 95% CrI 11.09, 33.29) but also had a lower average lymph node yield (LNY) compared with ERHC (MD 7.15, 95% CrI 5.71, 8.60). ERHC had a significantly higher incidence of post-operative ileus (Odds Ratio [OR] 3.47, 95% CrI 1.11, 10.84). There was also no difference observed for minimally invasive approaches, anastomotic leak rate, perioperative mortality, reoperation rates or length of stay.

CONCLUSIONS

While SFC may allow for reduced operative duration and improved bowel function postoperatively. SFC, LHC, ERHC are all acceptable approaches for curative resection of cancers of the splenic flexure, with no difference in OS observed. Thus, surgeon preference and candidate-specific factors will likely determine the management of SFTs.

Obesity, Sarcopenia and Myosteatosis: Impact on Clinical Outcomes in the Operative Management of Crohn's Disease

BACKGROUND

Obesity, sarcopenia, and myosteatosis in inflammatory bowel disease may confer negative outcomes, but their prevalence and impact among patients with Crohn's disease (CD) have not been systematically studied. The aim of this study was to assess nutritional status and body composition among patients undergoing resectional surgery for CD and determine impact on operative outcomes.

METHODS

Consecutive patients with CD undergoing resection from 2000 to 2018 were studied. Total, subcutaneous, and visceral fat areas and lean tissue area (LTA) and intramuscular adipose tissue (IMAT) were determined preoperatively by computed tomography at L3 using SliceOmatic (Tomovision, Canada). Univariable and multivariable linear, logistic, and Cox proportional hazards regression were performed.

RESULTS

One hundred twenty-four consecutive patients were studied (ileocolonic disease 53%, n = 62, biologic therapy 34.4% n = 43). Mean fat mass was 22.7 kg, with visceral obesity evident in 23.9% (n = 27). Increased fat stores were associated with reduced risk of emergency presentation but increased corticosteroid use (β 9.09, standard error 3.49; P = .011). Mean LBM was 9.9 kg. Sarcopenia and myosteatosis were associated with impaired baseline nutritional markers. Myosteatosis markers IMAT (P = .002) and muscle attenuation (P = .0003) were associated with increased grade of complication. On multivariable analysis, IMAT was independently associated with increased postoperative morbidity (odds ratio [OR], 1.08; 95% confidence interval (CI), 1.01-1.16; P = .037) and comprehensive complications index (P = .029). Measures of adiposity were not associated with overall morbidity; however, increased visceral fat area independently predicted venous thromboembolism (OR, 1.02; 95% CI, 1.00-1.05; P = .028), and TFA was associated with increased wound infection (OR, 1.00; 95% CI, 1.00-1.01; P = .042) on multivariable analysis.

CONCLUSION

Myosteatosis is associated with nutritional impairment and predicts increased overall postoperative morbidity following resection for CD. Despite its association with specific increased postoperative risks, increased adiposity does not increase overall morbidity, reflecting preservation of nutritional status and relatively more quiescent disease phenotype. Impaired muscle mass and function represent an appealing target for patient optimization to improve outcomes in the surgical management of CD.

Total neoadjuvant therapy versus standard neoadjuvant treatment strategies for the management of locally advanced rectal cancer: network meta-analysis of randomized clinical trials

BACKGROUND

This study compared the advantages and disadvantages of total neoadjuvant therapy (TNT) strategies for patients with locally advanced rectal cancer, compared with the more traditional multimodal neoadjuvant management strategies of long-course chemoradiotherapy (LCRT) or short-course radiotherapy (SCRT).

METHODS

A systematic review and network meta-analysis of exclusively RCTs was undertaken, comparing survival, recurrence, pathological, radiological, and oncological outcomes. The last date of the search was 14 December 2022.

RESULTS

In total, 15 RCTs involving 4602 patients with locally advanced rectal cancer, conducted between 2004 and 2022, were included. TNT improved overall survival compared with LCRT (HR 0.73, 95 per cent credible interval 0.60 to 0.92) and SCRT (HR 0.67, 0.47 to 0.95). TNT also improved rates of distant metastasis compared with LCRT (HR 0.81, 0.69 to 0.97). Reduced overall recurrence was observed for TNT compared with LCRT (HR 0.87, 0.76 to 0.99). TNT showed an improved pCR compared with both LCRT (risk ratio (RR) 1.60, 1.36 to 1.90) and SCRT (RR 11.32, 5.00 to 30.73). TNT also showed an improvement in cCR compared with LCRT (RR 1.68, 1.08 to 2.64). There was no difference between treatments in disease-free survival, local recurrence, R0 resection, treatment toxicity or treatment compliance.

CONCLUSION

This study provides further evidence that TNT has improved survival and recurrence benefits compared with current standards of care, and may increase the number of patients suitable for organ preservation, without negatively influencing treatment toxicity or compliance.

Comparing minimally invasive surgical and open approaches to pelvic exenteration for locally advanced or recurrent pelvic malignancies - Systematic review and meta-analysis

INTRODUCTION

Pelvic exenteration (PE) is a complex multivisceral surgical procedure indicated for locally advanced or recurrent pelvic malignancies. It poses significant technical challenges which account for the high risk of morbidity and mortality associated with the procedure. Developments in minimally invasive surgical (MIS) approaches and enhanced peri-operative care have facilitated improved long term outcomes. However, the optimum approach to PE remains controversial.

METHODS

A systematic literature search was conducted in accordance with PRISMA guidelines to identify studies comparing MIS (robotic or laparoscopic) approaches for PE versus the open approach for patients with locally advanced or recurrent pelvic malignancies. The methodological quality of the included studies was assessed systematically and a meta-analysis was conducted.

RESULTS

11 studies were identified, including 2009 patients, of whom 264 (13.1%) underwent MIS PE approaches. The MIS group displayed comparable R0 resections (Risk Ratio [RR] 1.02, 95% Confidence Interval [95% CI] 0.98, 1.07, p = 0.35)) and Lymph node yield (Weighted Mean Difference [WMD] 1.42, 95% CI -0.58, 3.43, p = 0.16), and although MIS had a trend towards improved towards improved survival and recurrence outcomes, this did not reach statistical significance. MIS was associated with prolonged operating times (WMD 67.93, 95% CI 4.43, 131.42, p < 0.00001) however, this correlated with less intra-operative blood loss, and a shorter length of post-operative stay (WMD -3.89, 955 CI -6.53, -1.25, p < 0.00001). Readmission rates were higher with MIS (RR 2.11, 95% CI 1.11, 4.02, p = 0.02), however, rates of pelvic abscess/sepsis were decreased (RR 0.45, 95% CI 0.21, 0.95, p = 0.04), and there was no difference in overall, major, or specific morbidity and mortality.

CONCLUSION

MIS approaches are a safe and feasible option for PE, with no differences in survival or recurrence outcomes compared to the open approach. MIS also reduced the length of post-operative stay and decreased blood loss, offset by increased operating time.

Evaluating the oncological safety of neoadjuvant chemotherapy in locally advanced colon carcinoma: a systematic review and meta-analysis of randomised clinical trials and propensity-matched studies

PURPOSE

Use of neoadjuvant chemotherapy (NAC) for locally advanced colon cancer (LACC) remains controversial. An integrated analysis of data from high-quality studies may inform the long-term safety of NAC for this cohort. Our aim was to perform a systematic review and meta-analysis of randomised clinical trials (RCTs) and propensity-matched studies to assess the oncological safety of NAC in patients with LACC.

METHODS

A systematic review was performed as per preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. Survival was expressed as hazard ratios using time-to-effect generic inverse variance methodology, while surgical outcomes were expressed as odds ratios (ORs) using the Mantel-Haenszel method. Data analysis was performed using Review Manager version 5.4.

RESULTS

Eight studies (4 RCTs and 4 retrospective studies) including 31,047 patients with LACC were included. Mean age was 61.0 years (range: 19-93 years) and mean follow-up was 47.6 months (range: 2-133 months). Of those receiving NAC, 4.6% achieved a pathological complete response and 90.6% achieved R0 resection (versus 85.9%, P < 0.001). At 3 years, patients receiving NAC had improved disease-free survival (DFS) (OR: 1.28, 95% confidence interval (CI): 1.02-1.60, P = 0.030) and overall survival (OS) (OR: 1.76, 95% CI: 1.10-2.81, P = 0.020). When using time-to-effect modelling, a non-significant difference was observed for DFS (HR: 0.79, 95% CI: 0.57-1.09, P = 0.150) while a significant difference in favour of NAC was observed for OS (HR: 0.75, 95% CI: 0.58-0.98, P = 0.030).

CONCLUSION

This study highlights the oncological safety of NAC for patients being treated with curative intent for LACC using RCT and propensity-matched studies only. These results refute current management guidelines which do not advocate for NAC to improve surgical and oncological outcomes in patients with LACC.

TRIAL REGISTRATION

International Prospective Register of Systematic Review (PROSPERO) registration: CRD4202341723.

Evaluation of model-based bioequivalence approach for single sample pharmacokinetic studies

In a traditional pharmacokinetic (PK) bioequivalence (BE) study, a two-way crossover study is conducted, PK parameters (namely the area under the time-concentration curve [AUC] and the maximal concentration [ C max $$ {C}_{\mathrm{max}} $$ ]) are obtained by noncompartmental analysis (NCA), and the BE analysis is performed using the two one-sided test (TOST) method. For ophthalmic drugs, however, only one sample of aqueous humor, in one eye, per eye can be obtained in each patient, which precludes the traditional BE analysis. To circumvent this issue, the U.S. Food and Drug Administration (FDA) has proposed an approach coupling NCA with either parametric or nonparametric bootstrap (NCA bootstrap). The model-based TOST (MB-TOST) has previously been proposed and evaluated successfully for various settings of sparse PK BE studies. In this paper, we evaluate, via simulations, MB-TOST in the specific setting of single sample PK BE study and compare its performance to NCA bootstrap. We performed BE study simulations using a published PK model and parameter values and evaluated multiple scenarios, including study design (parallel or crossover), sampling times (5 or 10 spread across the dosing interval), and geometric mean ratio (of 0.8, 0.9, 1, and 1.25). Using the simulated structural PK model, MB-TOST performed similarly to NCA bootstrap for AUC. For C max $$ {C}_{\mathrm{max}} $$ , the latter tended to be conservative and less powerful. Our research suggests that MB-TOST may be considered as an alternative BE approach for single sample PK studies, provided that the PK model is correctly specified and the test drug has the same structural model as the reference drug.

Comparison of restorative proctocolectomy with and without defunctioning loop ileostomy in patients with ulcerative colitis - A systematic review and meta-analysis

BACKGROUND

Restorative proctocolectomy (RPC) without a defunctioning loop Ileostomy (DLI) in patients with ulcerative colitis (UC) remains controversial.

AIM

To compare safety and efficacy of RPC with and without DLI in patients exclusively with UC.

METHODS

A systematic review was performed according to PRISMA/MOOSE guidelines. Dichotomous variables were pooled as odds ratios (OR). Continuous variables were pooled as weighted mean differences (WMD). Quality assessment was performed using the Newcastle-Ottawa score (NOS).

RESULTS

A total of 20 studies (5 paediatric and 15 adult) with 4550 UC patients (without DLI n=2370, 52.09%; with DLI n= 2180, 47.91%) were eligible for inclusion. The median NOS was 8 (range 6-9). There was no increased risk of anastomotic leak (AL) (OR 1.13, 95% Confidence Interval [CI]: 0.92, 1.39; p=0.25), pouch excision (OR 1.01, 95% CI: 0.68, 1.50; p=0.97) or overall major morbidity (OR 1.44; 95% CI, 0.91, 2.29; p=0.12) for RPC without DLI, and this technique was associated with less anastomotic strictures (OR 0.45, 95% CI: 0.29, 0.68; p=0.0002), and bowel obstruction (OR 0.73, 95% CI: 0.57, 0.93; p=0.01). However, RPC without DLI increased the likelihood of pelvic sepsis (OR 1.68; 95% CI: 1.03, 2.75; p=0.04) and emergency reoperation (OR 1.74; 95% CI: 1.22, 2.50; p=0.002).

CONCLUSION

RPC without DLI is not associated with increased clinically overt AL or pouch excision rates, however, it is associated with increased risk of pelvic sepsis and emergency reoperation. RPC without DLI is feasible, but should only be performed judiciously in select UC patient cohorts in high volume, specialist, tertiary centres.

P17 National antimicrobial point prevalence survey in adult inpatient mental health facilities in Ireland

Background

Antimicrobial use in mental health inpatient settings has not been extensively examined in Ireland. The Healthcare-Associated Infection and Antimicrobial Use in Long-Term Care Facilities (HALT) study 2016 found that Irish long-term care facilities caring for residents with psychiatric conditions had an antimicrobial prevalence rate of 7.7%, higher than the European average of 4.9%. National community antimicrobial prescribing guidelines are available at www.antibioticprescribing.ie. In addition, a preferred antibiotic initiative for community settings advocates prescribers to choose ‘Green’ (preferred) antibiotics over ‘Red’ (reserved) agents. Reserved agents are considered to have more adverse effects, drug interactions and potential for development of antimicrobial resistance. The patient safety implications of antimicrobial stewardship along with an ageing population, and potential drug–drug interactions between many antimicrobials and psychotropic medications prompted a review of antimicrobial use practices in mental health services.

Methods

A sample of adult inpatient mental health facilities (MHF) operated by the state's Health Service Executive (HSE) were surveyed by community antimicrobial pharmacists (AMPs) between November 2021 and January 2022. AMPs reviewed patients’ medication charts for systemic antimicrobial prescriptions in the previous 30 days in addition to medical notes and laboratory results (where available). Adherence to HSE National community antimicrobial guidelines and the systems and structures in place to support antimicrobial stewardship were assessed.

Results

In total, 1003 patients in 51 MHFs were surveyed. At the time of survey, 6.3% (n=66) patients were on a systemic antimicrobial and 15% (n=153) had received a systemic antimicrobial within the previous 30 days. Prophylaxis accounted for 50% of antibiotic use (3.3% of all patients), with the most common indication being the prevention of urinary tract infection (UTI) (58%). Prophylaxis duration exceeded six months in 61% of prescriptions. The median duration of treatment courses was seven days. The proportion of ‘Green’ (preferred) antimicrobials versus ‘Red’ (reserved) antimicrobials was 58% versus 38%. Co-amoxiclav, a ‘Red’ agent was the most commonly prescribed antibiotic for treatment of infection (31%). Adherence with choice of antimicrobial agent as per national antimicrobial guidelines was 76%; adherence of dosing regimen was 75% and adherence with recommended duration was 46%. The main themes for non-adherence with choice of agent were use of unnecessarily broad spectrum agents, nitrofurantoin prescribed in renal impairment and inappropriate formulation of nitrofurantoin chosen. Dipstick urinalysis was performed routinely (on admission and/or at designated intervals) for persons asymptomatic of UTI in 53% (n=27) of MHFs.

Conclusions

This PPS established antimicrobial use practices in HSE MHFs and identified opportunities for improvement relating to the safe and optimal use of antimicrobials. Key national recommendations from this survey were:

O02 Improving antimicrobial use in HSE older persons residential care facilities

Background

Antimicrobial use in Irish older persons residential care facilities (OP RCFs) is higher than in other European countries. In 2020/21, for the first time, an antimicrobial pharmacist (AMP) was appointed to each community healthcare organization (CHO) to monitor, develop and promote antimicrobial stewardship in community settings.

Objectives

To establish baseline antibiotic use, develop antimicrobial stewardship tools for OP RCFs, promote best practice in relation to antimicrobial stewardship (AMS) and monitor trends in antimicrobial use in HSE (state-run) OP RCFs.

Methods

A baseline point prevalence survey (PPS) of antimicrobial use was conducted across all HSE OP RCFs between October 2020 and August 2021. Following the survey, key national recommendations and AMS resources were developed in collaboration with the national Antimicrobial Resistance and Infection Control Programme. Feedback was provided to participating facilities by CHO AMPs with antimicrobial stewardship support and education for nursing and medical staff. In September 2021, monthly monitoring of antibiotic use was established in HSE OP RCFs in collaboration with local managers, to capture the proportion of antibiotics used for prophylaxis or treatment each month.

Results

A baseline PPS of antimicrobial use in 2020/21 showed that 11.9% (528/4446) of residents were on a systemic antibiotic, with 6.3% on antibiotic prophylaxis. Urinary tract infection accounted for 51% of antibiotic prescriptions. Following the baseline PPS, CHO AMPs developed an AMS toolkit for OP RCFs, engaged with nursing and medical staff to communicate PPS results, AMS resources and support implementation of AMS recommendations. Subsequently, monthly self-reporting of antimicrobial use in HSE OP RCFs was commenced in September 2021 and showed a sustained decrease in antimicrobial use with 7.9% residents on an antibiotic in Quarter 2 2022, with 2.7% on antibiotic prophylaxis.

Conclusions

Newly appointed CHO AMPs have successfully promoted AMS across HSE OP RCFs. Following audit, feedback, education, development and promotion of antimicrobial stewardship resources, there was a sustained decrease in the proportion of residents on antibiotics used for treatment and prophylaxis of infection.

88 NATIONAL ANTIMICROBIAL POINT PREVALENCE SURVEY IN HSE OLDER PERSONS RESIDENTIAL CARE FACILITIES (OPS-RCFS)

Background

The HALT study in 2016 found that residents in Irish OPS RCFs were twice as likely to be on systemic antimicrobial compared with European average (10% v 5%). National antibiotic prescribing guidelines are available at www.antibioticprescribing.ie and prescribers are encouraged to choose ‘green’ (preferred) over ‘red’ (reserved) agents. HSE Community Antimicrobial Pharmacists (AMPs) have been employed since 2020. We aimed to establish the quality and quantity of antimicrobial prescribing in OPS-RCFs to inform antimicrobial stewardship activities.

Methods

All residents in HSE OPS-RCFs were surveyed between October 2020 and August 2021. AMPs reviewed all medication charts for systemic antimicrobials prescribed within previous 30 days. Medical notes +/- laboratory results were reviewed for persons on antimicrobials. Adherence to guidelines was assessed and information obtained on practices related to antimicrobial use.

Results

The survey included 4,448 individuals in 121 OPS RCFs. 12% were on systemic antimicrobial at time of survey. 27% received an antimicrobial in the previous 30 days. 50% of antibiotic use on survey day was for prophylaxis (6.3% of all residents). Prophylaxis exceeded 6 months in 66% persons, and 12 months in 57%. There was high usage of green versus red agents (65% vs 30%). Co-amoxiclav (red) was most commonly prescribed antimicrobial to treat infection (19%). 42% of sites reported routine use of dipstick urinalysis to support diagnosis of UTI in asymptomatic residents. 36% of sites did not have onsite electronic laboratory access. 61% of facilities did not record residents’ pneumococcal vaccination status.

Conclusion

Key national recommendations: Review all UTI prophylaxis within 6 months of initiation with view to de-prescribing.Cease routine use of dipstick urinalysis to support diagnosis of UTI for asymptomatic persons.Electronic access to laboratory results on-site required to support timely decision-making.All staff should be aware of the national antimicrobial guidelines.Pneumococcal vaccine status should be determined, and provided as necessary.

Impact of model misspecification on model-based tests in PK studies with parallel design: real case and simulation studies

This article evaluates the performance of pharmacokinetic (PK) equivalence testing between two formulations of a drug through the Two-One Sided Tests (TOST) by a model-based approach (MB-TOST), as an alternative to the classical non-compartmental approach (NCA-TOST), for a sparse design with a few time points per subject. We focused on the impact of model misspecification and the relevance of model selection for the reference data. We first analysed PK data from phase I studies of gantenerumab, a monoclonal antibody for the treatment of Alzheimer’s disease. Using the original rich sample data, we compared MB-TOST to NCA-TOST for validation. Then, the analysis was repeated on a sparse subset of the original data with MB-TOST. This analysis inspired a simulation study with rich and sparse designs. With rich designs, we compared NCA-TOST and MB-TOST in terms of type I error and study power. With both designs, we explored the impact of misspecifying the model on the performance of MB-TOST and adding a model selection step. Using the observed data, the results of both approaches were in general concordance. MB-TOST results were robust with sparse designs when the underlying PK structural model was correctly specified. Using the simulated data with a rich design, the type I error of NCA-TOST was close to the nominal level. When using the simulated model, the type I error of MB-TOST was controlled on rich and sparse designs, but using a misspecified model led to inflated type I errors. Adding a model selection step on the reference data reduced the inflation. MB-TOST appears as a robust alternative to NCA-TOST, provided that the PK model is correctly specified and the test drug has the same PK structural model as the reference drug.

Heart Rate Variability Biofeedback to Treat Anxiety in Young People With Autism Spectrum Disorder: Findings From a Home-Based Pilot Study

Background

People with autism spectrum disorder (ASD) frequently experience high levels of anxiety. Despite this, many clinical settings do not provide specialist ASD mental health services, and demand for professional support frequently outstrips supply. Across many sectors of health, investigators have explored digital health solutions to mitigate demand and extend the reach of professional practice beyond traditional clinical settings.

Objective

This critical appraisal and pilot feasibility study examines heart rate variability (HRV) biofeedback as an approach to help young people with ASD to manage anxiety symptoms outside of formal settings. The aim is to explore the use of portable biofeedback devices to manage anxiety, while also highlighting the risks and benefits of this approach with this population.

Methods

We assessed the feasibility of using home-based HRV biofeedback for self-management of anxiety in young people with ASD. We adopted coproduction, involving people with ASD, to facilitate development of the study design. Next, a separate pilot with 20 participants with ASD (n=16, 80% male participants and n=4, 20% female participants, aged 13-24 years; IQ>70) assessed adoption and acceptability of HRV biofeedback devices for home use over a 12-week period. Data were collected from both carers and participants through questionnaires and interviews; participants also provided single-lead electrocardiogram recordings as well as daily reports through smartphone on adoption and use of their device.

Results

Pre-post participant questionnaires indicated a significant reduction in anxiety in children (t₆=2.55; P=.04; Cohen d=0.99) as well as adults (t₇=3.95; P=.006; Cohen d=0.54). Participant age was significantly negatively correlated with all HRV variables at baseline, namely high-frequency heart rate variability (HF-HRV: P=.02), the root mean square of successive differences in normal heartbeat contractions (RMSSD: P=.02) and the variability of normal-to-normal interbeat intervals (SDNN: P=.04). At follow-up, only SDNN was significantly negatively correlated with age (P=.05). Levels of ASD symptoms were positively correlated with heart rate both before (P=.04) and after the intervention (P=.01). The majority (311/474, 65.6%) of reports from participants indicated that the devices helped when used. Difficulties with the use of some devices and problems with home testing of HRV were noted. These initial findings are discussed within the context of the strengths and challenges of remotely delivering a biofeedback intervention for people with ASD.

Conclusions

HRV biofeedback devices have shown promise in this pilot study. There is now a need for larger evaluation of biofeedback to determine which delivery methods achieve the greatest effect for people with ASD.

Trial Registration

ClinicalTrials.gov NCT04955093; https://clinicaltrials.gov/ct2/show/NCT04955093

140 FAMILY DEMENTIA SUPPORT TRAINING—AN INTEGRATED CARE APPROACH

Background

There are approximately 64,000 people living with a diagnosis of dementia in Ireland. This number is expected to double to 150,000 by 2045. The growing need for post diagnostic support has been accentuated by the fact that we are living through an unprecedented Pandemic. Our Dementia Training Network identified the need for a localised educational resource for families supporting those diagnosed with dementia across our service.

Methods

Following a successful pilot in association with the Alzheimer’s Society of Ireland, staff from the Specialist Memory Service, Integrated Care Team, and Primary Care created a service-informed 6 week course aimed at supporting families. A focus group preceded the first course to establish preferred content. The course delivered education on Dementia; Post Diagnostic Steps; Communication; Non cognitive symptoms; Nutrition & hydration; Assistive Technology; Forward planning and Self-care. The multi-dimensional nature of staff delivering the course creates a rich tapestry of advice and information. All staff involved work together to identify, refer and support families living with dementia in the local area. The group takes place in an accessible location and time which accommodates families. Each course attendee completes a questionnaire prior to and after commencing the group. The level of satisfaction will be measured following every course.

Results

By the end of 2021, the group will have delivered education and support to 36 families. The automatic referral of all families to this resource will assist in building up confidence to support and enhance self-care. The combined participants from the catchment area will become a network of families joined together on their journey.

Conclusion

This innovative service collaboration enhances the integrated nature of the Post Diagnostic Care pathway. The Integrated care approach has served to enrich the programme and allow for timely support and advice regarding localised supports.

Bile duct clearance and cholecystectomy for choledocholithiasis: Definitive single-stage laparoscopic cholecystectomy with intraoperative endoscopic retrograde cholangiopancreatography versus staged procedures

BACKGROUND

Clinical equipoise exists regarding optimal sequencing in the definitive management of choledocholithiasis. Our current study compares sequential biliary ductal clearance and cholecystectomy at an interval to simultaneous laparoendoscopic management on index admission in a pragmatic retrospective manner.

METHODS

Records were reviewed for all patients admitted between January 2015 and December 2018 to a Swedish and an Irish university hospital. Both hospitals differ in their practice patterns for definitive management of choledocholithiasis. At the Swedish hospital, patients with choledocholithiasis underwent laparoscopic cholecystectomy with intraoperative rendezvous endoscopic retrograde cholangiopancreatography (ERCP) at index admission (one stage). In contrast, interval day-case laparoscopic cholecystectomy followed index admission ERCP (two stages) at the Irish hospital. Clinical characteristics, postprocedural complications, and inpatient duration were compared between cohorts.

RESULTS

Three hundred fifty-seven patients underwent treatment for choledocholithiasis during the study period, of whom 222 (62.2%) underwent a one-stage procedure in Sweden, while 135 (37.8%) underwent treatment in two stages in Ireland. Patients in both cohorts were closely matched in terms of age, sex, and preoperative serum total bilirubin. Patients in the one-stage group exhibited a greater inflammatory reaction on index admission (peak C-reactive protein, 136 ± 137 vs. 95 ± 102 mg/L; p = 0.024), had higher incidence of comorbidities (age-adjusted Charlson Comorbidity Index, ≥3; 37.8% vs. 20.0%; p = 0.003), and overall were less fit for surgery (American Society of Anesthesiologists, ≥3; 11.7% vs. 3.7%; p < 0.001). Despite this, a significantly shorter mean time to definitive treatment, that is, cholecystectomy (3.1 ± 2.5 vs. 40.3 ± 127 days, p = 0.017), without excess morbidity, was seen in the one-stage compared with the two-stage cohort. Patients in the one-stage cohort experienced shorter mean postprocedure length of stay (3.0 ± 4.7 vs. 5.0 ± 4.6 days, p < 0.001) and total length of hospital stay (6.5 ± 4.6 vs. 9.0 ± 7.3 days, p = 0.002). The only significant difference in postoperative complications between the cohorts was urinary retention, with a higher incidence in the one-stage cohort (19% vs. 1%, p = 0.004).

CONCLUSION

Where appropriate expertise and logistics exist within developing models of acute care surgery worldwide, consideration should be given to index-admission laparoscopic cholecystectomy with intraoperative ERCP for the treatment of choledocholithiasis. Our data suggest that this strategy significantly shortens the time to definitive treatment and decreases total hospital stay without any excess in adverse outcomes.

LEVEL OF EVIDENCE

Therapeutic/Care Management Level IV.

Colonoscopy-related injury among colonoscopists: an international survey

Background and study aims  Colonoscopy is physically demanding for endoscopists and patients. Repetitive movements during colonoscopy can lead to overuse injuries. We aimed to explore the prevalence and range of colonoscopy-related musculoskeletal injuries (CRIs) in endoscopists. Methods  A cross-sectional electronic survey of 1825 endoscopists was performed. The sample was composed of members of the British Society of Gastroenterology, European Society of Gastrointestinal Endoscopy, and National Nurse Endoscopy Group (UK). The survey comprised 20 questions. These included: endoscopists' workload, level of experience, and their perceived CRIs. All endoscopists who perform colonoscopy independently were included in the analysis. Results  A total of 368 questionnaires were completed of 1825 surveyed (20.16 %). Of those, 319 participants (17.48 %) were fully independent in colonoscopy. Of 319 endoscopists, 254 (79.6 %) have experienced musculoskeletal injuries. These were reported as either possibly (n = 143, 56.3 %) or definitely (n = 90, 35.4 %) related to colonoscopy. Commonly injured areas were the lower back (n = 85, 36.5 %), neck (n = 82, 35.2 %) and left thumb (n = 79, 33.9 %). Of the injured endoscopists, 98 (30.7 %) made some modification to their practice, such as stretching exercises and ergonomic changes. Of the endoscopists, 134 (42.0 %) thought that repetitive limb strain was a likely causative mechanism. Around 40 % believed that torquing the scope and challenging body position were precipitating CRIs. Several treatment modalities were used to treat CRIs. These included; physiotherapy (n = 109), medications (n = 70), rest (n = 43), splinting (n = 31), steroid injections (n = 26) and surgery (n = 11). Conclusions  A significant proportion of colonoscopists experience CRIs. The majority of the suggested modifications to practice can be adopted by any endoscopist. These results highlight the need to recognise CRI as an important occupational health hazard and to adopt preventative strategies routinely in the future.

P919 The correlation between cardiac biomarkers and findings on transthoracic echocardiography in the intensive care unit

BACKGROUND

Trans-thoracic echo (TTE) is a commonly performed non-invasive investigation for the cardiovascular assessment of critically ill patients in the Intensive Care Unit (ICU). Raised cardiac biomarkers are commonly cited as an indication for TTE, however the significance of these biomarker elevations in the critical care setting is unclear.

PURPOSE

The aim of this study was to describe findings on TTE in an Irish ICU cohort and to determine if there was any correlation between these findings and serum N-terminal pro b-type natiuretic (NT-proBNP) and high sensitivity troponin T (HsTnT) levels.

METHODS

Patients admitted to the ICU and who received a TTE between January 2018 and February 2019 were identified. Based on TTE findings, patients were divided into two groups: ‘Normal group’ and ‘Abnormal group’. For the purpose of this study, minor abnormalities including concentric left ventricular hypertrophy, diastolic dysfunction and hyper-dynamic left ventricular function were included in the Normal group. The Abnormal group included reductions in LV function, regional wall motion abnormalities and significant valvular heart disease. Continuous variables were expressed as medians and interquartile range. The groups were compared using the z-test for continuous variables and fishers exact test for categorical variables, with a p value of &lt; 0.05 considered significant.

RESULTS

There were 358 patients admitted to the ICU during the study period. The mean age was 59.8 ± 17 years and over half of the patients (55%) were male. One hundred and fifteen patients (32%) had a reported TTE, of which 55% were normal and 22% had minor abnormalities (Normal group). The remaining 23% showed significant abnormalities (Abnormal group).

The prevalence of a NT-proBNP result over 4 times the upper limit of normal (&gt;4xULN) was not significantly different between groups (67% in Normal group vs 71% in Abnormal group, Fisher exact test statistic value is 0.7887, p &lt; .05). However a HsTnT value &gt;4xULN was more common in the Abnormal group than the Normal group (73% vs 46%, Fisher exact test statistic value is 0.0231, p &lt; .05). Similarly, Median NT-proBNP did not differ significantly between the groups; (2254pg/mL; IQR: 11,758 in the Normal group vs 6428pg/mL; IQR: 5,789 in the Abnormal group, p = 0.52218) but Median HsTnT level was significantly higher in the Abnormal group than Normal group; (123ng/L ; IQR: 656 vs 51ng/L; IQR: 163.5 ,p = 0.0278).

CONCLUSION

TTE is performed commonly in the ICU, with one-third of ICU admissions receiving a TTE. Over 75% were reported as normal or showing only minor abnormalities. NT-Pro BNP was commonly significantly elevated but did not correlate with the subsequent diagnostic yield of significant abnormalities on echocardiography. HsTnT levels were more commonly significantly raised in patients with abnormal TTE results and the role of troponin in this setting requires further evaluation.

Public Engagement With and Recognition of the “Be Cancer Alert Campaign” - Colorectal Cancer Awareness

Background: Colorectal cancer is the most common cancers in males in Malaysia and the second most common cancer in females. Low awareness of cancer delays help-seeking and contributes to late presentation, poor detection and survival. We developed a culturally sensitive mass media campaign to increase awareness about the signs and symptoms of colorectal cancer among Malaysians, which was informed by previously successful campaigns in Northern Ireland. Aim: The aim of this study is to analyze the public engagement with the campaign on social media and to identify whether the public recognizes the campaign materials postintervention. Methods: Focus group discussions informed the cultural adaptation of the Be Cancer Alert Campaign - Colorectal Cancer (BCAC-CRC). Based on the focus discussions we developed a TV commercial and radio advertisement as well as a print advertisement campaign. In addition, we promoted the BCAC through a Web site and social media campaign. The BCAC-CRC will run from the 2nd of April for five weeks. The engagement with the Web site and the social media campaign will be analyzed on a daily basis to respond to public engagement immediately. A population-based survey postintervention including a randomly selected sample of approximately 700 participants will evaluate whether people recall the campaign key messages and have noticed the campaign materials. Results: Postintervention data collection will take place from May-July 2018. The results of the analysis will be presented at the conference. Conclusion: To our knowledge, the BCAC-CRC is the first colorectal cancer awareness campaign in Malaysia that will be evaluated for its public engagement on social media as well as public recognition of the TV, radio and print materials.

Effectiveness of Mass and Small Media Campaigns to Improve Cancer Awareness and Screening Rates in Asia: A Systematic Review

Background: Cancer presents an increasing burden for Asian countries and cancer-related deaths have been predicted to increase from 4.1 million in 2008 to 7.5 million in 2030 in Asia. Low-middle income countries are recommended to prioritize public education as a first step toward cancer prevention and early detection. Mass media campaigns have been found to be effective in increasing cancer awareness and screening uptake in western countries as well as cost-effective in reducing morbidity and mortality. A number of studies have used mass and or small media components in Asian countries. Aim: This systematic review aims to deliver an overview of small and mass media campaigns in Asia and to assess their effectiveness in improving cancer awareness. Methods: We searched MEDLINE, Embase, CINAHL, Web of Science, PsycINFO, Scopus, Cochrane Library, Gray literature and Google Scholar for relevant literature. Furthermore, we hand-search reference lists of relevant reviews and studies and run a search in relevant journals individually. Peer-reviewed studies that were published in the English language before September 2017 and targeted adults aged 18 year or over in Asia, were included. We excluded studies targeting minority populations living abroad as well as studies that included individual or group components in addition to the media components. Results: The search identified 10,676 titles after removal of duplicates. A total of 479 titles were included in the abstract screen and 51 articles were included in the full-text screen. The full-text screen is currently ongoing and the results will be presented at the conference. Conclusion: To our knowledge, this is the first systematic review summarizing the effectiveness of media campaigns to improve cancer awareness in Asia. The full results of the systematic review will be valuable to inform future mass and small media campaigns in Asian countries.

Strengthening Screening and Detection Services for Breast Cancer in Vietnam

Background: The incidence of breast cancer has increased consistently in Vietnam over the past two decades. Data from 2012 indicates an increase from an age-standardized rate of 16.2 per 100,000 in 2002, to 23.0 per 100,000 in 2012. Despite this, and consistent studies indicating late diagnosis, there has been a lack of empirical studies on what breast cancer services exist and how they function across different levels of the Vietnamese health system. Aim: Our project sought to examine the accessibility, affordability, and appropriateness of breast cancer services in Vietnam with the objective of making recommendations to strengthen service delivery. Methods: The project used a mixed-methods approach, collecting data through self-administered questionnaires (n=69) and in-depth interviews (n=23) with health professionals working at facilities across all four levels of the Vietnamese health system (national, provincial, district, & commune). We completed in-depth interviews with women (n=12) diagnosed with breast cancer, focusing on their experiences of accessing and using services. Our study was located across three provinces, representing the northern, central, and southern regions of the country. Results: Our results show that screening activities for breast cancer in the community are not systematically organized or provided. There are no stand-alone screening campaigns for breast cancer and facility-based opportunistic screening is limited. There is scope for strengthening the primary and secondary levels of the Vietnamese health system to detect, diagnose and treat breast cancer. Increased autonomy and support for commune-level health stations to conduct screening activities, the systematic incorporation of opportunistic screening, and the extension of breast cancer-specific training for commune and district level health care staff are potential areas for strengthening. Conclusion: Our study suggests that there should be concerted efforts to implement the Ministry of Health's strategic objectives to decentralise and strengthen commune and district levels of the health system in relation to detection, diagnosis and treatment of breast cancer. No studies have been conducted that pilot interventions to provide systematic and comprehensive breast cancer services at the lower levels of the health system. Specific attention should be given to increasing autonomy and support for commune level health stations to conduct screening activities; for the systematic incorporation of opportunistic screening; and the extension of breast cancer-specific training for commune and district level health care staff.

Colorectal Cancer Awareness and Beliefs in Malaysia: A Population-Based Survey

Background: Colorectal cancer (CRC) is the third most common cancer and the fourth major cause of cancer deaths globally; in Malaysia, CRC is the second most common cancer in both males and females. Low awareness of cancer delays help-seeking and contributes to late presentation, poor detection and survival. Aim: We aim to investigate the level of colorectal cancer awareness and beliefs among the Gombak district population of Malaysia as part of a larger study designed to evaluate a cancer awareness-raising campaign. Methods: A survey of colorectal cancer awareness was conducted in Rawang (Gombak district, Selangor) between January and March 2018. This district is representative of a mix of ethnicities, age groups, education levels and income groups. A total of 4000 households were selected randomly from a list of all households by the Government Department of Statistics Malaysia to attain a sample size of 730 adults as indicated by our power calculation and taking potential refusals into account. Trained enumerators randomly selected eligible adults aged over 40 years old from each household and conducted an interview that included sociodemographic information as well as the Bowel Cancer Awareness Measure (CAM), the Attitudes and Beliefs about Cancer questionnaire (ABC) and the Champion Health Belief Model Scale (CHBMS) which were validated in Malaysia. Results: Data collection for this part of the larger study was completed in March. Currently, we are cleaning and entering the survey data into a database in preparation for statistical analysis including χ2 tests of association and logistic regression. The results of the analysis will be presented at the conference. Conclusion: This analysis will provide the first profile of awareness and beliefs about colorectal cancer among the Gombak district population of Malaysia.

Indoor localisation through object detection within multiple environments utilising a single wearable camera

The recent growth in the wearable sensor market has stimulated new opportunities within the domain of Ambient Assisted Living, providing unique methods of collecting occupant information. This approach leverages contemporary wearable technology, Google Glass, to facilitate a unique first-person view of the occupants immediate environment. Machine vision techniques are employed to determine an occupant’s location via environmental object detection. This method provides additional secondary benefits such as first person tracking within the environment and lack of required sensor interaction to determine occupant location. Object recognition is performed using the Oriented Features from Accelerated Segment Test and Rotated Binary Robust Independent Elementary Features algorithm with a K-Nearest Neighbour matcher to match the saved key-points of the objects to the scene. To validate the approach, an experimental set-up consisting of three ADL routines, each containing at least ten activities, ranging from drinking water to making a meal were considered. Ground truth was obtained from manually annotated video data and the approach was previously benchmarked against a common method of indoor localisation that employs dense sensor placement in order to validate the approach resulting in a recall, precision, and F-measure of 0.82, 0.96, and 0.88 respectively. This paper will go on to assess to the viability of applying the solution to differing environments, both in terms of performance and along with a qualitative analysis on the practical aspects of installing such a system within differing environments.

Cognitive impairment among prostate cancer patients: An overview of reviews

To identify and clarify definitions and methods of measuring cancer-related cognitive impairment among prostate cancer patients treated with androgen deprivation therapy (ADT) and to assess the incidence and prevalence of cognitive impairment. A systematic review of Medline, EMBASE, PubMed, PsycINFO and CINAHL up to December 2015 was undertaken to identify English-language reviews. A total of 28 reviews were identified describing 20 primary studies. There were no studies of incidence. Reported prevalence rates varied between 10% and 69%. Cognitive domains impaired by ADT included: verbal memory, visuospatial ability and executive functions. Cognitive impairment was infrequently defined and four definitions were reported. A variety of measures and methods were used to assess cognitive function including neuropsychological tests, self-report measures and clinical assessments. The finding that, often, one measure was used to assess more than one aspect of cognition is likely to have contributed to imprecise estimates. There is a need to agree a definition of cognitive impairment in the clinical epidemiology of cancer and to standardise the selection of measures in order to aid accurate assessment and fair comparisons across studies regarding the prevalence of cognitive impairment among prostate cancer patients.

Managing Weight: What Do People with an Intellectual Disability Want from Mobile Technology?

Obesity is a significant health challenge. People with Intellectual Disability (ID) are particularly vulnerable to developing obesity. Mobile technology has been developed to support the management of weight and obesity in the form of apps, although not with people with an ID in mind. As a result existing off-the-shelf weight management apps currently available may not be functional in supporting weight reduction within this population. This paper presents the results of consultations with people with ID regarding weight management, comfort with mobile technology and desired characteristics in apps designed for people with ID that target weight management.

Gene selection and cloning approaches for co-expression and production of recombinant protein-protein complexes

Multiprotein complexes play essential roles in all cells and X-ray crystallography can provide unparalleled insight into their structure and function. Many of these complexes are believed to be sufficiently stable for structural biology studies, but the production of protein-protein complexes using recombinant technologies is still labor-intensive. We have explored several strategies for the identification and cloning of heterodimers and heterotrimers that are compatible with the high-throughput (HTP) structural biology pipeline developed for single proteins. Two approaches are presented and compared which resulted in co-expression of paired genes from a single expression vector. Native operons encoding predicted interacting proteins were selected from a repertoire of genomes, and cloned directly to expression vector. In an alternative approach, Helicobacter pylori proteins predicted to interact strongly were cloned, each associated with translational control elements, then linked into an artificial operon. Proteins were then expressed and purified by standard HTP protocols, resulting to date in the structure determination of two H. pylori complexes.

An investigation into the usability of the STAR training and re-skilling website for carers of persons with dementia

Due to the successes in medical science people are now beginning to live much longer. With this brings increased problems associated with ageing, with one exemplar being dementia. Persons with dementia require care with activities of daily living, for example, with washing, dressing and eating. This requires additional care, which is usually provided by family and friends who assume the role of informal carers. Provision of care by informal carers brings irreversible changes to their lives that can lead to depression and feelings of loneliness. In part, these changes are linked with carers having insufficient understanding and training with dementia. The EU funded STAR project created an web portal that aims to provide the necessary online training that carers need, however, the usability of such a provision warrants investigation. This paper presents the findings of a usability test conducted on five carers of people with dementia while using the STAR Training Website. For the 21 usability issues identified, the paper outlines proposed solutions.

Urea and deuterium mixtures at high pressures

Urea, like many network forming compounds, has long been known to form inclusion (guest-host) compounds. Unlike other network formers like water, urea is not known to form such inclusion compounds with simple molecules like hydrogen. Such compounds if they existed would be of interest both for the fundamental insight they provide into molecular bonding and as potential gas storage systems. Urea has been proposed as a potential hydrogen storage material [T. A. Strobel et al., Chem. Phys. Lett. 478, 97 (2009)]. Here, we report the results of high-pressure neutron diffraction studies of urea and D2 mixtures that indicate no inclusion compound forms up to 3.7 GPa.

Exploring lay views on physical activity and their implications for public health policy. A case study from East Belfast

It is now recognised that inactive lifestyles underpin much of the disease burden evident in the richer nations of the world. Indeed, the WHO has identified physical inactivity as a 'global public health problem' and has established minimum physical activity (PA) targets for people at different stages of the life-course. Yet, according to WHO, just under 1/3 of working age adults across the globe meet those targets and it is not at all clear how the disjunction between the recommendations of policy makers and the behaviour of ordinary people might be surmounted. Using an opportunity to examine the impact of an urban regeneration project on community residents in East Belfast (Northern Ireland) this paper examines the views of some 113 people on how to increase rates of PA in an area of multiple deprivation. The results of the analysis suggest that lay people rarely consider PA as a discrete issue, or one that centres on individuals and their motivation, but rather as one component in a complex web of concerns, processes and events that include such things as the actions of neighbours and relatives, material and political environments, vandalism, violence, and the weather. We explore and unravel the nature of those concerns using novel methods of content analysis that generate 'issue webs'. Particular attention is paid to the ways in which lay people conceptualize 'activity' and to the manner in which they point to ways of encouraging activity that are rooted in everyday life rather than in the corpocentric, agent-centred and often sport dominated strategies favoured by local policy makers. Our results support those who argue that interventions to increase rates of PA need to move beyond behavioural approaches that focus on individuals and consider the social, political and material contexts in which 'activity' occurs.

New LIC vectors for production of proteins from genes containing rare codons

In the effort to produce proteins coded by diverse genomes, structural genomics projects often must express genes containing codons that are rare in the production strain. To address this problem, genes expressing tRNAs corresponding to those codons are typically coexpressed from a second plasmid in the host strain, or from genes incorporated into production plasmids. Here we describe the modification of a series of LIC pMCSG vectors currently used in the high-throughput (HTP) production of proteins to include crucial tRNA genes covering rare codons for Arg (AGG/AGA) and Ile (AUA). We also present variants of these new vectors that allow analysis of ligand binding or co-expression of multiple proteins introduced through two independent LIC steps. Additionally, to accommodate the cloning of multiple large proteins, the size of the plasmids was reduced by approximately one kilobase through the removal of non-essential DNA from the base vector. Production of proteins from core vectors of this series validated the desired enhanced capabilities: higher yields of proteins expressed from genes with rare codons occurred in most cases, biotinylated derivatives enabled detailed automated ligand binding analysis, and multiple proteins introduced by dual LIC cloning were expressed successfully and in near balanced stoichiometry, allowing tandem purification of interacting proteins.