Endocrine disrupting chemical mixture exposure and risk of papillary thyroid cancer in U.S. military personnel: A nested case-control study

Single-pollutant methods to evaluate associations between endocrine disrupting chemicals (EDCs) and thyroid cancer risk may not reflect realistic human exposures. Therefore, we evaluated associations between exposure to a mixture of 18 EDCs, including polychlorinated biphenyls (PCBs), brominated flame retardants, and organochlorine pesticides, and risk of papillary thyroid cancer (PTC), the most common thyroid cancer histological subtype. We conducted a nested case-control study among U.S. military servicemembers of 652 histologically-confirmed PTC cases diagnosed between 2000 and 2013 and 652 controls, matched on birth year, sex, race/ethnicity, military component (active duty/reserve), and serum sample timing. We estimated mixture odds ratios (OR), 95% confidence intervals (95% CI), and standard errors (SE) for associations between pre-diagnostic serum EDC mixture concentrations, overall PTC risk, and risk of histological subtypes of PTC (classical, follicular), adjusted for body mass index and military branch, using quantile g-computation. Additionally, we identified relative contributions of individual mixture components to PTC risk, represented by positive and negative weights (w). A one-quartile increase in the serum mixture concentration was associated with a non-statistically significant increase in overall PTC risk (OR = 1.19; 95% CI = 0.91, 1.56; SE = 0.14). Stratified by histological subtype and race (White, Black), a one-quartile increase in the mixture was associated with increased classical PTC risk among those of White race (OR = 1.59; 95% CI = 1.06, 2.40; SE = 0.21), but not of Black race (OR = 0.95; 95% CI = 0.34, 2.68; SE = 0.53). PCBs 180, 199, and 118 had the greatest positive weights driving this association among those of White race (w = 0.312, 0.255, and 0.119, respectively). Findings suggest that exposure to an EDC mixture may be associated with increased classical PTC risk. These findings warrant further investigation in other study populations to better understand PTC risk by histological subtype and race.

Characterization of peer support services for substance use disorders in 11 US emergency departments in 2020: findings from a NIDA clinical trials network site selection process

INTRODUCTION

Emergency departments (ED) are incorporating Peer Support Specialists (PSSs) to help with patient care for substance use disorders (SUDs). Despite rapid growth in this area, little is published regarding workflow, expectations of the peer role, and core components of the PSS intervention. This study describes these elements in a national sample of ED-based peer support intervention programs.

METHODS

A survey was conducted to assess PSS site characteristics as part of site selection process for a National Institute on Drug Abuse (NIDA) Clinical Trials Network (CTN) evaluating PSS effectiveness, Surveys were distributed to clinical sites affiliated with the 16 CTN nodes. Surveys were completed by a representative(s) of the site and collected data on the PSS role in the ED including details regarding funding and certification, services rendered, role in medications for opioid use disorder (MOUD) and naloxone distribution, and factors impacting implementation and maintenance of ED PSS programs. Quantitative data was summarized with descriptive statistics. Free-text fields were analyzed using qualitative content analysis.

RESULTS

A total of 11 surveys were completed, collected from 9 different states. ED PSS funding was from grants (55%), hospital funds (46%), peer recovery organizations (27%) or other (18%). Funding was anticipated to continue for a mean of 16 months (range 12 to 36 months). The majority of programs provided "general recovery support (81%) Screening, Brief Intervention, and Referral to Treatment (SBIRT) services (55%), and assisted with naloxone distribution to ED patients (64%). A minority assisted with ED-initiated buprenorphine (EDIB) programs (27%). Most (91%) provided services to patients after they were discharged from the ED. Barriers to implementation included lack of outpatient referral sources, barriers to initiating MOUD, stigma at the clinician and system level, and lack of ongoing PSS availability due to short-term grant funding.

CONCLUSIONS

The majority of ED-based PSSs were funded through time-limited grants, and short-term grant funding was identified as a barrier for ED PSS programs. There was consistency among sites in the involvement of PSSs in facilitation of transitions of SUD care, coordination of follow-up after ED discharge, and PSS involvement in naloxone distribution.

Methodologies to measure access to care post-discharge in adults with serious injury-related disability: a scoping review

PURPOSE

This scoping review examined the methodologies used to measure access to care in serious injury-related disability populations, for whom access to care post-discharge has significant implications for patient outcomes and rehabilitation trajectories.

METHODS

Four electronic databases were searched for literature published between 1 January 2000 and 15 February 2022. Relevant articles needed to relate to access to care in adult community-dwelling trauma and rehabilitation populations.

RESULTS

The initial search identified 679 articles. Following de-duplication, the title/abstract screening was completed on 533 articles, and 56 full-text articles were reviewed. Thirty-eight articles met the eligibility criteria and were included in this review. Of the 38 studies included, there was large heterogeneity in the methodologies used to measure access to care. Two articles used multidimensional measures of access to care.

CONCLUSIONS

There is an urgent need to establish the use of multidimensional measures as standard practice in access-to-care research. Failure to account for the multidimensional nature of access to care limits the full realisation of access for people with serious injury-related disability and prevents the implementation of processes that could improve access to health, rehabilitation, and support services and enhance the quality of care for individuals with a serious injury-related disability.

Organochlorine pesticides and risk of papillary thyroid cancer in U.S. military personnel: a nested case-control study

BACKGROUND

The effects of organochlorine pesticide (OCP) exposure on the development of human papillary thyroid cancer (PTC) are not well understood. A nested case-control study was conducted with data from the U.S. Department of Defense Serum Repository (DoDSR) cohort between 2000 and 2013 to assess associations of individual OCPs serum concentrations with PTC risk.

METHODS

This study included 742 histologically confirmed PTC cases (341 females, 401 males) and 742 individually-matched controls with pre-diagnostic serum samples selected from the DoDSR. Associations between categories of lipid-corrected serum concentrations of seven OCPs and PTC risk were evaluated for classical PTC and follicular PTC using conditional logistic regression, adjusted for body mass index category and military branch to compute odds ratios (OR) and 95% confidence intervals (CIs). Effect modification by sex, birth cohort, and race was examined.

RESULTS

There was no evidence of associations between most of the OCPs and PTC, overall or stratified by histological subtype. Overall, there was no evidence of an association between hexachlorobenzene (HCB) and PTC, but stratified by histological subtype HCB was associated with significantly increased risk of classical PTC (third tertile above the limit of detection (LOD) vs. Collapse

Key Words

• Hexachlorobenzene
• Hexachlorocyclohexane
• Organochlorine pesticides
• Papillary thyroid cancer

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MESH Headings

• Male
• Humans
• Female
• Military Personnel
• Thyroid Cancer, Papillary/epidemiology
• Hexachlorobenzene
• Case-Control Studies
• Pesticides
• Hydrocarbons, Chlorinated
• Thyroid Neoplasms/chemically induced
• Thyroid Neoplasms/epidemiology
• Hexachlorocyclohexane

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Grants

• R01ES020361 NIH HHS
• R01ES020361 NIH HHS
• National Institutes of Health
• Murtha Cancer Center Research Program
• Oak Ridge Associated Universities
• National Cancer Institute Intramural Research Program

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Affiliation(s)

Jennifer A Rusiecki Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Room E-2009, Bethesda, MD, 20814, USA.
Jordan McAdam Murtha Cancer Center Research Program, 4494 North Palmer Road, Bethesda, MD, USA Henry M. Jackson Foundation for the Advancement of Military Medicine, 1401 Rockville Pike, Rockville, MD, USA
Hristina Denic-Roberts Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Room E-2009, Bethesda, MD, 20814, USA Oak Ridge Institute for Science and Education (ORISE), Oak Ridge, TN, USA
Andreas Sjodin Division of Laboratory Sciences, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
Mark Davis Division of Laboratory Sciences, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
Richard Jones Division of Laboratory Sciences, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
Thanh D Hoang Division of Endocrinology, Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
Mary H Ward Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, USA
Shuangge Ma Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
Yawei Zhang Department of Environmental Health Sciences, Yale School of Public Health, New Haven, CT, USA Department of Cancer Prevention and Control, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China

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Motiv8: a study protocol for a cluster-randomised feasibility trial of a weight management intervention for adults with severe mental illness in secure forensic services

INTRODUCTION

People with severe mental illness have physical comorbidities which result in significant reductions in quality of life and premature mortality. Effective interventions are required that are suitable for people in secure forensic mental health services. We conducted pilot work of a multidisciplinary weight management intervention (Motiv8) which showed improvements in physical and mental health and high levels of satisfaction. We aim to test the feasibility of Motiv8 under cluster randomised conditions, with an aim to investigate the acceptability, feasibility and potential effectiveness of this intervention to supplement standard secure care.

METHODS AND ANALYSIS

A randomised waitlist-controlled feasibility trial of a lifestyle intervention (Motiv8) + TAU compared with TAU (+ Motiv8 waitlist) for adults on secure mental health units will be conducted. Thirty-two people (4 cohorts) will be recruited from secure services in Greater Manchester Mental Health NHS Foundation Trust. Participants will be randomly allocated to Motiv8 or TAU + Motiv8 waitlist. All participants will receive Motiv8 during the trial. Assessor-blinded physical/mental health and lifestyle assessments will be conducted at baseline, 10 weeks (post-intervention/waitlist), and after 12 weeks (post-waitlist intervention/follow-up). Motiv8 is a multidisciplinary intervention including exercise sessions, cooking/nutrition classes, physical health education, psychology sessions, sleep hygiene, peer support and medication review by pharmacy. A nested qualitative study will be conducted with a subsample of participants (n = 10) to explore their experiences of taking part. The analysis will focus on feasibility outcomes and tabulated success indicators of the study (e.g. Recruitment rates, retention rates, follow-up retention and response rates, attendance at sessions, the experience of involvement in the trial and delivery of the intervention, assessment of safety, development of a manualised intervention). Thematic analysis will be conducted through qualitative interviews. The analysis will aim to inform the development of a definitive trial.

ETHICS AND DISSEMINATION

The trial has been granted ethical approval from the NHS Health Research Authority and adopted onto the UK Clinical Research Network Portfolio. Findings will be disseminated via peer-reviewed publications, professional and public networks, conferences and clinical services.

TRIAL REGISTRATION

ISRCTN13539285.

Knee Offloading by Patients During Walking and Running After Meniscectomy

Background

Changes in knee loading have been reported after meniscectomy. Knee loading has previously been assessed during jogging and treadmill running rather than overground running, which could give altered results.

Purpose/Hypothesis

The purpose of this study was to evaluate knee function during overground running and walking after meniscectomy. It was hypothesized that the affected limb would demonstrate higher external knee adduction moment, lower knee flexion moment (KFM), and lower knee rotation moment (KRM) compared with the contralateral limb and with healthy individuals.

Study Design

Controlled laboratory study.

Methods

Kinematic and kinetic data were collected during running and walking in individuals after a meniscectomy and healthy individuals. Total knee joint moments (TKJM) were calculated from the sagittal, frontal, and transverse knee moments. Isometric quadriceps strength, perceived knee function, and kinesiophobia were also assessed. A mixed linear model compared differences between the affected leg, the contralateral leg, and the healthy leg.

Results

Data were collected on 20 healthy individuals and 30 individuals after a meniscectomy (mean ± SD, 5.7 ± 2.9 months postsurgery), with 12, 16, and 2 individuals who had medial, lateral, and both medial and lateral meniscectomy, respectively. The affected limb demonstrated lower TKJM (P < .001), KFM (P = .004), and KRM (P < .001) during late stance of walking compared with the healthy group. Lower TKJM and KFM were observed during running in the affected limb compared with the contralateral limb and healthy group. No significant differences were observed between contralateral and healthy limbs except for KRM during late stance of walking. Lower quadriceps strength was observed in the affected (P < .001) and contralateral limbs (P = .001) compared with the healthy group. Individuals after a meniscectomy also reported greater kinesiophobia (P = .006) and lower perceived knee function (31.1%; P < .001) compared with the healthy group.

Conclusion

After meniscectomy, individuals who sustained a traumatic meniscal injury showed lower TKJM in the affected limb compared with the contralateral limb and healthy individuals. This decrease in TKJM can be attributed to altered knee-loading strategies in the sagittal and transverse planes.

Clinical Relevance

Improving movement strategies, quadriceps strength, and kinesiophobia through rehabilitation approaches will allow individuals to load their knee appropriately when returning to sport.

Registration

NCT03379415 (ClinicalTrials.gov identifier).

A phase I study of Hemay022, an irreversible dual EGFR/HER2 tyrosine kinase inhibitor in Chinese patients with HER2-positive advanced breast cancer

Objective

Hemay022 is a novel small-molecule and an irreversible tyrosine kinase inhibitor with the target of epidermal growth factor receptor (EGFR)/human epidermal growth factor receptor 2 (HER2), which demonstrated anti-tumor activity in preclinical studies. This first-in-human study evaluated the safety, pharmacokinetics, tolerability and preliminary anti-tumor activity of Hemay022 in HER2-positive advanced breast cancer patients.

Methods

Heavily pretreated patients with HER2-positive advanced breast cancer were assigned to eight dose cohorts in a 3+3 dose-escalation pattern at doses of 50-600 mg QD and 300 mg BID. Eligible patients were given a single dose of Hemay022 on d 1 in week 0, followed by once daily continuous doses for four weeks in 28-day cycles. Pharmacokinetic samples were obtained on d 1 and d 28. Clinical responses were assessed every eight weeks.

Results

Twenty-eight patients with advanced breast cancer were treated with Hemay022. The most frequently reported drug-related adverse events were diarrhoea (85.7%), vomiting (28.6%), nausea (25.0%) and decreased appetite (17.9%). No grade 4 drug-related adverse events were reported. At 50-600 mg doses, steady state areas under the concentration-time curve and peak concentrations increased with doses. One patient achieved complete response (CR), and three achieved partial response (PR). The objective response rate (ORR) and disease control rate (DCR) were 14.3% and 46.4% in 28 patients, respectively. The median progression-free survival (PFS) was 3.98 months.

Conclusions

Hemay022 at the dose of 500 mg once daily was well tolerated. The pharmacokinetic properties and encouraging anti-tumor activities of Hemay022 in advanced breast cancer patients warranted further evaluation of Hemay022 for treating breast cancer patients in the current phase III trial (No. NCT05122494).

CLEAR - clozapine in early psychosis: study protocol for a multi-centre, randomised controlled trial of clozapine vs other antipsychotics for young people with treatment resistant schizophrenia in real world settings

BACKGROUND

Clozapine is an antipsychotic drug with unique efficacy, and it is the only recommended treatment for treatment-resistant schizophrenia (TRS: failure to respond to at least two different antipsychotics). However, clozapine is also associated with a range of adverse effects which restrict its use, including blood dyscrasias, for which haematological monitoring is required. As treatment resistance is recognised earlier in the illness, the question of whether clozapine should be prescribed in children and young people is increasingly important. However, most research to date has been in older, chronic patients, and evidence regarding the efficacy and safety of clozapine in people under age 25 is lacking. The CLEAR (CLozapine in EARly psychosis) trial will assess whether clozapine is more effective than treatment as usual (TAU), at the level of clinical symptoms, patient rated outcomes, quality of life and cost-effectiveness in people below 25 years of age. Additionally, a nested biomarker study will investigate the mechanisms of action of clozapine compared to TAU.

METHODS AND DESIGN

This is the protocol of a multi-centre, open label, blind-rated, randomised controlled effectiveness trial of clozapine vs TAU (any other oral antipsychotic monotherapy licenced in the British National Formulary) for 12 weeks in 260 children and young people with TRS (12-24 years old).

AIM AND OBJECTIVES

The primary outcome is the change in blind-rated Positive and Negative Syndrome Scale scores at 12 weeks from baseline. Secondary outcomes include blind-rated Clinical Global Impression, patient-rated outcomes, quality of life, adverse effects, and treatment adherence. Patients will be followed up for 12 months and will be invited to give consent for longer term follow-up using clinical records and potential re-contact for further research. For mechanism of action, change in brain magnetic resonance imaging (MRI) biomarkers and peripheral inflammatory markers will be measured over 12 weeks.

DISCUSSION

The CLEAR trial will contribute knowledge on clozapine effectiveness, safety and cost-effectiveness compared to standard antipsychotics in young people with TRS, and the results may guide future clinical treatment recommendation for early psychosis.

TRIAL REGISTRATION

ISRCTN Number: 37176025, IRAS Number: 1004947.

TRIAL STATUS

In set-up. Protocol version 4.0 01/08/23. Current up to date protocol available here: https://fundingawards.nihr.ac.uk/award/NIHR131175# /.

Allogeneic Hematopoietic Cell Transplantation with Non-Myeloablative Conditioning and Post-Transplant Cyclophosphamide Prophylaxis in Patients with Reduced Systolic Function

Post-transplantation cyclophosphamide (PTCy) has become standard of care for graft-versus-host disease (GVHD) prophylaxis after allogeneic hematopoietic cell transplantation (alloHCT), allowing for expanded donor options. However, there is scant literature examining outcomes of patients with reduced systolic function receiving PTCy. The present study aimed to describe our experience in performing alloHCT in patients with reduced systolic function, including their nonrelapse mortality (NRM), overall survival (OS), and cumulative incidence of early cardiac events (ECEs). We performed a retrospective descriptive analysis using the Johns Hopkins Hematologic Malignancy database. From 2017 through 2021, 1118 consecutive patients underwent alloHCT with nonmyeloablative (NMA) conditioning and PTCy. Forty-three of those patients had a pretransplantation left ventricular ejection fraction (LVEF) ≤45% measured by transthoracic echocardiography. Patients whose LVEF improved on treatment prior to transplantation were also included. These 2 cohorts were stratified into 2 groups-heart failure with reduced ejection fraction (HFrEF) and heart failure with recovered ejection fraction (HFrecEF)-and subgroup analyses compared NRM, OS, and cumulative incidence of ECEs, including arrhythmia, coronary artery disease, reduction in LVEF, and pericardial effusion, within 100 days post-transplantation. The median LVEF was 40% to 45% (range, 30% to 45%) for the 31 patients undergoing transplantation with HFrEF and 35% to 40% (range, 20% to 45%) for the 12 patients with HFrecEF. The NRM for all 43 patients was 16% (95% confidence interval [CI], 5% to 27%) at 100 days and 23% (95% CI, 11% to 36%) at 2 years. The NRM was 23% (95% CI, 8% to 38%) at 100 days and 26% (95% CI, 10% to 42%) at 2 years for the HFrEF cohort and 0 at 100 days and 18% (95% CI, 0 to 41%) at 2 years for the HFrecEf cohort. The OS at 3 years was 41% (95% CI, 26% to 62%), 40% (95% CI, 25% to 65%) and 38% (95% CI, 14% to 100%) in the combined, HFrEF, and HFrecEF cohorts, respectively. The cumulative incidence of any ECE was 37.2% (95% CI, 22% to 51.9%), including 39% of HFrEF subjects and 33% of HFrecEF subjects. Grade ≥3 toxicities were seen in 56% of patients. Reduced ejection fraction was the most common ECE. One death was attributable to a cardiac etiology. Cardiac toxicities seemed to be more frequent and severe in patients with a history of systolic dysfunction, but this did not lead to worse survival outcomes. This study adds to and extends the existing literature supporting the use of NMA conditioning and PTCy in patients with systolic dysfunction.

Managed care updates of subscriber jail release to prompt community suicide prevention: clinical trial protocol

BACKGROUND

Recent jail detention is a marker for trait and state suicide risk in community-based populations. However, healthcare providers are typically unaware that their client was in jail and few post-release suicide prevention efforts exist. This protocol paper describes an effectiveness-implementation trial evaluating community suicide prevention practices triggered by advances in informatics that alert CareSource, a large managed care organization (MCO), when a subscriber is released from jail.

METHODS

This randomized controlled trial investigates two evidence-based suicide prevention practices triggered by CareSource's jail detention/release notifications, in a partial factorial design. The first phase randomizes ~ 43,000 CareSource subscribers who pass through any Ohio jail to receive Caring Contact letters sent by CareSource or to Usual Care after jail release. The second phase (running simultaneously) involves a subset of ~ 6,000 of the 43,000 subscribers passing through jail who have been seen in one of 12 contracted behavioral health agencies in the 6 months prior to incarceration in a stepped-wedge design. Agencies will receive: (a) notifications of the client's jail detention/release, (b) instructions for re-engaging these clients, and (c) training in suicide risk assessment and the Safety Planning Intervention for use at re-engagement. We will track suicide-related and service linkage outcomes 6 months following jail release using claims data.

CONCLUSIONS

This design allows us to rigorously test two intervention main effects and their interaction. It also provides valuable information on the effects of system-level change and the scalability of interventions using big data from a MCO to flag jail release and suicide risk.

TRIAL REGISTRATION

The trial is registered at clinicaltrials.gov (NCT05579600). Registered 27 June, 2023.

PTCy: The "new" standard for GVHD prophylaxis

High dose Post transplant cyclophosphamide (PTCy) is now regarded as a very effective way of preventing acute and chronic GvHD, and it's use has rapidly expanded world-wide.

Comparison of the clinical characteristics of SARS-CoV-2 Delta (B.1.617.2) and Omicron (B.1.1.529) infected patients from a single hospitalist service

BACKGROUND

While existing evidence suggests less severe clinical manifestations and lower mortality are associated with the Omicron variant as compared to the Delta variant. However, these studies fail to control for differences in health systems facilities and providers. By comparing patients hospitalized on a single medical service during the Delta and Omicron surges we were able to conduct a more accurate comparison of the two varaints' clinical manifestations and outcomes.

METHODS

We conducted a prospective study of 364 Omicron (BA.1) infected patients on a single hospitalist service and compared these findings to a retrospective analysis of 241 Delta variant infected patients managed on the same service. We examined differences in symptoms, laboratory measures, and clinical severity between the two variants and assessed potential risk drivers for case mortality.

FINDINGS

Patients infected with Omicron were older and had more underlying medical conditions increasing their risk of death. Although they were less severely ill and required less supplemental oxygen and dexamethasone, in-hospital mortality was similar to Delta cases, 7.14% vs. 4.98% for Delta (q-value = 0.38). Patients older than 60 years or with immunocompromised conditions had much higher risk of death during hospitalization, with estimated odds ratios of 17.46 (95% CI: 5.05, 110.51) and 2.80 (1.03, 7.08) respectively. Neither vaccine history nor variant type played a significant role in case fatality. The Rothman score, NEWS-2 score, level of neutrophils, level of care, age, and creatinine level at admission were highly predictive of in-hospital death.

INTERPRETATION

In hospitalized patients, the Omicron variant is less virulent than the Delta variant but is associated with a comparable mortality. Clinical and laboratory features at admission are informative about the risk of death.

Skills to Enhance Positivity in adolescents at risk for suicide: Protocol for a randomized controlled trial

BACKGROUND

Suicide and suicidal behavior during adolescence have been steadily increasing over the past two decades. The preponderance of interventions focuses on crisis intervention, underlying psychiatric disorders, regulating negative affect, and reducing cognitive distortions. However, low positive affectivity may be a mechanism that contributes to adolescent suicidal ideation and behaviors independent of other risk factors. Skills to Enhance Positivity (STEP) is an acceptance-based intervention, designed to increase attention to, and awareness of, positive affect and positive experiences. Results from a pilot RCT demonstrated engagement of the target (positive affect) and a decrease in clinical outcomes (suicidal events; i.e., either a suicide attempt or an emergency intervention for an acute suicidal crisis), providing support to test the clinical effectiveness of STEP in a larger clinical trial with clinical staff implementing the intervention.

OBJECTIVE

To test the effectiveness of STEP, compared to Enhanced Treatment as Usual (ETAU), in reducing suicidal events and ideation in adolescents admitted to inpatient psychiatric care due to suicide risk. We hypothesize that those randomized to STEP, compared to ETAU, will have lower rates of suicide events, active suicidal ideation (SI), and depressed mood over the 6-month follow-up period. We hypothesize that those randomized to STEP, compared to ETAU, will demonstrate greater improvement in the hypothesized mechanisms of attention to positive affect stimuli and gratitude and satisfaction with life.

METHODS

Participants will be randomized to either STEP or ETAU. STEP consists of four in-person sessions focused on psychoeducation regarding positive and negative affect, mindfulness meditation, gratitude, and savoring. Mood monitoring prompts and skill reminders will be sent via text messaging daily for the first month post-discharge and every other day for the following two months. The ETAU condition will receive text-delivered reminders to use a safety plan provided at discharge from the hospital and healthy habits messages, matched in frequency to the STEP group. This trial was registered on 6 August 2021 (ClinicalTrials.gov NCT04994873).

RESULTS

The STEP protocol was approved by the National Institute of Mental Health (NIMH) Data and Safety Monitoring Board on March 4, 2022. The RCT is currently in progress.

DISCUSSION

The STEP protocol is an innovative, adjunctive treatment that has the potential to have positive effects on adolescent suicidal ideation and attempts beyond that found for standard treatment alone.

Complete genome sequence of a new mitovirus associated with walking iris (Trimezia northiana)

The complete genome sequence of a new member of the family Mitoviridae was obtained from walking iris (Trimezia northiana (Schneev.) Ravenna by high-throughput sequencing. This is the first putative mitovirus identified in a monocotyledonous plant. The new mitovirus was tentatively named "walking iris virus 1" (WIV1). The complete genome of WIV1 is 2,858 nt in length with a single ORF encoding a viral replicase (RdRp). The highest level of amino acid sequence identity was 45% to Beta vulgaris mitovirus 1. In the viral replicase, a conserved protein domain for mitovirus RNA-dependent RNA polymerase and six highly conserved motifs were detected, consistent with other members of the family Mitoviridae. Phylogenetic inferences placed WIV1 among members of the genus Duamitovirus (family Mitoviridae) in a monophyletic clade with other plant mitoviruses. Sequence comparison and phylogenetic analysis support the classification of WIV1 as a new member of the genus Duamitovirus (family Mitoviridae).

The Effects of Occupational Complexity on Late Life Cognition in ACTIVE: Examining the Mediating and Moderating Effects of Race

Objectives: This article sought to determine (1) whether occupational complexity (OC) explains individual differences in cognition at baseline, (2) whether this relationship is differentially related to cognition by Black/White race, and (3) whether OC mediates some or all of the Black/White race-related variance in late life cognition. Methods: 2371 participants from the Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) study reported longest held jobs and received OC ratings based on a factor analysis of 63 variables from the Dictionary of Occupational Titles. Results: We found that multiple dimensions of OC are related to cognition, but there were relatively few Black/White differences in these associations. Across all cognitive dimensions except for useful field of view, a history of having jobs lower in substantive complexity and fine motor skills and higher in physical demands may explain some of the Black/White race differences in elder's cognition. Discussion: We conclude that occupations can be a target to reduce social disparities in late life cognition.

Evaluating Social Determinants of Health Domains and Their Predictive Validity Within Black/African American and White Older Adults From the ACTIVE Trial

OBJECTIVE

To assess domains of social determinants of health (SDoH) and their associations with cognition and quality of life.

METHOD

This investigation uses baseline data from individuals participating in the ACTIVE trial (n = 2505) to reproduce the SDoH domains described in Healthy People 2030 (economic stability, health care, education, neighborhood and built environment, and social and community context). Results: Results support using data from the ACTIVE trial to assess all five SDoH domains, and the ability of the composites to predict baseline performance on measures of cognition and self-reported quality of life within a sample of older adults. Additionally, higher SDoH domain scores were associated with better functioning on composite measures of cognition and higher scores for mental and general health-related quality of life with Access to Healthcare associated with all outcomes. Discussion: These findings can inform investigators interested in assessing multiple domains of SDoH and highlight the importance of access to health care within older Black/African American and White older adults.

Managed Care Updates of Subscriber Jail Release to Prompt Community Suicide Prevention: Clinical Trial Protocol

Background

Recent jail detention is a marker for trait and state suicide risk in community-based populations. However, healthcare providers are typically unaware that their client was in jail and few post-release suicide prevention efforts exist. This protocol paper describes an effectiveness-implementation trial evaluating community suicide prevention practices triggered by advances in informatics that alert CareSource, a large managed care organization (MCO), when a subscriber is released from jail.

Methods

This randomized controlled trial investigates two evidence-based suicide prevention practices triggered by CareSource's jail detention/release notifications, in a partial factorial design. The first phase randomizes ~43,000 CareSource subscribers who pass through any Ohio jail to receive Caring Contact letters sent by CareSource or to Usual Care after jail release. The second phase (running simultaneously) involves a subset of ~6,000 of the 43,000 subscribers passing through jail who have been seen in one of 12 contracted behavioral health agencies in the 6 months prior to incarceration in a stepped-wedge design. Agencies will receive: (a) notifications of the client's jail detention/release, (b) instructions for re-engaging these clients, and (c) training in suicide risk assessment and the Safety Planning Intervention for use at re-engagement. We will track suicide-related and service linkage outcomes 6 months following jail release using claims data.

Conclusions

This design allows us to rigorously test two intervention main effects and their interaction. It also provides valuable information on the effects of system-level change and the scalability of interventions using big data from a MCO to flag jail release and suicide risk.

Trial Registration

The trial is registered at clinicaltrials.gov (NCT05579600). Registered 27 June, 2023, https://beta.clinicaltrials.gov/study/NCT05579600?cond=Suicide&term=Managed%20Care&rank=1.

Effectiveness of out-patient based acute heart failure care: a pilot randomised controlled trial

OBJECTIVES

Acute heart failure (AHF) hospitalisation is associated with 10% mortality. Outpatient based management (OPM) of AHF appeared effective in observational studies. We conducted a pilot randomised controlled trial (RCT) comparing OPM with standard inpatient care (IPM).

METHODS

We randomised patients with AHF, considered to need IV diuretic treatment for ≥2 days, to IPM or OPM. We recorded all-cause mortality, and the number of days alive and out-of-hospital (DAOH). Quality of life, mental well-being and Hope scores were assessed. Mean NHS cost savings and 95% central range (CR) were calculated from bootstrap analysis. Follow-up: 60 days.

RESULTS

Eleven patients were randomised to IPM and 13 to OPM. There was no statistically significant difference in all-cause mortality during the index episode (1/11 vs 0/13) and up to 60 days follow-up (2/11 vs 2/13) [p = .86]. The OPM group accrued more DAOH {47 [36,51] vs 59 [41,60], p = .13}. Two patients randomised to IPM (vs 6 OPM) were readmitted [p = .31]. Hope scores increased more with OPM within 30 days but dropped to lower levels than IPM by 60 days. More out-patients had increased total well-being scores by 60 days (p = .04). OPM was associated with mean cost savings of £2658 (95% CR 460-4857) per patient.

CONCLUSIONS

Patients with acute HF randomised to OPM accrued more days alive out of hospital (albeit not statistically significantly in this small pilot study). OPM is favoured by patients and carers and is associated with improved mental well-being and cost savings.

Prenatal exposure to polybrominated diphenyl ethers and inattention/hyperactivity symptoms in mid to late adolescents

Introduction

Prenatal exposure to polybrominated diphenyl ethers (PBDEs) has been associated with increased symptoms of attention deficit/hyperactivity disorder (ADHD) in early to middle childhood, as well as early adolescence. However, data are limited for the long-lasting impact of exposure on outcomes assessed across the entire adolescent period and the sex-specificity of such associations.

Methods

We investigated the association between continuous natural-log-transformed cord plasma PBDE concentrations and ADHD rating scale 4th edition (ADHD-RS-IV) score from mid adolescence (approximately 11 years old) to late adolescence (approximately 17 years old). The study sample includes a subset (n = 219) of the African American and Dominican children enrolled in the Columbia Center for Children's Environmental Health Mothers and Newborns birth cohort. We used generalized estimating equations to account for the repeated measure of ADHD-RS scores. We examined interactions between exposure to PBDE and sex using cross-product terms and sex-stratified models. In addition, we used linear regression using an age-stratified sample as a sensitivity analysis.

Results and Discussion

Associations between prenatal exposure and parents' reports of ADHD symptoms varied by sex (p-interaction <0.20), with positive relationships observed among girls but not boys from sex-stratified models. Our finding suggests prenatal exposure to PBDE may affect ADHD symptoms assessed during middle to late adolescence and the sex-specificity of such impact. Our results can be confirmed by future studies with larger and more diverse samples.

The evolution of atmospheric particulate matter in an urban landscape since the Industrial Revolution

Atmospheric particulate matter (PM) causes 3.7 million annual deaths worldwide and potentially damages every organ in the body. The cancer-causing potential of fine particulates (PM_2.5) highlights the inextricable link between air quality and human health. With over half of the world's population living in cities, PM_2.5 emissions are a major concern, however, our understanding of exposure to urban PM is restricted to relatively recent (post-1990) air quality monitoring programmes. To investigate how the composition and toxicity of PM has varied within an urban region, over timescales encompassing changing patterns of industrialisation and urbanisation, we reconstructed air pollution records spanning 200 years from the sediments of urban ponds in Merseyside (NW England), a heartland of urbanisation since the Industrial Revolution. These archives of urban environmental change across the region demonstrate a key shift in PM emissions from coarse carbonaceous 'soot' that peaked during the mid-twentieth century, to finer combustion-derived PM_2.5 post-1980, mirroring changes in urban infrastructure. The evolution of urban pollution to a recent enhanced PM_2.5 signal has important implications for understanding lifetime pollution exposures for urban populations over generational timescales.

Enforcing walking speed and step-length affects joint kinematics and kinetics in male and female healthy adults

BACKGROUND

Individuals increase walking speed by increasing their step-length, increasing their step-frequency, or both. During basic training military recruits are introduced to marching "in-step", and thus the requirement to walk at fixed speeds and step-lengths. The extent to which individuals are required to under- or over-stride will vary depending on their stature, and the stature of others in their section. The incidence of stress fractures in female recruits undergoing basic training is higher than that for their male counterparts.

RESEARCH QUESTION

Therefore, the purpose of this study was to determine how joint kinematics and kinetics are affected by walking speed, step-length, and sex.

METHODS

Thirty-seven (19 female) aerobically active non-injured individuals volunteered for this study. Synchronised three-dimensional kinematic and kinetic data were collected while participants walked overground at prescribed speeds. Audio and visual cues were used to control step-lengths. Linear mixed models were run to analyse the effects of speed, step-length condition, and sex on peak joint moments.

RESULTS AND SIGNIFICANCE

The findings of this study showed that, in general, walking faster and over-striding predominantly increased peak joint moments, suggesting that over-striding is more likely to negatively affect injury risk than under-striding. This is especially important for individuals unaccustomed to over-striding as the cumulative effect of increased joint moments may affect a muscles capability to withstand the increased external forces associated with walking faster and with longer step-lengths, which could then lead to an increased risk of developing an injury.

No differences in knee joint loading between individuals who had a medial or lateral meniscectomy: An ancillary study

BACKGROUND

Arthroscopic partial meniscectomy is a frequently undertaken procedure for traumatic meniscal injuries. The location of knee joint degeneration and long-term prognosis differs between knees who have had a medial or lateral meniscectomy. However, there is no evidence comparing knee loading following a medial or lateral meniscectomy during sporting tasks. This study compared knee loading during walking and running between individuals who either had a medial or lateral meniscectomy.

METHODS

Knee kinematic and kinetic data were collected during walking and running in individuals three to twelve months post-surgery. Participants were grouped according to the location of surgery (medial, n = 12, and lateral, n = 16). An independent t-test compared knee biomechanics between the groups and Hedge's g effects sizes were also conducted.

RESULTS

External knee adduction and knee flexion moments were similar between groups for walking and running with negligible to small effect sizes (effect size, 0.08-0.30). Kinematic (effect size, 0.03-0.22) and spatiotemporal (effect size, 0.02-0.59) outcomes were also similar between the groups.

CONCLUSIONS

The lack of differences in surrogate knee loading variables between medial and lateral meniscectomy groups was unexpected. These findings suggest that combining groups in the short-term period following surgery is applicable. However, the data presented in this study cannot explain the differences in long-term prognosis between medial and lateral meniscectomies.

Volanesorsen and triglyceride levels in familial chylomicronemia syndrome: Long-term efficacy and safety data from patients in an open-label extension trial

BACKGROUND

Familial chylomicronemia syndrome (FCS) is a rare, autosomal recessive genetic disorder characterized by a marked increase in plasma triglyceride (TG) levels and recurrent episodes of pancreatitis. The response to conventional TG-lowering therapies is suboptimal. Volanesorsen, an antisense oligonucleotide that targets hepatic apoC-III mRNA, has been shown to significantly reduce TGs in patients with FCS.

OBJECTIVE

To further evaluate the safety and efficacy of extended treatment with volanesorsen in patients with FCS.

METHODS

This phase 3 open-label extension study evaluated the efficacy and safety of extended treatment with volanesorsen in three groups of patients with FCS: Those who had previously received volanesorsen or placebo in the APPROACH and COMPASS studies, and treatment-naive patients not participating in either study. Key endpoints included change in fasting TG and other lipid measurements, and safety over 52 weeks.

RESULTS

Volanesorsen treatment resulted in sustained reductions in plasma TG levels in previously treated patients from the APPROACH and COMPASS studies. Volanesorsen-treated patients from the three populations studied had mean decreases in fasting plasma TGs from index study baseline to months 3, 6, 12 and 24 as follows: decreases of 48%, 55%, 50%, and 50%, respectively (APPROACH); decreases of 65%, 43%, 42%, and 66%, respectively (COMPASS); and decreases of 60%, 51%, 47%, and 46%, respectively (treatment-naive). Common adverse events were injection site reactions and platelet count decrease, consistent with previous studies.

CONCLUSION

Extended open-label treatment with volanesorsen in patients with FCS resulted in sustained reductions of plasma TG levels and safety consistent with the index studies.

Abstract 2996: CT26 neoantigen presentation and immunogenicity

The foundation of personalized cancer therapy is teaching a patient’s own immune system to directly kill the cancer cells. Vaccination against tumor antigens is one method being explored to generate immune responses against tumors, and may be particularly effective in conjunction with therapies currently in the clinic, such as checkpoint inhibition. Identification of antigens for use in a vaccine is the pinch point of this method, and many algorithms have been developed in an attempt to predict what epitopes will be both presented and immunogenic. Importantly, both public (common to multiple individuals/cancer types) and private (single individual) epitopes may contribute to the development of effective vaccines. Experimental identification of presented and immunogenic epitopes is crucial to building effective anti-cancer vaccines. Using immunopeptidome profiling, we have narrowed a collection of published potential neoantigens to those which were presented by MHC class I in the CT26 mouse colorectal cancer cell line. These peptides were synthesized and used to immunize BALB/c mice. The immunogenicity of the peptide mix was then evaluated by ELIspot to assess IFN-gamma responses in immunized mice. These experiments support a complete workflow for selection of potential cancer neoantigens which experimentally exhibit both MHC presentation and immunogenicity.

Citation Format: Seeta Nyayapathy, Richard Jones, Michael Ford, Micah Doty, Julie M. Rumble. CT26 neoantigen presentation and immunogenicity [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 2996.

Inpatient Mortality in Parkinson's Disease

Introduction

Although a majority of the American public prefer to die at home, a large percentage of Parkinson's disease patients die in acute care hospitals. We examine trends in the clinical and demographic characteristics of Parkinson's disease patients who die in a hospital to identify populations potentially vulnerable to unwanted inpatient mortality.

Methods

Patients with Parkinson's disease admitted to a hospital from 2002-2016 were identified from the National Inpatient Sample (n = 710,013) along with their associated clinical and demographic characteristics. The main outcome examined was mortality during inpatient admission. From these data, logistic regression models were estimated to obtain the odds ratios of inpatient mortality among clinical and demographic attributes, and their change over time.

Results

Characteristics significantly associated with increased odds of inpatient mortality included increased age (OR = 1.70 for 55-65, 2.52 for 66-75, 3.99 for 76-85, 5.72 for 86+, all P < 0.001), length of stay ≤5 days (reference; 6 + days OR = 0.37, P < 0.001), white race or ethnicity (reference; Black OR = .84 P < .001, Hispanic OR = 0.91 P = 0.01), male (reference; female OR = 0.93 P < 0.001), hospitalization in Northeast (reference; Midwest OR = 0.78, South 0.84, West OR = 0.82; all P < 0.001), higher severity of illness (moderate OR = 1.50, major OR = 2.32, extreme OR = 5.57; all P < 0.001), and mortality risk (moderate OR = 2.88, major OR = 10.92, extreme OR = 52.30; all P < 0.001). Fitted probabilities overall declined over time.

Conclusion

Differences exist among PD patient populations regarding likelihood of in-hospital mortality that are changing with time. Insight into which PD patients are most at risk for inpatient mortality may enable clinicians to better meet end-of-life care needs.

Imaging the Cerebral Veins in Pediatric Patients: Beyond Dural Venous Sinus Thrombosis

The range of intracranial venous anomalies in children differs from that in adults. As a commonly encountered highly morbid disease, sinovenous thrombosis has been discussed extensively in the literature, and the associated imaging considerations are similar in pediatric and adult patients. The authors shift the focus to less frequently discussed cerebral venous diseases in pediatric patients. First, the practical embryology pertinent to malformations, syndromes, and variants such as vein of Galen aneurysmal malformation, Sturge-Weber syndrome, and developmental venous anomalies are discussed. Second, anatomic considerations that are applicable to neuroimaging in pediatric patients with cerebral venous anomalies are reviewed. In the discussion of anatomy, special attention is given to the medullary venous system that serves the cerebral white matter, superficial cortical veins (tributaries of the dural venous sinuses), and bridging veins, which carry blood from the superficial cortical veins through the potential subdural space into the dural venous sinuses. Third, the selection of imaging modalities (US, CT and CT venography, and MRI) is addressed, and various MR venographic pulse sequences (time-of-flight, phase-contrast, and contrast-enhanced sequences) are compared. Finally, a broad variety of congenital and acquired superficial and deep venous diseases in children are reviewed, with emphasis on less frequently discussed entities involving the medullary (eg, deep medullary venous engorgement and thrombosis, periventricular hemorrhagic venous infarction due to germinal matrix hemorrhage), cortical (eg, cortical venous thrombosis), and bridging (eg, acute and chronic manifestations of injury in abusive head trauma) veins, as well as the deep veins and dural venous sinuses (eg, varix). © RSNA, 2023 Quiz questions for this article are available through the Online Learning Center. Online supplemental material and the slide presentation from the RSNA Annual Meeting are available for this article.

Role of sex and stature on the biomechanics of normal and loaded walking: implications for injury risk in the military

Load carriage and marching 'in-step' are routine military activities associated with lower limb injury risk in service personnel. The fixed pace and stride length of marching typically vary from the preferred walking gait and may result in overstriding. Overstriding increases ground reaction forces and muscle forces. Women are more likely to overstride than men due to their shorter stature. These biomechanical responses to overstriding may be most pronounced when marching close to the preferred walk-to-run transition speed. Load carriage also affects walking gait and increases ground reaction forces, joint moments and the demands on the muscles. Few studies have examined the effects of sex and stature on the biomechanics of marching and load carriage; this evidence is required to inform injury prevention strategies, particularly with the full integration of women in some defence forces. This narrative review explores the effects of sex and stature on the biomechanics of unloaded and loaded marching at a fixed pace and evaluates the implications for injury risk. The knowledge gaps in the literature, and distinct lack of studies on women, are highlighted, and areas that need more research to support evidence-based injury prevention measures, especially for women in arduous military roles, are identified.

The reliability of lower limb 3D gait analysis variables during a change of direction to 90- and 135-degree manoeuvres in recreational soccer players

BACKGROUND

Several biomechanical outcomes are being used to monitor the risk of injuries; therefore, their reliability and measurement errors need to be known.

OBJECTIVE

To measure the reliability and measurement error in lower limb 3D gait analysis outcomes during a 90∘ and 135∘ change of direction (COD) manoeuvre.

METHODS

A test re-test reliability study for ten healthy recreational players was conducted at seven-day intervals. Kinematics (Hip flexion, adduction, internal rotation angles and knee flexion abduction angles) and kinetics (Knee abduction moment and vertical ground reaction force) data during cutting 90∘ and 135∘ were collected using 3D gait analysis and force platform. Five trials for each task and leg were collected. Standard error of measurement (SEM) and the intraclass correlation coefficient (ICC) were calculated from the randomised leg.

RESULT

The ICC values of the kinematics, kinetics, and vertical ground reaction force (VGRF) outcomes (90∘ and 135∘) ranged from 0.85 to 0.95, showing good to excellent reliability. The SEM for joint angles was less than 1.69∘. The VGRV showed a higher ICC value than the other outcomes.

CONCLUSION

The current study results support the use of kinematics, kinetics, and VGRF outcomes for the assessment of knee ACL risk in clinic or research. However, the hip internal rotation angle should be treated with caution since the standard measurement error exceeded 10% compared to the mean value. The measurement errors provided in the current study are valuable for future studies.

Longitudinal Analysis of Shoulder Arthroplasty Utilization, Clinical Outcomes, and Value: a Comparative Assessment of Changes in Improvement Over 15 Years with a Single Platform Shoulder Prosthesis

BACKGROUND

The goal of this longitudinal analysis of aTSA and rTSA utilization from 2007-2021 is to quantify changes in clinical outcomes, cost, and value, resulting from the introduction and adoption of new shoulder arthroplasty technologies.

METHODS

We analyzed an international database of a single shoulder arthroplasty prosthesis (Equinoxe; Exactech, Inc; Gainesville, FL, USA) for all clinical sites that have continuously enrolled cases from 2007 to 2021 to compare changes in primary aTSA and primary rTSA utilization and outcomes across three, 5-year cohorts based upon the date of implantation. A value analysis was conducted across the 5-year implantation cohorts, with value measured by the ratio of each postoperative outcome measure at 24-36 months and 36-60 months after surgery and the average implant selling price each year for the US sites in constant 2007 US dollars, these measures of value were compared between cohorts to quantify the impact of new technology introduced over the study period.

RESULTS

A dramatic increase in rTSA utilization was observed across the 6 sites over the 15-year study period, along with a rapid adoption of new aTSA and rTSA technologies. The average patient receiving primary aTSA and primary rTSA changed over the 15-year study period, with significant shifts in diagnosis, comorbidities, and preoperative functional status. A comparison of postoperative results demonstrated that both aTSA and rTSA clinical and radiographic outcomes showed improvement relative to 2007-2011. Over this 15-year study period, the average aTSA implant selling price has been relatively stable while the average rTSA implant selling price has significantly declined. As a result, the value associated with the Equinoxe rTSA significantly increased for nearly every outcome measure at 24-36 months and 36-60 months after surgery, while value associated with the Equinoxe aTSA stayed relatively constant from 2007-2021.

CONCLUSION

Our 6,042-patient longitudinal analysis quantified numerous changes in utilization, outcomes, and value across 6 clinical sites over the past 15-years. Rapid adoption of new aTSA and rTSA technologies was observed and clinical and radiographic outcomes improved relative to 2007-2011. These clinical improvements, in combination with steady aTSA and declining rTSA implant prices, have driven rTSA value to continuously increase while aTSA value has been maintained at a high-level over the 15-year study period with this particular shoulder arthroplasty system, even when considering the cost and adoption of new technologies.

1328 CGA AND RELATED INTERVENTIONS TO IMPROVE OUTCOMES FOR OLDER PATIENTS UNDERGOING TRANSCATHETER AORTIC VALVE IMPLANTATION

Introduction

The number of transcatheter aortic valve implantations (TAVIs) performed in the UK is increasing exponentially, providing a new treatment avenue for patients with severe symptomatic aortic stenosis previously deemed too frail for surgical intervention. Frailty is known to be associated with poor outcomes following TAVI, however little is known as to whether comprehensive geriatric assessment (CGA), the gold standard intervention for older adults in a range of clinical settings, can change outcomes for older adults undergoing this procedure.

Methods

Databases EMBASE, MEDLINE, CINAHL and Cochrane CENTRAL, along with the World Health Organisation clinical trials registry platform and Clinicaltrials.gov registry were searched for relevant reports between 01/01/1980 - 26/01/2022 using a pre-specified search strategy. Patients had to be 65 or over and studies had to evaluate single- or multi-domain interventions that may form part of a CGA. Studies were not limited to those only looking at patients living with or at risk of frailty.

Results

No studies of adequate quality evaluated the effect of CGA on outcomes for older adults undergoing TAVI. 18 studies evaluating CGA-related interventions were identified that met eligibility criteria, with the majority evaluating cardiac rehabilitation (CR) as a post-procedural intervention. Other interventions evaluated included cognitive behavioural therapy, alternative exercise-based interventions and post-procedural protocols that promoted early mobilisation and allied health professional involvement. A high risk of bias and significant methodological flaws were found in the included studies. There was little evidence that post-procedural CR reduces mortality and to support the role of occupational and physical therapy for improving in-hospital outcomes for these patients.

Conclusion(s)

There is no convincing evidence to support CGA or related single domain interventions to improve outcomes for older adults undergoing TAVI. Further robust research is required to establish whether CGA improves outcomes for this group.

Disappearing colorectal liver metastases in the era of state-of-the-art triple-modality diagnostic imaging

INTRODUCTION

Systemic therapy can result in disappearance of colorectal liver metastases in up to 40% of patients. This might be an overestimation caused by suboptimal imaging modalities. The aim of this study was to investigate the use of imaging modalities and the incidence, management and outcome of patients with disappearing liver metastases (DLMs).

METHODS

This was a retrospective study of consecutive patients treated for colorectal liver metastases at a high volume hepatobiliary centre between January 2013 and January 2015 after receiving induction or neoadjuvant systemic therapy. Main outcomes were use of imaging modalities, incidence, management and longterm outcome of patients with DLMs.

RESULTS

Of 158 patients included, 32 (20%) had 110 DLMs. Most patients (88%) had initial diagnostic imaging with contrast enhanced-CT, primovist-MR and FDG-PET and 94% of patients with DLMs were restaged using primovist-MR. Patients with DLMs had significantly smaller metastases and the median initial size of DLMs was 10 mm (range 5-61). In the per lesion analysis, recurrence after "watch & wait" for DLMs occurred in 36%, while in 19 of 20 resected DLMs no viable tumour cells were found. Median overall (51 vs. 28 months, p < 0.05) and progression free survival (10 vs. 3 months, p = 0.003) were significantly longer for patients with DLMs.

CONCLUSION

Even state-of-the-art imaging and restaging cannot solve problems associated with DLMs. Regrowth of these lesions occurs in approximately a third of the lesions. Patients with DLMs have better survival.

The effect of foot position during static calibration trials on knee kinematic and kinetics during walking

BACKGROUND

Gait analysis has been used extensively for computing knee kinematics and kinetics, in particular, in healthy and impaired individuals. One variable assessed is the external knee adduction moment (EKAM). Variations in EKAM values between investigations may be caused by changes in static standing position, especially foot placement angles which may increase or reduce any differences seen.

PURPOSE OF THE STUDY

The current study aimed to explore the influence of static trial foot position on knee kinematic and kinetic variables during walking.

METHODS

Twelve healthy male participants completed three different static standing trials; 1) 20-degrees toe-in, 2) 0° and 3) 20-degrees toe-out before walking at their own pace during a lower limb kinematics and kinetics assessment. First and second peak EKAM was compared between static foot position trials, as well other knee kinematic and kinetic outcomes. Repeated measures ANOVA was used with post hoc pairwise comparison to determine the differences between static foot position trials.

RESULTS

The first peak of EKAM was significantly smaller in the 20^o toe-out angle, than the 20^o toe-in angle (p = 0.04-8.16% reduction). Furthermore, significant changes were found in peak knee kinematics and kinetics variables (adduction angle, external rotation angle, knee flexion moment external rotation moment, abduction angle and internal rotation angle) in the different positions.

CONCLUSION

Modification in static foot position between study visits may result in changes especially in the 1st peak EKAM and other kinematics and kinetics variables during walking. Therefore, standardisation of static foot position should be utilised in longitudinal studies to ensure changes in EKAM are not masked or accentuated between assessments.

A simple core dataset for triglyceride-induced acute pancreatitis

OBJECTIVE

The objective of this study is to generate a core clinical dataset (CD) containing the minimum acceptable amount of information that should be collected for each patient presenting with triglyceride-induced acute pancreatitis within global treatment centres or sites.

METHOD

The Jandhyala Method, including systematic literature review and SMART interviews, was used to observe expert opinion from ten leaders in the treatment of triglyceride-induced acute pancreatitis (TG-IAP) across the US and EU.

RESULTS

Using the PRISMA Literature Review Protocol, data were extracted from 123 of the 6718 identified studies. A total of 243 items were identified from the data extracted from these studies and, combined with the unique items coded from the Awareness Round (1) survey, formed the Consensus Round (2) survey. One hundred and ninety-five of the 243 items (80%) met the consensus threshold and were included for appraisal in the SMART interview phase. A total of 109 items were agreed to form part of the current clinical diagnostic and monitoring procedure by all experts once the weights across all the stakeholder disciplines were balanced to eliminate bias. These items were further condensed to form the core dataset, comprising a total of 87 items.

CONCLUSION

Once validated and adopted, the TG-IAP CD will improve the overall management of patients with TG-IAP by speeding up diagnosis and detecting changes in disease severity and subsequent disease progression, informing personalized patient management plans, and improving patient outcomes.

Prenatal exposure to polybrominated diphenyl ethers and birth outcomes

BACKGROUND

Polybrominated diphenyl ethers (PBDEs) were used as flame retardants and from their end-use products they can be released to accumulate within indoor environments. This may result in exposures to pregnant women with potential adverse effects on the developing fetus. While studies have shown associations between prenatal PBDE exposure and poor birth outcomes, research has mainly focused on birth weight and gestational age and may miss important indicators of newborn size.

METHODS

The sample included a cohort of Dominican and African American mother-child pairs from New York City recruited from 1998 to 2006. PBDE congeners (BDE-47, BDE-99, BDE-100, and BDE-153) were measured in cord serum at birth and dichotomized into low (<80th percentile) and high (>80th percentile) categories. Weight, length, head circumference, and gestational age were measured at birth and the ponderal index (birth weight/length x 100), size for gestational age, and population-based z-scores were calculated (n = 305). Separate regression analyses were conducted to estimate associations between PBDEs or PBDE sum (ng/g lipid) and birth outcomes. Quantile g-computation was performed to estimate the effect of total PBDE mixture. We also assessed effect modification by sex and ethnicity.

RESULTS

Adjusting for relevant covariates, the high exposure category of BDE-153 was associated with lower birth weight z-score (-0.25, 95% CI: -0.5, 0.0) and longer gestation (0.43 weeks, 95% CI: 0.07, 0.79). The high exposure category of BDE-99 was associated with lower birth length z-score (-0.55, 95% CI: -0.98, -0.12). There was a negative association between the overall PBDE mixture and birth length z-score (-0.10, 95% CI: -0.21, 0.00) per 1 quintile increase in PBDEs. There was no effect modification by sex or ethnicity.

CONCLUSIONS

These results suggest that prenatal exposures to BDE-153, BDE-99, and total PBDE mixture are associated with birth outcomes in a cohort of Dominican and African American newborns.

ADAPTATION OF FACE-TO-FACE COGNITIVE ASSESSMENTS FOR TELEPHONE ADMINISTRATION: A POTENTIAL THREAT TO VALIDITY

Telephone-administered cognitive assessments are a cost-effective, feasible, and sometimes necessary alternative to in-person assessments. However, there is a scarcity of information in large cohort studies concerning mode effects, or differences in cognitive performance attributable to assessment method instead of underlying cognition, as a potential measurement threat. We evaluated mode effects on individual cognitive items and overall cognitive score using a population-based sample of community-living older adults aged 65-79 in the US in the 2014 Health and Retirement Study for whom interview mode was randomized (n=6825). We assessed mode differences in test means and reliability, whether mode modifies associations of cognition with criterion variables, and formal measurement invariance testing by mode. Relative to those assessed face-to-face, people assessed by telephone tended to have higher scores for memory and calculation items (0.06 to 0.013 standard deviations (SD)) and lower scores for non-memory items (-0.09 to -0.01 SD). We also found evidence that estimated cognition was significantly differentially related to IADL score depending on mode of assessment, observing a stronger association among participants completing telephone interviews. Measurement invariance testing identified the largest mode differences in memory and attention items: immediate noun recall, delayed noun recall, and serial 7s scores were higher when administered by telephone. Differences by telephone vs face-to-face mode of administration are apparent in cognitive measurement in older adults, and most pronounced for tests of memory and attention that can be easier to answer via telephone. Future investigations are warranted to further evaluate methods to correct for such differences.

Emergency Urology procedures during the COVID-19 pandemic in the UK: A 3-month prospective study

OBJECTIVE

COVID-19 resulted in Regional tiered restrictions being introduced across the UK with subsequent implications for planned and emergency surgical care. Specific to Merseyside, Tier 4, Tier 2 and Tier 5 restrictions were introduced in late 2020 and early 2021. The purpose of this study was to examine the nature and workload of emergency urological procedures during three different national lockdown Tiers in the North West of England.

METHOD

A 3-month prospective study examining all emergency urological activity was conducted from November 2020 when Tier 4 restrictions were introduced and included Tier 2 restrictions in December and then concluded at the end of January 2021 when Tier 5 restrictions were in place. Data was obtained by identifying patients using the electronic theatre listing system.

RESULTS

A total of 71 emergency cases were performed (24 in November (Tier 4), 28 in December (Tier 2), 19 in January 2021 (Tier 5)) with 15 different types of procedures performed. The most frequently performed procedure was stent insertion (36), followed by scrotal exploration (10). The least commonly performed procedure was suprapubic catheter insertion under general anaesthesia (1). One patient required transfer to a different hospital. In total 6 calls were made by general surgery and 3 by gynaecology for urgent urological assistance in theatre. Three urology patients returned to the theatre as emergencies following elective procedures.

CONCLUSION

Unlike the Spring lockdown, acute urological presentations requiring operative intervention still presented daily. Of the 71 cases performed, most occurred in Tier 2. Stent insertion was the most commonly performed procedure, with the majority of the cases performed by registrars.

Heterogeneity of management practices surrounding operable gallbladder cancer - results of the OMEGA-S international HPB surgical survey

BACKGROUND

Gallbladder cancer (GBC) is an aggressive, uncommon malignancy, with variation in operative approaches adopted across centres and few large-scale studies to guide practice. We aimed to identify the extent of heterogeneity in GBC internationally to better inform the need for future multicentre studies.

METHODS

A 34-question online survey was disseminated to members of the European-African Hepatopancreatobiliary Association (EAHPBA), American Hepatopancreatobiliary Association (AHPBA) and Asia-Pacific Hepatopancreatobiliary Association (A-PHPBA) regarding practices around diagnostic workup, operative approach, utilization of neoadjuvant and adjuvant therapies and surveillance strategies.

RESULTS

Two hundred and three surgeons responded from 51 countries. High liver resection volume units (>50 resections/year) organised HPB multidisciplinary team discussion of GBCs more commonly than those with low volumes (p < 0.0001). Management practices exhibited areas of heterogeneity, particularly around operative extent. Contrary to consensus guidelines, anatomical liver resections were favoured over non-anatomical resections for T3 tumours and above, lymphadenectomy extent was lower than recommended, and a minority of respondents still routinely excised the common bile duct or port sites.

CONCLUSION

Our findings suggest some similarities in the management of GBC internationally, but also specific areas of practice which differed from published guidelines. Transcontinental collaborative studies on GBC are necessary to establish evidence-based practice to minimise variation and optimise outcomes.

Co Transducing B7H3 CAR-NK cells with the DNR preserves their cytolytic function against GBM in the presence of exogenous TGF-β

Cord blood (CB)-derived natural killer (NK) cells that are genetically engineered to express a chimeric antigen receptor (CAR) are an attractive off-the-shelf therapy for the treatment of cancer, demonstrating a robust safety profile in vivo. For poor prognosis brain tumors such as glioblastoma multiforme (GBM), novel therapies are urgently needed. Although CAR-T cells demonstrate efficacy in preclinical GBM models, an off-the-shelf product may exhibit unwanted side effects like graft-versus-host disease. Hence, we developed an off-the-shelf CAR-NK cell approach using a B7H3 CAR and showed that CAR-transduced NK cells have robust cytolytic activity against GBM cells in vitro. However, transforming growth factor (TGF)-β within the tumor microenvironment has devastating effects on the cytolytic activity of both unmodified and CAR-transduced NK cells. To overcome this potent immune suppression, we demonstrated that co-transducing NK cells with a B7H3 CAR and a TGF-β dominant negative receptor (DNR) preserves cytolytic function in the presence of exogenous TGF-β. This study demonstrates that a novel DNR and CAR co-expression strategy may be a promising therapeutic for recalcitrant CNS tumors like GBM.

Prenatal exposure to polybrominated diphenyl ethers and BMI Z-scores from 5 to 14 years

BACKGROUND

Polybrominated diphenyl ethers (PBDEs) are flame-retardant compounds widely used in household products until phase out in 2004. PBDEs are endocrine disruptors and are suggested to influence signaling related to weight control. Prenatal exposures to PBDEs may alter childhood adiposity, yet few studies have examined these associations in human populations.

METHODS

Data were collected from a birth cohort of Dominican and African American mother-child pairs from New York City recruited from 1998 to 2006. PBDE congeners BDE-47, - 99, - 100, and - 153 were measured in cord plasma (ng/μL) and dichotomized into low (< 80th percentile) and high (>80th percentile) exposure categories. Height and weight were collected at ages 5, 7, 9, 11, and an ancillary visit from 8 to 14 years (n = 289). Mixed-effects models with random intercepts for participant were used to assess associations between concentrations of individual PBDE congeners or the PBDE sum and child BMI z-scores (BMIz). To assess associations between PBDEs and the change in BMIz over time, models including interactions between PBDE categories and child age and (child age)² were fit. Quantile g-computation was used to investigate associations between BMIz and the total PBDE mixture. Models were adjusted for baseline maternal covariates: ethnicity, age, education, parity, partnership status, and receipt of public assistance, and child covariates: child sex and cord cholesterol and triglycerides.

RESULTS

The prevalence of children with obesity at age 5 was 24.2% and increased to 30% at age 11. Neither cord levels of individual PBDEs nor the total PBDE mixture were associated with overall BMIz in childhood. The changes in BMIz across childhood were not different between children with low or high PBDEs. Results were similar when adjusting for postnatal PBDE exposures.

CONCLUSIONS

Prenatal PBDE exposures were not associated with child growth trajectories in a cohort of Dominican and African American children.

A nested case-control study of serum polychlorinated biphenyls and papillary thyroid cancer risk among U.S. military service members

BACKGROUND AND OBJECTIVES

Although polychlorinated biphenyls (PCBs) were banned decades ago, populations are continuously exposed to PCBs due to their persistence and bioaccumulation/biomagnification in the environment. Results from limited epidemiologic studies linking PCBs to thyroid cancer have been inconclusive. This study aimed to investigate the association between individual PCBs and PCB mixture and papillary thyroid cancer (PTC), the most common thyroid cancer histologic subtype.

METHODS

We carried out a nested case-control study including 742 histologically confirmed PTC cases diagnosed in 2000-2013 and 742 individually matched controls among U.S. military service members. Pre-diagnostic serum samples that were collected on average nine years before PTC diagnosis were used to measure PCB congeners by gas chromatography isotope dilution high resolution mass spectrometry (GC/ID-HRMS). Conditional logistic regression, Bayesian kernel machine regression (BKMR), and weighted quantile sum (WQS) regression were employed to estimate the association between single PCB congeners as well as their mixture and PTC.

RESULTS

Four PCB congeners (PCB-74, PCB-99, PCB-105, PCB-118) had significant associations and dose-response relationships with increased risk of PTC in single congener models. When considering the effects from all measured PCBs and their potential interactions in the BKMR model, PCB-118 showed positive trends of association with PTC. Increased exposure to the PCB congeners as a mixturewas also associated with an increased risk of PTC in the WQS model, with the mixture dominated by PCB-118, followed by PCB-74 and PCB-99. One PCB congener, PCB-187, showed an inverse trend of association with PTC in the mixture analysis.

DISCUSSION

This study suggests that exposure to certain PCBs as well as a mixture of PCBs were associated with an increased risk of PTC. The observed association was mainly driven by PCB-118, and to a lesser extent by PCB-74 and PCB-99. The findings warrant further investigation.

Search for Subsolar-Mass Binaries in the First Half of Advanced LIGO's and Advanced Virgo's Third Observing Run

We report on a search for compact binary coalescences where at least one binary component has a mass between 0.2  M_{⊙} and 1.0  M_{⊙} in Advanced LIGO and Advanced Virgo data collected between 1 April 2019 1500 UTC and 1 October 2019 1500 UTC. We extend our previous analyses in two main ways: we include data from the Virgo detector and we allow for more unequal mass systems, with mass ratio q≥0.1. We do not report any gravitational-wave candidates. The most significant trigger has a false alarm rate of 0.14  yr^{-1}. This implies an upper limit on the merger rate of subsolar binaries in the range [220-24200]  Gpc^{-3} yr^{-1}, depending on the chirp mass of the binary. We use this upper limit to derive astrophysical constraints on two phenomenological models that could produce subsolar-mass compact objects. One is an isotropic distribution of equal-mass primordial black holes. Using this model, we find that the fraction of dark matter in primordial black holes in the mass range 0.2  M_{⊙}<m_{PBH}<1.0  M_{⊙} is f_{PBH}≡Ω_{PBH}/Ω_{DM}≲6%. This improves existing constraints on primordial black hole abundance by a factor of ∼3. The other is a dissipative dark matter model, in which fermionic dark matter can collapse and form black holes. The upper limit on the fraction of dark matter black holes depends on the minimum mass of the black holes that can be formed: the most constraining result is obtained at M_{min}=1  M_{⊙}, where f_{DBH}≡Ω_{DBH}/Ω_{DM}≲0.003%. These are the first constraints placed on dissipative dark models by subsolar-mass analyses.

Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

Spatial variation of plastic debris on important turtle nesting beaches of the remote Chagos Archipelago, Indian Ocean

We report Anthropogenic Marine Debris (AMD) in Chagos Archipelago in the Indian Ocean, globally amongst the most isolated island groups. AMD on 14 island beaches in five atolls were surveyed in 2019 using two techniques: Marine Debris Tracker (MDT) along littoral vegetation and photoquadrats in open beach. Over 60 % of AMD in both beach zones was composed of plastics, especially bottles and fragments (mean = 44.9 %, 27.2 %, range = 16.5-73.2 %, 4.8-55.9 % respectively in vegetation; mean = 28.7 %, 31.5 %, range = 17.7-40.7 %, 11.6-60.0 % respectively in open beach). The density of plastic debris in littoral vegetation (MDT data: 1995 bottles, 3328 fragments per 100 m²) was 10-fold greater than in open beach (photoquadrat data: 184 bottles, 106 fragments per 100 m²). Significant latitudinal variation in vegetation AMD occurred (8-fold greater in southern atolls, p = 0.006). AMD varied within island zones: most debris observed on oceanside beaches (oceanside vs lagoon, W = 365, p < 0.001; ocean vs island tip, W = 107, p = 0.034). Standardisation of surveys using the open-source MDT App is recommended. Debris accumulation hotspots overlapped with sea turtle nesting habitat, guiding future beach clean-up prioritisation.