Molecular biology of cholangiocarcinoma and its implications for targeted therapy in patient management

Cholangiocarcinoma (CCA) remains a devastating malignancy and a significant challenge to treat. The majority of CCA patients are diagnosed at an advanced stage, making the disease incurable in most cases. The advent of high-throughput genetic sequencing has significantly improved our understanding of the molecular biology underpinning cancer. The identification of 'druggable' genetic aberrations and the development of novel targeted therapies against them is opening up new treatment strategies. Currently, 3 targeted therapies are approved for use in CCA; Ivosidenib in patients with IDH1 mutations and Infigratinib/Pemigatinib in those with FGFR2 fusions. As our understanding of the biology underpinning CCA continues to improve it is highly likely that additional targeted therapies will become available in the near future. This is important, as it is thought up to 40 % of CCA patients harbour a potentially actionable mutation. In this review we provide an overview of the molecular pathogenesis of CCA and highlight currently available and potential future targeted treatments.

Observation of Seven Astrophysical Tau Neutrino Candidates with IceCube

We report on a measurement of astrophysical tau neutrinos with 9.7 yr of IceCube data. Using convolutional neural networks trained on images derived from simulated events, seven candidate ν_{τ} events were found with visible energies ranging from roughly 20 TeV to 1 PeV and a median expected parent ν_{τ} energy of about 200 TeV. Considering backgrounds from astrophysical and atmospheric neutrinos, and muons from π^{±}/K^{±} decays in atmospheric air showers, we obtain a total estimated background of about 0.5 events, dominated by non-ν_{τ} astrophysical neutrinos. Thus, we rule out the absence of astrophysical ν_{τ} at the 5σ level. The measured astrophysical ν_{τ} flux is consistent with expectations based on previously published IceCube astrophysical neutrino flux measurements and neutrino oscillations.

Prospective policy analysis-a critical interpretive synthesis review

Most policy analysis methods and approaches are applied retrospectively. As a result, there have been calls for more documentation of the political-economy factors central to health care reforms in real-time. We sought to highlight the methods and previous applications of prospective policy analysis (PPA) in the literature to document purposeful use of PPA and reflect on opportunities and drawbacks. We used a critical interpretive synthesis (CIS) approach as our initial scoping revealed that PPA is inconsistently defined in the literature. While we found several examples of PPA, all were researcher-led, most were published recently and few described mechanisms for engagement in the policy process. In addition, methods used were often summarily described and reported on relatively short prospective time horizons. Most of the studies stemmed from high-income countries and, across our sample, did not always clearly outline the rationale for a PPA and how this analysis was conceptualized. That only about one-fifth of the articles explicitly defined PPA underscores the fact that researchers and practitioners conducting PPA should better document their intent and reflect on key elements essential for PPA. Despite a wide recognition that policy processes are dynamic and ideally require multifaceted and longitudinal examination, the PPA approach is not currently frequently documented in the literature. However, the few articles reported in this paper might overestimate gaps in PPA applications. More likely, researchers are embedded in policy processes prospectively but do not necessarily write their articles from that perspective, and analyses led by non-academics might not make their way into the published literature. Future research should feature examples of testing and refining the proposed framework, as well as designing and reporting on PPA. Even when policy-maker engagement might not be feasible, real-time policy monitoring might have value in and of itself.

Split-bolus single-phase versus single-bolus split-phase CT acquisition protocols for staging in patients with testicular cancer: A retrospective study

INTRODUCTION

Computed tomography (CT) imaging has become indispensable in the management of medical oncology patients. Risks associated with high cumulative effective dose (CED) are relevant in testicular cancer patients. Split-bolus protocols, whereby the contrast medium injection is divided into two, followed by combining the required phase images in a single scan acquisition has been shown to provide images of comparable image quality and less radiation dose compared to single-bolus split-phase CT for various indications. We retrospectively evaluated the performance of split-bolus and single-bolus protocols in patients having follow-up CT imaging for testicular cancer surveillance.

METHODS

45 patients with testicular cancer undergoing surveillance CT imaging of the thorax, abdomen, and pelvis who underwent split-bolus and single-bolus protocols were included. Quantitative image quality analysis was conducted by placing region of interests in pre-defined anatomical sub-structures within the abdominal cavity. The signal-to-noise ratio (SNR) and radiation dose in the form of dose length product (DLP) and effective dose (ED) were recorded.

RESULTS

The DLP and ED for the single-bolus, split-phase acquisition was 506 ± 89 mGy cm and 7.59 ± 1.3 mSv, respectively. For the split-bolus, single-phase acquisition, 397 ± 94 mGy∗cm and 5.95 ± 1.4 mSv, respectively (p < 0.000). This represented a 21.5 % reduction in radiation dose exposure. The SNR for liver, muscle and fat for the single-bolus were 7.4, 4.7 and 8, respectively, compared to 5.5, 3.8 and 7.4 in the split-bolus protocol (p < 0.001).

CONCLUSION

In a testicular cancer patient cohort undergoing surveillance CT imaging, utilization of a split-bolus single-phase acquisition CT protocol enabled a significant reduction in radiation dose whilst maintaining subjective diagnostic acceptability.

IMPLICATIONS FOR PRACTICE

Use of split-bolus, single-phase acquisition has the potential to reduce CED in surveillance of testicular cancer patients.

HIV and viremia prevalence in non-migrating members of migrant households in Rakai region, Uganda: A cross-sectional population-based study

Introduction

In sub-Saharan Africa, migrants are more likely to be HIV seropositive and viremic than non-migrants. However, little is known about HIV prevalence and viremia in non-migrants living in households with in- or out-migration events. We compared HIV outcomes in non-migrating persons in households with and without migration events using data from the Rakai Community Cohort Study (RCCS), an open population-based cohort in Uganda.

Methods

We analyzed RCCS survey data from one survey round collected between August 2016 and May 2018 from non-migrating participants aged 15-49. Migrant households were classified as those reporting ≥1 member moving into or out of the household since the prior survey. A validated rapid test algorithm determined HIV serostatus. HIV viremia was defined as >1,000 copies/mL. Modified Poisson regression was used to estimate associations between household migration and HIV outcomes, with results reported as adjusted prevalence ratios (adjPR) with 95% confidence intervals (95%CI). Analyses were stratified by gender, direction of migration (into/out of the household), and relationship between non-migrants and migrants (e.g., spouse).

Results

There were 14,599 non-migrants (7,654, 52% women) identified in 9,299 households. 4,415 (30%) lived in a household with ≥1 recent migrant; of these, 972(22%) had migrant spouses, 1,102(25%) migrant children, and 875(20%) migrant siblings. Overall, HIV prevalence and viremia did not differ between non-migrants in migrant and non-migrant households. However, in stratified analyses, non-migrant women with migrant spouses were significantly more likely to be HIV seropositive compared to non-migrant women with non-migrant spouses (adjPR:1.44, 95%CI:1.21-1.71). Conversely, non-migrant mothers living with HIV who had migrant children were less likely to be viremic (adjPR:0.34, 95%CI:0.13-0.86). Among non-migrant men living with HIV, spousal migration was associated with a non-significant increased risk of viremia (adjPR:1.37, 95%CI:0.94-1.99). Associations did not typically differ for migration into or out of the household.

Conclusions

Household migration was associated with HIV outcomes for certain non-migrants, suggesting that the context of household migration influences the observed association with HIV outcomes. In particular, non-migrating women with migrating spouses were more likely to have substantially higher HIV burden. Non-migrants with migrant spouses may benefit from additional support when accessing HIV services.

HIV incidence among non-migrating persons following a household migration event: a population-based, longitudinal study in Uganda

Background

The impact of migration on HIV risk among non-migrating household members is poorly understood. We measured HIV incidence among non-migrants living in households with and without migrants in Uganda.

Methods

We used four survey rounds of data collected from July 2011-May 2018 from non-migrant participants aged 15-49 years in the Rakai Community Cohort Study, an open, population-based cohort. Non-migrants were individuals with no evidence of migration between surveys or at the prior survey. The primary exposure, household migration, was assessed using census data and defined as ≥1 household member migrating in or out of the house from another community between surveys (∼18 months). Incident HIV cases tested positive following a negative result at the preceding visit. Incidence rate ratios (IRR) with 95% confidence intervals were estimated using Poisson regression with generalized estimating equations and robust standard errors. Analyses were stratified by gender, migration into or out of the household, and the relationship between non-migrants and migrants (i.e., any household migration, spouse, child).

Findings

Overall, 11,318 non-migrants (5,674 women) were followed for 37,320 person-years. 28% (6,059/21,370) of non-migrant person-visits had recent migration into or out of the household, and 240 HIV incident cases were identified in non-migrating household members. Overall, non-migrants in migrant households were not at greater risk of acquiring HIV. However, HIV incidence among men was significantly higher when the spouse had recently migrated in (adjIRR:2·12;95%CI:1·05-4·27) or out (adjIRR:4·01;95%CI:2·16-7·44) compared to men with no spousal migration. Women with in- and out-migrant spouses also had higher HIV incidence, but results were not statistically significant.

Interpretation

HIV incidence is higher among non-migrating persons with migrant spouses, especially men. Targeted HIV testing and prevention interventions such as pre-exposure prophylaxis could be considered for those with migrant spouses.

Funding

National Institutes of Health, US Centers for Disease Control and Prevention.

Research in context

We searched PubMed for studies focused on HIV acquisition, prevalence or sexual behaviors among non-migrants who lived with migrants in sub-Saharan Africa (SSA) using search terms such as "HIV", "Emigration and Immigration", "family", "spouses", "household", "parents", and "children". Despite high levels of migration and an established association with HIV risk in SSA, there is limited data on the broader societal impacts of migration on HIV acquisition risk among non-migrant populations directly impacted by it.There has been only one published study that has previously evaluated impact of migration on HIV incidence among non-migrating persons in sub-Saharan Africa. This study, which exclusively assessed spousal migration, was conducted in Tanzania more than two decades earlier prior to HIV treatment availability and found that non-migrant men with long-term mobile partners were more than four times as likely to acquire HIV compared to men who had partners that were residents. To the best of our knowledge, this is the first study to examine the effect of non-spousal migration, including any household migration and child migration, on HIV incidence among non-migrants.

Added value of this study

In this study, we used data from the Rakai Community Cohort Study (RCCS), a population-based HIV surveillance cohort to measure the impact of migration on HIV incidence for non-migrant household members. The RCCS captures HIV incident events through regular, repeat HIV testing of participants and migration events through household censuses. Our study adds to the current literature by examining the general effect of migration in the household on HIV incidence in addition to child, and spousal migration. Using data from over 11,000 non-migrant individuals, we found that spousal, but not other types of household migration, substantially increased HIV risk among non-migrants, especially among men. Taken together, our results suggest that spousal migration may be associated with an increased risk of HIV acquisition in the period surrounding and immediately after spousal migration.

Implications of all the available evidence

Our findings suggest that spousal migration in or out of the household is associated with greater HIV incidence. Targeted HIV testing and prevention interventions such as pre-exposure prophylaxis could be considered for men with migrant spouses.

A new method for trans-vaginal extraction of an impacted vaginal calculus: A case report

INTRODUCTION

Vaginal stones are a rare pathology, with no clear guidelines on management and optimal removal techniques.

PRESENTATION OF CASE

We report a novel surgical technique, leading to safe transvaginal extraction of the largest reported impacted vaginal stone. In this case we removed an 11 cm struvite stone transvaginally from a 46 year old patient. This was achieved by hollowing it out with surgical drills, allowing safe collapse of the outer cortex and complete removal.

DISCUSSION

Our technique allowed for the safe, minimally invasive removal of the largest stone to be reported so far in the literature, preventing further complications for the patient. A full description of our technique is outlined to allow other clinicians utilisation of this for similar cases in the future.

CONCLUSION

Future vaginal calculi could be managed using this technique, preventing the need for laparotomy or vaginal trauma.

From 'no problem' to 'a lot of difficulties': barriers to health service utilization among migrants in Rakai, Uganda

Migration is increasingly common in Africa, especially for employment. Migrants may face additional barriers to accessing health care, including human immunodeficiency virus (HIV) prevention and treatment, compared with long-term residents. Exploring migrants' experiences with health services can provide insights to inform the design of health programmes. In this study, we used qualitative methods to understand migrants' barriers to health service utilization in south-central Uganda. This secondary data analysis used data from in-depth semi-structured interviews with 35 migrants and 25 key informants between 2017 and 2021. Interviews were analysed thematically through team debriefings and memos. We constructed three representative migrant journeys to illustrate barriers to accessing health services, reflecting experiences of migrant personas with differing HIV status and wealth. Migrants reported experiencing a range of barriers, which largely depended on the resources they could access, their existing health needs and their ability to form connections and relationships at their destination. Migrants were less familiar with local health services, and sometimes needed more time and resources to access care. Migrants living with HIV faced additional barriers to accessing health services due to anticipated discrimination from community members or health workers and difficulties in continuing antiretroviral therapy when switching health facilities. Despite these barriers, social networks and local connections facilitated access. However, for some migrants, such as those who were poorer or living with HIV, these barriers were more pronounced. Our work highlights how local connections with community members and health workers help migrants access health services. In practice, reducing barriers to health services is likely to benefit both migrants and long-term residents.

Post COVID-19 trends in simulation use within diagnostic radiography and radiation therapy education

PURPOSE

Simulation is used within medical radiation science training. Recent global events and simulation resource uptake has led to significant changes. The aim of this study was to capture post COVID-19 trends and activity of simulation-based education (SBE) in diagnostic radiography and radiation therapy.

METHODS

An online survey was designed to investigate the role of simulation within diagnostic radiography and radiation therapy education. Survey design was based on literature and experience within the research team. Questions were based around access and use of simulation, future trends and the effects of COVID-19. Participants were diagnostic radiography and/or radiation therapy educators. Data captured in this study was undertaken in March 2022 and compared with previous data from Bridge and colleagues (2021).

RESULTS

Sixty-seven responses were received across five continents (two from North/South America), Europe was the most widely represented (n = 58, 87%). Fifty-three (79%) of participants reported that they use simulation as part of their teaching and learning. Twenty-seven (51%) respondents reported that they had increased their use of simulation because of COVID-19. Sixteen (30%) respondents stated that they were now able to enrol more students because of the pandemic. Fixed models and immersive environments were the two most common simulation activities. Participants reported, to different degrees, that simulation was used across all parts of the curriculum.

CONCLUSIONS

Simulation is deeply embedded into diagnostic radiography and radiation therapy education. Evidence suggests that the growth of simulation may be slowing. Opportunities exist for the development of guidance, training and best practice resources around simulation.

IMPLICATIONS FOR PRACTICE

Simulation is a key pedagogical approach for diagnostic radiography and radiation therapy education. Key stakeholders now need to work collaboratively to define standards and best practices.

Radiographers' perspectives on clinical supervision of students in Ireland

INTRODUCTION

Optimising clinical education in radiography is crucial to ensure competent graduates provide safe and effective patient care. Radiographers play a vital role in student supervision undertaken in the complex clinical environment. A greater understanding of factors influencing their ability to undertake this role effectively is needed. The study aimed to explore radiographers' attitudes and perceptions of confidence in undertaking clinical supervision and perceived barriers in a 'real-life' clinical department.

METHODS

The lens of Bandura's social-cognitive theory was utilised to assist the exploration of the desired constructs. An anonymous online survey was developed and circulated among qualified radiographers in Ireland. Descriptive (frequencies and percentages) and inferential statistical testing was undertaken. Thematic analysis was conducted on optional free-text comments.

RESULTS

217 responses were received. Although most radiographers reported a positive attitude (73.3%), a significant minority reported not being confident across survey items related to the tasks required (ranging from 20.7%-29.1%). Time pressures from clinical workload, perceived lack of organisational support, and lack of guidance on expectations were highlighted challenges.

CONCLUSION

The survey has enabled first-hand identification of some challenges radiographers encounter in undertaking students' clinical supervision. Radiographers must be supported to optimise the clinical learning environment where both students and educators are valued.

IMPLICATIONS FOR PRACTICE

The findings highlight impact on educational support, practice, policy and future research. Effective clinical supervision is dependent on collaborative engagement and support being evident at all levels, including the clinical department, academic and healthcare institutions, and national organisations.

University stakeholders largely unaware and unsupportive of university pouring rights contracts with companies supplying sugar-sweetened beverages

Background: Pouring rights contracts are agreements in which beverage companies pay universities for exclusive marketing and rights to sell sugar-sweetened beverages (SSB) in campus. This study explored university stakeholder's awareness and opinions of university pouring rights contracts. Methods: Nine hundred fifteen university stakeholders self-reported their awareness and support of pouring rights contracts along with several possible determinants of support (age, gender, nutrition education, beliefs about SSBs, beverage intake). Results: About 64.2% of participants reported no awareness of pouring rights contracts whereas only 38% reported agreeing with university pouring rights contracts. Males, undergraduate students, and those who felt individuals are responsible for their SSB consumption were more likely to support pouring rights contracts. Conclusions: University stakeholders were largely unaware of and unsupportive of pouring rights contracts. Universities are encouraged to consider the health impacts and opinions of university stakeholders when deciding whether to enter into pouring rights contracts.

STRETCH: Stinging tree exposures to Cairns Hospital

OBJECTIVES

To evaluate the burden of disease, investigate the treatment and response to treatment caused by exposure to stinging tree plants presenting to Cairns Hospital over a 3-year period. Our secondary aim was to examine the benefit from treating such exposures with topical dilute hydrochloric acid (HCl).

METHODS

A retrospective chart review of all patients presenting to Cairns ED over a 3-year period because of stinging tree exposure. Symptoms, signs, treatment and outcomes were recorded.

RESULTS

There were 48 presentations, all having immediate pain after contact with the stinging tree, with 87% describing the pain as moderate or severe. Nearly all were stung on limbs (96%). There were 13 different treatments prior to presentation. In hospital, 60% needed opioid analgesia and a median oral morphine dose equivalent of 15 mg. Of the 29 receiving HCl nine patients reported good relief or complete relief.

CONCLUSIONS

Stinging tree exposure results in significant presentations to the Cairns ED each year. Pain is immediate and severe and there are no clear first aid or definitive treatment recommendations. Further work is needed to ascertain the best first aid and definitive treatment including a formal trial of dilute HCl.

Mode of delivery following obstetric anal sphincter injury: a 7-year retrospective review and follow-up cohort survey

INTRODUCTION AND HYPOTHESIS

Limited evidence exists regarding long-term outcomes following birth after prior obstetric anal sphincter injury (OASI). This article set out to describe outcomes following birth after OASI by reviewing the grades of tear, endoanal ultrasound (EAUS) findings, subsequent delivery outcomes and long-term symptoms.

METHODS

This study was conducted in two parts. The first involved a retrospective review of all OASI at a tertiary hospital in Australia over 7 years (2013-2019 inclusive) where the patient underwent a subsequent delivery. Following this, a retrospective cohort survey of this group was performed.

RESULTS

There were 27,284 vaginal births and 828 OASIs (3.03%); 247 (29.8%) had at least one subsequent birth by January 2021. Vaginal delivery occurred in 68%; recurrence of OASI was 5.4%. There were 90 responses (36.4%) to the follow-up survey. EAUS had been performed in 87.5%; none demonstrated a defect. Vaginal birth was the preferred mode for 77.8%; this occurred in 64%. The majority had high levels of satisfaction, this related to communication rather than the mode of delivery itself. Ongoing faecal or flatal incontinence was reported by 12%. There was no statistically significant difference in St Mark's incontinence scores between modes of birth.

CONCLUSIONS

In our unit most women who sustain OASI will have a subsequent vaginal delivery in future pregnancies. The majority remain asymptomatic at long-term follow-up with no statistically significant difference in incontinence scores regardless of mode of delivery. The rate of recurrent OASI was 5.4%.

National audit of non-melanoma skin cancer excisions performed by plastic surgery in the UK

A national, multi-centre audit of non-melanoma skin cancer excisions by plastic surgery.

The influence of anastomotic techniques on postoperative anastomotic complications: Results of the Oesophago-Gastric Anastomosis Audit

BACKGROUND

The optimal anastomotic techniques in esophagectomy to minimize rates of anastomotic leakage and conduit necrosis are not known. The aim of this study was to assess whether the anastomotic technique was associated with anastomotic failure after esophagectomy in the international Oesophago-Gastric Anastomosis Audit cohort.

METHODS

This prospective observational multicenter cohort study included patients undergoing esophagectomy for esophageal cancer over 9 months during 2018. The primary exposure was the anastomotic technique, classified as handsewn, linear stapled, or circular stapled. The primary outcome was anastomotic failure, namely a composite of anastomotic leakage and conduit necrosis, as defined by the Esophageal Complications Consensus Group. Multivariable logistic regression modeling was used to identify the association between anastomotic techniques and anastomotic failure, after adjustment for confounders.

RESULTS

Of the 2238 esophagectomies, the anastomosis was handsewn in 27.1%, linear stapled in 21.0%, and circular stapled in 51.9%. Anastomotic techniques differed significantly by the anastomosis sites (P < .001), with the majority of neck anastomoses being handsewn (69.9%), whereas most chest anastomoses were stapled (66.3% circular stapled and 19.3% linear stapled). Rates of anastomotic failure differed significantly among the anastomotic techniques (P < .001), from 19.3% in handsewn anastomoses, to 14.0% in linear stapled anastomoses, and 12.1% in circular stapled anastomoses. This effect remained significant after adjustment for confounding factors on multivariable analysis, with an odds ratio of 0.63 (95% CI, 0.46-0.86; P = .004) for circular stapled versus handsewn anastomosis. However, subgroup analysis by anastomosis site suggested that this effect was predominantly present in neck anastomoses, with anastomotic failure rates of 23.2% versus 14.6% versus 5.9% for handsewn versus linear stapled anastomoses versus circular stapled neck anastomoses, compared with 13.7% versus 13.8% versus 12.2% for chest anastomoses.

CONCLUSIONS

Handsewn anastomoses appear to be independently associated with higher rates of anastomotic failure compared with stapled anastomoses. However, this effect seems to be largely confined to neck anastomoses, with minimal differences between techniques observed for chest anastomoses. Further research into standardization of anastomotic approach and techniques may further improve outcomes.

Retail Purchases of Red and Processed Meat by State in the United States

The specific aim was to characterize retail purchases of red and processed meat and other major protein-rich foods in the U.S. and by state. Supermarket scanner data from grocery stores, supermarkets, and big box stores collected from 2017-2019 (NielsenIQ, New York, NY) was used to characterize retail purchases of red meat, processed meat, and other protein-rich foods in thirty-one states representative of US retail food sales. Red meat, processed meat, poultry, seafood, eggs, other meats, and non-meat foods (beans, nuts, seeds, meat alternatives) by weight accounted for 25.9%, 20.4%, 25.8%, 5.9%, 12.6%, 1.3%, and 10.1%, respectively of total sales in 2017-2019. Mean per capita purchases of red meat by weight was 30.1 g/d, ranging from 45.4 g/d in Mississippi to 21.9 g/d in New York. Mean per capita purchases of processed meat by weight was 23.8 g/d, ranging from 36.6 g/d in Mississippi to 15.2 g/d in California. We observed statistically significant correlations between red and processed meat purchases with cardiovascular mortality and colorectal cancer by state. Per capita retail purchases of red and processed meat appear to reflect a dietary pattern that is not consistent with current national and international dietary recommendations.

Ethnicity, gender, and migration status: Applying intersectionality methodology to explore barriers to equitable health systems for maternal and newborn health among immigrant populations in Masindi, Uganda

Globally, 298,000 women die due to pregnancy related causes and half of this occurs in Africa. In Uganda, maternal mortality has marginally reduced from 526 to 336 per 100,000 live births between 2001 and 2016. Health facility delivery is an important factor in improving maternal and neonatal outcomes. However, the concept of using a skilled birth attendant is not popular in Uganda. An earlier intervention to mobilize communities in the Masindi region for maternal and newborn health services discovered that immigrant populations used maternal health services less compared to the indigenous populations. The aim of this qualitative study was therefore to better understand why immigrant populations were using maternal health services less and what the barriers were in order to suggest interventions that can foster equitable access to maternal health services. Five focus group discussions (FGDs) (three among women; 2 with men), 8 in-depth interviews with women, and 7 key informant interviews with health workers were used to better understand the experiences of immigrants with maternal and newborn services. Interviews and FGDs were conducted from July to September 2016. Data were analyzed using content analysis and intersectionality. Results were based on the following thematic areas: perceived discrimination based on ethnicity as a barrier to access, income, education and gender. Immigrant populations perceived they were discriminated against because they could not communicate in the local dialect, they were poor casual laborers, and/or were not well schooled. Matters of pregnancy and childbearing were considered to be matters for women only, while financial and other decisions at the households are a monopoly of men. The silent endurance of labor pains was considered a heroic action. In contrast, care-seeking early during the onset of labor pains attracted ridicule and was considered frivolous. In this context, perceived discrimination, conflicting gender roles, and societal rewards for silent endurance of labor pains intersect to create a unique state of vulnerability, causing a barrier to access to maternal and newborn care among immigrant women. We recommend platforms to demystify harmful cultural norms and training of health workers on respectful treatment based on the 12 steps to safe and respectful mother baby-family care.

Radiographers' knowledge, attitudes and expectations of artificial intelligence in medical imaging

INTRODUCTION

Artificial intelligence (AI) is increasingly utilised in medical imaging systems and processes, and radiographers must embrace this advancement. This study aimed to investigate perceptions, knowledge, and expectations towards integrating AI into medical imaging amongst a sample of radiographers and determine the current state of AI education within the community.

METHODS

A cross-sectional online quantitative study targeting radiographers based in Europe was conducted over ten weeks. Captured data included demographical information, participants' perceptions and understanding of AI, expectations of AI and AI-related educational backgrounds. Both descriptive and inferential statistical techniques were used to analyse the obtained data.

RESULTS

A total of 96 valid responses were collected. Of these, 64% correctly identified the true definition of AI from a range of options, but fewer (37%) fully understood the difference between AI, machine learning and deep learning. The majority of participants (83%) agreed they were excited about the advancement of AI, though a level of apprehensiveness remained amongst 29%. A severe lack of education on AI was noted, with only 8% of participants having received AI teachings in their pre-registration qualification.

CONCLUSION

Overall positive attitudes towards AI implementation were observed. The slight apprehension may stem from the lack of technical understanding of AI technologies and AI training within the community. Greater educational programs focusing on AI principles are required to help increase European radiography workforce engagement and involvement in AI technologies.

IMPLICATIONS FOR PRACTICE

This study offers insight into the current perspectives of European based radiographers on AI in radiography to help facilitate the embracement of AI technology and convey the need for AI-focused education within the profession.

Textbook outcome following oesophagectomy for cancer: international cohort study

Background

Textbook outcome has been proposed as a tool for the assessment of oncological surgical care. However, an international assessment in patients undergoing oesophagectomy for oesophageal cancer has not been reported. This study aimed to assess textbook outcome in an international setting.

Methods

Patients undergoing curative resection for oesophageal cancer were identified from the international Oesophagogastric Anastomosis Audit (OGAA) from April 2018 to December 2018. Textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least 15 lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. A multivariable binary logistic regression model was used to identify factors independently associated with textbook outcome, and results are presented as odds ratio (OR) and 95 per cent confidence intervals (95 per cent c.i.).

Results

Of 2159 patients with oesophageal cancer, 39.7 per cent achieved a textbook outcome. The outcome parameter ‘no major postoperative complication’ had the greatest negative impact on a textbook outcome for patients with oesophageal cancer, compared to other textbook outcome parameters. Multivariable analysis identified male gender and increasing Charlson comorbidity index with a significantly lower likelihood of textbook outcome. Presence of 24-hour on-call rota for oesophageal surgeons (OR 2.05, 95 per cent c.i. 1.30 to 3.22; P = 0.002) and radiology (OR 1.54, 95 per cent c.i. 1.05 to 2.24; P = 0.027), total minimally invasive oesophagectomies (OR 1.63, 95 per cent c.i. 1.27 to 2.08; P &lt; 0.001), and chest anastomosis above azygous (OR 2.17, 95 per cent c.i. 1.58 to 2.98; P &lt; 0.001) were independently associated with a significantly increased likelihood of textbook outcome.

Conclusion

Textbook outcome is achieved in less than 40 per cent of patients having oesophagectomy for cancer. Improvements in centralization, hospital resources, access to minimal access surgery, and adoption of newer techniques for improving lymph node yield could improve textbook outcome.

Textbook outcome following oesophagectomy for cancer: international cohort study

BACKGROUND

Textbook outcome has been proposed as a tool for the assessment of oncological surgical care. However, an international assessment in patients undergoing oesophagectomy for oesophageal cancer has not been reported. This study aimed to assess textbook outcome in an international setting.

METHODS

Patients undergoing curative resection for oesophageal cancer were identified from the international Oesophagogastric Anastomosis Audit (OGAA) from April 2018 to December 2018. Textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least 15 lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. A multivariable binary logistic regression model was used to identify factors independently associated with textbook outcome, and results are presented as odds ratio (OR) and 95 per cent confidence intervals (95 per cent c.i.).

RESULTS

Of 2159 patients with oesophageal cancer, 39.7 per cent achieved a textbook outcome. The outcome parameter 'no major postoperative complication' had the greatest negative impact on a textbook outcome for patients with oesophageal cancer, compared to other textbook outcome parameters. Multivariable analysis identified male gender and increasing Charlson comorbidity index with a significantly lower likelihood of textbook outcome. Presence of 24-hour on-call rota for oesophageal surgeons (OR 2.05, 95 per cent c.i. 1.30 to 3.22; P = 0.002) and radiology (OR 1.54, 95 per cent c.i. 1.05 to 2.24; P = 0.027), total minimally invasive oesophagectomies (OR 1.63, 95 per cent c.i. 1.27 to 2.08; P < 0.001), and chest anastomosis above azygous (OR 2.17, 95 per cent c.i. 1.58 to 2.98; P < 0.001) were independently associated with a significantly increased likelihood of textbook outcome.

CONCLUSION

Textbook outcome is achieved in less than 40 per cent of patients having oesophagectomy for cancer. Improvements in centralization, hospital resources, access to minimal access surgery, and adoption of newer techniques for improving lymph node yield could improve textbook outcome.

Long-term efficacy and safety of addition of carboplatin with or without veliparib to standard neoadjuvant chemotherapy in triple-negative breast cancer: 4-year follow-up data from BrighTNess, a randomized phase 3 trial

BACKGROUND

Primary analyses of the phase 3 BrighTNess trial showed addition of carboplatin with/without veliparib to neoadjuvant chemotherapy significantly improved pathological complete response (pCR) rates with manageable acute toxicity in patients with triple-negative breast cancer (TNBC). Here, we report 4.5-year follow-up data from the trial.

DESIGN

Women with untreated stage II-III TNBC were randomized (2:1:1) to paclitaxel (weekly for 12 doses) plus either: (a) carboplatin (every 3 weeks for four cycles) plus veliparib (twice daily); (b) carboplatin plus veliparib placebo; or (c) carboplatin placebo plus veliparib placebo. All patients then received doxorubicin and cyclophosphamide (AC) every 2‒3 weeks for four cycles. The primary endpoint was pCR. Secondary endpoints included event-free survival (EFS), overall survival (OS), and safety. Since the co-primary endpoint of increased pCR with carboplatin plus veliparib with paclitaxel versus carboplatin with paclitaxel was not met, secondary analyses are descriptive.

RESULTS

Of 634 patients, 316 were randomized to carboplatin plus veliparib with paclitaxel, 160 to carboplatin with paclitaxel, and 158 to paclitaxel. With median follow-up of 4.5 years, the hazard ratio [HR] for EFS for carboplatin plus veliparib with paclitaxel versus paclitaxel was 0.63 (95% confidence interval [CI] 0.43‒0.92, P=0.02), but 1.12 (95% CI 0.72‒1.72, P=0.62) for carboplatin plus veliparib with paclitaxel versus carboplatin with paclitaxel. In post hoc analysis, HR for EFS was 0.57 (95% CI 0.36‒0.91, P=0.02) for carboplatin with paclitaxel versus paclitaxel. OS did not differ significantly between treatment arms, nor did rates of myelodysplastic syndromes, acute myeloid leukemia, or other secondary malignancies.

CONCLUSION

Improvement in pCR with addition of carboplatin was associated with long-term EFS benefit with a manageable safety profile, and without increasing the risk of second malignancies, while adding veliparib did not impact EFS. These findings support the addition of carboplatin to weekly paclitaxel followed by AC neoadjuvant chemotherapy for early stage TNBC.

Curating the Evidence About COVID-19 for Frontline Public Health and Clinical Care: The Novel Coronavirus Research Compendium

The public health crisis created by the COVID-19 pandemic has spurred a deluge of scientific research aimed at informing the public health and medical response to the pandemic. However, early in the pandemic, those working in frontline public health and clinical care had insufficient time to parse the rapidly evolving evidence and use it for decision-making. Academics in public health and medicine were well-placed to translate the evidence for use by frontline clinicians and public health practitioners. The Novel Coronavirus Research Compendium (NCRC), a group of >60 faculty and trainees across the United States, formed in March 2020 with the goal to quickly triage and review the large volume of preprints and peer-reviewed publications on SARS-CoV-2 and COVID-19 and summarize the most important, novel evidence to inform pandemic response. From April 6 through December 31, 2020, NCRC teams screened 54 192 peer-reviewed articles and preprints, of which 527 were selected for review and uploaded to the NCRC website for public consumption. Most articles were peer-reviewed publications (n = 395, 75.0%), published in 102 journals; 25.1% (n = 132) of articles reviewed were preprints. The NCRC is a successful model of how academics translate scientific knowledge for practitioners and help build capacity for this work among students. This approach could be used for health problems beyond COVID-19, but the effort is resource intensive and may not be sustainable in the long term.

Postoperative outcomes in oesophagectomy with trainee involvement

BACKGROUND

The complexity of oesophageal surgery and the significant risk of morbidity necessitates that oesophagectomy is predominantly performed by a consultant surgeon, or a senior trainee under their supervision. The aim of this study was to determine the impact of trainee involvement in oesophagectomy on postoperative outcomes in an international multicentre setting.

METHODS

Data from the multicentre Oesophago-Gastric Anastomosis Study Group (OGAA) cohort study were analysed, which comprised prospectively collected data from patients undergoing oesophagectomy for oesophageal cancer between April 2018 and December 2018. Procedures were grouped by the level of trainee involvement, and univariable and multivariable analyses were performed to compare patient outcomes across groups.

RESULTS

Of 2232 oesophagectomies from 137 centres in 41 countries, trainees were involved in 29.1 per cent of them (n = 650), performing only the abdominal phase in 230, only the chest and/or neck phases in 130, and all phases in 315 procedures. For procedures with a chest anastomosis, those with trainee involvement had similar 90-day mortality, complication and reoperation rates to consultant-performed oesophagectomies (P = 0.451, P = 0.318, and P = 0.382, respectively), while anastomotic leak rates were significantly lower in the trainee groups (P = 0.030). Procedures with a neck anastomosis had equivalent complication, anastomotic leak, and reoperation rates (P = 0.150, P = 0.430, and P = 0.632, respectively) in trainee-involved versus consultant-performed oesophagectomies, with significantly lower 90-day mortality in the trainee groups (P = 0.005).

CONCLUSION

Trainee involvement was not found to be associated with significantly inferior postoperative outcomes for selected patients undergoing oesophagectomy. The results support continued supervised trainee involvement in oesophageal cancer surgery.

The prevalence and safety of direct oral anticoagulants in patients with non-atrial fibrillation associated intra-cardiac thrombus

Background

The standard of care in management of intra-cardiac thrombus has been the use of vitamin K antagonists (VKAs). The emergence and use of direct oral anticoagulants (DOACs) in other conditions has led to the consideration of their use in patients with intra-cardiac thrombus. Thus far, case-reports have provided the majority of data regarding the efficacy of DOACs in this population.

Purpose

The aim of this observational study was to investigate the safety and efficacy of DOACs in intracardiac thrombus not associated with atrial fibrillation, compared to the current standard of care, VKAs.

Methods

An observational study was conducted between 10 hospitals in our region. The study was conducted between 2013 and 2019 in patients with a diagnosis of intracardiac thrombus. All left and right, atrial and ventricular thrombi were included. Patients with atrial fibrillation were excluded. Patient information was collected from the hospital electronic record. The primary endpoints were clinically significant bleeding requiring transfusion and thromboembolic events, excluding myocardial infarction.

Results

1153 patients had a diagnosis of intracardiac thrombus. 878 out of 1153 patients were discharged on warfarin and 275 were discharged on a DOAC. In the warfarin population 73 of 878 patients (8.3%) had clinically significant bleeding events compared to 21 of 275 patients (7.6%) in the DOAC population (p=0.801). The median ages were 60.5 and 58 respectively. The median time period to a bleeding event was 151 and 198 days respectively. In the warfarin population, 116 of 878 patients (13.2%) had thromboembolic disease versus 34 of 275 patients (12.4%) in the DOAC arm (p=0.759). The median ages were 62 and 62.5 respectively. The median time period to a thromboembolic event was 114 and 184 days respectively. In the warfarin arm, 3 patients had systemic thromboembolism and 113 patients had embolic strokes. In the DOAC arm, 2 patients had systemic thromboembolism, 32 patients had embolic strokes.

Conclusion

The data from this study suggests that DOACs may be a feasible alternative to warfarin in patients with intracardiac thrombus. There was no statistically significant difference in the rates of clinically significant bleeding or in incidence of thromboembolic disease. To our knowledge, this is the largest observational study to date on this topic. Randomized controlled trials are needed to fully establish the efficacy of DOACs in this patient population.

Funding Acknowledgement

Type of funding sources: None. Table 1

Nutrition and origin of US chain restaurant seafood

BACKGROUND

Seafood has a nutritional profile that can be beneficial to human health, which gives it a role to play in healthy diets. In addition, because its production and harvesting can have fewer environmental impacts than some forms of animal protein, it can contribute to sustainable diets. However, the positive health and environmental outcomes are not guaranteed-they depend on how seafood is prepared and served and whether it is sourced from sustainable fisheries and aquaculture industries.

OBJECTIVES

We examined the availability and nutritional attributes of seafood meals at chain restaurants in the United States. We assessed nutritional attributes by store type and geography. We also assessed menu labeling for species, production methods, and origin.

METHODS

The study population was 159 chain restaurants with 100,948 branch locations in the United States. Data were harvested from online restaurant menus, and the nutritional profile of seafood meals was calculated.

RESULTS

The average seafood menu item provides up to 49-61% of the total daily limit of saturated fat, 65% of the total daily limit of sodium, and 58-71% of total daily protein requirement for adult men and women. Restaurant chains located in the Deep South and Ohio River Valley, and casual dining chains nationally, carry seafood meals with more total calories and saturated fat per 100 g than other regions or chain types. Most menu items did not list origin or production methods, which is information that would help consumers make informed decisions.

CONCLUSIONS

The added ingredients and cooking methods used at chain restaurants can attenuate the health benefits of seafood. We recommend reformulating menus to reduce portion sizes, total calories, added fat, and sodium content per meal and to improve consumer-facing information about origin and production methods.

Mortality from esophagectomy for esophageal cancer across low, middle, and high-income countries: An international cohort study

BACKGROUND

No evidence currently exists characterising global outcomes following major cancer surgery, including esophageal cancer. Therefore, this study aimed to characterise impact of high income countries (HIC) versus low and middle income countries (LMIC) on the outcomes following esophagectomy for esophageal cancer.

METHOD

This international multi-center prospective study across 137 hospitals in 41 countries included patients who underwent an esophagectomy for esophageal cancer, with 90-day follow-up. The main explanatory variable was country income, defined according to the World Bank Data classification. The primary outcome was 90-day postoperative mortality, and secondary outcomes were composite leaks (anastomotic leak or conduit necrosis) and major complications (Clavien-Dindo Grade III - V). Multivariable generalized estimating equation models were used to produce adjusted odds ratios (ORs) and 95% confidence intervals (CI95%).

RESULTS

Between April 2018 to December 2018, 2247 patients were included. Patients from HIC were more significantly older, with higher ASA grade, and more advanced tumors. Patients from LMIC had almost three-fold increase in 90-day mortality, compared to HIC (9.4% vs 3.7%, p < 0.001). On adjusted analysis, LMIC were independently associated with higher 90-day mortality (OR: 2.31, CI95%: 1.17-4.55, p = 0.015). However, LMIC were not independently associated with higher rates of anastomotic leaks (OR: 1.06, CI95%: 0.57-1.99, p = 0.9) or major complications (OR: 0.85, CI95%: 0.54-1.32, p = 0.5), compared to HIC.

CONCLUSION

Resections in LMIC were independently associated with higher 90-day postoperative mortality, likely reflecting a failure to rescue of these patients following esophagectomy, despite similar composite anastomotic leaks and major complication rates to HIC. These findings warrant further research, to identify potential issues and solutions to improve global outcomes following esophagectomy for cancer.

Comparison of short-term outcomes from the International Oesophago-Gastric Anastomosis Audit (OGAA), the Esophagectomy Complications Consensus Group (ECCG), and the Dutch Upper Gastrointestinal Cancer Audit (DUCA)

BACKGROUND

The Esophagectomy Complications Consensus Group (ECCG) and the Dutch Upper Gastrointestinal Cancer Audit (DUCA) have set standards in reporting outcomes after oesophagectomy. Reporting outcomes from selected high-volume centres or centralized national cancer programmes may not, however, be reflective of the true global prevalence of complications. This study aimed to compare complication rates after oesophagectomy from these existing sources with those of an unselected international cohort from the Oesophago-Gastric Anastomosis Audit (OGAA).

METHODS

The OGAA was a prospective multicentre cohort study coordinated by the West Midlands Research Collaborative, and included patients undergoing oesophagectomy for oesophageal cancer between April and December 2018, with 90 days of follow-up.

RESULTS

The OGAA study included 2247 oesophagectomies across 137 hospitals in 41 countries. Comparisons with the ECCG and DUCA found differences in baseline demographics between the three cohorts, including age, ASA grade, and rates of chronic pulmonary disease. The OGAA had the lowest rates of neoadjuvant treatment (OGAA 75.1 per cent, ECCG 78.9 per cent, DUCA 93.5 per cent; P < 0.001). DUCA exhibited the highest rates of minimally invasive surgery (OGAA 57.2 per cent, ECCG 47.9 per cent, DUCA 85.8 per cent; P < 0.001). Overall complication rates were similar in the three cohorts (OGAA 63.6 per cent, ECCG 59.0 per cent, DUCA 62.2 per cent), with no statistically significant difference in Clavien-Dindo grades (P = 0.752). However, a significant difference in 30-day mortality was observed, with DUCA reporting the lowest rate (OGAA 3.2 per cent, ECCG 2.4 per cent, DUCA 1.7 per cent; P = 0.013).

CONCLUSION

Despite differences in rates of co-morbidities, oncological treatment strategies, and access to minimal-access surgery, overall complication rates were similar in the three cohorts.

Curating and translating the evidence about SARS-CoV-2 and COVID-19 for frontline public health and clinical care: The Novel Coronavirus Research Compendium (NCRC)

The public health crisis created by the SARS-CoV-2 pandemic has spurred a deluge of scientific research aimed at informing public health and medical response to the COVID-19 pandemic. However, those working in frontline public health and clinical care had insufficient time to parse the rapidly evolving evidence and use it for decision making. Academics in public health and medicine were well-placed to translate the evidence for use by frontline clinicians and public health practitioners. The Novel Coronavirus Research Compendium (NCRC), a group of >50 faculty and trainees, began in March 2020 with the goal to quickly triage and review the large volume of preprints and peer-reviewed publications on SARS-CoV-2 and COVID-19, and to summarize the most important, novel evidence to inform pandemic response. From April 6, 2020 through January 1, 2021, 54,192 papers and preprints were screened by NCRC teams and 527 were selected for review and uploaded to the NCRC website for public consumption. The majority of papers reviewed were peer-reviewed publications (n=395, 75%), published in 102 journals; 25% (n=132) of papers reviewed were of preprints. The NCRC is a successful model of how academics can support practitioners by translating scientific knowledge into action and help to build capacity among students for this work. This approach could be used for health problems beyond COVID-19, but the effort is resource intensive and may not be sustainable over the long term.

Surgical innovation revisited: A historical narrative of the minimally invasive “Agarwal sliding‐clip renorrhaphy” technique for partial nephrectomy and its application to an Australian cohort

Objective

To evaluate local clinical outcomes of sliding clip renorrhaphy, from inception to current utilization for open, laparoscopic, and robotically assisted partial nephrectomy.

Methods

We reviewed prospectively maintained databases of three surgeons performing partial nephrectomies with the sliding‐clip technique at teaching hospitals between 2005 and 2019. Baseline characteristics, operative parameters, including surgical approach, RENAL Nephrometry Score, and post‐operative outcomes, including Clavien‐Dindo classification of complications, were recorded for 76 consecutive cases. We compared perioperative and 90‐day events with patient and tumor characteristics, stratified by operative approach and case complexity, using Wilcoxon rank‐sum test for continuous variables and the Chi‐squared or Fisher's exact test, for binary and categorical variables, respectively.

Results

Open surgery (n = 15) reduced ischemia time and operative time, but increased hospital admission time. Pre‐ and post‐operative estimated glomerular filtration rates did not change significantly by operative approach. Older patients (P = .007) and open surgery (P = .003) were associated with a higher rate of complications (any‐grade). Six grade ≥3 complications occurred: these were associated with higher RENAL Nephrometry Score (P = .016) and higher pathological tumor stage (P = .045). Limits include smaller case volumes which incorporate the learning curve cases; therefore, these data are most applicable to lower volume teaching hospitals.

Conclusion

The sliding‐clip technique for partial nephrectomy was first described by Agarwal et al and has low complication rates, acceptable operative time, and preserves renal function across open and minimally invasive surgeries. This series encompasses the initial learning curve with developing the technique through to present‐day emergence as a routine standard of practice.

Metabolomics and a breath sensor identify acetone as a biomarker for heart failure

Introduction

Metabolomics delivers more biological and clinical insight than targeted investigations. We applied metabolomics to patients with heart failure (HF) with reduced ejection fraction (HFrEF).

Methods

46 patients with HFrEF and 20 controls underwent metabolomic profiling, including liquid/gas chromatography mass spectrometry (LC-MS/GC-MS), nuclear magnetic resonance (NMR) metabolomics and solid-phase microextraction (SPME) volatilomics in plasma and urine. HFrEF was defined using left ventricular global longitudal strain (GLS) &lt;18%, ejection fraction &lt;50% and NTproBNP ≥35 pmol/L. A low cost consumer breath acetone (BrACE) sensor validated SPME results in 69 patients.

Results

34 metabolites were identified by GCMS, 33 by LCMS and 2 volatiles by SPME (acetone, 2-pentanone in plasma and urine). Alanine, aspartate and glutamate, citric acid cycle, arginine biosynthesis, glyoxylate and dicarboxylate metabolism were altered in HFrEF. Plasma acetone correlated with NT-proBNP (r=0.59, 95% CI 0.4 to 0.7), triacylglycerol (55:9), 2-oxovaleric and cis-aconitic acid, involved with ketone metabolism and mitochondrial energetics. BrACE &gt;1.5 ppm discriminated HF from other cardiac pathology (AUC 0.88, 95% CI 0.77 to 0.99, P&lt;0.0001).

Conclusion

Breath acetone was detectable in HFrEF patients using a consumer sensor ($1/test) and although not cardiac specific, discriminated HF from other cardiac pathology.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Health Research Council of New Zealand

Robotic-assisted complete mesocolic excision, central vascular ligation and para-aortic lymph node dissection in multifocal carcinoid: A case report and technical description

•

Neuroendocrine tumours are the most common type of small bowel neoplasm.

•

Robotic technique may be superior to open technique for lymph node dissection.

•

Robotic-assisted complete mesocolic excision is a safe and effective technique.

Introduction

Neuroendocrine tumours are the most common type of primary small bowel neoplasm. Consensus guidelines recommend a multimodal approach to treatment of such tumours, with aggressive surgical resection remaining the mainstay of management. There is evidence that complete mesocolic excision (CME) of lymph nodes is associated with superior oncological outcomes including longer disease-free survival in patients with colorectal cancer than standard lymph node dissection and there is increasing evidence to suggest that the robotic approach may be superior to laparoscopic or open CME. This report discusses a robotic-assisted approach to CME with central vessel ligation (CVL) and para-aortic lymph node dissection in a case of multifocal neuroendocrine tumour of the small bowel.

Presentation of case and technical approach

This report details the case of a 73-year-old male with multifocal small bowel neuroendocrine tumour. He underwent a robotic-assisted right hemicolectomy, small bowel resection, CME, CVL and para-aortic lymph node dissection. The approach described involved undertaking CME, CVL and bowel resection with a standard right hemicolectomy robotic set-up before re-docking the robot to perform the retroperitoneal para-aortic lymph node dissection.

Discussion

This case highlights the management of multifocal small bowel neuroendocrine tumour using a robotic approach for surgical resection and lymph node clearance.

Conclusion

The robotic approach provides a safe and effective technique for undertaking surgical resection of small bowel neuroendocrine tumour as well as complete mesocolic excision of lymph nodes. With a change in port positions, a robotic approach can be utilised for CME/CVL as well as retroperitoneal node dissection.

Developing new health technologies for neglected diseases: a pipeline portfolio review and cost model

Background: Funding for neglected disease product development fell from 2009-2015, other than a brief injection of Ebola funding. One impediment to mobilizing resources is a lack of information on product candidates, the estimated costs to move them through the pipeline, and the likelihood of specific launches. This study aimed to help fill these information gaps. Methods: We conducted a pipeline portfolio review to identify current candidates for 35 neglected diseases. Using an adapted version of the Portfolio to Impact financial modelling tool, we estimated the costs to move these candidates through the pipeline over the next decade and the likely launches. Since the current pipeline is unlikely to yield several critical products, we estimated the costs to develop a set of priority “missing” products. Results: We found 685 neglected disease product candidates as of August 31, 2017; 538 candidates met inclusion criteria for input into the model. It would cost about $16.3 billion (range $13.4-19.8B) to move these candidates through the pipeline, with three-quarters of the costs incurred in the first 5 years, resulting in about 128 (89-160) expected product launches.  Based on the current pipeline, there would be few launches of complex new chemical entities; launches of highly efficacious HIV, tuberculosis, or malaria vaccines would be unlikely. Estimated additional costs to launch one of each of 18 key missing products are $13.6B assuming lowest product complexity or $21.8B assuming highest complexity ($8.1B-36.6B). Over the next 5 years, total estimated costs to move current candidates through the pipeline and develop these 18 missing products would be around $4.5B (low complexity missing products) or $5.8B/year (high complexity missing products). Conclusions: Since current annual global spending on product development is about $3B, this study suggests the annual funding gap over the next 5 years is at least $1.5-2.8B.