"I'll meet you at our bench": adaptation, innovation and resilience among VCSE organisations who supported marginalised and minoritised communities during the Covid-19 pandemic in Northern England - a qualitative focus group study

BACKGROUND

The Covid-19 pandemic has exacerbated pre-existing inequalities and increased adversity and challenges for vulnerable and marginalised communities worldwide. In the UK, the Voluntary Community and Social Enterprise (VCSE) sector play a vital role in supporting the health and wellbeing of people who are marginalised or experiencing multiple complex needs. However, only a small number of studies have focused on the impact that Covid-19 had on the VCSE sector.

METHODS

As part of a Health Inequalities Impact Assessment (HIIA), we conducted qualitative focus groups with staff and volunteers from five organisations to examine short, medium and longer-term impacts of Covid-19 upon the VCSE sector in Northern England. Nine online focus groups were conducted between March and July 2021.

FINDINGS

Focus group transcripts were analysed using Framework Analysis and yielded three central themes: (1) exacerbation of pre-existing inequalities, adversity and challenges for vulnerable and marginalised populations; (2) the 'price' of being flexible, innovative and agile for VCSE staff and volunteers; and (3) the voluntary sector as a 'lifeline' - organisational pride and resilience.

CONCLUSIONS

While the voluntary sector 'adapted at pace' to provide support during Covid-19 and in its continued aftermath, this resilience has potentially come at the cost of workforce and volunteer wellbeing, compounded by political obstacles and chronic shortage in funding and support. The VCSE sector has a vital role to play in the post-lockdown 'levelling up' agenda. The expertise, capacity and resilience of VCSE organisations, and their ability to respond to Covid-19, should be celebrated, recognised and supported adequately to maintain its resilience. To not do so threatens the sector's sustainability and risks jeopardising attempts to involve the sector in addressing the social determinants of health.

Annual Report to the Nation on the Status of Cancer, part 2: Early assessment of the COVID-19 pandemic's impact on cancer diagnosis

BACKGROUND

With access to cancer care services limited because of coronavirus disease 2019 control measures, cancer diagnosis and treatment have been delayed. The authors explored changes in the counts of US incident cases by cancer type, age, sex, race, and disease stage in 2020.

METHODS

Data were extracted from selected US population-based cancer registries for diagnosis years 2015-2020 using first-submission data from the North American Association of Central Cancer Registries. After a quality assessment, the monthly numbers of newly diagnosed cancer cases were extracted for six cancer types: colorectal, female breast, lung, pancreas, prostate, and thyroid. The observed numbers of incident cancer cases in 2020 were compared with the estimated numbers by calculating observed-to-expected (O/E) ratios. The expected numbers of incident cases were extrapolated using Joinpoint trend models.

RESULTS

The authors report an O/E ratio <1.0 for major screening-eligible cancer sites, indicating fewer newly diagnosed cases than expected in 2020. The O/E ratios were lowest in April 2020. For every cancer site except pancreas, Asians/Pacific Islanders had the lowest O/E ratio of any race group. O/E ratios were lower for cases diagnosed at localized stages than for cases diagnosed at advanced stages.

CONCLUSIONS

The current analysis provides strong evidence for declines in cancer diagnoses, relative to the expected numbers, between March and May of 2020. The declines correlate with reductions in pathology reports and are greater for cases diagnosed at in situ and localized stage, triggering concerns about potential poor cancer outcomes in the coming years, especially in Asians/Pacific Islanders.

PLAIN LANGUAGE SUMMARY

To help control the spread of coronavirus disease 2019 (COVID-19), health care organizations suspended nonessential medical procedures, including preventive cancer screening, during early 2020. Many individuals canceled or postponed cancer screening, potentially delaying cancer diagnosis. This study examines the impact of the COVID-19 pandemic on the number of newly diagnosed cancer cases in 2020 using first-submission, population-based cancer registry database. The monthly numbers of newly diagnosed cancer cases in 2020 were compared with the expected numbers based on past trends for six cancer sites. April 2020 had the sharpest decrease in cases compared with previous years, most likely because of the COVID-19 pandemic.

A New Personalized Oral Cancer Survival Calculator to Estimate Risk of Death From Both Oral Cancer and Other Causes

Importance

Standard cancer prognosis models typically do not include much specificity in characterizing competing illnesses or general health status when providing prognosis estimates, limiting their utility for individuals, who must consider their cancer in the context of their overall health. This is especially true for patients with oral cancer, who frequently have competing illnesses.

Objective

To describe a statistical framework and accompanying new publicly available calculator that provides personalized estimates of the probability of a patient surviving or dying from cancer or other causes, using oral cancer as the first data set.

Design, Setting, and Participants

The models used data from the Surveillance, Epidemiology, and End Results (SEER) 18 registry (2000 to 2011), SEER-Medicare linked files, and the National Health Interview Survey (NHIS) (1986 to 2009). Statistical methods developed to calculate natural life expectancy in the absence of the cancer, cancer-specific survival, and other-cause survival were applied to oral cancer data and internally validated with 10-fold cross-validation. Eligible participants were aged between 20 and 94 years with oral squamous cell carcinoma.

Exposures

Histologically confirmed oral cancer, general health status, smoking, and selected serious comorbid conditions.

Main Outcomes and Measures

Probabilities of surviving or dying from the cancer or from other causes, and life expectancy in the absence of the cancer.

Results

A total of 22 392 patients with oral squamous cell carcinoma (13 544 male [60.5%]; 1476 Asian and Pacific Islander [6.7%]; 1792 Black [8.0%], 1589 Hispanic [7.2%], 17 300 White [78.1%]) and 402 626 NHIS interviewees were included in this calculator designed for public use for patients ages 20 to 86 years with newly diagnosed oral cancer to obtain estimates of health status-adjusted age, life expectancy in the absence of the cancer, and the probability of surviving, dying from the cancer, or dying from other causes within 1 to 10 years after diagnosis. The models in the calculator estimated that patients with oral cancer have a higher risk of death from other causes than their matched US population, and that this risk increases by stage.

Conclusions and relevance

The models developed for the calculator demonstrate that survival estimates that exclude the effects of coexisting conditions can lead to underestimates or overestimates of survival. This new calculator approach will be broadly applicable for developing future prognostic models of cancer and noncancer aspects of a person's health in other cancers; as registries develop more linkages, available covariates will become broader, strengthening future tools.

Key Points for Clinicians About the SEER Oral Cancer Survival Calculator

Importance

In the setting of a new cancer diagnosis, the focus is usually on the cancer as the main threat to survival, but people may have other conditions that pose an equal or greater threat to their life than their cancer: a competing risk of death. This is especially true for patients who have cancer of the oral cavity, because prolonged exposure to alcohol and tobacco are risk factors for cancer in this location but also can result in medical conditions with the potential to shorten life expectancy, competing as a cause of death that may intervene in conjunction with or before the cancer.

Observations

A calculator designed for public use has been released that allows patients age 20 to 86 years who have a newly diagnosed oral cancer to obtain estimates of their health status-adjusted age, life expectancy in the absence of the cancer, and probability of surviving, dying of the cancer, or dying of other causes within 1 to 10 years after diagnosis. The models in the calculator showed that patients with oral cavity cancer had a higher than average risk of death from other causes than the matched US population, and this risk increases by stage.

Conclusions and Relevance

The Surveillance, Epidemiology and End Results Program Oral Cancer Survival Calculator supports a holistic approach to the life of the patient, and the risk of death of other causes is treated equally to consideration of the probability of death of the cancer. This tool may be usefully paired with the other available prognostic calculators for oral cancer and is an example of the possibilities now available with registry linkages to partially overlapping or independent data sets and statistical techniques that allow the use of 2 time scales in 1 analysis.

Evidencing general acceptability of open-label placebo use for tackling overtreatment in primary care: a mixed methods study

BACKGROUND

Overtreatment poses a challenge to healthcare systems due to harmful consequences of avoidable side-effects and costs. This study presents the first account for examining the feasibility of placebo use for reducing overtreatment in primary care, including whether public attitudes support the use of different placebo types in place of inappropriate prescriptions of antibiotics, antidepressants, or analgesics.

METHODS

We used a multi-study, mixed-methods design, including patient and public (PPI) consultations, focus groups (Study 1) and two pre-registered online experiments (Studies 2 and 3).

RESULTS

Study 1 (N = 16) explored everyday conceptions and practicalities of potential placebo use in the context of respiratory infections. Findings highlighted the importance of trusting doctor-patient relationships and safety-netting. Study 2 employed a randomised experiment with a representative UK sample (N = 980), investigating attitudes towards 5 different treatment options for respiratory infections: (1) blinded + pure placebo, (2) open-label + pure placebo, (3) open-label + impure placebo, (4) antibiotic treatment, and (5) no treatment. Study 2 also examined how attitudes varied based on wording and individual differences. Findings indicated general support (ηp2 = .149, large effect size) for replacing inappropriate antibiotics with open-label + impure placebos, although personal placebo acceptability was lower. Also, older people, individuals suffering from chronic illness or those showing higher levels of health anxiety appeared less amenable to placebo use. Study 3 (N = 1177) compared attitudes towards treatment options across three clinical scenarios: respiratory infection, depression and pain. Findings suggested significant differences in the acceptability of placebo options based on the clinical context. In the infection scenario, options for open-label + pure placebos, open-label + impure placebos and no treatment were rated significantly more acceptable (ηp2 = .116, medium effect size) compared to the depression and pain scenarios. Again, general support for placebos was higher than placebo acceptability for personal use.

CONCLUSIONS

Findings from PPI and three studies indicate general support for combatting overprescribing in primary care through clinical placebo use. This is an indicator for wider UK public support for a novel, behavioural strategy to target a long-standing healthcare challenge. General acceptability appears to be highest for the use of open-label + impure placebos in the context of antibiotic overprescribing.

Enhancing involvement of people with multiple sclerosis in clinical trial design

BACKGROUND

Although often overlooked, patient and public involvement (PPI) is vital when considering the design and delivery of complex and adaptive clinical trial designs for chronic health conditions such as multiple sclerosis (MS).

METHODS

We conducted a rapid review to assess current status of PPI in the design and conduct of clinical trials in MS over the last 5 years. We provide a case study describing PPI in the development of a platform clinical trial in progressive MS.

RESULTS

We identified only eight unique clinical trials that described PPI as part of articles or protocols; nearly, all were linked with funders who encourage or mandate PPI in health research. The OCTOPUS trial was co-designed with people affected by MS. They were central to every aspect from forming part of a governance group shaping the direction and strategy, to the working groups for treatment selection, trial design and delivery. They led the PPI strategy which enabled a more accessible, acceptable and inclusive design.

CONCLUSION

Active, meaningful PPI in clinical trial design increases the quality and relevance of studies and the likelihood of impact for the patient community. We offer recommendations for enhancing PPI in future MS clinical trials.

Impact of Children's Presence on Police Responses to Domestic Violence Call Situations

The link between children exposed to intimate partner violence (IPV) and child maltreatment is well established; however, less is known about the impact children's presence may have on domestic violence disputes. This study investigated the role of children's presence in IPV police calls using data (N = 2709) from supplementary reports provided by an Ontario, Canada police force, one-third of which led to criminal charges (n = 909). When children were present: charges were less likely to be laid; the accused's emotional state was more likely to be rated by police as calm and the accused was less likely to be identified as using alcohol and/or drugs at the time of the call; and victim support interventions were more likely to be offered and accepted. Findings were considered in the context of when charges were laid versus not laid. Implications for police and support service interventions were discussed.

The community engagement course and action network: strengthening community and academic research partnerships to advance health equity

Background

Historically Black Colleges and Universities and Minority Serving Institutions are uniquely positioned to implement community-campus research partnerships based on a history of service, the pursuit of community trustworthiness and student demographics often similar to surrounding marginalized communities. The Morehouse School of Medicine Prevention Research Center collaborates with members of Historically Black Colleges and Universities, Minority Serving Institutes, and community organizations on the Community Engaged Course and Action Network. This network is the first of its kind and aims to strengthen members' ability to implement Community-Based Participatory Research (CBPR) principles and partnerships. Projects address public health priorities including mental health among communities of color, zoonotic disease prevention, and urban food deserts.

Materials and methods

To assess the effectiveness of the network, a Participatory Evaluation framework was implemented to conduct process evaluation which included review of partnership structures, operations, project implementation processes, and preliminary outcomes of the research collaborations. A focus group of Community Engagement Course and Action Network members (community and academic) was also conducted to identify benefits and challenges of the network with emphasis on key areas for improvement to further enhance the relationships between partners and to facilitate their subsequent community-campus research.

Results

Network improvements were tied to themes strengthening community-academic partnerships including sharing and fellowship, coalition building and collaboration, and greater connections and awareness of community needs through their current community-academic partnerships. The need to conduct ongoing evaluation during and after implementation, for determining the early adoption of CBPR approaches was also identified.

Conclusion

Evaluation of the network's processes, infrastructure, and operation provides early lessons learned to strengthen the network. Ongoing assessment is also essential for ensuring continuous quality improvement across partnerships such as determining CBPR fidelity, assessing partnership synergy, and dynamics, and for quality improvement of research protocol. The implications and potential for advancing implementation science through this and similar networks are great towards advancing leadership in modeling how foundations in community service can advance to CBPR partnership formation and ultimately, health equity approaches, that are local defined and assessed.

'How I'm feeling today, I probably won't be feeling tomorrow'. Using I-Poems to explore young people's changing emotions during the Covid-19 pandemic - A qualitative, longitudinal study

Background

Relatively little published qualitative research has explored children and young people's (CYP) prolonged or longitudinal experiences of the pandemic, and their emotional responses to such unreserved change to everyday life. As part of a broader, qualitative longitudinal study, this paper explores change and continuity in young people's emotions over time during the Covid-19 pandemic in North East England.

Methods

I-Poems were curated for each of the 26 young people in this study from serial interview transcripts and diary entries, collected over the course of 16 months. Creation of I-Poems require researchers to focus on sentences made by the interviewee that include the word "I," and without changing the order of those sentences, to present them in poetic stanzas.

Findings

Young people's voices and experiences became more poignant and powerful when their 'I' narrative was centralised, silencing the presence of the researcher. Further, presenting the data in this way allowed us to see how the following emotions shifted over time: grief, sadness, frustration, anger, anxiety, joy, pleasure, excitement. We contend that young people experienced significant rupture and change over the course of our 16 month project, with both positive and negative repercussions for their emotional wellbeing.

Conclusions

Large scale (quantitative and qualitative) studies remain much needed to focus on the long-term impacts of the pandemic on young people's social, emotional and cultural lives. Longitudinal and creative qualitative approaches (such as I-Poems) have the potential to centralise participant voice, break down power dynamics, and allow exploration of shifting experiences and emotions over time.

Abstract 3431: Molecular determinants of KRAS p.G12C inhibitor efficacy in advanced NSCLC

Background: Irreversible allosteric KRAS p.G12C inhibitors (KG12Ci) such as sotorasib and adagrasib have revolutionized the therapeutic landscape of advanced KG12C-mutant NSCLC, however individual responses are heterogeneous and curtailed by innate and adaptive/acquired resistance. Molecular determinants of KG12Ci efficacy in NSCLC are poorly defined. We dissected the impact of major KG12C co-mutations and explored the effects of less prevalent co-alterations on the clinical activity of KG12Ci in the largest treated cohort to date of patients (pts) with advanced NSCLC. Key findings were validated in preclinical KG12C NSCLC models.

Methods: Baseline clinico-genomic features and clinical outcome data from pts with stage IV KG12C NSCLC (ECOG PS 0-2) treated with single-agent KG12Ci were collected retrospectively from 20 centers in the US and Europe. The Kaplan-Meier method was used to estimate PFS and OS and differences were assessed with the log-rank test. Hazard ratios (HR) and their 95% CI were estimated using a Cox proportional hazards model stratified for clinical co-variates. The impact of selected co-alterations on sotorasib efficacy was assessed in syngeneic (C57BL/6) KG12C NSCLC models.

Results: 411 eligible pts were included in the study. Median age was 68 years, 77% of pts had received both platinum-based chemotherapy and PD-(L)1 inhibitors and 35% had brain metastases. 83% of pts received sotorasib. ORR with KG12Ci was 32.4% (95% CI, 27.9-37.1), PFS was 5.1m (95% CI, 4.5-5.6) and OS was 10.2m (95% CI, 8.4-12.1). Co-alterations in KEAP1, SMARCA4 and CDKN2A/B were each associated with significantly shorter PFS (KEAP1: 2.8m vs 5.5m, HR 2.50, P&lt;0.001; SMARCA4: 1.7m vs 5.5m, HR 2.64, P=0.001; CDKN2A/B: 2.3m vs 5.3m, HR 2.57, P&lt;0.001) and OS with KG12Ci even after adjustment for clinical covariates. STK11 co-mutations without concurrent KEAP1 alterations did not impact clinical outcomes with KG12Ci. In an exploratory analysis, co-mutations in DNA damage repair (DDR) genes and genes encoding components of the ATRX/DAXX/EZH2 pathway were associated with improved KG12Ci efficacy, whereas PI3K/AKT/MTOR/PTEN alterations and missense ROS1/ALK/BRAF/NTRK1-3 mutations resulted in inferior outcomes. The impact of SMARCA4 and DDR gene inactivation was validated in isogenic syngeneic KG12CNSCLC models; additional co-alterations are under evaluation. Integration of KEAP1/SMARCA4/CDKN2A/B co-mutations identified a subgroup (KSCMUT, 37.6% of all pts) with significantly shorter PFS (2.7m vs 6.2m, P&lt;0.001) and OS (6.3m vs 14.6m, P&lt;0.001) that accounted for 57.3% of pts with primary refractory (PFS≤3m) disease.

Conclusions: Co-mutations in KEAP1, SMARCA4 and CDKN2A/2B define subgroups of KG12C NSCLC pts with markedly distinct outcomes with KG12Ci monotherapy. Tailoring of KG12C inhibitor-anchored therapeutic strategies and patient stratification should take into account the co-mutation status of individual tumors.

Citation Format: Marcelo V. Negrao, Haniel A. Araujo, Giuseppe Lamberti, Alissa J. Cooper, Teng Zhou, Neal Akhave, Lukas Delasos, J Kevin Hicks, Mihaela Aldea, Gabriele Minuti, Jacobi Hines, Jacqueline V. Aredo, Michael J. Dennis, Turja Chakrabarti, Susan Scott, Paolo Bironzo, Matthias Scheffler, Petros Christopoulos, So Yeon Kim, Sarah Goldberg, Ying Ni, Blerina Resuli, Lorenza Landi, Shu-Chi Tseng, Mizuki Nishino, Dwight Owen, Collin Blakely, Giannis Mountzios, Catherine A. Shu, Christine Bestvina, Marina Garassino, Kristen Marrone, Jhanelle Gray, Sandip Pravin Patel, Amy L. Cummings, Heather A. Wakelee, Jurgen Wolf, Giorgio V. Scagliotti, Federico Cappuzzo, Fabrice Barlesi, Pradnya Patil, Don L. Gibbons, Funda Meric-Bernstam, J Jack Lee, John V. Heymach, David S. Hong, Rebecca S. Heist, Mark M. Awad, Ferdinandos Skoulidis. Molecular determinants of KRAS p.G12C inhibitor efficacy in advanced NSCLC [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 3431.

Liquid biopsy approaches to capture tumor evolution and clinical outcomes during cancer immunotherapy

Circulating cell-free tumor DNA (ctDNA) can serve as a real-time biomarker of tumor burden and provide unique insights into the evolving molecular landscape of cancers under the selective pressure of immunotherapy. Tracking the landscape of genomic alterations detected in ctDNA may reveal the clonal architecture of the metastatic cascade and thus improve our understanding of the molecular wiring of therapeutic responses. While liquid biopsies may provide a rapid and accurate evaluation of tumor burden dynamics during immunotherapy, the complexity of antitumor immune responses is not fully captured through single-feature ctDNA analyses. This underscores a need for integrative studies modeling the tumor and the immune compartment to understand the kinetics of tumor clearance in association with the quality of antitumor immune responses. Clinical applications of ctDNA testing in patients treated with immune checkpoint inhibitors have shown both predictive and prognostic value through the detection of genomic biomarkers, such as tumor mutational burden and microsatellite instability, as well as allowing for real-time monitoring of circulating tumor burden and the assessment of early on-therapy responses. These efforts highlight the emerging role of liquid biopsies in selecting patients for cancer immunotherapy, monitoring therapeutic efficacy, determining the optimal duration of treatment and ultimately guiding treatment selection and sequencing. The clinical translation of liquid biopsies is propelled by the increasing number of ctDNA-directed interventional clinical trials in the immuno-oncology space, signifying a critical step towards implementation of liquid biopsies in precision immuno-oncology.

The role of hospital antimicrobial and infectious diseases pharmacists in the UK: a theoretically underpinned exploration

Objectives

We sought to characterise the role of hospital infection pharmacists in the UK and to understand the core challenges being faced, future role development desires and the required support to address these.

Methods

We developed a questionnaire underpinned by the theoretical domains framework exploring the barriers and enablers to pharmacists fulfilling their perceived roles and responsibilities. Any pharmacist whose role included 'specialist antimicrobial' or 'infectious diseases' was invited to complete a questionnaire sent via national infection and pharmacy groups/networks. Descriptive statistics were used to report responses to each item, and a content analysis was undertaken to summarize the key messages from an extended response option.

Results

Of the 102 respondents, 91 (89.2%) were from English hospitals. Fifty-three (52%) were from district general hospitals and 45 (45.1%) from teaching hospitals. Most (97, 95%) respondents were of a senior grade. The need for a comprehensive educational programme, recognition of research as core to the role and integration with infection/microbiology departments were key requirements along with protected time to engage with the activities. Highlights of the role were opportunities to teach, making a significant contribution to patient care and scope to contribute to strategy and vision. The COVID-19 pandemic negatively impacted on respondents' capacity to undertake their perceived roles and responsibilities.

Conclusions

Our study delineates the need for UK infection and pharmacy policy makers to review hospital infection pharmacist developmental pathways and roles. Joint learning, and closer working, with infection/microbiology departments may be an efficient strategy to address the issues raised.

Letter to the Editor Regarding: Evolving Business Models in Orthotics by Schneider, N

The purpose of this letter is to continue the dialogue regarding the paper "Evolving business models in Orthotics" in the Canadian Prosthetics & Orthotics Journal Volume 4, Issue2, No.3, 2021. In it we present the perspective of the current Alberta Association of Orthotists and Prosthetists (AAOP) and provide additional context and information on historical events. Finally, we provide additional clarity on how costing is approached in the Province of Alberta (Canada) and the purported inequity in compensation between the two disciplines.

Annual report to the nation on the status of cancer, part 1: National cancer statistics

BACKGROUND

The American Cancer Society, the Centers for Disease Control and Prevention, the National Cancer Institute, and the North American Association of Central Cancer Registries collaborate to provide annual updates on cancer occurrence and trends in the United States.

METHODS

Data on new cancer diagnoses during 2001-2018 were obtained from the North American Association of Central Cancer Registries' Cancer in North America Incidence file, which is comprised of data from Centers for Disease Control and Prevention-funded and National Cancer Institute-funded, population-based cancer registry programs. Data on cancer deaths during 2001-2019 were obtained from the National Center for Health Statistics' National Vital Statistics System. Five-year average incidence and death rates along with trends for all cancers combined and for the leading cancer types are reported by sex, racial/ethnic group, and age.

RESULTS

Overall cancer incidence rates were 497 per 100,000 among males (ranging from 306 among Asian/Pacific Islander males to 544 among Black males) and 431 per 100,000 among females (ranging from 309 among Asian/Pacific Islander females to 473 among American Indian/Alaska Native females) during 2014-2018. The trend during the corresponding period was stable among males and increased 0.2% on average per year among females, with differing trends by sex, racial/ethnic group, and cancer type. Among males, incidence rates increased for three cancers (including pancreas and kidney), were stable for seven cancers (including prostate), and decreased for eight (including lung and larynx) of the 18 most common cancers considered in this analysis. Among females, incidence rates increased for seven cancers (including melanoma, liver, and breast), were stable for four cancers (including uterus), and decreased for seven (including thyroid and ovary) of the 18 most common cancers. Overall cancer death rates decreased by 2.3% per year among males and by 1.9% per year among females during 2015-2019, with the sex-specific declining trend reflected in every major racial/ethnic group. During 2015-2019, death rates decreased for 11 of the 19 most common cancers among males and for 14 of the 20 most common cancers among females, with the steepest declines (>4% per year) reported for lung cancer and melanoma. Five-year survival for adenocarcinoma and neuroendocrine pancreatic cancer improved between 2001 and 2018; however, overall incidence (2001-2018) and mortality (2001-2019) continued to increase for this site. Among children (younger than 15 years), recent trends were stable for incidence and decreased for mortality; and among, adolescents and young adults (aged 15-39 years), recent trends increased for incidence and declined for mortality.

CONCLUSIONS

Cancer death rates continued to decline overall, for children, and for adolescents and young adults, and treatment advances have led to accelerated declines in death rates for several sites, such as lung and melanoma. The increases in incidence rates for several common cancers in part reflect changes in risk factors, screening test use, and diagnostic practice. Racial/ethnic differences exist in cancer incidence and mortality, highlighting the need to understand and address inequities. Population-based incidence and mortality data inform prevention, early detection, and treatment efforts to help reduce the cancer burden in the United States.

Incidence of Tendon Rupture After Collagenase Clostridium Histolyticum Injection for Treatment of Dupuytren Contracture in Adults: A Postmarketing Safety Analysis

Purpose

Based, in part, on the clinical study reports of tendon rupture events after collagenase clostridium histolyticum (CCH) (Xiaflex, Endo Pharmaceuticals Inc) treatment for Dupuytren contracture (DC), a Risk Evaluation and Mitigation Strategy program was instituted in 2010 by Auxilium Pharmaceuticals (now Endo Pharmaceuticals Inc) to ensure that the benefits of CCH injection outweighed the risks when treating DC. Using the postmarketing surveillance data collected in this program, a retrospective analysis was conducted to evaluate the incidence of flexor tendon rupture after CCH treatment for DC in the clinical practice setting.

Methods

The Endo Pharmaceuticals Inc safety database was searched for cases of tendon rupture reported between February 2, 2010, and October 8, 2015. Total number of CCH treatments for DC and incidence of tendon rupture were estimated using CCH dosing derived from clinical trial experience (1.7 CCH vials/treatment) or clinical practice evidence (1.08 CCH vials/treatment).

Results

Over the 5.8-year surveillance period, 97,609 vials of CCH were distributed for the treatment of DC, equivalent to an estimated total of 57,416 treatments (at 1.7 CCH vials/treatment) or 90,378 treatments (at 1.08 CCH vials/treatment). Although CCH distribution increased during the surveillance period, reports of tendon rupture were infrequent (approximately 13 cases/y; total cases: flexor tendon, n = 57; ligament/pulley, n = 2), corresponding to a 0.10% (1.7 CCH vials/treatment) or 0.06% (1.08 CCH vials/treatment) mean estimated incidence of tendon rupture in patients with DC after CCH treatment.

Conclusions

This retrospective analysis showed that flexor tendon rupture occurred infrequently in patients with DC who were treated with CCH in real-world practice settings between 2010 and 2015. On the basis of these findings and other favorable safety evidence, the Risk Evaluation and Mitigation Strategy program requirement for CCH for the treatment of DC was ended by the US Food and Drug Administration in November 2016.

Type of study/level of evidence

Therapeutic IV.

LGG-22. SJ901: Phase I/II evaluation of single agent mirdametinib (PD-0325901), a brain-penetrant MEK1/2 inhibitor, for the treatment of children, adolescents, and young adults with low-grade glioma (LGG)

BACKGROUND: MEK inhibitor trials in pediatric low-grade glioma (pLGG) have yielded promising results, but there remains room for improvement since objective responses are rarely complete and disease recurrence after completion of therapy is common. Mirdametinib (PD-0325901) is a highly selective MEK1/MEK2 inhibitor that, in preclinical studies, has been reported to have superior blood-brain-barrier penetration compared to other MEK inhibitors. As such, we recently launched the SJ901 clinical trial (NCT04923126) to determine the safety, recommended phase 2 dose, pharmacokinetics, and preliminary efficacy of mirdametinib in patients with pLGG when administered continuously. Here, we present preliminary phase 1 data. METHODS: SJ901 is a multi-arm phase I/II trial of mirdametinib in patients &gt;2 and &lt;25 years with LGG. Phase I requires participants to have no prior exposure to MEK inhibitors and recurrent/progressive disease with biopsy-proven evidence of MAPK pathway activation. Three escalating dose levels (2 mg/m2/dose BID, 2.5mg/m2/dose BID and 3mg/m2/dose BID) are planned using a rolling 6 design. RESULTS: Accrual began in June 2021. As of Jan 13, 2022, eleven patients enrolled: 5 on dose level 1 (DL1) and 6 on dose level 2 (DL2). Median age is 10 (3-21) years. Ten patients have somatic gene rearrangements (7 BRAF, 1 MYB, 1 RAF1, 1 FGFR1) and one has an NF1 germline mutation. Four have metastatic disease. No dose-limiting toxicities occurred for DL1 (whereas data are pending for DL2) and only grade 1/2 treatment-related adverse events have been observed. No MEK-related retinopathy or cardiopathy has been observed. Four of the six patients with at least one follow-up disease evaluation have a minor response (&gt;25%-&lt;50% decrease). Median time on therapy is 6.6 (2.2-7) months. No disease progressions have occurred. CONCLUSION: Thus far, mirdametinib is well-tolerated and clinically promising when dosed continuously in patients with recurrent/progressive pLGG. More information will be forthcoming.

A good investment: longer-term cost savings of sensitive parenting in childhood

Introduction

Good quality parenting in early childhood is reliably associated with positive mental and physical health over the lifespan.

Objectives

The hypothesis that early parenting quality has significant long-term financial benefits has not been previously tested.

Methods

Design: Longitudinal study with follow-up from 2012 to 2016; UK multicentre study cohort. Participants: 174 young people drawn from 2 samples, one at moderate risk of poor outcomes and one at high risk, assessed aged 4–6 years then followed up in early adolescence (mean age 12.1 years). Measures: The primary outcome was total costs: health, social care, extra school support, out-of-home placements and family-born expenditure, determined through semistructured economic interviews. Early parenting quality was independently assessed through direct observation of parent–child interaction.

Results

Costs were lower for youths exposed to more sensitive parenting (most sensitive quartile mean £1,619, least sensitive quartile mean £21,763; p < .001). Costs were spread across personal family expenditure and education, health, social and justice services. The cost difference remained significant after controlling for several potential confounders. These included demographic variables (family poverty, parental education); exposure to child abuse; and child/young person variables including level of antisocial behaviour in both childhood and adolescence, IQ and attachment security.

Conclusions

This study is the first showing that more sensitive early parental care predicts lower costs to society many years later, independent of poverty, child and youth antisocial behaviour levels and IQ. The findings provide novel evidence for the public health impact of early caregiving quality and likely financial benefits of improving it.

Disclosure

No significant relationships.

Factors Influencing Psychological Distress During the COVID-19 Pandemic in People Aging with HIV

Older adults living with HIV may be at increased risk of experiencing distress during the coronavirus disease 2019 (COVID-19) pandemic. We took advantage of a cohort study in older adults living with HIV in Canada (The Positive Brain Health Now [+BHN]) to study the psychological impact of the first wave of the COVID-19 pandemic. A longitudinal study was conducted in which participants in the +BHN study who had access to the internet and agreed to be contacted were queried on symptoms of psychological distress and its predictors each week between mid-April and the end of June 2020. Evolution of distress, measured with the Hospital Anxiety and Depression Scale (HADS), was modeled using Group Based Trajectory Analysis and logistic regression was used to identify factors predictive of psychological distress in the clinical range. The study was approved by the Research Ethics Board of the McGill University Health Center and all participants provided informed consent. The 77 +BHN participants who took part in this study were mostly men (92%) and on average 57.3 years of age. Over the study period, 32.5% experienced psychological distress in the clinical range at one or more weekly surveys. In the transition between the pre-COVID-19 and the COVID-19 periods, the HADS scores followed five distinct trajectories: (1) 39.5 % of the sample, with normal HADS scores in the several months preceding the pandemic, experienced an increase in HADS scores; (2) 30.6% of the sample had normal prepandemic HADS scores, remained stable; and (3) 29.9%, with prepandemic presence of distress, had a decrease in HADS scores. During the first wave of COVID-19, some attenuation in distress was seen over time. Feeling lonely and financial insecurity were associated with distress. Presence of psychological distress during the first wave of the COVID-19 pandemic was not universal among older adults with HIV, with as many as one third of the participants reporting an improvement in mental health. Distress was predicted by loneliness and financial insecurity.

Language used to describe medication review activities: does it require standardisation? A narrative synthesis

Introduction

Medication review (MR) is a health care professional’s systematic assessment of a patient’s medications with recommendations for improvement (1). To enable comparison between different evaluations of medication review-based interventions to determine whether the nature of activity differs, it is important that standardised language is used. Currently, there is no accepted international taxonomy for describing medication review activities. Therefore, we undertook a systematic review of literature with narrative synthesis to determine whether standardisation may be appropriate.

Aim

To determine the range of terms used to describe medication review activities.

Method

A PROSPERO registered systematic review (CRD 42020215992) was performed using search terms according to the Population, Intervention, Comparison and Outcome (PICO) framework. ‘Population’ & ‘Comparison’ were not used. Synonyms for medication review activities were used for both ‘Intervention’ and ‘Outcomes’, e.g., stop, start, change, alter. We included all papers reporting medication review activities in English with empirical data. Papers not using language to describe medication review activities were excluded. Two researchers reviewed all titles, abstracts, and full-text papers independently; discussion resolved any disagreement. Data extraction was carried out independently as per Cochrane Effective Practice and Organisation of Care (EPOC) as follows:

The papers were assessed using the Mixed Method Appraisal Tool (MMAT). The research team themed the extracted terms.

Results

After deleting duplicates, 9746 titles were screened. Twenty-one studies were included: eight quantitative non-randomised trials, eight randomised controlled trials, and five quantitative descriptive studies. The studies covered the UK, Netherlands, Australia, Sweden, Norway, Belgium, Canada, and Jordan. The table summarises the medication review activities reported in these papers.

Conclusion

Various authors reported medication review activities. ‘Alter’ and ‘adaptation’ are examples of ambiguous terms. Determining whether actions are related with activities to reduce or increase doses is difficult due to such terminology. As a result, comparing medication review approaches may be difficult. Limiting the search strategy to English-language only may have missed some studies. A taxonomy to describe and define medication review activities, thereby standardising MR reporting, should improve the presentation of data from process evaluations and the ability to compare activity between studies.

Reference

(1) Christensen M, Lundh A. Medication review in hospitalised patients to reduce morbidity and mortality. Cochrane Database Syst Rev [Internet]. 2016 Feb 20; Available from: https://doi.wiley.com/10.1002/14651858.CD008986.pub3

Trainee-Led Quality Improvement Project to Improve Fertility Preservation Counseling for Patients With Cancer

PURPOSE

Oncofertility counseling regarding the reproductive risks associated with cancer therapy is essential for quality cancer care. We aimed to increase the rate of oncofertility counseling for patients of reproductive age (18-40 years) with cancer who were initiating systemic therapy at the Johns Hopkins Cancer Center from a baseline rate of 37% (25 of 68, June 2019-January 2020) to 70% by February 2021.

METHODS

We formed an interprofessional, multidisciplinary team as part of the ASCO Quality Training Program. We obtained data from the electronic medical record and verified data with patients by phone. We surveyed patients, oncologists, and fertility specialists to identify barriers. After considering a prioritization matrix, we implemented Plan-Do-Study-Act (PDSA) cycles.

RESULTS

We identified the following improvement opportunities: (1) oncologist self-reported lack of knowledge about counseling and local fertility preservation options and (2) lack of a standardized referral mechanism to fertility services. During the first PDSA cycle (February 2020-August 2020, disrupted by COVID-19), we introduced the initiative to increase oncofertility counseling at faculty meetings. From September 2020 to November 2020, we implemented a second PDSA cycle: (1) educating and presenting the initiative at Oncology Grand Rounds, (2) distributing informative pamphlets to oncologists and patients, and (3) implementing an electronic medical record order set. In the third PDSA cycle (December 2020-February 2021), we redesigned the order set to add information (eg, contact information for fertility coordinator) to the patient after-visit summary. Postimplementation (September 2020-February 2021), counseling rates increased from 37% to 81% (38 of 47).

CONCLUSION

We demonstrate how a trainee-led, patient-centered initiative improved oncofertility care. Ongoing work focuses on ensuring sustainability and assessing the quality of counseling.

The Digital Undertow: How the Corollary Effects of Digital Transformation Affect Industry Standards

Digital transformation research shows how waves of digitalization produce strategic changes within and across firms, enabling new forms of value creation. We argue that different but no less important processes of digital transformation are generated by the undertow produced by these waves. Digital undertow, a corollary effect of waves of digitalization, profoundly influences how firms operate by transforming the industry standards that coordinate and regulate their core business activities. This is producing what we refer to as digital displacement, a process that is significantly challenging the capacity of standards to effectively manage industry operations in the digital age.

Validation of a Frailty Ladder Using Rasch Analysis: If the Shoe Fits

The current measurement approach to frailty is to classify people on frailty status, rather than measure the degree to which they are frail. Here, we test the extent to which a set of items identified within the frailty concept fits a hierarchical linear model (Rasch model) and form a true measure reflective of the frailty construct and confirm the model using the NuAge dataset. The development sample included 234 individuals (aged 57 to 97) drawn from three sources: at-risk seniors (n=141); post-colorectal surgery (n=47); and post-rehabilitation hip fracture (n=46). We defined our frailty construct based on items commonly used in frailty indices, self-report measures, and performance tests. Of the 68 items, 29 fit the Rasch Model: 19 self-report items on physical function and 10 performance tests including one for cognition. Items typically identified as reflecting the frailty concept fit the Rasch model. The Frailty Ladder would facilitate personalized intervention.

Exploring young people's perspectives of inequalities in health: a qualitative study

Background

Reducing inequalities in health is an enduring global public health challenge. Worryingly in England, inequalities across some groups and places are worsening, highlighted and exacerbated by the Covid-19 pandemic. While there has been growing interest in exploring public understandings of health inequalities, few studies have explored the views of young people. Our study seeks to redress this by exploring young people's perspectives of inequalities in health.

Methods

Working with existing youth organisations, we recruited young people (aged 13-21) from six youth groups in areas of high deprivation across three geographical locations in England. Each group took part in three interlinked focus groups (n = 18), the majority of which were run online using video conferencing platforms. Focus groups were co-delivered with partnering youth organisations during 2021. They involved participatory concept mapping activities, and the discussion of health related news articles.

Results

Key themes emerged around young people's perspectives of: i) factors influencing health within their local area; ii) understandings of inequalities in health; and iii) key messages to convey to those with a role in addressing health inequalities at a place level.

Conclusions

Our study highlights the importance of exploring and understanding young people's perspectives of inequalities in order to better shape policies which are supported by the communities and people they impact.

Key messages

Young people have a nuanced, experiential understanding of key factors influencing their health and inequalities in health within their local areas. Building upon young people’s understandings of inequalities in health provides opportunities to mobilise support for policies seeking to change the distribution of key social determinants.

'Well-leg' compartment syndrome associated with gynaecological surgery: a perioperative risk-reduction protocol and checklist

'Well-leg' compartment syndrome (WLCS) is an uncommon, but potentially devastating, complication associated with prolonged patient positioning for abdomino-pelvic surgery. Gynaecologists, anaesthetists and the wider theatre team share a responsibility to minimise the risk of this highly morbid, and even fatal, postoperative complication. This article provides an overview of WLCS related to gynaecological surgery - raising awareness amongst gynaecologists and highlighting the time-critical nature of diagnosis and management. Given the potential litiginous nature of this complication, we also present a perioperative checklist and risk-reduction protocol to suggest a standardised approach to prevention and relevant documentation. TWEETABLE ABSTRACT: Gynaecologists share a responsibility to minimise the risk of postoperative 'well-leg' compartment syndrome.

Vulvar Aphthous Ulcer in an Adolescent With COVID-19

BACKGROUND

Vulvar aphthous ulcers have been associated with various prodromal viral illnesses. We describe the case of an adolescent girl who developed vulvar aphthous ulcers during infection with Coronavirus, SARS-CoV-2.

CASE

A 19-year-old girl presented to the emergency department with cough, sore throat, fevers, and rash, and tested positive for COVID-19. She re-presented 2 days later with vulvar pain and was found to have a vulvar aphthous ulcer. She was admitted for pain control and treated with oral steroids. Improvement in her vulvar pain was noted, along with resolution of fevers, cough, and rash.

SUMMARY AND CONCLUSION

This case illustrates the novel association of COVID-19 with vulvar aphthous ulcers in adolescents. Use of oral steroids for symptomatic management of COVID-19 led to rapid clinical improvement.

6 Improving Patient Flow in a Multi-Specialty Assessment Area by Introducing Referral Pathways for Orthopaedics and Plastic Surgery during the COVID-19 Pandemic

Introduction

The COVID-19 pandemic has seen fundamental organisational changes to emergency departments internationally. Specialties throughout the hospital setting have been asked to change their working practice, often with the aim of adapting to new processes in emergency departments. Early in the pandemic, the orthopaedic team at one district general hospital were required to provide 24/7 onsite cover in a multi-specialty area. Confusion over the referral pathways of two specialties (orthopaedics and plastic surgery) led to increase waiting times, constrained patient flow and poor patient and staff satisfaction.

Method

This quality improvement project occurred over three cycles of data collection and intervention over a two-month period. A novel referral pathway was developed and implemented after discussion with consultants in orthopaedics, plastics, and emergency medicine. Interventions included staff teaching, clarifying of roles at morning meetings and the deployment of posters.

Results

In cycle 1, 39% of orthopaedic referrals were inappropriately referred. By cycle 3, 0% of orthopaedic patients were inappropriately referred. Average time in department for patients referred to orthopaedics improved from 124 minutes to 88 minutes. Staff reported increased satisfaction, with appreciation for the clarification on referral criteria.

Conclusions

This QUIP demonstrates how simple interventions during times of crisis can solve complex organisational issues.

Functional mutants of Azospirillum brasilense elicit beneficial physiological and metabolic responses in Zea mays contributing to increased host iron assimilation

Iron (Fe), an essential element for plant growth, is abundant in soil but with low bioavailability. Thus, plants developed specialized mechanisms to sequester the element. Beneficial microbes have recently become a favored method to promote plant growth through increased uptake of essential micronutrients, like Fe, yet little is known of their mechanisms of action. Functional mutants of the epiphytic bacterium Azospirillum brasilense, a prolific grass-root colonizer, were used to examine mechanisms for promoting iron uptake in Zea mays. Mutants included HM053, FP10, and ipdC, which have varying capacities for biological nitrogen fixation and production of the plant hormone auxin. Using radioactive iron-59 tracing and inductively coupled plasma mass spectrometry, we documented significant differences in host uptake of Fe2+/3+ correlating with mutant biological function. Radioactive carbon-11, administered to plants as 11CO2, provided insights into shifts in host usage of 'new' carbon resources in the presence of these beneficial microbes. Of the mutants examined, HM053 exhibited the greatest influence on host Fe uptake with increased plant allocation of 11C-resources to roots where they were transformed and exuded as 11C-acidic substrates to aid in Fe-chelation, and increased C-11 partitioning into citric acid, nicotianamine and histidine to aid in the in situ translocation of Fe once assimilated.

A comparison of gastric gas volumes measured by computed tomography after high-flow nasal oxygen therapy or conventional facemask ventilation. Anaesthesia 2021;76:1184-1189. [PMID: 33651914 DOI: 10.1111/anae.15433]

High-flow nasal oxygen therapy is increasingly used to improve peri-intubation oxygenation. However, it is unknown whether it may cause or exacerbate insufflation of gas into the stomach. High-flow nasal oxygen therapy is now standard practice in our hospital for adult patients undergoing percutaneous thermal ablation of liver cancer under general anaesthesia with tracheal intubation. We compared gastric gas volumes measured from computed tomography images that had been acquired immediately after intubation in two series of patients: 50 received peri-intubation high-flow nasal oxygen therapy and another 50 received conventional facemask pre-oxygenation and ventilation before intubation and before high-flow nasal oxygen therapy became standard practice in our unit. Median (IQR [range]) gastric gas volume was 24.0 (14.2-59.9 [3-167]) cm³ in the high-flow nasal oxygen therapy group and 23.8 (12.6-38.8 [0-185]) cm³ in the facemask group. There was no difference between the two groups in the volume of gastric gas measured by computed tomography imaging (Mann-Whitney U-test, U = 1136, p = 0.432, n₁  = n₂  = 50). Our results demonstrate that a small volume of gastric gas is commonly present after induction of anaesthesia, but that the use of peri-intubation high-flow nasal oxygen therapy for pre-oxygenation and during apnoea does not increase this volume compared with conventional facemask pre-oxygenation and ventilation. This is clinically relevant, as high-flow nasal oxygen therapy is increasingly being used in a peri-intubation context and in patients at higher risk of aspiration.

[Recommendations for the Protocol of functional examination of the anorectal zone and disorders classification: the International Anorectal Physiology Working Group consensus and Russian real-world practice]

This manuscript summarizes consensus reached by the International Anorectal Physiology Working Group (IAPWG) for the performance, terminology used, and interpretation of anorectal function testing including anorectal manometry (focused on high-resolution manometry), the rectal sensory test, and the balloon expulsion test. Based on these measurements, a classification system for disorders of anorectal function is proposed. Aim to provide information about methods of diagnosis and new classification of functional anorectal disorders to a wide range of specialists general practitioners, therapists, gastroenterologists, coloproctologists all who face the manifestations of these diseases in everyday practice and determine the diagnostic and therapeutic algorithm. Current paper provides agreed statements of IAPWG Consensus and comments (in italics) of Russian experts on real-world practice, mainly on methodology of examination. These comments in no way intended to detract from the provisions agreed by the international group of experts. We hope that these comments will help to improve the quality of examination based on the systematization of local experience with the use of the methods discussed and the results obtained. Key recommendations: the International Anorectal Physiology Working Group protocol for the performance of anorectal function testing recommends a standardized sequence of maneuvers to test rectoanal reflexes, anal tone and contractility, rectoanal coordination, and rectal sensation. Major findings not seen in healthy controls defined by the classification are as follows: rectoanal areflexia, anal hypotension and hypocontractility, rectal hyposensitivity, and hypersensitivity. Minor and inconclusive findings that can be present in health and require additional information prior to diagnosis include anal hypertension and dyssynergia.

Induced abortions in women with systemic lupus erythematosus

OBJECTIVES

To determine the rates of induced abortions in women with systemic lupus erythematosus (SLE) compared to women from the general population and assess disease-related predictors of induced abortion in women with SLE.

METHODS

We identified women with SLE (15-45 years) and determined the number of induced abortions, using Quebec's administrative databases. We calculated the standardized incidence ratio (SIR) using general population rates. We also performed a nested-case control analysis to investigate predictors of induced abortions in SLE women (such as teratogenic immunosuppressive and corticosteroid exposures).

RESULTS

Among 2508 women with SLE, we observed 293 induced abortions [incidence rate of 17.1 induced abortions per 1000 person-years (95% CI 15.2, 19.2)]. There was no clear difference in the number of induced abortions among women with SLE versus women from the general population (SIR 1.10; 95% CI 0.98, 1.24). In the multivariable analysis, we did not observe higher rates of induced abortions among women exposed to teratogenic immunosuppressives [rate ratio (RR) 0.37; 95% CI 0.13, 1.07] or using corticosteroids (RR 0.67; 95% CI 0.39, 1.16).

CONCLUSION

Our findings suggest that women with SLE have a similar rate of induced abortions as compared to the general population. This raises some concerns as unplanned pregnancies in SLE women can lead to adverse maternal and fetal outcomes. Our results should prompt further research on family planning counselling in women with SLE.

Spontaneous renal fornix rupture in pregnancy and the post partum period: a systematic review of outcomes and management

BACKGROUND

Spontaneous renal fornix rupture (SRFR) causing urinoma is an uncommon but serious condition in pregnancy. Limited information is available to describe the natural history and outcomes to guide appropriate treatment. The aim of this study was to determine the natural history and outcomes of SRFR to determine appropriate management recommendations.

METHODS

A systematic review of literature databases was performed, using the Meta-analysis Of Observational Studies in Epidemiology (MOOSE) checklist from 1950 - April 2020. Inclusion criteria included any urinary extravasation from the kidney or ureter during pregnancy, or in the 8 weeks following delivery, confirmed via imaging or surgery. Haematomas and non-confirmed cases were excluded.

RESULTS

A total of 1579 records were originally identified, of which 39 case reports were appropriate for inclusion. SRFR was most commonly reported during the first pregnancy (72%), 19/30 during the third trimester and 9 in the post-natal period. All patients presented with pain, with haematuria positive on urine dipstick in only 36% of 26 reported cases. Ultrasound was the most frequently used imaging modality, resulting in a diagnosis in 42% of cases. All cases reported on treatment procedures including ureteric stents (46%), percutaneous drain (15%), conservative management (15%), nephrostomy (13%) and ureteral catherization (10%). Long term urological outcomes were positive, however women suffering SRFR were significantly more likely to undergo pre-term labour.

CONCLUSION

While selected cases may be successfully managed conservatively, urinary diversion, through ureteric stents, should be considered the management of choice in these individuals. Clinicians should be mindful of an increased risk of premature delivery and its' associated negative fetal outcomes.

Collateral damage: the impact on outcomes from cancer surgery of the COVID-19 pandemic

BACKGROUND

Cancer diagnostics and surgery have been disrupted by the response of health care services to the coronavirus disease 2019 (COVID-19) pandemic. Progression of cancers during delay will impact on patients' long-term survival.

PATIENTS AND METHODS

We generated per-day hazard ratios of cancer progression from observational studies and applied these to age-specific, stage-specific cancer survival for England 2013-2017. We modelled per-patient delay of 3 and 6 months and periods of disruption of 1 and 2 years. Using health care resource costing, we contextualise attributable lives saved and life-years gained (LYGs) from cancer surgery to equivalent volumes of COVID-19 hospitalisations.

RESULTS

Per year, 94 912 resections for major cancers result in 80 406 long-term survivors and 1 717 051 LYGs. Per-patient delay of 3/6 months would cause attributable death of 4755/10 760 of these individuals with loss of 92 214/208 275 life-years, respectively. For cancer surgery, average LYGs per patient are 18.1 under standard conditions and 17.1/15.9 with a delay of 3/6 months (an average loss of 0.97/2.19 LYGs per patient), respectively. Taking into account health care resource units (HCRUs), surgery results on average per patient in 2.25 resource-adjusted life-years gained (RALYGs) under standard conditions and 2.12/1.97 RALYGs following delay of 3/6 months. For 94 912 hospital COVID-19 admissions, there are 482 022 LYGs requiring 1 052 949 HCRUs. Hospitalisation of community-acquired COVID-19 patients yields on average per patient 5.08 LYG and 0.46 RALYGs.

CONCLUSIONS

Modest delays in surgery for cancer incur significant impact on survival. Delay of 3/6 months in surgery for incident cancers would mitigate 19%/43% of LYGs, respectively, by hospitalisation of an equivalent volume of admissions for community-acquired COVID-19. This rises to 26%/59%, respectively, when considering RALYGs. To avoid a downstream public health crisis of avoidable cancer deaths, cancer diagnostic and surgical pathways must be maintained at normal throughput, with rapid attention to any backlog already accrued.

Annual Report to the Nation on the Status of Cancer, Featuring Cancer in Men and Women Age 20-49 Years

Background

The American Cancer Society, Centers for Disease Control and Prevention, National Cancer Institute, and North American Association of Central Cancer Registries provide annual updates on cancer occurrence and trends by cancer type, sex, race, ethnicity, and age in the United States. This year’s report highlights the cancer burden among men and women age 20–49 years.

Methods

Incidence data for the years 1999 to 2015 from the Centers for Disease Control and Prevention- and National Cancer Institute–funded population-based cancer registry programs compiled by the North American Association of Central Cancer Registries and death data for the years 1999 to 2016 from the National Vital Statistics System were used. Trends in age-standardized incidence and death rates, estimated by joinpoint, were expressed as average annual percent change.

Results

Overall cancer incidence rates (per 100 000) for all ages during 2011–2015 were 494.3 among male patients and 420.5 among female patients; during the same time period, incidence rates decreased 2.1% (95% confidence interval [CI] = −2.6% to −1.6%) per year in men and were stable in females. Overall cancer death rates (per 100 000) for all ages during 2012–2016 were 193.1 among male patients and 137.7 among female patients. During 2012–2016, overall cancer death rates for all ages decreased 1.8% (95% CI = −1.8% to −1.8%) per year in male patients and 1.4% (95% CI = −1.4% to −1.4%) per year in females. Important changes in trends were stabilization of thyroid cancer incidence rates in women and rapid declines in death rates for melanoma of the skin (both sexes). Among adults age 20–49 years, overall cancer incidence rates were substantially lower among men (115.3 per 100 000) than among women (203.3 per 100 000); cancers with the highest incidence rates (per 100 000) among men were colon and rectum (13.1), testis (10.7), and melanoma of the skin (9.8), and among women were breast (73.2), thyroid (28.4), and melanoma of the skin (14.1). During 2011 to 2015, the incidence of all invasive cancers combined among adults age 20–49 years decreased −0.7% (95% CI = −1.0% to −0.4%) among men and increased among women (1.3%, 95% CI = 0.7% to 1.9%). The death rate for (per 100 000) adults age 20–49 years for all cancer sites combined during 2012 to 2016 was 22.8 among men and 27.1 among women; during the same time period, death rates decreased 2.3% (95% CI = −2.4% to −2.2%) per year among men and 1.7% (95% CI = −1.8% to −1.6%) per year among women.

Conclusions

Among people of all ages and ages 20–49 years, favorable as well as unfavorable trends in site-specific cancer incidence were observed, whereas trends in death rates were generally favorable. Characterizing the cancer burden may inform research and cancer-control efforts.

Annual report to the nation on the status of cancer, part I: National cancer statistics

BACKGROUND

The American Cancer Society, the Centers for Disease Control and Prevention, the National Cancer Institute, and the North American Association of Central Cancer Registries collaborate to provide annual updates on cancer occurrence and trends in the United States.

METHODS

Data on new cancer diagnoses during 2001 through 2016 were obtained from the Centers for Disease Control and Prevention-funded and National Cancer Institute-funded population-based cancer registry programs and compiled by the North American Association of Central Cancer Registries. Data on cancer deaths during 2001 through 2017 were obtained from the National Center for Health Statistics' National Vital Statistics System. Trends in incidence and death rates for all cancers combined and for the leading cancer types by sex, racial/ethnic group, and age were estimated by joinpoint analysis and characterized by the average annual percent change during the most recent 5 years (2012-2016 for incidence and 2013-2017 for mortality).

RESULTS

Overall, cancer incidence rates decreased 0.6% on average per year during 2012 through 2016, but trends differed by sex, racial/ethnic group, and cancer type. Among males, cancer incidence rates were stable overall and among non-Hispanic white males but decreased in other racial/ethnic groups; rates increased for 5 of the 17 most common cancers, were stable for 7 cancers (including prostate), and decreased for 5 cancers (including lung and bronchus [lung] and colorectal). Among females, cancer incidence rates increased during 2012 to 2016 in all racial/ethnic groups, increasing on average 0.2% per year; rates increased for 8 of the 18 most common cancers (including breast), were stable for 6 cancers (including colorectal), and decreased for 4 cancers (including lung). Overall, cancer death rates decreased 1.5% on average per year during 2013 to 2017, decreasing 1.8% per year among males and 1.4% per year among females. During 2013 to 2017, cancer death rates decreased for all cancers combined among both males and females in each racial/ethnic group, for 11 of the 19 most common cancers among males (including lung and colorectal), and for 14 of the 20 most common cancers among females (including lung, colorectal, and breast). The largest declines in death rates were observed for melanoma of the skin (decreasing 6.1% per year among males and 6.3% among females) and lung (decreasing 4.8% per year among males and 3.7% among females). Among children younger than 15 years, cancer incidence rates increased an average of 0.8% per year during 2012 to 2016, and cancer death rates decreased an average of 1.4% per year during 2013 to 2017. Among adolescents and young adults aged 15 to 39 years, cancer incidence rates increased an average of 0.9% per year during 2012 to 2016, and cancer death rates decreased an average of 1.0% per year during 2013 to 2017.

CONCLUSIONS

Although overall cancer death rates continue to decline, incidence rates are leveling off among males and are increasing slightly among females. These trends reflect population changes in cancer risk factors, screening test use, diagnostic practices, and treatment advances. Many cancers can be prevented or treated effectively if they are found early. Population-based cancer incidence and mortality data can be used to inform efforts to decrease the cancer burden in the United States and regularly monitor progress toward goals.

A state-of-art review on collagenase Clostridium Histolyticum and Peyronie's disease: drug profile, clinical evidence and safety outcomes

Introduction: Collagenase clostridium histolyticum (CCH) is the first and only licensed medical treatment for men with Peyronie's disease (PD). Published literature shows intralesional CCH injection as an effective and safe minimally invasive treatment in a specific subgroup of PD patients.Areas covered: The authors discuss pharmacodynamics and pharmacokinetics as well as clinical outcomes and safety profile from major CCH studies in PD. All relevant CCH studies published in PubMed and EMBASE databases up to June 2019 were included.Expert opinion: Given the variability in treatment schedule and drug access coupled with the potential need for further treatment, strict patient selection and the use of adjunctive strategies are key determinants to maximize clinical efficacy of intralesional CCH. Furthermore, longer-term follow-up data on the clinical outcomes, safety and durability of CCH in larger multi-center studies and post-marketing surveillance data are necessary to provide a comparison to other standard PD treatment options.

Risk of Ocular Anomalies in Children Exposed In Utero to Antimalarials: A Systematic Literature Review

OBJECTIVE

To determine whether offspring from mothers with systemic lupus erythematosus (SLE), exposed in utero to antimalarials, have an increased risk of ocular anomalies during childhood versus unexposed SLE offspring.

METHODS

We systematically performed searches of PubMed, Embase, and Web of Science databases for original human data on fetal and/or child ocular outcomes following exposure to antimalarials during pregnancy and/or lactation, from their inception until March 2017.

RESULTS

A total of 10 cohort studies and 2 randomized controlled trials, ranging in size from 6 to 444 exposed infants studied, and 3 case reports met the inclusion criteria for our systematic review. Collectively, 1,477 infants were studied, 789 of which were exposed to hydroxychloroquine or chloroquine. In all, 563 exposed infants had follow-up visits after delivery (ranging from <3 months to 19 years), and 331 of these exposed infants underwent ophthalmologic examinations during the follow-up period. Our review of the literature suggests a low-to-nonexistent risk of visual abnormalities in offspring exposed to antimalarials.

CONCLUSION

In children exposed to appropriate doses of antimalarials antenatally, the risk of ocular toxicity appears low to nonexistent. The potential benefits and risks of antimalarials should be discussed in all SLE pregnancies, and high dosages should continue to be avoided.

Annual report to the nation on the status of cancer, part II: Progress toward Healthy People 2020 objectives for 4 common cancers

BACKGROUND

The Centers for Disease Control and Prevention, the American Cancer Society, the National Cancer Institute, and the North American Association of Central Cancer Registries collaborate to provide annual updates on cancer occurrence and trends in the United States and to address a special topic of interest. Part I of this report focuses on national cancer statistics, and part 2 characterizes progress in achieving select Healthy People 2020 cancer objectives.

METHODS

For this report, the authors selected objectives-including death rates, cancer screening, and major risk factors-related to 4 common cancers (lung, colorectal, female breast, and prostate). Baseline values, recent values, and the percentage change from baseline to recent values were examined overall and by select sociodemographic characteristics. Data from national surveillance systems were obtained from the Healthy People 2020 website.

RESULTS

Targets for death rates were met overall and in most sociodemographic groups, but not among males, blacks, or individuals in rural areas, although these groups did experience larger decreases in rates compared with other groups. During 2007 through 2017, cancer death rates decreased 15% overall, ranging from -4% (rural) to -22% (metropolitan). Targets for breast and colorectal cancer screening were not yet met overall or in any sociodemographic groups except those with the highest educational attainment, whereas lung cancer screening was generally low (<10%). Targets were not yet met overall for cigarette smoking, recent smoking cessation, excessive alcohol use, or obesity but were met for secondhand smoke exposure and physical activity. Some sociodemographic groups did not meet targets or had less improvement than others toward reaching objectives.

CONCLUSIONS

Monitoring trends in cancer risk factors, screening test use, and mortality can help assess the progress made toward decreasing the cancer burden in the United States. Although many interventions to reduce cancer risk factors and promote healthy behaviors are proven to work, they may not be equitably applied or work well in every community. Implementing cancer prevention and control interventions that are sustainable, focused, and culturally appropriate may boost success in communities with the greatest need, ensuring that all Americans can access a path to long, healthy, cancer-free lives.

A qualitative exploration of school-based staff's experiences of delivering an alcohol screening and brief intervention in the high school setting: findings from the SIPS JR-HIGH trial

BACKGROUND

Whilst underage drinking in the UK has been declining in recent years, prevalence is still higher than in most other Western European countries. Therefore, it is important to deliver effective interventions to reduce risk of harm.

METHODS

Semi-structured interviews with staff delivering an alcohol screening and brief intervention in the high-school setting. The analysis was informed by normalization process theory (NPT), interviews were open coded and then a framework applied based on the four components of NPT.

RESULTS

Five major themes emerged from the analysis. The majority of participants felt that the intervention could be useful, and that learning mentors were ideally suited to deliver it. However, there was a feeling that the intervention should have been targeted at young people who drink the most.

CONCLUSIONS

The intervention was generally well received in schools and seen as an effective tool for engaging young people in a discussion around alcohol. However, in the future schools need to consider the level of staffing in place to deliver the intervention. Furthermore, the intervention could focus more on the long-term risks of initiating alcohol consumption at a young age.

Power series method for solving TASEP-based models of mRNA translation

We develop a method for solving mathematical models of messenger RNA (mRNA) translation based on the totally asymmetric simple exclusion process (TASEP). Our main goal is to demonstrate that the method is versatile and applicable to realistic models of translation. To this end we consider the TASEP with codon-dependent elongation rates, premature termination due to ribosome drop-off and translation reinitiation due to circularisation of the mRNA. We apply the method to the model organism Saccharomyces cerevisiae under physiological conditions and find an excellent agreement with the results of stochastic simulations. Our findings suggest that the common view on translation as being rate-limited by initiation is oversimplistic. Instead we find theoretical evidence for ribosome interference and also theoretical support for the ramp hypothesis which argues that codons at the beginning of genes have slower elongation rates in order to reduce ribosome density and jamming.

Marijuana use in young mothers and adverse pregnancy outcomes: a retrospective cohort study

OBJECTIVE

To evaluate the association between marijuana use and a composite adverse pregnancy outcome using biological sampling.

DESIGN

Retrospective cohort study.

SETTING

Single tertiary center.

POPULATION

Young women (13-22 years old) with singleton, non-anomalous pregnancies delivered from September 2011 to May 2017.

METHODS

Exposure was defined as marijuana detected on universal urine toxicology testing or by self-report. Multivariable logistic regression modelling was used to estimate the effect of any marijuana use on the primary composite outcome. The effect of marijuana exposure was also estimated for self-reported use, toxicology-detected use, and multiple use detected by toxicology.

MAIN OUTCOME MEASURE

The primary composite outcome included spontaneous preterm birth, hypertensive disorders of pregnancy, stillbirth, or small for gestational age.

RESULTS

Of 1206 pregnant young women, 17.5% (n = 211) used marijuana. Among the women who used marijuana, 8.5% (n = 18) were identified by self-report alone, 63% (n = 133) by urine toxicology alone, and 28.4% (n = 60) by both. Urine toxicology testing results were available for 1092 (90.5%) births. The composite outcome occurred more frequently in pregnancies exposed to marijuana (46 versus 34%, P < 0.001). This remained significant after adjusting for race/ethnicity and tobacco in the multivariable model (adjusted OR 1.50, 95% CI 1.09-2.05). When marijuana exposure was defined by self-report only, the association with adverse pregnancy outcome became non-significant (adjusted OR 1.01, 95% CI 0.62-1.64).

CONCLUSION

In a population of young women with nearly universal biological sampling, marijuana exposure was associated with adverse pregnancy outcomes. The heterogeneity of findings in existing studies evaluating the impact of marijuana on mothers and neonates may result from the incomplete ascertainment of exposure.

TWEETABLE ABSTRACT

Marijuana use, as detected by universal urine testing, was associated with a composite adverse pregnancy outcome among young mothers.

Variation in uptake of Healthy Start Food Vouchers in the Six Health and Social Care Partnerships

Background

The primary aim of this study was to assess the difference in uptake levels of Healthy Start Food Vouchers, a means tested benefit to afford nutritious food, between 6 Health and Community Partnerships (HSCP) in Greater Glasgow and Clyde (GGC). Our secondary aim was to explore possible reasons for the observed variation.

Methods

Routinely collected Healthy Start data for the months of August to September 2017 were obtained from the UK Department of Health. Postcode sectors were matched up with their corresponding HSCPs in GGC. Analysis looked for associations between uptake rates and various HSCP area-based characteristics.

Results

Large variations were observed within GGC. Chi-square test showed a significant association between uptake and HSCP area (P &lt; 0.0005). Trend analysis of uptake with area deprivation (P = 0.001) and resource allocation (P &lt; 0.001) was also significant. Subjective analysis of trend direction suggested that uptake increased with deprivation and resource allocation of the HSCP.

Conclusions

Significant trends were found and the observed patterns suggested that the relationship between uptake rates and HSCP area is more complex than the geographical characteristics alone. Future studies need to look at the difference in management and awareness of the voucher scheme between Maternity teams in HSCPs.

Key messages

There is significant variation in the uptake of means tested benefits with some areas having a nearly forty percent of eligible individuals not receiving available support. A qualitative approach is required to determine the causes of low uptake rates of benefits and improve the effectiveness of maternity teams in different areas.