Radiotherapy Utilization and Outcomes on a Contemporary Trial for Pediatric High-Risk Hodgkin Lymphoma Study

PURPOSE/OBJECTIVE(S)

Contemporary trials in pediatric Hodgkin lymphoma (cHL) evaluate strategies to reduce radiotherapy (RT) utilization while maintaining excellent progression-free survival (PFS). An alternative strategy is to irradiate selective sites at higher risk of relapse, and/or use proton therapy (PT) to minimize exposure to healthy tissue. We investigated the use of PT and photon therapy (XRT) and associated early outcomes among patients receiving involved site RT (ISRT) to high-risk sites on the Children's Oncology Group (COG) trial AHOD1331 (NCT021664643).

MATERIALS/METHODS

This multicenter randomized, open-label phase 3 study enrolled patients 2-21 years (yrs) with previously untreated cHL: stages IIB + bulk, IIIB, IVA, IVB. Patients were randomized to 5 cycles of either ABVE-PC (doxorubicin, bleomycin, vincristine, etoposide, prednisone, cyclophosphamide) or the brentuximab vedotin (BV) containing regimen BV-AVE-PC given every 21 days. ISRT to 21 Gy was given to bulky mediastinal adenopathy and slow responding lesions (SRL) defined by 5-point score 4 or 5 on PET-CT after 2 cycles. ISRT could be delivered as 3D conformal XRT (3D), intensity modulated XRT (IMRT), or proton therapy (PT). Utilization of RT was compared by mode and by study enrollment midpoint among irradiated patients. Severe acute toxicity assessment included any incident grade 3 or higher toxicity during the ISRT period, except for neuropathy.

RESULTS

Among 587 eligible patients who were enrolled across 153 institutions between March 2015 and August 2019 with a median follow up of 43.1 months, the 3-yr PFS was 82.5% (90% CI, 78.3%-85.9%) with ABVE-PC and 92.5% (90% CI 89.5%-94.6%) with BV-AVE-PC (p = 0.0002). There was no difference in ISRT receipt or modality by study arm (p = 0.33). Among those who received RT 69.7% received it due to bulky mediastinal adenopathy, 6.6% due to SRL, and 23.7% for both. Overall, 317 (54.0%) patients received protocol RT of which 28.7% received 3D, 44.8% received IMRT, and 26.5% received PT. PT utilization increased over the course of the study from 21.5% among the first 50% of irradiated patients to 31.5% in the second half of irradiated patients (p = 0.045). The 3-yr progression-free survival rates overall by RT were comparable: PT (88.0%, 90% CI 80.6% - 92.7%%); XRT (87.1%, 90% CI 82.9%-90.4%) (p = 0.85). No difference in PFS was observed between 3D versus IMRT (p = 0.65). No differences were observed in severe acute toxicities (8.33% vs. 8.15%, p = 0.96) between PT and XRT.

CONCLUSION

Selective use of RT results in excellent outcomes for pediatric patients with high-risk HL and combination chemotherapy inclusive of the novel agent BV. Over the course of the study, PT utilization increased as an RT modality. Early results suggest that PT does not compromise disease control and has similar acute toxicity as XRT. Long term follow-up (>10 years) is needed to evaluate for secondary malignancies and cardiac toxicity among the different RT modalities.

Understanding who is and isn't involved and engaged in health research: capturing and analysing demographic data to diversify patient and public involvement and engagement

BACKGROUND

Patient and public involvement and engagement (PPIE) can improve the relevance, quality, ethics and impact of research thus contributing to high quality research. Currently in the UK, people who get involved in research tend to be aged 61 years or above, White and female. Calls for greater diversity and inclusion in PPIE have become more urgent especially since the COVID-19 pandemic, so that research can better address health inequalities and be relevant for all sectors of society. Yet, there are currently no routine systems or requirements to collect or analyse the demographics of people who get involved in health research in the UK. The aim of this study was to develop to capture and analyse the characteristics of who does and doesn't take part in patient and public involvement and engagement (PPIE) activities.

METHODS

As part of its strategic focus on diversity and inclusion, Vocal developed a questionnaire to assess the demographics of people taking part in its PPIE activities. Vocal is a non-profit organisation which supports PPIE in health research across the region of Greater Manchester in England. The questionnaire was implemented across Vocal activities between December 2018 and March 2022. In that time. Vocal was working with approximately 935 public contributors. 329 responses were received: a return rate of 29.3%. Analysis of findings and comparison against local population demographic data, and available national data related to public contributors to health research, was performed.

RESULTS

Results show that it is feasible to assess the demographics of people who take part in PPIE activities, through a questionnaire system. Further, our emerging data indicate that Vocal are involving people from a wider range of ages and with a greater diversity of ethnic backgrounds in health research, as compared to available national data. Specifically, Vocal involves more people of Asian, African and Caribbean heritage, and includes a wider range of ages in its PPIE activities. More women than men are involved in Vocal's work.

CONCLUSION

Our 'learn by doing' approach to assessing who does and doesn't take part in Vocal's PPIE activities has informed our practice and continues influence our strategic priorities for PPIE. Our system and learning reported here may be applicable and transferable to other similar settings in which PPIE is carried out. We attribute the greater diversity of our public contributors to our strategic priority and activities to promote more inclusive research since 2018.

Adult life-course trajectories of psychological distress and economic outcomes in midlife during the COVID-19 pandemic: evidence from the 1958 and 1970 British birth cohorts

PURPOSE

Financial adversity in times of economic recession have been shown to have an unequal effect on individuals with prior mental health problems. This study investigated the relationship between mental health groupings across the adult life-course and change in financial situation and employment status during the COVID-19 pandemic, as well as the use of financial measures to mitigate the economic shock.

METHODS

Using two nationally representative British birth cohorts, the National Child Development Study (1958) n = 17,415 and 1970 British Cohort Study n = 17,198, we identified 5 different life-course trajectories of psychological distress from adolescence to midlife which were similar but not identical across the two cohorts. We explored their relation to changes in financial and employment circumstances at different stages during the pandemic from May 2020 to March 2021, applying multinomial logistic regression and controlling for numerous early life covariates, including family socio-economic status (SES). In addition, we ran modified Poisson models with robust standard errors to identify whether different mental health trajectories were supported by government and used other methods to mitigate their financial situation.

RESULTS

We found that the financial circumstances of pre-pandemic trajectories of psychological distress with differential onset, severity, and chronicity across the life-course were exacerbated by the COVID-19 economic shock. The 'stable-high' (persistent severe symptoms) and 'adult-onset' (symptoms developing in 30s, but later decreasing) groups were vulnerable to job loss. Compared to pre-pandemic trajectory groupings with no, minor, or psychological distress symptoms in early adulthood, the 'stable-high', 'midlife-onset' (symptoms developing in midlife), and 'adult-onset' trajectory groups were more likely to seek support from the UK governments economic response package. However, trajectories with pre-pandemic psychological distress were also at greater risk of reducing consumption, dis-saving, relying on increased financial help from family and friends, and also taking payment holidays (agreements with lenders to pause mortgage, credit card or loan payments for a set period) and borrowing.

CONCLUSION

This work highlights different trajectories of pre-pandemic psychological distress, compared to groups with no symptoms were more vulnerable to pandemic-related economic shock and job loss. By adopting unsustainable mitigating measures (borrowing and payment holidays) to support their financial circumstances during COVID-19, these mental health trajectories are at even more risk of lasting adverse impacts and future economic difficulties.

Prevalence of illicit drug use in young sudden cardiac death patients; an Australian prospective cohort study

Background

Illicit drug use may accelerate coronary disease and cardiac hypertrophy or stimulate arrhythmias. Rates of illicit drug use in young sudden cardiac death (SCD) patients are uncertain.

Purpose

To identify rates of illicit drug use in young SCD patients in Australia.

Methods

A prospective multi-centre registry identified out of hospital cardiac arrest (OHCA) patients aged 1–50 years between April 2019 and April 2020. Clinical characteristics were compared between patients with and without illicit drug use (defined by toxicological results or reported regular use). Illicit drugs included stimulants such as amphetamine-type substances and cocaine, or non-stimulants such as heroin, cannabis and novel psychoactive substances (cathinones and synthetic cannabinoids).

Results

770 OHCAs occurred, with 555 patients undergoing forensic assessment. 287 patients had confirmed cardiac cause of OHCA, with 274 undergoing toxicological assessment and 79 (28.8%) having positive toxicology for illicit drugs (n=60) or reported regular drug use (n=19). An additional 121 patients experienced non-cardiac SCD due to illicit drug toxicity, resulting in a total of 200 patients (36.0% of OHCAs) with illicit drug use. Patients with SCD and illicit drug use were more commonly male (86.1% vs 72.3%, p=0.015), regular smokers (36.7% vs 21.5%, p=0.009), had cardiomegaly (76.5% vs 57.5%, p=0.007), and higher rates of coronary disease and cardiomyopathy (coronary disease 44.3% vs 33.3%, cardiomyopathy 30.4% vs 18.5%, p=0.003). Methamphetamines (n=42, 53.1%) were the most common illicit drug identified and polysubstance abuse occurred frequently (n=15, 19.0%).

Conclusion

Approximately one-third of young SCD patients use illicit drugs, with high rates of polysubstance abuse. Illicit drug use in SCD patients is associated with coronary disease and cardiomyopathy.

Funding Acknowledgement

Type of funding sources: None.

Prevalence of coronary artery anomalies in young sudden cardiac death: insights from a prospective state-wide registry

Background

Coronary artery anomalies (CAAs) have been previously implicated as a major cause of young sudden cardiac death (SCD), particularly in exercise-related SCD with a reported prevalence of up to 33%.

Methods

A state-wide prospective out-of-hospital cardiac arrest registry identified all patients aged 1–50 years who experienced an SCD and underwent autopsy from April 2019 to April 2021. Rates of normal anatomy, normal variants and CAAs were identified and circumstances and cause of death for patients with CAAs examined.

Results

Of 1,477 patients who experienced cardiac arrest during the study period, 490 underwent autopsy and were confirmed to have experienced SCD. Of these 490 patients, five (1.0%) had a CAA identified with three having anomalies of coronary origin and two having anomalies of coronary course. In no cases was the CAA deemed responsible for the SCD. In two cases, severe coronary disease and intra-coronary thrombus with histological evidence of acute myocardial infarction were identified, in the third critical coronary disease was found, the fourth had an unrelated thoracic aortic dissection and the fifth had cardiomegaly in the setting of illicit drug use. Of 27 patients who experienced their SCD during exercise, only one had a CAA identified (the patient with thoracic aortic dissection).

Conclusion

In this prospective cohort of consecutive young patients with SCD who underwent autopsy, CAAs occurred in 1.0% of patients and did not cause any deaths. The role of CAAs in causing young SCD appears to be less significant than previously hypothesised.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): NHMRC, NHF

Clinical and pathologic features of out-of-hospital cardiac arrest in pregnancy: insights from a state-wide registry

Background

Cardiovascular disease is the most common cause of indirect maternal mortality worldwide, and cardiac arrest occurs in up to 1 in 12,000 pregnancies.

Objective

To define rates, clinical and pathologic factors of out-of-hospital cardiac arrest (OHCA) in pregnant and post-partum females.

Methods

A prospective state-wide cardiac arrest registry combining ambulance, hospital and forensic data captured all OHCAs from 2019–2021. Clinical and pathological details for pregnant patients were identified.

Results

1,482 OHCAs occurred, including 376 females of child-bearing age of whom eight were pregnant or post-partum. OHCA incidence was lower in pregnant females compared to non-pregnant females of child-bearing age (5.2 OHCAs per 100,000 pregnant females vs 23.1 per 100,000 females of child-bearing age, p<0.0001). Seven patients (87.5%) died, with five (62.5%) having a cardiac cause of OHCA (unascertained = 2, cardiomyopathy = 2 (1 hypertrophic), ischemic heart disease = 1). Two patients had pre-existing cardiac risk factors, but none had a cardiac diagnosis pre-arrest. Compared to in-hospital cardiac arrests (IHCAs) in pregnancy, OHCAs are more likely to have a cardiac cause (odds ratio 3.81) and lower maternal survival (odds ratio 0.09).

Conclusion

Maternal OHCA affects approximately 1 in 20,000 pregnancies with high maternal mortality rates. OHCA occurs at one-quarter the rate in non-pregnant females of child-bearing age. Approximately two-thirds of maternal OHCAs had an underlying cardiac cause, but low rates of cardiac diagnosis pre-arrest. OHCAs differ markedly from IHCAs in pregnant females, requiring ongoing evaluation as to specific causes and preventability.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): NHMRC, NHF

Obesity in young sudden cardiac death: rates, clinical features, and insights into people with body mass index >50kg/m2

Background

Obesity is common in young sudden cardiac death (SCD) victims but it is unclear whether it is more common than in the general population. This study aimed to contextualize young SCD obesity rates, identifying clinical and pathologic features in WHO class II and III obesity.

Methods

A prospective state-wide out-of-hospital cardiac arrest registry included all SCDs in Victoria, Australia from 2019–2021. Body mass indices (BMIs) of patients 18–50 years were compared to age-referenced general population. Characteristics of SCD patients with WHO Class II obesity (BMI ≥30kg/m2) and non-obesity (BMI <30kg/m2) were compared. Clinical characteristics of people with BMI >50kg/m2 were assessed.

Results

504 patients were included. Obesity was strongly over-represented in young SCD compared to the age-matched general population (55.0% vs 28.7%, p<0.0001). Obese SCD patients more frequently had hypertension, diabetes and obstructive sleep apnoea (p<0.0001, p=0.009 and p=0.001 respectively), ventricular fibrillation as their arrest rhythm (p=0.008) and left ventricular hypertrophy (LVH) (p<0.0001). Obese patients were less likely to have toxicology positive for illicit substances (22.0% vs 32.6%, p=0.008) or significant alcohol history (18.8% vs 26.9%, p=0.030). Patients with BMI >50 kg/m2 represented 8.5% of young SCD. LVH (n=26, 60.5%) was their predominant cause of death and only 10 (9.3%) patients died from coronary disease.

Conclusion

Over half of young Australian SCD patients are obese, with all obesity classes over-represented compared to the general population. Obese patients had more cardiac risk factors. Almost two thirds of patients with BMI>50 kg/m2 died with LVH, with fewer than 10% dying from coronary disease.

Funding Acknowledgement

Type of funding sources: None.

Safe provision of elective endocrine surgery operations amid the COVID-19 crisis

INTRODUCTION

The aim of this study was to determine the impact of the COVID-19 pandemic on the provision of clinical services (perioperative clinical outcomes and productivity) of the department of endocrine and general surgery at a teaching hospital in the UK.

METHODS

A retrospective chart review was conducted of all patients who were operated in our department during two periods: 1 April to 31 October 2019 (pre-COVID-19 period) and 1 April to 31 October 2020 (COVID-19 period). The perioperative clinical outcomes and productivity of our department for the two time periods were compared.

RESULTS

In the pre-COVID-19 period, 130 operations were carried out, whereas in the COVID-19 group, this reduced to 89. The baseline characteristics between the two groups did not significantly differ. Parathyroid operations decreased significantly by 68% between the two study periods. Overall, during the COVID-19 phase, the department maintained 68% of its operating workload compared with the respective 2019 time period. The clinical outcomes for the patients who had a thyroid/parathyroid/adrenal operation were not statistically different for the two study periods. There were no COVID-19 related perioperative complications for any of the operated patients and no patient tested positive for COVID-19 while an inpatient. For the COVID-19 group, the department maintained 67% of its outpatient appointments for endocrine surgery and 26% for general surgery pathologies.

CONCLUSIONS

The COVID-19 pandemic significantly reduced the clinical activity of our department. However, it is possible to continue providing clinical services for urgent/cancer cases with the appropriate safety measures in place.

POS1257 READING THE WAVES: IDENTIFYING DISTINCT PHENOTYPES OF MULTISYSTEM INFLAMMATORY SYNDROME IN CHILDREN IN A SINGLE CANADIAN CENTER DURING THE 2020-2021 COVID-19 PANDEMIC

Background

The COVID-19-associated multisystem inflammatory syndrome in children (MIS-C) is characterized by Kawasaki disease (KD)-like features and circulatory shock [1]. The genesis of SARS-CoV-2 variants triggered successive waves of mass infections followed by MIS-C outbreaks.

Objectives

To compare MIS-C phenotypes across the waves of the COVID-19 pandemic. To identify predictors of pediatric intensive care unit (PICU) admission and treatment with biologic agents.

Methods

Youth aged 0-18 years, fulfilling the WHO case definition of MIS-C, and admitted to the Alberta Children’s Hospital during the COVID-19 pandemic (May 2020-December 2021) were included. Clinical, laboratory, imaging, and treatment data were captured (KD-like manifestations, signs of shock and/or hypotension, peak C-reactive protein (CRP) and ferritin, platelet count nadir, peak NT-proBNP and troponin, liver enzyme abnormalities, sodium and albumin nadir, echocardiogram findings, biologic agents).

Results

57 consecutive MIS-C patients (median age 6 years, IQR 4-6; 72% males) were included. 31 patients (54%) required PICU admission. All received immunoglobulins, 44 (77%) received corticosteroids, 8 patients (14%) were treated with biologic agents. Patients presenting during the third (mainly driven by Alpha variant) or fourth wave (mainly driven by Delta variant) presented with higher ferritin and NT-proBNP levels, and more liver enzyme abnormalities, hypoalbuminemia and thrombocytopenia compared to those presenting during the first or second wave (Table 1, Figure 1). PICU admission was associated with the presence of shock/hypotension, higher CRP, ferritin, and NT-proBNP levels, lower albumin levels, and the presence of ventricular dysfunction on echocardiogram (Table 1). A logistic regression model combining peak NT-proBNP, troponin and ferritin levels explained 70% (Nagelkerke R2) of the variance in PICU admission and correctly classified 91% of the cases. NT-proBNP was the sole significant contributor (p=0.017). Treatment with biologic agents was associated with higher CRP (mean 148.8 mg/l versus 251.7 mg/l; p=0.024) and ferritin (797 μg/l versus 1280 μg/l; p=0.049) levels.

Table 1.

Upper panel: Differences in MIS-C features of patients presenting during the first phase of the COVID-19 pandemic (first + second wave) compared to those presenting during the second phase (third + fourth wave) (*one missing value). Lower panel: Differences regarding MIS-C features between patients admitted to PICU compared to those managed on the general ward.

Phase 1(n = 31)Phase 2(n = 26)P-valuePeak ferritin, μg/l (mean, SD)548 (529)1129 (724)<0.001Liver enzyme abnormalities (n, %)10 (32)18 (69)0.008Peak NT-proBNP, ng/l (mean, SD)5250 (4721)13366 (11211)0.012Hypoalbuminemia (n, %)24 (80)*25 (100)*0.027Thrombocytopenia (n, %)11 (35)18 (69)0.017PICUNo(n = 26)Yes(n = 31)P-valueShock/hypotension (n, %)19 (73)31 (100)0.002Peak CRP, mg/l (mean, SD)140.7 (92)203.8 (84)0.008Peak ferritin, μg/l (mean, SD)612 (676)1183 (627)0.002Peak NT-proBNP, ng/l (mean, SD)3772 (5074)15584 (9662)<0.001Albumin nadir, g/l (mean, SD)24 (4)19 (3)0.014Ventricular dysfunction (n, %)2 (8)18 (58)<0.001Figure 1.

Violin plots depicting differences in key laboratory MIS-C features between the waves (A) and both phases (phase 1 = wave 1 + 2, phase 2 = wave 3 + 4; B) of the COVID-19 pandemic.

Conclusion

A shift in MIS-C phenotype was identified across the successive COVID-19 waves, including the predominance of features associated with macrophage activation syndrome in later stages. These findings may reflect the impact of distinct SARS-CoV-2 variants. NT-proBNP emerged as the most important MIS-C feature predicting PICU admission, underscoring the importance of monitoring.

References

[1]Riphagen S, Gomez X, Gonzalez-Martinez C, et al. Hyperinflammatory shock in children during COVID-19 pandemic. Lancet 2020;395(10237):1607–8

Disclosure of Interests

None declared

Evaluation of a lateral-flow nanoparticle fluorescence assay for TB infection diagnosis

BACKGROUND:

Programmatic management of TB infection is a critical component of the WHO End TB Strategy. Interferon-gamma release assays (IGRAs) overcome some limitations of the tuberculin skin test, but implementation of IGRA testing in low-resource settings is challenging.

METHODS:

In this feasibility study, we evaluated performance of a novel digital lateral-flow assay, the QIAreach® QuantiFERON® TB (QIAreach-QFT) test, against the QuantiFERON®-TB Gold Plus (QFT-Plus) assay. A population with a mix of risk factors for TB infection (111 donors) were sampled over multiple days. A total of 207 individual blood samples were tested according to the manufacturer’s instructions.

RESULTS:

The overall percentage agreement was 95.6% (two-sided 95% CI 91.8–98), with a positive percentage agreement (i.e., sensitivity) of 100% (95% CI 94.7–100) and a negative percentage agreement (i.e., specificity) of 95.6% (95% CI 90.6–98.4). All QFT-Plus positive specimens with TB1-Nil and TB2-Nil values less than 1 IU/ml tested positive on QIAreach-QFT.

CONCLUSIONS:

QIAreach QFT is a deployable, accurate testing solution for decentralised testing. It has the potential to overcome key hurdles for TB infection screening in high-burden settings thus helping to achieve the WHO End TB programme goals.

Substance use behaviours and the UK furlough scheme: evidence from eight longitudinal population surveys

Disruptions to economic activity such as job loss can impact substance use behaviours. During the COVID-19 pandemic many countries implemented a furlough scheme to prevent job loss. We examine how furlough was associated with respondents' substance use behaviours in the initial stages of the pandemic in the UK. Data were from over 27,000 participants in eight adult longitudinal surveys. Participants self-reported economic activity (furlough or job loss vs stable employment) and smoking (any current), vaping (any current) and drinking alcohol (>4 days/week or 5+ drinks per typical occasion) both before and during the initial stages of the pandemic. Changes in frequency/quantity of substance use were also examined. Risk ratios were estimated within each study using modified Poisson regression, adjusting for a range of potential confounders, including pre-pandemic behaviour (though this was excluded in analyses of behaviour change). Findings were synthesised using a random effects meta-analysis. Compared to stable employment, participation in the furlough scheme was associated with smoking (risk ratio: 1.24 [95% CI: 1.08-1.42]; I2=0%) while job loss was associated with vaping (1.72 [1.10-2.71]; I2=25%) and heavier drinking (1.21 [1.02-1.43]; I2=2%), but these associations were largely accounted for by confounders (adjusted risk ratios: smoking: 1.06 [0.96-1.16]; I2=8%; vaping: 1.55 [0.93-2.56]; I2=42%; and drinking: 1.03 [0.89-1.20]; I2=35%). Furlough was associated with drinking more than before the pandemic (adjusted risk ratio: 1.15 [1.00-1.33]; I2=70%), and with increases in vaping behaviour (1.54 [1.14-2.07]; I2=0%). Increased drinking associated with furlough is concerning, while increased vaping likely represents moves to reduce smoking and may be positive.

Diet, physical activity, and sleep in relation to furlough during the COVID-19 pandemic in the UK: evidence from eight longitudinal studies

The recent Covid-19 pandemic, and its mitigations, are expected to have long-term consequences on the health and health behaviours. In an effort to reduce the effect of lockdown on the economy, the UK government launched their Coronavirus Job Retention Scheme (commonly known as furlough) in March 2020, which entitled employees who were unable to work to 80% of their monthly pay up to a cap of £2,500. We investigated the association between changes in economic activity and health behaviours of the working-age participants of eight longitudinal studies, during the early stages of the pandemic. Specifically, we investigate the post-pandemic levels, and the pre-to-post pandemic change, in fruit and vegetable consumption, physical activity, and sleeping patterns. We obtained study-specific estimates using modified Poisson regression, adjusting for a comparable set of potential confounders, and combined results in a random-effects meta-analyses. Compared to those who continually worked, furloughed workers were more likely to report an increase in their fruit and vegetable consumption (1.22 [1.04-1.43]; I2 = 52%), and an increase in their physical activity (1.19 [1.04-1.35]; I2 = 73%). However, furlough appears to have a polarizing effect on sleeping patterns (change from 6 - 9 h to outside this range: 1.46 [1.03, 2.08]; I2 = 75%; change from outside of the 6 -9 h to within this range: 1.78 [1.03, 3.07]; I2 = 75%), especially amongst women and those with no higher education degree. This polarization is partially explained by the age of the survey participants, indicating that sleeping patterns of the younger cohorts were more adversely affected. Furlough schemes may be associated with better diet and more physical activity, while inconsistent effects on sleeping patterns may place younger generations at particular risk of atypical sleep.

Health care disruption inequalities during Covid-19: Evidence from eleven longitudinal studies

Like other health systems worldwide, the UK, the National Health Service (NHS) has faced major disruptions due to high Covid-19 burden and repeated lockdown measures. These disruptions can have both short and long-term health impacts. The NHS provides free healthcare and prioritises equity of delivery, but despite this, inequalities in access to health care remain and it is plausible that pandemic-related disruptions affect different groups disproportionally, thus widening health inequalities. This paper investigates associations between well-established axes of health inequality (sex, age, social class, education and ethnicity) and self-reported health care disruptions (medication access, procedures, or appointments) in over 65,000 participants across eleven longitudinal studies in the UK. Participants reported disruptions from March 2020 through to as late as January 2021. We obtained study-specific estimates using logistic regression models and combined them in a random-effects meta-analysis. Analyses were adjusted for sex, age and ethnicity where relevant. Between 10.1% (Millennium Cohort Study) and 31.8 % (Understanding Society) of study participants reported experiencing health care disruptions. Results show that females (OR: 1.27 [95%CI: 1.15,1.4]; I2=56%), older participants (e.g. OR: 1.39 [1.13,1.72]; I2=77% for 65-75y vs 45-54y), and non-white ethnic minorities (OR: 1.17 [1.02,1.34]; I2=0% vs white) were more likely to report healthcare disruptions. Those in a more disadvantaged social class (e.g. OR: 1.18 [1.08, 1.21]; I2=0% for manual/routine vs managerial/professional) were also more likely to report healthcare disruptions, but no clear differences were observed for education. Our findings highlight inequities in healthcare disruptions, which, if unaddressed, could contribute to the maintenance or widening of existing health inequalities.

"We are not hard to reach, but we may find it hard to trust" …. Involving and engaging 'seldom listened to' community voices in clinical translational health research: a social innovation approach

BACKGROUND

Public involvement in clinical translational research is increasingly recognised as essential for relevant and reliable research. Public involvement must be diverse and inclusive to enable research that has the potential to reach those that stand to benefit from it the most, and thus address issues of health equity. Several recent reports, however, indicate that public involvement is exclusive, including in its interactions with ethnic groups. This paper outlines a novel community-led methodology - a community sandpit - to address the inclusion of ethnic groups in public involvement in research, reports on its evaluation, findings, legacy and impact.

METHODS

Through detailed planning - thinking through and taking into account all stakeholders perspectives in the planning and design of the sandpit, relationship-building, co-design and co-delivery between the Public Programmes team based at Manchester University NHS Foundation Trust and the Greater Manchester Black and Minority Ethnic Network - the community sandpit was held in July 2018.

RESULTS

Fifteen community organisations took part in the two-day event, as well as six researchers, and six creative practitioners. Six community-based partnership projects were seed-funded; four of these received additional funding from other sources also.

CONCLUSIONS

Evaluation of the sandpit showed the format to be well-received by all: it levelled power relationships between community organisations, health researchers and research infrastructure; it developed capacity amongst researchers about the accessibility, role and potential of community organisations. Described as "not another community seed fund" by community partners, the sandpit offered community partners, equitable avenues for collaboration within Greater Manchester translational research and led to the formation of the Black, Asian and Minority Ethnic Research Advisory Group (BRAG Vocal Website information, - https://www.wearevocal.org/opportunities/black-asian-and-minority-ethnic-research-advisory-group-brag/ , 2021). The method has the potential to be replicated elsewhere to support inclusive public involvement in research and inclusive research.

Spontaneous coronary artery dissection: novel pathophysiological insights from histological and ultrastructural tissue analysis

Introduction

Spontaneous coronary artery dissection (SCAD) is a cause of acute coronary syndromes and rarely sudden cardiac death (SCD). SCAD is characterised by medial false lumen haematoma formation and periadventitial inflammatory cell infiltrate. Although SCAD has been linked to connective tissue disorders, its pathophysiology remains poorly understood and the role of inflammation unknown.

Purpose

We sought to establish the definitive histopathological features of SCAD and explore pathophysiological mechanisms through assessment of dermal connective tissue ultrastructure.

Methods

N=36 SCD cases diagnosed as SCAD on autopsy were identified in pathology archives at four international centres. Their demographic and clinical characteristics were compared with n=359 survivors recruited in a SCAD survivors cohort. Haematoxylin & eosin sections were examined under light microscope. Immunohistochemistry (IHC) was employed for quantification of inflammatory cell infiltrate (CD68, CD3) and vasa vasorum density (CD31) of SCAD cases (n=20) compared to age- and sex-matched controls (n=10). Dermal extracellular matrix components (EMC) of n=32 SCAD survivors and n=16 healthy volunteers (HV) were compared using electron microscopy (EM).

Results

The autopsy series cases were more likely to be male (p=0.0256) and had higher incidence of left main stem (p=0.0475) and proximal left anterior descending (p&lt;0.001) disease compared to SCAD survivors. N=24 (66%) of SCAD autopsy case showed no evidence of myocardial necrosis. N=17 (47%) showed mild-moderate atherosclerotic changes but no features of fibromuscular dysplasia. There were no differences in vasa vasorum density between SCAD and control cases (A). The degree of inflammatory cell infiltrate varied greatly but significantly higher than controls (B), comprising CD68+ macrophages, eosinophils and CD3+ positive T-cells. There was a statistically significant association (p=0.006) between the degree of inflammatory cell infiltrate and the length of time from onset of symptoms to death (Panel C), as well as significantly (p&lt;0.001) denser inflammatory cell infiltrate adjacent to the dissection plane (D, exemplary sections E&F). EM revealed no differences between SCAD and HV in dermal fibroblast size & activity or elastin size & damage indicators, but possible changes in subgroups with more extreme clinical phenotype or pregnancy-related SCAD (G).

Conclusions

To our knowledge this is the largest SCAD pathology case series so far. We show for the first time that periadvential inflammation in SCAD appears to be time-dependent and localising to the dissected coronary segment, suggesting healing response to injury rather than causal contribution. We found no evidence to suggest increased vasa vasorum density is pathophysiologically important. Connective tissue changes were only linked to a small proportion of cases. These novel findings may have important implications for the management of SCAD patients.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): British Heart Foundation, Leicester NIHR Biomedical Research Centre

Economic impact of sudden cardiac arrest

Background

Each year, there are approximately 5,000 out-of-hospital cardiac arrests (OHCAs) in the state of Victoria, Australia (population 6.4 million, state healthcare budget AUD$2.9 billion / €1.8billion). Mortality from OHCA approaches ninety percent. High mortality rates and survivors not returning to work is likely to have an adverse effect on the Victorian economy but this has not been previously investigated.

Purpose

To model the economic impact of OHCA mortality and survivors not returning to work.

Methods

Data on all OHCAs transported by Ambulance Victoria from July 2017- June 2018 in Victoria, Australia was collected, including age, gender, survival to hospital, survival to discharge, and survival to 12 months. Cases were excluded if arrest was precipitated by trauma, exsanguination, overdose, terminal illness, hanging, SIDS, electrocution, sepsis, respiratory causes, drowning, or neurological causes. Pre-arrest employment status of patients was modelled using the Australian Bureau of Statistics Economic Security dataset, which provides contemporary employment rates for gender-matched five-year cohorts for Australians aged 15–79 years. For survivors to 12 months, pre-arrest and post-arrest work status were confirmed. Economic impact was then calculated to a five year horizon utilizing a Markov model with probabilistic sensitivity analysis.

Results

4,934 arrests meeting the inclusion criteria were transported by Ambulance Victoria in twelve months, of whom 4,639 were determined to be cardiac arrests without any exclusion criteria as a precipitant. 695 patients survived to hospital (15.0%), and 325 to discharge (7.0%). At 12 months, 303 patients were alive (6.5% of overall cases, 93.2% of those discharged from hospital). Economic modelling of age and gender-matched data indicated that 1516 patients (35%) would have been employed pre-cardiac arrest, but only 216 survivors (4.7%) would be employed at five years post-arrest. Using Markov modelling incorporating estimated earnings and the pre-determined value of a statistical life, the annual economic burden of cardiac arrest approximated AUD$4 billion (€2.5 billion) at a five-year horizon.

Conclusion

The annual economic impact of cardiac arrest in Victoria, Australia is approximately AUD$4 billion (€2.5 billion) in a five-year horizon. As the annual Victorian state budget for all healthcare is AUD$2.93 billion (€1.8 billion), our data suggests that the economic impact of cardiac arrest is under-appreciated. Therefore, research in this area and providing state-of-the-art care for all cardiac arrest patients should be a healthcare priority.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): NHMRC/NHF Postgraduate Scholarship, RACP JJ Billings Scholarship

Impact of involving people with dementia and their care partners in research: a qualitative study

OBJECTIVES

We aimed to evaluate the impact of patient and public involvement (PPI) at each stage of the research cycle in a dementia research programme.

DESIGN

We used monitoring forms to record the impact of the research programme's PPI at different stages of research and qualitative interviews with all participants to evaluate the impact of PPI.

SETTING

We evaluated Research User Groups (RUGs-older people with dementia and care partners) which were established to provide PPI support for the research programme in multiple European sites.

PARTICIPANTS

We purposively sampled RUG members (n=34) and researchers (n=13) who had participated in PPI activities. Inclusion criteria for the study were: (a) RUG members who had participated in the research awareness training and in PPI activities and had the capacity to consent; (b) researchers who involved RUGs in their work.

RESULTS

Impact on the research: changes to the study conduct were made as a result of the feedback from RUGs. These included prioritisation of clinical recommendations, the wording of study information and recruitment materials, the content and layout of the user interface for a computerised memory test, interpretation of intervention results and advice on dissemination avenues. Impact on RUG members: they reported that involvement had given them a sense of purpose and satisfaction. Their perception of health research changed from being an exclusive activity to one, which lay people, could have meaningful involvement. Impact on researchers: PPI was a new way of working and interacting with PPI members had given them insight into the impact of their work on people living with dementia.

CONCLUSIONS

PPI can have a substantial impact on dementia research and the people involved in the research. To justify the time and expense of PPI, the advantageous practical impacts of PPI should be systematically recorded and consistently reported.

Evaluation of a research awareness training programme to support research involvement of older people with dementia and their care partners

BACKGROUND

Best-practice guidelines recommend that appropriate support be provided to public contributors to facilitate their involvement in research. One form of support is research awareness training. Older people with dementia and care partners were involved in four Research User Groups (RUGs) in the UK, France, Cyprus and Greece. We delivered research awareness training (RAT) to the RUGs. The aim of this study was to evaluate the acceptability and perceived outcomes of the training from the perspective of RUG members.

METHODS

At the end of each research training session, participants completed the Training Acceptability Rating Scale-section 2, which records the respondent's impressions of the training process and the outcomes of training. Participants were also invited to take part in semi-structured interviews at the end of the programme.

RESULTS

Thirty-four RUG members completed the TARS-section 2 with 23 completing semi-structured interviews. Over two-thirds (67%) of participants rated their overall satisfaction with the RAT 'a great deal'. Qualitative responses indicated that participants found group work to be beneficial for learning, the structure of training activities and topics covered appropriate. The type and format of the training materials were viewed as helpful, and they valued the new knowledge gained.

CONCLUSIONS

The training contents were applicable, useful and relevant to the participants' role within the research. We highlight the importance of facilitating participation by (a) fostering awareness of relevant research issues and (b) tailoring delivery of training according to the needs of the participants.

Machine learning to predict early recurrence after oesophageal cancer surgery

BACKGROUND

Early cancer recurrence after oesophagectomy is a common problem, with an incidence of 20-30 per cent despite the widespread use of neoadjuvant treatment. Quantification of this risk is difficult and existing models perform poorly. This study aimed to develop a predictive model for early recurrence after surgery for oesophageal adenocarcinoma using a large multinational cohort and machine learning approaches.

METHODS

Consecutive patients who underwent oesophagectomy for adenocarcinoma and had neoadjuvant treatment in one Dutch and six UK oesophagogastric units were analysed. Using clinical characteristics and postoperative histopathology, models were generated using elastic net regression (ELR) and the machine learning methods random forest (RF) and extreme gradient boosting (XGB). Finally, a combined (ensemble) model of these was generated. The relative importance of factors to outcome was calculated as a percentage contribution to the model.

RESULTS

A total of 812 patients were included. The recurrence rate at less than 1 year was 29·1 per cent. All of the models demonstrated good discrimination. Internally validated areas under the receiver operating characteristic (ROC) curve (AUCs) were similar, with the ensemble model performing best (AUC 0·791 for ELR, 0·801 for RF, 0·804 for XGB, 0·805 for ensemble). Performance was similar when internal-external validation was used (validation across sites, AUC 0·804 for ensemble). In the final model, the most important variables were number of positive lymph nodes (25·7 per cent) and lymphovascular invasion (16·9 per cent).

CONCLUSION

The model derived using machine learning approaches and an international data set provided excellent performance in quantifying the risk of early recurrence after surgery, and will be useful in prognostication for clinicians and patients.

Locus of Control and Adaptive Behavior in Visually Impaired Children

Locus of control for academic achievement and correlating competencies in adaptive behavior were measured in a group of residential school children of normal intelligence and singularly impaired. There were both low vision and totally blind students in the sample. The Intellectual Achievement Responsibility Questionnaire (IAR) and the new Vineland Adaptive Behavior Scales (VABS) were administered. For the total group, responsibility for positive intellectual achievement events correlated significantly with increase in Adaptive Behavior scores. Discussion highlights the importance of facilitating development of skills of independence to enhance self-responsibility for academic and other life events in visually impaired children.

Patient and public involvement in dementia research in the European Union: a scoping review

Background

Internationally, there is a drive to involve patients and the public in health research, due to recognition that patient and public involvement (PPI) may increase the impact and relevance of health research. This scoping review describes the extent and nature of PPI in dementia research in the European Union (EU) and summarises: (i) how PPI is carried out; and (ii) the impact of PPI on people living with dementia and the public, researchers, and the research process.

Methods

Relevant studies were identified by searches in electronic reference databases and then filtered by two reviewers independently. Eligibility criteria for included studies were: (i) people living with dementia and/or care partners; (ii) PPI activity in dementia research conducted in the European Union (EU); and (iii) published between 2000 and 2018. An adapted version of the Guidance for Reporting Involvement of Patients and the Public (GRIPP2 SF) was used to collate the data. There was no language restriction other than the abstract needed to be available in English.

Results

We found 19 studies from the UK and one from the Netherlands meeting inclusion criteria. No studies from other EU countries met inclusion criteria. Studies reported various methods of PPI including workshops, drop-in sessions, meetings, consensus conference, reader consultation and participatory approach. The reported aims of PPI included identifying and prioritising research questions (n = 4), research design (n = 5), undertaking and managing research (n = 8), and data analysis and interpretation (n = 3). All PPI related to design and implementation of non-pharmacological studies. One study described two pharmacological studies as case studies incorporating PPI. Seventeen studies reported anecdotal impacts of PPI.

Conclusions

Further development of PPI in dementia research in the EU and in pharmacological dementia research is required. Given the wide range of objectives of PPI in dementia research, PPI methods should be flexible and appropriate for the research context. Researchers should also formally evaluate and report the impacts of PPI for researchers, patients and the general public using good quality research designs to foster development of the field and enable the benefits and challenges of PPI to be better understood.

Trial registration

PROSPERO 2017: CRD42017053260.

Electronic supplementary material

The online version of this article (10.1186/s12877-019-1217-9) contains supplementary material, which is available to authorized users.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

Innovating public engagement and patient involvement through strategic collaboration and practice

BACKGROUND

Patient and public involvement and engagement is an important and expected component of health-related research activity in the UK. Specifically within the health research sphere, public engagement (usually defined as raising awareness of research) and patient involvement (usually defined as actively involving people in research) have traditionally been seen as separate but have much to gain from working together towards a common goal of better health outcomes for all.

METHODS

This paper describes a unique approach taken by the Public Programmes Team: a small interdisciplinary team of public engagement specialists, with backgrounds in science, community development, public engagement and involvement, policy, ethics, communications, industry, museums and creative practice, embedded within translational research infrastructure and delivery in Manchester in the North West of England. We propose a new model of professional practice - a 'cycle' of engagement and involvement - innovating across the complementary fields of public engagement and patient involvement, and working inclusively and in partnership with people in health research. Further, our approach capitalises on strategic collaboration offering economies of scale and a joined up way of working. Our ambition is to boldly experiment, learn and reflect, responsibly and based on evidence and partnerships, using methods of engagement that address issues of social justice.

RESULTS

Here, we report on preliminary case studies exemplifying the impact of our approach, and data relating to achievements and learning between April 2017 and March 2018. Informed by our findings, we propose that our approach has the potential to be replicated elsewhere.

CONCLUSIONS

Our practice and the beginning of its evaluation lead us to believe that our way of working and model of professional practice - the 'cycle' of engagement and involvement - is effective in: addressing our vision of making health research relevant and inclusive for everyone; and embedding and joining up public involvement in a busy and fertile translational health research ecosystem.

A protocol to evaluate the impact of involvement of older people with dementia and age-related hearing and/or vision impairment in a multi-site European research study

PLAIN ENGLISH SUMMARY

Involving older people with dementia in research is increasingly recognised as important to ensure that research is relevant and beneficial for older people with dementia. But researchers need to know how best to involve older people with dementia and to be able to show the benefits of involving older people with dementia in dementia research.This paper describes a research plan to explore the involvement of older people with dementia and age-related hearing and/or vision impairment in a European research project investigating the combined impact of dementia with hearing and/or vision impairment. We set up four Research User Groups (RUGs) of older people with dementia with age-related hearing and/or vision impairment and their carers based in the UK, France, Cyprus and Greece to advise our researchers. We provided training to group members to support their input to the research.We will use a questionnaire and interview people in our RUGs to understand what they thought of the training and their experiences of being part of the RUG. We will also interview researchers to understand if they thought the advice from the groups was useful.This study will help us to understand how to effectively involve older people with dementia and age-related hearing and/or vision impairment in research and what the benefits of involving older people with dementia in research are.

ABSTRACT

Background Research to prevent and treat dementia is an international priority. Involvement of older people with dementia in the research is important to ensure the relevance and utility of the research outcomes in clinical practice to them. Efforts to involve such people in research are growing due to increased recognition of the usefulness of incorporating the views of older people with dementia into the research process. Research User Groups (RUGs) of older people with dementia and carers for people with dementia were set up in UK (Manchester), France (Nice), Cyprus (Nicosia) and Greece (Athens) to advise on the research. We report a protocol for a study which aims to evaluate i) the perceptions of RUG members of the usefulness of Research Awareness Training that was provided to support their involvement in the research and ii) perceived impacts of the involvement of older people with dementia and age-related hearing and/or vision impairment on research from the point of view of RUG members and researchers. Methods Both qualitative and quantitative methods will be used to evaluate the acceptability, appropriateness and satisfaction with Research Awareness Training and the perceived impact of involvement of RUGs on research. Focus groups interviews with RUG members and one to one interviews with both RUG members (n = 24) and researchers (n = 6) will be conducted to understand the perceived impacts of patient and public involvement on research from the point of view of older people with dementia, carers and researchers. Any comparative differences in cultural, attitudinal and environmental differences between RUGs in outcomes of training and impact across the four European sites will be reported. Discussion This study is unique in its exploration of the impact of the involvement of older people with dementia and age-related hearing and/or vision impairment in a large multi-site European dementia research study. This work will be crucial in informing understanding of how to effectively involve older people with dementia and age-related hearing and/or vision impairment and carers in dementia research to ensure research addresses the needs and priorities of older people with dementia and age-related hearing and/or vision impairment.

Arthroscopic subtalar arthrodesis through the sinus tarsi portal approach: A series of 77 cases

BACKGROUND

Subtalar arthrodesis through an open approach carries significant risk of complications. An arthroscopic approach aims to minimise damage to the soft tissue envelope to improve recovery, union and complication rates. A two portal approach through the sinus tarsi was used.

METHODS

A retrospective review of all patients undergoing isolated arthroscopic arthrodesis was performed.

RESULTS

Seventy-seven procedures were performed. Successful arthrodesis was achieved in 75 (97.4%). Two patients underwent successful revision arthrodesis for aseptic nonunion. There was one (1.3%) superficial infection and one (1.3%) partial sural nerve injury.

CONCLUSIONS

Two-portal sinus tarsi arthroscopic subtalar arthrodesis is safe and effective. Advantages over other arthroscopic approaches are the access to all three facets of the joint, avoidance of a posterolateral portal in order to minimise risk to the sural nerve, and the ability to use the same approach to arthrodese the entire triple hindfoot joint complex. Technical tips and pitfalls are discussed.

What do young people with rheumatic conditions in the UK think about research involvement? A qualitative study

BACKGROUND

Involving people of all ages in health research is now widely advocated. To date, no studies have explored whether and how young people with chronic rheumatic conditions want to be involved in influencing health research. This study aimed to explore amongst young people with rheumatic conditions, 1) their experiences of research participation and involvement 2) their beliefs about research involvement and 3) beliefs about how young people's involvement should be organized in the future.

METHODS

Focus groups discussions with young people aged 11-24 years with rheumatic conditions across the UK. Data was analysed using a qualitative Framework approach.

RESULTS

Thirteen focus groups were held involving 63 participants (45 F: 18 M, mean age 16, range 10 to 24 years) across the UK. All believed that young people had a right to be involved in influencing research and to be consulted by researchers. However, experience of research involvement varied greatly. For many, the current project was the first time they had been involved. Amongst those with experience of research involvement, awareness of what they had been involved in and why was often low. Those who had previously participated in research appeared more positive and confident about influencing research in the future. However, all felt that there were limited opportunities for them to be both research participants and to get involved in research as public contributors.

CONCLUSIONS

These findings suggest that there is an on-going need to both increase awareness of research involvement and participation of young people in rheumatology as well as amongst young people themselves.

Research protocol for a complex intervention to support hearing and vision function to improve the lives of people with dementia

BACKGROUND

Hearing and vision impairments are among the most common and disabling comorbidities in people living with dementia. Intervening to improve sensory function could be a means by which the lives of people living with dementia may be improved. However, very few studies have tried to ameliorate outcomes in dementia by improving sensory function. This paper describes the multi-step development of a new intervention designed to support hearing and vision function in people living with dementia in their own homes. At the end of the development programme, it is anticipated that a 'sensory support' package will be ready for testing in a full scale randomised controlled trial.

METHODS

This programme is based on the process of 'intervention mapping' and comprises four integrated steps, designed to address the following: (1) scoping the gaps in understanding, awareness and service provision for the hearing and/or vision impairment care needs of people with dementia using a systematic literature review and Expert Reference Group; (2) investigating the support care needs through a literature search, stakeholder surveys, focus groups, semi-structured interviews and an Expert Reference Group, leading to a prototype sensory support package; (3) refining the prototype by additional input from stakeholders using focus groups and semi-structured interviews; and (4) field testing the draft intervention using an open-labelled, non-randomised feasibility study, integrating feedback from people with dementia and their significant others to develop the final intervention ready for full scale definitive trialling. Input from the 'patient and public voice' is a cornerstone of the work and will interlink with each step of the development process. The programme will take place in study centres in Manchester, Nicosia and Bordeaux.

DISCUSSION

Quantitative and qualitative data analyses will be employed, dependent upon the sub-studies in question. Data from the steps will be integrated with consideration given to weighting of evidence for each step of the programme. This programme represents the logical development of a complex intervention to fulfil an unmet need. It is based on a theoretical framework and will lead to a subsequent full scale efficacy trial. The challenges in integrating the data and addressing the contextual issues across study sites will be scrutinised.

What do young people with rheumatic disease believe to be important to research about their condition? A UK-wide study

BACKGROUND

The involvement of people of all ages including young people in research is now widely advocated but prioritisation of research topics is still driven largely by professional agendas. Evidence from adult literature has reported a mismatch between a researcher and patient generated list of research topics. There have been no studies to date exploring the priorities of young people with long term conditions other than in SLE. The study aimed to explore the research priorities of young people across the UK with respect to rheumatic conditions.

METHODS

Focus groups were undertaken with young people aged 11-24 years with rheumatic conditions recruited across the UK via members of the Barbara Ansell National Network for Adolescent Rheumatology BANNAR and relevant national charities. Data was analysed using a Framework approach. Participants discussed their beliefs about what should be researched in: Basic Science; Clinical Medicine; Health Services, Psychosocial, and Public Health. They were then invited to prioritize these areas in terms of how much funding they should receive.

RESULTS

Thirteen focus groups were held involving 63 participants (18 males: 45 females, mean age 16 years, range 10 to 24) in all four nations of the UK. Young people's research priorities were influenced by whether they felt research would achieve benefits for all or just some patients and long or short term goals. Another influence was whether participants felt that research areas were already well funded. Across all groups, Basic Science was a key priority and participants felt that psychosocial research should be prioritized more. Health Services Research was a lower priority, as the majority of participants were happy with their care. Clinical medicine was not a high priority as young people were happy with their medication or uncomfortable with trying new ones. Finally, for nearly all groups, Public Health was a low priority. Differences were also observed between the two age groups and across the geographically diverse focus groups.

CONCLUSION

Understanding young people's research priorities is important to develop research that is in tune with their needs. The results highlight the importance of considering the whole age range of adolescence and young adulthood as well as geographical diversity. The findings from this work will inform the future research of the Barbara Ansell National Network for Adolescent Rheumatology BANNAR in the UK.