A controlled evaluation of social prescribing on loneliness for adults in Queensland: 8-week outcomes

Introduction

There have been few controlled evaluations of Social Prescribing (SP), in which link workers support lonely individuals to engage with community-based social activities. This study reports early outcomes of a trial comparing General Practitioner treatment-as-usual (TAU) with TAU combined with Social Prescribing (SP) in adults experiencing loneliness in Queensland.

Methods

Participants were 114 individuals who were non-randomly assigned to one of two conditions (SP, n = 63; TAU, n = 51) and assessed at baseline and 8 weeks, on primary outcomes (loneliness, well-being, health service use in past 2 months) and secondary outcomes (social anxiety, psychological distress, social trust).

Results

Retention was high (79.4%) in the SP condition. Time × condition interaction effects were found for loneliness and social trust, with improvement observed only in SP participants over the 8-week period. SP participants reported significant improvement on all other outcomes with small-to-moderate effect sizes (ULS-8 loneliness, wellbeing, psychological distress, social anxiety). However, interaction effects did not reach significance.

Discussion

Social prescribing effects were small to moderate at the 8-week follow up. Group-based activities are available in communities across Australia, however, further research using well-matched control samples and longer-term follow ups are required to provide robust evidence to support a wider roll out.

Comparative assessment of radiation therapy-induced vasculitis using [18F]FDG-PET/CT in patients with non-small cell lung cancer treated with proton versus photon radiotherapy

PURPOSE

To assess radiation therapy (RT)-induced vasculitis in patients with non-small cell lung cancer (NSCLC) by examining changes in the uptake of 18F-fluoro-D-deoxyglucose ([18F]FDG) by positron emission tomography/computed tomography (PET/CT) images of the ascending aorta (AA), descending aorta (DA), and aortic arch (AoA) before and after proton and photon RT.

METHOD

Thirty-five consecutive locally advanced NSCLC patients were definitively treated with proton (n = 27) or photon (n = 8) RT and concurrent chemotherapy. The patients were prospectively enrolled to undergo [18F]FDG-PET/CT imaging before and 3 months after RT. An adaptive contrast-oriented thresholding algorithm was applied to generate mean standardized uptake values (SUVmean) for regions of interest (ROIs) 3 mm outside and 3 mm inside the outer perimeter of the AA, DA, and AoA. These ROIs were employed to exclusively select the aortic wall and remove the influence of blood pool activity. SUVmeans before and after RT were compared using two-tailed paired t-tests.

RESULTS

RT treatments were associated with increased SUVmeans in the AA, DA, and AoA-1.9%, 0.3%, and 1.3% for proton and 15.8%, 9.5%, and 15.5% for photon, respectively. There was a statistically significant difference in the ∆SUVmean (post-RT SUVmean - pre-RT SUVmean) in patients treated with photon RT when compared to ∆SUVmean in patients treated with proton RT in the AA (p = 0.043) and AoA (p = 0.015). There was an average increase in SUVmean that was related to dose for photon patients (across structures), but that was not seen for proton patients, although the increase was not statistically significant.

CONCLUSION

Our results suggest that patients treated with photon RT for NSCLC may exhibit significantly more RT-induced inflammation (measured as ∆SUVmean) in the AA and AoA when compared to patients who received proton RT. Knowledge gained from further analyses in larger cohorts could aid in treatment planning and help prevent the significant morbidity and mortality associated with RT-induced vascular complications.

TRIAL REGISTRATION

NCT02135679.

Achievement of Target Gain Larger than Unity in an Inertial Fusion Experiment

On December 5, 2022, an indirect drive fusion implosion on the National Ignition Facility (NIF) achieved a target gain G_{target} of 1.5. This is the first laboratory demonstration of exceeding "scientific breakeven" (or G_{target}>1) where 2.05 MJ of 351 nm laser light produced 3.1 MJ of total fusion yield, a result which significantly exceeds the Lawson criterion for fusion ignition as reported in a previous NIF implosion [H. Abu-Shawareb et al. (Indirect Drive ICF Collaboration), Phys. Rev. Lett. 129, 075001 (2022)PRLTAO0031-900710.1103/PhysRevLett.129.075001]. This achievement is the culmination of more than five decades of research and gives proof that laboratory fusion, based on fundamental physics principles, is possible. This Letter reports on the target, laser, design, and experimental advancements that led to this result.

Long term outcomes in children with trichohepatoenteric syndrome

Trichohepatoenteric syndrome (THES) is a rare autosomal recessive disorder caused by mutations in either TTC37 or SKIV2L, usually leading to congenital diarrhea as part of a multisystem disease. Here, we report on the natural history of the disease for the largest UK cohort of patients with THES from 1996 to 2020. We systematically reviewed the clinical records and pathological specimens of patients diagnosed with THES managed in a single tertiary pediatric gastroenterology unit. Between 1996 and 2020, 13 patients (7 female and 6 male) were diagnosed with THES either by mutation analysis or by clinical phenotype. Two patients died from complications of infection. All patients received parenteral nutrition (PN) of which six patients were weaned off PN. All patients had gastrointestinal tract inflammation on endoscopy. Almost half of the cohort were diagnosed with monogenic inflammatory bowel disease (IBD) by the age of 11 years, confirmed by endoscopic and histological findings. Protracted diarrhea causing intestinal failure improves with time in all patients with THES, but monogenic IBD develops in later childhood that is refractory to conventional IBD treatments. Respiratory issues contribute to significant morbidity and mortality, and good respiratory care is crucial to prevent comorbidity.

Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Measurement of Electron-Neutrino Charged-Current Cross Sections on ^{127}I with the COHERENT NaIνE Detector

Using an 185-kg NaI[Tl] array, COHERENT has measured the inclusive electron-neutrino charged-current cross section on ^{127}I with pion decay-at-rest neutrinos produced by the Spallation Neutron Source at Oak Ridge National Laboratory. Iodine is one the heaviest targets for which low-energy (≤50  MeV) inelastic neutrino-nucleus processes have been measured, and this is the first measurement of its inclusive cross section. After a five-year detector exposure, COHERENT reports a flux-averaged cross section for electron neutrinos of 9.2_{-1.8}^{+2.1}×10^{-40}  cm^{2}. This corresponds to a value that is ∼41% lower than predicted using the MARLEY event generator with a measured Gamow-Teller strength distribution. In addition, the observed visible spectrum from charged-current scattering on ^{127}I has been measured between 10 and 55 MeV, and the exclusive zero-neutron and one-or-more-neutron emission cross sections are measured to be 5.2_{-3.1}^{+3.4}×10^{-40} and 2.2_{-0.5}^{+0.4}×10^{-40}  cm^{2}, respectively.

Identification of candidate novel production variants on the Bos taurus chromosome X

Chromosome X is often excluded from bovine genetic studies due to complications caused by the sex specific nature of the chromosome. As chromosome X is the second largest cattle chromosome and makes up approximately 6% of the female genome, finding ways to include chromosome X in dairy genetic studies is important. Using female animals and treating chromosome X as an autosome, we performed X chromosome inclusive genome-wide association studies in the selective breeding environment of the New Zealand dairy industry, aiming to identify chromosome X variants associated with milk production traits. We report on the findings of these genome-wide association studies and their potential effect within the dairy industry. We identify missense mutations in the MOSPD1 and CCDC160 genes that are associated with decreased milk volume and protein production and increased fat production. Both of these mutations are exonic SNP that are more prevalent in the Jersey breed than in Holstein-Friesians. Of the 2 candidates proposed it is likely that only one is causal, though we have not been able to identify which is more likely.

A Technology-Informed Approach to Clinical Trial Equity

PURPOSE/OBJECTIVE(S)

Despite efforts to increase participation of diverse communities in clinical trials, ethnic/racial minorities remain underrepresented. One such determinant may be lack of access to a comprehensive cancer center that conducts clinical research. Historically, our institution has had low accrual from rural regions further away from our cancer center, with Hispanic or Latino (HL) patients (pts) being especially underrepresented in our clinical research. In this study, we explored the impact of a clinical trial that allowed pts to receive chemotherapy (chemo) with their local oncologist. We hypothesize that allowing pts to receive chemo locally will lead to higher rates of enrollment from populations under-represented in clinical trials.

MATERIALS/METHODS

We conducted a study for pts with rectal cancer to undergo short-course radiation followed by 4 months of chemo with the option to pursue watch and wait if pts achieve a clinical complete response. Radiation was administered at our institution while pts could receive standard-of-care chemo closer to home with their local oncologist. For pts who received chemo locally, the research coordinator and co-investigators held video visits with the pts prior to each chemo infusion to review adverse events (AE), labs, and chemo dosing. We compared demographic data of pts on this trial with that of pts enrolled across all adult therapeutic oncologic clinical trials over the same time period at our institution. Distance to our institution was calculated based on pts' primary residence zip code. Protocol compliance with AE reporting for pts who received chemo locally was assessed by chart review.

RESULTS

Between May 2020 and January 2023, 24/35 enrolled pts completed both radiation and chemo on trial. 13/24 pts (54%) received chemo locally. Of the 24 pts, 16 were White (67%), 7 Asian (29%), 1 Native Hawaiian/ Pacific Islander (4%). Of all enrolled patients, 4 were HL (16.7%), compared to our institutional average of 16.5%. All enrolled HL pts received their chemo locally. The average distance traveled by non-HL pts from their home to our institution was 87.7 miles (range 5.1 - 308). In contrast, HL pts traveled an average of 147.8 miles (range 110 - 249), 68% further than their non-HL counterparts. There was 100% compliance with AE reporting among those pts who received their chemo locally.

CONCLUSION

Although the percentage of HL participation in our study was consistent with our institutional average, all HL pts enrolled on the trial received treatment locally and lived substantially further from our institution than non-HL. By allowing pts to receive this part of treatment locally, we provided pts who live further away an opportunity to engage in clinical research without the associated financial and time toxicities related with traveling for treatment. By decentralizing clinical trials and leveraging telemedicine, we can promote the participation of under-represented groups in clinical trials.

First Probe of Sub-GeV Dark Matter beyond the Cosmological Expectation with the COHERENT CsI Detector at the SNS

The COHERENT Collaboration searched for scalar dark matter particles produced at the Spallation Neutron Source with masses between 1 and 220  MeV/c^{2} using a CsI[Na] scintillation detector sensitive to nuclear recoils above 9  keV_{nr}. No evidence for dark matter is found and we thus place limits on allowed parameter space. With this low-threshold detector, we are sensitive to coherent elastic scattering between dark matter and nuclei. The cross section for this process is orders of magnitude higher than for other processes historically used for accelerator-based direct-detection searches so that our small, 14.6 kg detector significantly improves on past constraints. At peak sensitivity, we reject the flux consistent with the cosmologically observed dark-matter concentration for all coupling constants α_{D}<0.64, assuming a scalar dark-matter particle. We also calculate the sensitivity of future COHERENT detectors to dark-matter signals which will ambitiously test multiple dark-matter spin scenarios.

Measurement of the Coherent Elastic Neutrino-Nucleus Scattering Cross Section on CsI by COHERENT

We measured the cross section of coherent elastic neutrino-nucleus scattering (CEvNS) using a CsI[Na] scintillating crystal in a high flux of neutrinos produced at the Spallation Neutron Source at Oak Ridge National Laboratory. New data collected before detector decommissioning have more than doubled the dataset since the first observation of CEvNS, achieved with this detector. Systematic uncertainties have also been reduced with an updated quenching model, allowing for improved precision. With these analysis improvements, the COHERENT Collaboration determined the cross section to be (165_{-25}^{+30})×10^{-40}  cm^{2}, consistent with the standard model, giving the most precise measurement of CEvNS yet. The timing structure of the neutrino beam has been exploited to compare the CEvNS cross section from scattering of different neutrino flavors. This result places leading constraints on neutrino nonstandard interactions while testing lepton flavor universality and measures the weak mixing angle as sin^{2}θ_{W}=0.220_{-0.026}^{+0.028} at Q^{2}≈(50  MeV)^{2}.

Computed tomography-derived fractional flow reserve (FFRCT) has no additional clinical impact over the anatomical Coronary Artery Disease - Reporting and Data System (CAD-RADS) in real-world elective healthcare of coronary artery disease

AIM

To evaluate the impact of computed tomography-derived fractional flow reserve (FFR_CT) compared to the anatomical Coronary Artery Disease - Reporting and Data System (CAD-RADS) in the elective assessment of coronary artery disease in real-world cardiology practise.

MATERIALS AND METHODS

A retrospective review was undertaken of 1,239 coronary CT examinations from August 2018 to December 2019 with a minimum follow-up period of 1 year. Coronary disease was classified according to the CAD-RADS system. A non-occlusive ≥30% maximum diameter stenosis was considered eligible for FFR_CT. Lesion-specific FFR_CT and FFR were considered positive if ≤ 0.80. The patients were followed up using the hospital radiology information system and the electronic patient record. A positive outcome was defined by a subsequent invasive angiogram (ICA) showing disease requiring revascularisation or FFR ≤0.80 or a positive stress test or medical therapy for angina in CAD-RADS 4.

RESULTS

Of the 1,145 analysable studies (mean follow up 618 ± 153 days) the incidence of a positive result was 7% with a 5.4% elective revascularisation rate. Two hundred and forty-five patients (CAD-RADS 2-4) had FFR_CT. FFR_CT reduced the accuracy of the CAD-RADS grade from 91% to 78.4% (p<0.001). In CAD-RADS 2, the accuracy is reduced from 99% to 90.7% (p=0.005), and in CAD-RADS 3 from 93.9% to 67.7% (p<0.001). In CAD-RADS 4, FFR_CT increases accuracy from 69.4% to 75.5% (p=0.025), but 89.8% of FFR_CT are positive and specificity is low (26.7%).

CONCLUSION

In the present "real-world" practise, FFR_CT does not improve standard radiological assessment of coronary disease graded by the CAD-RADS alone.

Lawson Criterion for Ignition Exceeded in an Inertial Fusion Experiment

For more than half a century, researchers around the world have been engaged in attempts to achieve fusion ignition as a proof of principle of various fusion concepts. Following the Lawson criterion, an ignited plasma is one where the fusion heating power is high enough to overcome all the physical processes that cool the fusion plasma, creating a positive thermodynamic feedback loop with rapidly increasing temperature. In inertially confined fusion, ignition is a state where the fusion plasma can begin "burn propagation" into surrounding cold fuel, enabling the possibility of high energy gain. While "scientific breakeven" (i.e., unity target gain) has not yet been achieved (here target gain is 0.72, 1.37 MJ of fusion for 1.92 MJ of laser energy), this Letter reports the first controlled fusion experiment, using laser indirect drive, on the National Ignition Facility to produce capsule gain (here 5.8) and reach ignition by nine different formulations of the Lawson criterion.

Parent-infant interaction quality is related to preterm status and sensory processing

BACKGROUND

Parent-infant interactions provide the foundation for the development of infant socioemotional wellbeing. Preterm birth can have a substantial, and often detrimental, impact on the quality of early parent-infant interactions. Sensory processing difficulties, common in preterm infants, are further associated with poorer interaction quality. There is a paucity of research, however, examining the links between the quality of parent-infant interaction, preterm birth, and sensory processing difficulties. This study aimed to characterise the quality of interactions of parent-infant dyads involving preterm infants who may display sensory processing differences and examine the associations between parent-infant interaction quality, preterm status and infant sensory processing.

METHOD

67 parent-infant dyads (12-months infant age, 22 preterm, 45 full-term) participated in a recorded, semi-structured 15-minute play interaction. Parents also filled out questionnaires on demographics, and infant sensory processing (Infant and Toddler Sensory Profile-2; ITSP-2). Interaction quality was rated using the Parenting Interactions with Children: Checklist of Observations Linked to Outcomes (PICCOLO).

RESULTS

Preterm and full-term infants differed in sensory processing and parent-infant interaction. Infant prematurity was associated with the sensory domains of; visual (r = - 0.37, p = .005), touch (r = - 0.39, p = .002), and movement (r_s = - .32, p = .01), as well as the interaction domains of; responsivity (r_s;= - .43, p = .001), teaching (r_s = - .31, p = .02), and interaction total score (r = - 0.34, p = .01). Interaction quality was related to sensory registration (r_s = - .38, p = .008), auditory (r_s = - .34, p = .02), seeking (r_s = .29, p = .05) and sensory behavioural scores (r_s = - .52, p < .001). Overall, interaction quality was best predicted by infant prematurity and auditory scores, R² = .15, F(1, 47) = 4.01, p = .02.

DISCUSSION

Preterm infants differed from their full-term peers in both their sensory processing and in their dyadic interactions with parents. Preterm status was associated with less responsivity and teaching and was found to predict overall interaction quality. Poorer infant sensory processing was associated with less parental teaching, affection and responsivity during interactions. Our results suggest that preterm birth is related to sensory processing difficulties, and that prematurity and sensory processing are differentially associated with aspects of interaction quality. These findings support the further examination of the interplay between preterm birth, sensory processing, and parent-infant interaction quality.

Data-driven quality improvement program to prevent hospitalisation and improve care of people living with coronary heart disease: Protocol for a process evaluation

BACKGROUND

Practice-level quality improvement initiatives using rapidly advancing technology offers a multidimensional approach to reduce cardiovascular disease burden. For the "QUality improvement in primary care to prevent hospitalisations and improve Effectiveness and efficiency of care for people Living with heart disease" (QUEL) cluster randomised controlled trial, a 12-month quality improvement intervention was designed for primary care practices to use data and implement progressive changes using "Plan, Do, Study, Act" cycles within their practices with training in a series of interactive workshops. This protocol aims to describe the systematic methods to conduct a process evaluation of the data-driven intervention within the QUEL study.

METHODS

A mixed-method approach will be used to conduct the evaluation. Quantitative data collected throughout the intervention period, via surveys and intervention materials, will be used to (1) identify the key elements of the intervention and how, for whom and in what context it was effective; (2) determine if the intervention is delivered as intended; and (3) describe practice engagement, commitment and capacity associated with various intervention components. Qualitative data, collected via semi-structured interviews and open-ended questions, will be used to gather in-depth understanding of the (1) satisfaction, utility, barriers and enablers; (2) acceptability, uptake and feasibility, and (3) effect of the COVID-19 pandemic on the implementation of the intervention.

CONCLUSION

Findings from the evaluation will provide new knowledge on the implementation of a complex, multi-component intervention at practice-level using their own electronic patient data to enhance secondary prevention of cardiovascular disease.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR) number ACTRN12619001790134.

Laparoscopy uptake for paediatric appendicectomy: a comparison of general surgeons versus specialist paediatric surgeons in England from 1997 to 2015

INTRODUCTION

Laparoscopy is used in as many as 95% of adult appendicectomies. There is level I evidence showing that it reduces wound infection, postoperative ileus and length of inpatient stay in children compared with the open approach. The aim of this study was to report the uptake of laparoscopy for paediatric appendicectomy in England and to determine whether this was similar for general surgeons (GS) and specialist paediatric surgeons (SPS).

METHODS

Hospital Episode Statistics data were obtained for all children aged <16 years who had an OPCS 4.6 code for emergency appendicectomy from 1997 to 2015 (18 years). Data are analysed to compare rate of laparoscopic vs open procedures for GS and SPS over time and to investigate factors associated with the use of laparoscopy.

RESULTS

There were 196,987 appendicectomies and where specialty was available, 133,709 (79%) cases were undertaken by GS and 35,141 (21%) by SPS. The rate of cases undertaken with laparoscopy for both specialties combined increased from 0.8% in 1998 to 50% in 2014 (p<0.0001). In 2014, this rate was 41% for GS compared with 71% for SPS (p<0.0001). Female gender (odds ratio (OR)=1.84, 95% confidence interval (CI) 1.80-1.90), increasing age (OR=1.18, 95% CI 1.18-1.19 per year) and treatment by SPS (OR=3.71, 95% CI 3.60-3.82) were all factors positively associated with use of laparoscopy in multivariate analysis.

CONCLUSIONS

There has been a vast increase in the proportion of appendicectomies undertaken laparoscopically in children. Despite adjusting for patient factors, laparoscopy was used significantly less by GS when compared with SPS. This difference is most apparent in younger children.

Lessons from the implementation of the Health Care Homes program

Australia’s primary health care system works well for most Australians, but 20% of people live with multimorbidity, often receiving fragmented care in a complex system.

Australia’s 10‐year plan for primary health care recognises that person‐centred care is essential to securing universal health coverage, improving health outcomes and achieving an integrated sustainable health system.

The Health Care Homes trial tested a new model of person‐centred care for people with chronic and complex health conditions.

This model demonstrated that change can be achieved with dedicated transformational support and highlighted the importance of enablers and reform streams that are now established in the 10‐year plan.

Value‐based primary care in Australia: how far have we travelled?

In this article, we discuss how the value‐based health care concept has matured across recent years, and consider how it can be achieved in the primary health care sector.

We provide illustrations of related initiatives across the four domains of value‐based health care, highlight the need for cultural transformation and reorientation of the system, and call for a national framework and agreed plan of action.

Stormwater runoff reduction benefits of distributed curbside infiltration devices in an urban catchment

Distributed infiltration systems can benefit downstream water bodies by reducing the runoff flowrate and volume discharges from the catchment. Investigating their runoff flowrate and volume reduction potential at the catchment scale will inform decision makers regarding their efficacy for managing catchment outflows. To this end, we conducted field investigations at the residential catchment scale for three years. The study monitored the catchment for one year before the installation of leaky well systems (preinstallation) and two years after installation (postinstallation). The hydrological model, calibrated to preinstallation catchment outflows, acted as a virtual control tool. Runoff flow outputs from the control model and two years of monitored runoff flow data from the postinstallation period were analysed using statistical methods. The statistical tests showed a significant 13% reduction in average flowrates in storms with a corresponding runoff flowrate of up to 50 L/s. The study further reported the ability of infiltration systems to reduce runoff volume in the catchment by 9%. This reduction was not significant, however, as per the results of the statistical analysis. We then fitted the generalized linear model (GLM) to the monitored and simulated runoff volume data. This enabled us to break down the effect of curbside infiltration systems on runoff volume according to corresponding peak flowrates during the storm. The results of the two-way ANOVA performed to detect significant differences in the regression slopes of the GLM indicated that curbside infiltration systems significantly reduced runoff volume for storms when the runoff flowrates remained below 100 L/s.

Pretreatment ADC Histogram Analysis as a Prognostic Imaging Biomarker for Patients with Recurrent Glioblastoma Treated with Bevacizumab: A Systematic Review and Meta-analysis

BACKGROUND

The mean ADC value of the lower Gaussian curve (ADC_L) derived from the bi-Gaussian curve-fitting histogram analysis has been reported as a predictive/prognostic imaging biomarker in patients with recurrent glioblastoma treated with bevacizumab; however, its systematic summary has been lacking.

PURPOSE

We applied a systematic review and meta-analysis to investigate the predictive/prognostic performance of ADC_L in patients with recurrent glioblastoma treated with bevacizumab.

DATA SOURCES

We performed a literature search using PubMed, Scopus, and EMBASE.

STUDY SELECTION

A total of 1344 abstracts were screened, of which 83 articles were considered potentially relevant. Data were finally extracted from 6 studies including 578 patients.

DATA ANALYSIS

Forest plots were generated to illustrate the hazard ratios of overall survival and progression-free survival. The heterogeneity across the studies was assessed using the Cochrane Q test and I² values.

DATA SYNTHESIS

The pooled hazard ratios for overall survival and progression-free survival in patients with an ADC_L lower than the cutoff values were 1.89 (95% CI, 1.53-2.31) and 1.98 (95% CI, 1.54-2.55) with low heterogeneity among the studies. Subgroup analysis of the bevacizumab-free cohort showed a pooled hazard ratio for overall survival of 1.20 (95% CI, 1.08-1.34) with low heterogeneity.

LIMITATIONS

The conclusions are limited by the difference in the definition of recurrence among the included studies.

CONCLUSIONS

This systematic review with meta-analysis supports the prognostic value of ADC_L in patients with recurrent glioblastoma treated with bevacizumab, with a low ADC_L demonstrating decreased overall survival and progression-free survival. On the other hand, the predictive role of ADC_L for bevacizumab treatment was not confirmed.

The M-CHooSe pilot: the acceptability and utilisation of the nurse-led, general practice clinic co-located ‘Mater CALD Healthcare Coordinator Service’ for patients from multicultural backgrounds

BACKGROUND

Patients from culturally and linguistically diverse (CALD) backgrounds often have unmet healthcare coordination needs. We aimed to evaluate the acceptability, utilisation and perceived benefits of the Mater CALD Health Coordinator Service (M-CHooSe), a pilot, nurse-led, general practice co-located, healthcare coordination service for patients from CALD backgrounds.

METHODS

M-CHooSe began in March 2020 at five Brisbane (Queensland) sites. Process and service user data were collected over 12months at one site. A survey evaluated primary healthcare professionals' perceived benefits of the service. Another survey of M-CHooSe nurses examined indicators of service complexity.

RESULTS

In total, 206 individuals accessed M-CHooSe over the 12-month period. Commonly delivered services included health service advocacy, chart reviews and health system navigation, including addressing social determinants. M-CHooSe nurses reported frequently performing tasks such as following up with external health services and performing health and social care system coordination. M-CHooSe benefits reported by primary healthcare professionals included better patient access to external health services and improved patient understanding of their conditions and treatments.

CONCLUSION

Patients were accepting of referrals to M-CHooSE. Primary healthcare professionals also reported a variety of benefits to themselves and their patients because of M-CHooSe. M-ChooSe highlights the potential of a healthcare coordination service for multicultural patients to improve healthcare equity, accessibility, and system efficiency. This project demonstrates the potential value of coordination services to increase patient access and uptake of existing health and social care services for modern Australian communities, thus improving the efficiency and effectiveness of our health system. Further investigations, including user experience, opinions and cost analyses, will be required to confirm the promising benefits of embedding M-CHooSe into usual care.

Lack of pro-arrhythmic potential for the novel soluble guanylate cyclase stimulator vericiguat: results from preclinical studies

Introduction

Vericiguat is an orally-administered soluble guanylate cyclase stimulator, developed for the treatment of symptomatic chronic heart failure (HF) in adult patients who have had a previous decompensation event. At the maximum therapeutic dose of 10 mg once daily in patients with HF, the protein-unbound plasma concentrations of vericiguat and its major pharmacologically inactive N-glucuronide metabolite M-1 are approximately 18 nmol/l and 43 nmol/l, respectively. As part of an integrated risk assessment, vericiguat and its M-1 metabolite were characterised electrophysiologically in vivo and in vitro. This was performed according to the International Council for Harmonisation standard S7B guideline and to recent related “best practice” revisions (draft ICH E14/S7B Q&A), being adopted as a result of the Comprehensive In Vitro Proarrhythmia Assay (CIPA) initiative.

Purpose

To assess the potential for a proarrhythmic risk from vericiguat and its M-1 metabolite in a series of preclinical studies.

Methods

The potential for proarrhythmic risk was investigated in conscious telemetered dogs and in a series of in vitro electrophysiological studies, including mechanistic ion channel studies, using both generally accepted and CIPA voltage-clamp protocols under conditions simulating normal and diseased physiological states. The ion channels studied were hERG, hNav1.5, hCav1.2, hKvLQT1/minK and hKv4.3. Transfected human embryonic kidney cell lines were used for the hERG, hNav1.5 and hKvLQT1/minK studies; transfected Chinese hamster ovary cell lines were used for the hCav1.2 and hKv4.3 studies.

Results

In dogs, administration of vericiguat as single oral doses was associated with dose-dependent decreases in arterial blood pressure (consistent with its mode of action) and compensatory increases in heart rate (Table 1). Heart rate-corrected QT (QTc) intervals were not prolonged by vericiguat to a clinically meaningful extent. Neither vericiguat nor its M-1 metabolite inhibited cardiac ion channels (hERG, hNav1.5, hCav1.2, hKvLQT1/minK and hKv4.3) at exposure multiples of &gt;150-fold (Table 2).

Conclusion

There was no preclinical evidence of proarrhythmic risk from the in vitro (simulating normal and diseased physiological states) and in vivo assessment of vericiguat or its major N-glucuronide metabolite M-1. This integrated risk assessment of non-clinical data supports the conclusion that administration of vericiguat 10 mg once daily in humans is not associated with meaningful QTc prolongation.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Funding for this research was provided by Bayer AG, Berlin, Germany and Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA.

Acute regional changes in myocardial strain may predict ventricular remodelling after myocardial infarction in a large animal model

To identify predictors of left ventricular remodelling (LVR) post-myocardial infarction (MI) and related molecular signatures, a porcine model of closed-chest balloon MI was used along with serial cardiac magnetic resonance imaging (CMRI) up to 5-6 weeks post-MI. Changes in myocardial strain and strain rates were derived from CMRI data. Tissue proteomics was compared between infarcted and non-infarcted territories. Peak values of left ventricular (LV) apical circumferential strain (ACS) changed over time together with peak global circumferential strain (GCS) while peak GLS epicardial strains or strain rates did not change over time. Early LVR post-MI enhanced abundance of 39 proteins in infarcted LV territories, 21 of which correlated with LV equatorial circumferential strain rate. The strongest associations were observed for D-3-phosphoglycerate dehydrogenase (D-3PGDH), cysteine and glycine-rich protein-2, and secreted frizzled-related protein 1 (sFRP1). This study shows that early changes in regional peak ACS persist at 5-6 weeks post-MI, when early LVR is observed along with increased tissue levels of D-3PGDH and sFRP1. More studies are needed to ascertain if the observed increase in tissue levels of D-3PGDH and sFRP1 might be casually involved in the pathogenesis of adverse LV remodelling.

How do healthcare providers support people with prediabetes to eat well? An in-depth, mixed-methods case study of provider practices

BACKGROUND AND OBJECTIVES

Guidelines recommend people with prediabetes receive diet and lifestyle support to avoid type 2 diabetes, yet it is unclear whether this care is provided in practice. The aim of this article is to explore the perspectives and nutrition care practices of healthcare providers (HCPs) for patients with prediabetes.

METHOD

This was a mixed-methods case study of an urban practice comprising a retrospective chart review and semi-structured interviews. Charts of adult patients with prediabetes were reviewed and informed a protocol used to interview HCPs. Interviews were thematically analysed.

RESULTS

Charts of 47 patients, representing 1096 consultations, were reviewed. The majority (74.5%) of patients had 'diet' noted in their chart, yet this accounted for only 8.1% of consultations. Only 19.1% of patients were referred to a dietitian. Interviews provided HCP explanations of the quantitative findings.

DISCUSSION

HCPs value nutrition care, yet are limited by the healthcare system to provide comprehensive care to people with prediabetes.

Aedes species (Diptera: Culicidae) ecological and host feeding patterns in the north-eastern parts of South Africa, 2014-2018

Background

There is a paucity of recent data and knowledge on mosquito diversity and potential vectors of arboviruses in South Africa, with most of the available data dating back to the 1950s–1970s. Aedes and Culex species are the major vectors of some of the principal arboviruses which have emerged and re-emerged in the past few decades.

Methods

In this study we used entomological surveillance in selected areas in the north-eastern parts of South Africa from 2014 to 2018 to assess mosquito diversity, with special emphasis on the Aedes species. The impact of trap types and environmental conditions was also investigated. Identification of the blood meal sources of engorged females collected during the study period was carried out, and DNA barcodes were generated for selected species.

Results

Overall, 18.5% of the total Culicidae mosquitoes collected belonged to the genus Aedes, with 14 species recognised or suspected vectors of arboviruses. Species belonging to the Neomelaniconion subgenus were commonly collected in the Bushveld savanna at conservation areas, especially Aedes mcintoshi and Aedes circumluteolus. Aedes aegypti was present in all sites, albeit in low numbers. Temperature was a limiting factor for the Aedes population, and they were almost exclusively collected at temperatures between 18 °C and 27 °C. The cytochrome oxidase subunit I (COI) barcode fragment was amplified for 21 Aedes species, and for nine of these species it was the first sequence information uploaded on GenBank.

Conclusion

This study provides a better understanding of the diversity and relative abundance of Aedes species in the north-east of South Africa. The information provided here will contribute to future arboviral research and implementation of efficient vector control and prevention strategies.

Graphical abstract

Supplementary Information

The online version contains supplementary material available at 10.1186/s13071-021-04845-9.

Identifying inequities in an urban Latin American population: a cross-sectional study in Australian primary health care

In Australia, people from culturally and linguistically diverse backgrounds often face inequitable health outcomes and access to health care. An important, but under-researched, population is people of Latin American descent. A cross-sectional study obtained clinical data on Latin American Spanish-speaking patients from Brisbane's south-west. Extracted data included demographic characteristics, risk factors, chronic disease and service use. A total of 382 people (60.5% female, 39.5% male), mainly from El Salvador and Chile and predominantly older people (70% over 50 years), were identified. Compared with the general Australian population, the proportion of people with dyslipidaemia, diabetes, arthritis and musculoskeletal, mental health disorders and being obese or overweight was high. There was also a higher use of the 20-40min general medicine consultation than in the general population. The proportion of patients receiving health promotion and chronic disease management activities was higher than in other reports. However, there were gaps in the provision of these services. The study shows an ageing population group with significant risk factors and an important burden of chronic disease and comorbidity. Addressing inequalities in health for culturally and linguistically diverse populations demands improvements in healthcare delivery and targeted actions based on a solid understanding of their complex health needs and their health, social and cultural circumstances.

Tired of feeling tired - The role of circulating inflammatory biomarkers and long-term cancer related fatigue in breast cancer survivors

BACKGROUND

Low-grade inflammation has been associated with cancer related fatigue (CRF). However, most studies focused on CRF during or shortly after treatment. Longitudinal studies are rare with inconsistent results. We assessed the association of inflammatory biomarkers with total CRF and all subdomains (physical, cognitive, affective) in long-term breast cancer survivors.

METHOD

Patients recruited between 2002 and 2005 provided information on CRF at first follow-up (FU1) (N = 1292) and second follow-up (FU2) (N = 1205), after a median of 6.2 years and 11.7 years, respectively. Associations of 11 inflammatory biomarkers with CRF at FU1 and at FU2 were assessed using linear regression models. Logistic regression models were used to compare patients fatigued at both time-points and those never fatigued (N = 932).

RESULTS

C-reactive protein (CRP) was significantly associated with total CRF at FU1 (β = 1.47, 95%CI = 0.62-2.31, p = 0.0007), at FU2 (β = 1.98, 95 %CI = 0.96-2.99, p = 0.0001) and with persistent CRF (OR = 1.29, 95%CI = 1.13-1.47, p < 0.0001). IL-6 levels were associated with total CRF at FU1 (β = 1.01, 95%CI = 0.43-1.59, p = 0.0006), but not with CRF at FU2 or persistent CRF. No association remained significant after adjustment for relevant covariates.

DISCUSSION

CRP and Il-6 were associated with risk of CRF in long-term breast cancer survivors, but were not independent of other known risk factors, suggesting that currently studied inflammatory markers are not suitable to identify patients at risk of long-term CRF.

First Measurement of Coherent Elastic Neutrino-Nucleus Scattering on Argon

We report the first measurement of coherent elastic neutrino-nucleus scattering (CEvNS) on argon using a liquid argon detector at the Oak Ridge National Laboratory Spallation Neutron Source. Two independent analyses prefer CEvNS over the background-only null hypothesis with greater than 3σ significance. The measured cross section, averaged over the incident neutrino flux, is (2.2±0.7)×10^{-39}  cm^{2}-consistent with the standard model prediction. The neutron-number dependence of this result, together with that from our previous measurement on CsI, confirms the existence of the CEvNS process and provides improved constraints on nonstandard neutrino interactions.

How relevant is the ISCHEMIA trial to a rapid access chest pain clinic cohort of patients?

Background

The ISCHEMIA trial demonstrated that optimal medical therapy (OMT) is not inferior to an early interventional approach for stable angina. This could significantly impact on clinical practice. This study aimed to check the relevance of the ISCHEMIA trial in a real-world population of patients referred to a tertiary centre with recent onset chest pain (CP).

Methods

In this registry study, electronic notes of all patients assessed in a Rapid Access Chest Pain Clinic (RACPC) within a 12-month period (2018–19) were reviewed. Patients were selected if they met key ISCHEMIA trial inclusion criteria.

Results

2416 patients were assessed, 378 (15.6%) presented with typical anginal CP, 1357 (56.2%) had atypical CP and 681 (28.2%) had non anginal CP.

Of the typical CP group, 158 patients were excluded (91 known CAD, 62 ACS, 2 eGFR &lt;30mL/min, 3 severe LVSD). This resulted in 220 patients, representing 58.2% of the typical chest pain population and 9.1% of all patients seen in RACPC. These patients had a median age of 60 years, 96 (44%) female, 119 (54.1%) had high cholesterol, 44 (20%) had diabetes, 115 (52.3%) had hypertension, 104 (47.3%) had a family history of ischaemic heart disease, and 32 (14.5%) were current smokers.

Of these 220 patients, 48 (21.8%) had a CT coronary angiogram (CTCA) requested as their first line investigation (42 completed) with 1 (2.4%) patients result suggestive of significant left main stem (LMS) disease. 15 (6.8%) patients had stress echocardiography requested as their first line investigation (13 completed), 4 (31%) were positive for inducible ischaemia. 3 (1.4%) patients had stress CMR requested as their first line investigation (2 completed), both were negative. 143 (65%) patients had an invasive coronary angiogram (ICA) requested as their first line investigation (112 completed). 8 patients had severe LMS disease and were referred for surgical opinion. A further 11 patients were referred for surgical opinion due to multivessel disease or aberrant coronary anatomy. In total 24 (21.4%) patients were treated with PCI following ICA as their first line investigation.

All patients were started on medical therapy for presumed CAD with up-titration while awaiting investigations. The median wait time for a CTCA was 55 days compared to 165.5 days for ICA.

Two patients (0.9%) from the cohort of 220 patients died during the follow up period, compared to 2.5% of patients admitted from RACPC with an ACS diagnosis.

Conclusion

Patients present with undifferentiated chest pain, consequently the outcomes of the ISCHEMIA trial must be considered cautiously. Within our cohort of 2416 patients, only 9% of patients met key inclusion criteria of the trial. Ultimately, only 19.5% patients with typical chest pain were revascularised, unlike 80% of patients in the invasive arm of ISCHEMIA. It is unclear how the results of the ISCHEMIA trial will impact on UK practice, but it is clear that OMT plays a central role.

Funding Acknowledgement

Type of funding source: None

Efficient removal of bacteria from aqueous media with kaolinite and diatomaceous earth products

AIMS

To understand the relationships between physical and chemical parameters of kaolinite and diatomaceous earth, and their capacities to remove bacteria from aqueous media. To determine the optimal aqueous media parameters for use of these products in water disinfection processes.

METHODS AND RESULTS

Seven kaolinite and three diatomaceous earth products were evaluated. Escherichia coli, Pseudomonas aeruginosa, Staphylococcus aureus and Bacillus megaterium were used as proxy for bacterial pathogens. Fully calcined kaolin and amorphous diatomaceous earth demonstrated the highest extent and consistency in removing all the bacteria. The removal depended on ionic strength and pH of aqueous media with 100 mmol l^-1 pH 5 potassium hydrogen phthalate buffer revealing the highest (2 log per gram) extent of the removal. Al³⁺ cations enhanced sorption up to 4 log per gram.

CONCLUSIONS

Calcined kaolin and amorphous diatomaceous earth are excellent sorbents for bacteria.

SIGNIFICANCE AND IMPACT OF THE STUDY

Fully calcined kaolin and amorphous diatomaceous earth are perspective tools for wastewater and water disinfection against waterborne bacterial pathogens.

Clinically Significant Fibrosis Is Associated With Longitudinal Increases in Fibrosis-4 and Nonalcoholic Fatty Liver Disease Fibrosis Scores

BACKGROUND & AIMS

There is limited knowledge regarding the longitudinal utility of biomarkers of fibrosis, such as the nonalcoholic fatty liver disease (NAFLD) fibrosis score (NFS) or the fibrosis-4 score (FIB-4) score. We examined longitudinal changes in the NFS and the FIB-4 score in patients with NAFLD, with and without clinically significant fibrosis (CSF).

METHODS

We performed a retrospective study of 230 patients with NAFLD, collecting clinical and laboratory records to calculate NFS and FIB-4 scores at 6 monthly intervals for 5 years before hepatology assessment of fibrosis. Linear mixed models with random intercept and slope and adjusted for age at baseline were used to assess the progression of NFS and log-transformed FIB-4 scores over time in subjects with and without CSF, determined by liver stiffness measurements of 8.2 kPa or greater.

RESULTS

Patients had a median of 11 (minimum, 10; maximum, 11) retrospective observations over a median time period of 5 years (minimum, 4.5 y; maximum, 5 y). Of patients with low baseline NFS and FIB-4 scores, 31.11% and 37.76%, respectively, had CSF at the time of hepatology assessment. There was a correlation between NFS and log₁₀ FIB-4 over time (repeated measure r = 0.55; 95% CI, 0.52-0.59). The rate of increase in NFS and log₁₀ FIB-4 was significantly higher in patients with than without CSF (both P < .001). Predicted NFS increased by 0.17 and 0.06 units per year in subjects with and without CSF, respectively. Predicted log₁₀ FIB-4 score increased by 0.032 and 0.0003 units per year in subjects with and without CSF, respectively.

CONCLUSIONS

Noninvasively measured fibrosis scores increase progressively in patients with NAFLD and CSF. Further studies are needed to determine whether repeated measurements can identify patients at risk for CSF.

QUality improvement in primary care to prevent hospitalisations and improve Effectiveness and efficiency of care for people Living with coronary heart disease (QUEL): protocol for a 24-month cluster randomised controlled trial in primary care

Background

Cardiovascular disease (CVD), including coronary heart disease (CHD) and stroke, is the leading cause of death and disability globally. A large proportion of mortality occurs in people with prior CHD and effective and scalable strategies are needed to prevent associated deaths and hospitalisations. The aim of this study is to determine if a practice-level collaborative quality improvement program, focused on patients with CHD, reduces the rate of unplanned CVD hospitalisations and major adverse cardiovascular events, and increases the proportion of patients achieving risk factor targets at 24 months.

Methods

Cluster randomised controlled trial (cRCT) to evaluate the effectiveness of a primary care quality improvement program in 50 primary care practices (n~ 10,000 patients) with 24-month follow-up. Eligible practices will be randomised (1:1) to participate in either the intervention (collaborative quality improvement program) or control (standard care) regimens. Outcomes will be assessed based on randomised allocation, according to intention-to-treat. The primary outcome is the proportion of patients with unplanned CVD hospitalisations at 2 years. Secondary outcomes are proportion of patients with major adverse cardiovascular events, proportion of patients who received prescriptions for guideline-recommended medicines, proportion of patients achieving national risk factor targets and proportion with a chronic disease management plan or review. Differences in the proportion of patients who are hospitalised (as well as binary secondary outcomes) will be analysed using log-binomial regression or robust Poisson regression, if necessary.

Discussion

Despite extensive research with surrogate outcomes, to the authors’ knowledge, this is the first randomised controlled trial to evaluate the effectiveness of a data-driven collaborative quality improvement intervention on hospitalisations, CVD events and cardiovascular risk amongst patients with CHD in the primary care setting. The use of data linkage for collection of outcomes will enable evaluation of this potentially efficient strategy for improving management of risk and outcomes for people with heart disease.

Trial registration

Australian New Zealand Clinical Trials Registry (ANZCTR) number ACTRN12619001790134 (dated 20th December 2019).

Comparison of methods to determine primary tumour size in canine apocrine gland anal sac adenocarcinoma

OBJECTIVES

To assess agreement between measurement of primary apocrine gland anal sac adenocarcinoma tumours using digital palpation, CT and formalin-fixed tissue and to look for associations with metastasis at presentation.

MATERIALS AND METHODS

Retrospective study of different methods of measuring primary tumour size in histopathologically-confirmed canine apocrine gland anal sac adenocarcinoma.

RESULTS

One hundred sixteen tumours from 107 dogs were included. There was moderate agreement between maximal dimension of the primary tumour measured by CT compared to formalin-fixed tissue and digital palpation. There was no significant difference in median maximum dimension between the measurement methods. Vascular invasion, CT stage, digital rectal examination stage and formalin-fixed tissue stage were significantly associated with metastasis at presentation, while mitotic index of the primary tumour was not. Dogs with tumours >2.5 cm (tumour-stage 2) were significantly more likely to present with metastatic disease.

CLINICAL SIGNIFICANCE

In canine apocrine gland anal sac adenocarcinoma, primary tumour size, tumour-stage and vascular invasion are strong predictors of metastasis at presentation.

P1548 Changes in left ventricular deformation with weight loss in obese adolescents with intellectual and developmental delays (IDD)

Funding Acknowledgements

AHA Career Development grant

Background

Adolescents with IDD have twice the prevalence of obesity as their typically developed peers, leading to frequent early obesity-related subclinical cardiac dysfunction, detected by strain echo. The effects of weight loss on cardiac deformation are unknown in this population.

Purpose

To evaluate early cardiac dysfunction in overweight IDD adolescents before and after a 6-month caloric restriction-weight loss program.

Methods

Subjects with IDD co-enrolling in a weight loss program were consented for this strain imaging study, excluding those with congenital heart disease. An echo measuring LVEF (bullet), 2D speckle longitudinal LV global strain (GLS) and strain rate (GLSr) from 3 apical views and global circumferential strain from a parasternal short axis view at the paps (GCS) was performed at baseline and 6 months. Analysis included paired T-test and regression analysis, p ≤ 0.05 significant.

Results

Overweight (5) and obese (15) adolescents (40% female) had baseline LV strain measurements that were mildly diminished with increased baseline body weight predicting diminished GLS (P = 0.034) and GCS (P = 0.046) on regression modeling. After 6 months, weight and BMI decreased significantly with improvements in GLS and GCS and non-significant trends towards improvement in GLSr and early diastolic global strain rate. BMI change at 6 months predicted change in GLS (p = 0.015) and GCS (p = 0.0087) on regression modeling. At baseline, LVEF and LV end-diastolic volume were normal with no change over 6 months (p &gt; 0.55).

Conclusions

Baseline abnormalities in LV deformation with preserved LVEF are present in this young, obese IDD population with improvements in BMI predicting those in GLS and GCS after a 6-month caloric restriction-weight loss program. These data provide compelling justification for larger studies in this population.

n Baseline (mean ± SD) 6-mo. follow up 0-6 mo. change p-value Age (years) 20 17.0 ± 2.0 17.5 ± 2.1 0.5 ± 0.1 Weight (kg) 20 86.9 ± 22.2 83.1 ± 22.7 -3.7 ± 5.9 0.014 BMI (kg/m&sup2;) 20 32.2 ± 5.3 30.4 ± 5.7 -1.8 ± 2.2 0.0031 GLS (%) 20 16.9 ± 1.6 19.2 ± 2.7 2.4 ± 2.0 0.00023 GLSr 20 1.15 ± 0.018 1.22 ± 0.18 0.06 ± 0.16 0.096 EaGLSr 20 1.83 ± 0.038 2.01 ± 0.46 0.18 ± 0.45 0.098 GCS (%) 20 19.1 ± 2.3 22.0 ± 2.6 2.82 ± 2.6 0.00019 LV deformation before and after weight loss. GLS, GLSr, and GCS are reported as positive values (absolute values). Body Mass Index (BMI); Early Diastolic Global Longitudinal Strain Rate (EaGLSr)

Modeling the Effects of Future Hydroclimatic Conditions on Microbial Water Quality and Management Practices in Two Agricultural Watersheds

Anticipated future hydroclimatic changes are expected to alter the transport and survival of fecally-sourced waterborne pathogens, presenting an increased risk of recreational water quality impairments. Managing future risk requires an understanding of interactions between fecal sources, hydroclimatic conditions and best management practices (BMPs) at spatial scales relevant to decision makers. In this study we used the Hydrologic Simulation Program FORTRAN to quantify potential fecal coliform (FC - an indicator of the potential presence of pathogens) responses to a range of mid-century climate scenarios and assess different BMP scenarios (based on reduction factors) for reducing the risk of water quality impairment in two, small agricultural watersheds - the Chippewa watershed in Minnesota, and the Tye watershed in Virginia. In each watershed, simulations show a wide range of FC responses, driven largely by variability in projected future precipitation. Wetter future conditions, which drive more transport from non-point sources (e.g. manure application, livestock grazing), show increases in FC loads. Loads typically decrease under drier futures; however, higher mean FC concentrations and more recreational water quality criteria exceedances occur, likely caused by reduced flow during low-flow periods. Median changes across the ensemble generally show increases in FC load. BMPs that focus on key fecal sources (e.g., runoff from pasture, livestock defecation in streams) within a watershed can mitigate the effects of hydroclimatic change on FC loads. However, more extensive BMP implementation or improved BMP efficiency (i.e., higher FC reductions) may be needed to fully offset increases in FC load and meet water quality goals, such as total maximum daily loads and recreational water quality standards. Strategies for managing climate risk should be flexible and to the extent possible include resilient BMPs that function as designed under a range of future conditions.

Determination of Zearalenone in Barley, Maize and Wheat Flour, Polenta, and Maize-Based Baby Food by Immunoaffinity Column Cleanup with Liquid Chromatography: Interlaboratory Study

An interlaboratory study was performed on behalf of the UK Food Standards Agency to evaluate the effectiveness of an affinity column cleanup liquid chromatography (LC) method for the determination of zearalenone (ZON) in a variety of cereals and cereal products at proposed European regulatory limits. The test portion is extracted with acetonitrile:water. The sample extract is filtered, diluted, and applied to an affinity column. The column is washed, and ZON is eluted with acetonitrile. ZON is quantified by reversed-phase LC with fluorescence detection. Barley, wheat and maize flours, polenta, and a maize-based baby food naturally contaminated, spiked, and blank (very low level) were sent to 28 collaborators in 9 European countries and 1 collaborator in New Zealand. Participants were asked to spike test portions of all samples at a ZON concentration equivalent to 100 μg/kg. Average recoveries ranged from 91–111%. Based on results for 4 artificially contaminated samples (blind duplicates) and 1 naturally contaminated sample (blind duplicate), the relative standard deviation for repeatability (RSDr) ranged from 6.9–35.8%, and the relative standard deviation for reproducibility (RSDR) ranged from 16.4–38.2%. The method showed acceptable within- and between-laboratory precision for all 5 matrixes, as evidenced by HorRat values &lt;1.7.

Garnet, the archetypal cubic mineral, grows tetragonal

Garnet is the archetypal cubic mineral, occurring in a wide variety of rock types in Earth’s crust and upper mantle. Owing to its prevalence, durability and compositional diversity, garnet is used to investigate a broad range of geological processes. Although birefringence is a characteristic feature of rare Ca–Fe³⁺ garnet and Ca-rich hydrous garnet, the optical anisotropy that has occasionally been documented in common (that is, anhydrous Ca–Fe²⁺–Mg–Mn) garnet is generally attributed to internal strain of the cubic structure. Here we show that common garnet with a non-cubic (tetragonal) crystal structure is much more widespread than previously thought, occurring in low-temperature, high-pressure metamorphosed basalts (blueschists) from subduction zones and in low-grade metamorphosed mudstones (phyllites and schists) from orogenic belts. Indeed, a non-cubic symmetry appears to be typical of common garnet that forms at low temperatures (<450 °C), where it has a characteristic Fe–Ca-rich composition with very low Mg contents. We propose that, in most cases, garnet does not initially grow cubic. Our discovery indicates that the crystal chemistry and thermodynamic properties of garnet at low-temperature need to be re-assessed, with potential consequences for the application of garnet as an investigative tool in a broad range of geological environments.

Identifying areas of need relative to liver disease: geographic clustering within a health service district

Background Many people with chronic liver disease (CLD) are not detected until they present to hospital with advanced disease, when opportunities for intervention are reduced and morbidity is high. In order to build capacity and liver expertise in the community, it is important to focus liver healthcare resources in high-prevalence disease areas and specific populations with an identified need. The aim of the present study was to examine the geographic location of people seen in a tertiary hospital hepatology clinic, as well as ethnic and sociodemographic characteristics of these geographic areas. Methods The geographic locations of hepatology out-patients were identified via the out-patient scheduling database and grouped into statistical area (SA) regions for demographic analysis using data compiled by the Australian Bureau of Statistics. Results During the 3-month study period, 943 individuals from 71 SA Level 3 regions attended clinic. Nine SA Level 3 regions accounted for 55% of the entire patient cohort. Geographic clustering was seen especially for people living with chronic hepatitis B virus. There was a wide spectrum of socioeconomic advantage and disadvantage in areas with high liver disease prevalence. Conclusions The geographic area from which people living with CLD travel to access liver health care is extensive. However, the greatest demand for tertiary liver disease speciality care is clustered within specific geographic areas. Outreach programs targeted to these areas may enhance liver disease-specific health service resourcing. What is known about the topic? The demand for tertiary hospital clinical services in CLD is rising. However, there is limited knowledge about the geographic areas from which people living with CLD travel to access liver services, or the ethnic, socioeconomic and education characteristics of these areas. What does this paper add? The present study demonstrates that a substantial proportion of people living with CLD and accessing tertiary hospital liver services are clustered within specific geographic areas. The most striking geographic clustering was seen for people living with chronic hepatitis B, in regions with a relatively high proportion of people born in Vietnam and China. In addition to ethnicity, the data show an apparent ecological association between liver disease and both socioeconomic and educational and/or occupational disadvantage. What are the implications for practitioners? Identifying where demand for clinical services arises is an important step for service planning and preparing for potential outreach programs to optimise community-based care. It is likely that outreach programs to engage and enhance primary care services in geographic areas from which the greatest demand for tertiary liver disease speciality care arises would yield greater relative return on investment than non-targeted outreach programs.