Development of an infection prevention and control pathway to facilitate high-throughput cataract surgery in Scotland

INTRODUCTION

Cataract surgery offers significant improvement to quality of life for patients with cataracts. However, there are growing waiting lists and challenges in providing this type of surgery in a timely manner. Feedback from stakeholders had previously indicated infection prevention and control (IPC) as a potential barrier to high-throughput surgery. Antimicrobial Resistance and Healthcare Associated Infection Scotland was asked to support the implementation of high-throughput cataract surgery aimed at addressing these challenges.

AIM

To develop an IPC pathway to facilitate high-throughput surgery. This would be based on best practice, and would address any barriers identified by stakeholders.

METHODS

A short life working group with input from key stakeholders, including clinical teams, was established. A rapid literature review was also undertaken.

RESULTS

An agreed patient pathway was developed, with the aim of helping to facilitate high-throughput surgery. Pre-, intra- and postoperative phases were considered. Where literature was unavailable, expert/consensus opinion was utilized. Facilities for high-throughput surgery were also considered, including the Jack and Jill theatre arrangement which lends itself well to this concept.

CONCLUSION

Through collaboration with stakeholders, an IPC pathway was developed to facilitate high-throughput cataract surgery and address any potential IPC barriers to implementation. The process and the output described could be utilized to develop similar pathways for other surgeries that lend themselves well to high throughput, improving quality of life for patients and reducing waiting times. This study highlights the importance of establishing surveillance for postoperative endophthalmitis following implementation.

Therapeutic approaches of diametaphyseal radius fractures in children

BACKGROUND

There are clear standards for when to operate on both distal epiphyseal and diaphyseal forearm fractures in children. However, paediatric surgeons are often faced with fractures in the transition zone between metaphysis and diaphysis. This aim of the study is to compare different treatment approaches for diametaphyseal forearm fractures, to classify different types of these fractures, and to define further assessment parameters and treatment recommendations.

METHODS

This retrospective study included all patients with diametaphyseal radial fractures who were seen at a paediatric surgery clinic between 01.01.2010 and 31.12.2013. Patients were treated either non-surgically (C) or surgically using bicortical Kirschner wire (BC-KW), intramedullary K-wire (IM-KW), elastic stable intramedullary nailing (ESIN), or combined bicortical and intramedullary K-wire (BCIM-KW).

RESULTS

During the study period, 547 patients presented with forearm fractures of which 88 patients (16%) had a fracture in the diametaphyseal region. The majority of diametaphyseal fractures were greenstick fractures (54.4%) followed by transverse fractures (44.3%). Distal fractures were predominantly treated with bicortical K-wiring (BC-KW, 40.5%) or non-surgically (C, 26.2%). Proximal fractures were treated by ESIN osteosynthesis (50%), followed by IM-KW (30%). Intermediate fractures were just as likely to be treated with one out of the 5 above-mentioned techniques. The ulna was involved in 64 of 88 cases. Depending on the type of fracture, it was treated either by ESIN osteosynthesis or non-surgically. No superior operative technique was identified.

CONCLUSIONS

The description of diametaphyseal fractures as a separate entity is important, because the therapy of these fractures is heterogeneous and challenging. A classification into proximal, intermediate, and distal may be useful in clinical decision-making. Despite the retrospective nature of this study, our data suggest that the use of a K-wire or combined technique BCIM-KW-technique, whenever technically feasible, achieves better radiological results without secondary dislocation. Further prospective studies are needed to provide better guidance to trauma surgeons.

Cancer burden in adolescents and young adults in Europe

BACKGROUND

Cancer epidemiology is unique in adolescents and young adults (AYAs; aged 15-39 years). The European Society for Medical Oncology/European Society for Paediatric Oncology (ESMO/SIOPE) AYA Working Group aims to describe the burden of cancers in AYAs in Europe and across European Union (EU) countries.

PATIENTS AND METHODS

We used data available on the Global Cancer Observatory. We retrieved crude and age-standardised (World Standard Population) incidence and mortality rates. We reported about AYA cancer burden in Europe and between 28 EU member states. We described incidence and mortality for all cancers and for the 13 cancers most relevant to the AYA population.

RESULTS

Incidence and mortality varied widely between countries with the highest mortality observed in Eastern EU countries. Cancers of the female breast, thyroid and male testis were the most common cancers across countries followed by melanoma of skin and cancers of the cervix. Variations in cancer incidence rates across different populations may reflect different distribution of risk factors, variations in the implementation or uptake of screening as well as overdiagnosis. AYA cancer mortality disparities may be due to variation in early-stage diagnoses, different public education and awareness of cancer symptoms, different degrees of access or availability of treatment.

CONCLUSIONS

Our results highlight the future health care needs and requirements for AYA-specialised services to ensure a homogeneous treatment across different countries as well as the urgency for preventive initiatives that can mitigate the increasing burden.

Observational Learning in Networks of Competition: How structures of attention among rivals can bring interpretive advantage

Much of social network analysis has focused on learning in communication networks among collaborators in which actors can make direct inquiries to seek clarification about alters’ behavior or views. But such inquiries are typically not possible among rivals. Learning among rivals occurs primarily in observational networks in which actors must make inferences of the logics guiding their competitors’ behavior in markets. What promotes interpretive advantage in these networks of observation? We combine multimarket competition theory and structural-hole theory to highlight the benefits of multiple exposure to disconnected competitors. In network-analytic terms we suggest that competitors’ interpretative advantage lies in non-redundant dyadic closure, especially when dealing with uncertain market niches. Dyadic closure, measuring ego’s exposure to her direct competitors in multiple markets, increases the ability to interpret competitors’ observed behavior. Redundancy, measuring the extent to which ego’s competitors are exposed to each other, reduces the diversity of views to which ego is exposed and hence the capacity to cope with uncertainty. We test our hypothesis by analyzing the network of competition created by securities analysts and the stocks they cover. We find that estimates issued by an analyst with multiple exposures to disconnected competitors are more accurate when confronted by more challenging, high risk, high reward, volatile stocks. Shifting the focus from direct social ties to the cognitive ties that link actors based on the objects, problems, or issues to which they pay attention, we develop a new approach to network analysis. Observation networks, we argue, operate neither as pipes nor as prisms but can be better conceived as scopes.

122 Tetanus Prophylaxis for Injuries Referred to a Plastic Surgery Service

Aim

To ascertain whether there is appropriate documentation of tetanus immunisation status. To determine whether appropriate tetanus prophylaxis is offered to those with an incomplete or unknown immunisation history for tetanus prone and high-risk tetanus prone wounds. To improve adherence to the green book of immunisation tetanus guidance.

Method

We performed an audit of wounds referred to plastic surgery in a 3-week period to ascertain whether the green book guidance was satisfied. A poster intervention for junior colleagues that illustrated the guidance was implemented. Re-audit was performed.

Results

Tetanus immunisation status was documented in 17 (34%) patients. Of 22 with tetanus prone wounds, 11 (50%) had an incomplete tetanus immunisation, but only 3 (27%) received a booster vaccine. Of the 11 high risk tetanus prone wounds, 10 (91%) had an incomplete tetanus immunisation status, but only 5 (50%) received a booster vaccine and none were offered tetanus immunoglobulins.

Following intervention, tetanus immunisation status was documented in 23 (46%) patients. In the re-audit, 12 (24%) sustained a tetanus prone injury and 4 (33%) of these had complete immunisation. Of the remaining 8, 7 (88%) received a booster vaccine and 1 patient refused. Of the 4 high risk tetanus prone wounds, 3 (75%) had an incomplete tetanus immunisation status, all of whom received a booster vaccine and 1 (25%) was offered tetanus immunoglobulins.

Conclusions

We observed greater engagement with the tetanus immunisation guidance and improvement in the assessment and management of tetanus prone injuries.

Induction of specific brain oscillations may restore neural circuits and be used for the treatment of Alzheimer's disease

Brain oscillations underlie the function of our brains, dictating how we both think and react to the world around us. The synchronous activity of neurons generates these rhythms, which allow different parts of the brain to communicate and orchestrate responses to internal and external stimuli. Perturbations of cognitive rhythms and the underlying oscillator neurons that synchronize different parts of the brain contribute to the pathophysiology of diseases including Alzheimer's disease, (AD), Parkinson's disease (PD), epilepsy and other diseases of rhythm that have been studied extensively by Gyorgy Buzsaki. In this review, we discuss how neurologists manipulate brain oscillations with neuromodulation to treat diseases and how this can be leveraged to improve cognition and pathology underlying AD. While multiple modalities of neuromodulation are currently clinically indicated for some disorders, nothing is yet approved for improving memory in AD. Recent investigations into novel methods of neuromodulation show potential for improving cognition in memory disorders. Here, we demonstrate that neuronal stimulation using audiovisual sensory stimulation that generated 40-HZ gamma waves reduced AD-specific pathology and improved performance in behavioural tests in mouse models of AD, making this new mode of neuromodulation a promising new avenue for developing a new therapeutic intervention for the treatment of dementia.

Racial attention deficit

Despite efforts toward equity in organizations and institutions, minority members report that they are often ignored, their contributions undervalued. Against this backdrop, we conduct a large-sample, multiyear experimental study to investigate patterns of attention. The findings provide causal evidence of a racial attention deficit: Even when in their best interest, White Americans pay less attention to Black peers. In a baseline study, we assign an incentivized puzzle to participants and examine their willingness to follow the example of their White and Black peers. White participants presume that Black peers are less competent—and fail to learn from their choices. We then test two interventions: Providing information about past accomplishments reduces the disparity in evaluations of Black peers, but the racial attention deficit persists. When Whites can witness the accomplishments of Black peers, rather than being told about them, the racial attention deficit subsides. We suggest that such a deficit can explain racial gaps documented in science, education, health, and law.

Presumptive neural microsporidiosis in a young adult German Shepherd dog from rural Australia

CASE REPORT

A 1-year-old, neutered male German Shepherd was presented with a 5-month history of episodic lethargy, intermittent fever, weight loss and a hunched posture. The dog was diagnosed with presumptive microsporidian meningoencephalitis based on cytological findings on cerebrospinal fluid analysis and a positive PCR test. The dog initially responded favourably to a 4-week course of trimethoprim-sulfadiazine, pyrimethamine and fenbendazole, and remained well for 12 weeks following cessation of treatment. Disease then recurred, and despite an initial positive response to treatment, he deteriorated and was euthanased 11 weeks later, 7.5 months after definitive diagnosis and 13 months after clinical signs were first reported.

CONCLUSION

To the authors knowledge, this is the first case of canine microsporidiosis in Australia.

Adolescents and young adults (AYA) with cancer: a position paper from the AYA Working Group of the European Society for Medical Oncology (ESMO) and the European Society for Paediatric Oncology (SIOPE)

It is well recognised that adolescents and young adults (AYA) with cancer have inequitable access to oncology services that provide expert cancer care and consider their unique needs. Subsequently, survival gains in this patient population have improved only modestly compared with older adults and children with cancer. In 2015, the European Society for Medical Oncology (ESMO) and the European Society for Paediatric Oncology (SIOPE) established the joint Cancer in AYA Working Group in order to increase awareness among adult and paediatric oncology communities, enhance knowledge on specific issues in AYA and ultimately improve the standard of care for AYA with cancer across Europe. This manuscript reflects the position of this working group regarding current AYA cancer care, the challenges to be addressed and possible solutions. Key challenges include the lack of specific biological understanding of AYA cancers, the lack of access to specialised centres with age-appropriate multidisciplinary care and the lack of available clinical trials with novel therapeutics. Key recommendations include diversifying interprofessional cooperation in AYA care and specific measures to improve trial accrual, including centralising care where that is the best means to achieve trial accrual. This defines a common vision that can lead to improved outcomes for AYA with cancer in Europe.

Underground testing: Name-altering practices as probes in electronic music

Name-altering practices are common in many creative fields-pen names in literature, stage names in the performing arts, and aliases in music. More than just reflecting artistic habits or responding to the need for distinctive brands, these practices can also serve as test devices to probe, validate, and guide the artists' active participation in a cultural movement. At the same time, they constitute a powerful probe to negotiate the boundaries of a subculture, especially when its features are threatened by appropriation from the mass-oriented culture. Drawing evidence from electronic music, a field where name-altering practices proliferate, we outline dynamics of pseudonymity, polyonymy, and anonymity that surround the use of aliases. We argue that name-altering practices are both a tool that artists use to probe the creative environment and a device to recursively put one's creative participation to the test. In the context of creative subcultures, name-altering practices constitute a subtle but effective form of underground testing.

Put to the test: For a new sociology of testing

In an age defined by computational innovation, testing seems to have become ubiquitous, and tests are routinely deployed as a form of governance, a marketing device, an instrument for political intervention, and an everyday practice to evaluate the self. This essay argues that something more radical is happening here than simply attempts to move tests from the laboratory into social settings. The challenge that a new sociology of testing must address is that ubiquitous testing changes the relations between science, engineering, and sociology: Engineering is today in the very stuff of where society happens. It is not that the tests of 21st-century engineering occur within a social context but that it is the very fabric of the social that is being put to the test. To understand how testing and the social relate today, we must investigate how testing operates on social life, through the modification of its settings. One way to clarify the difference is to say that the new forms of testing can be captured neither within the logic of the field test nor of the controlled experiment. Whereas tests once happened inside social environments, today's tests directly and deliberately modify the social environment.

Quantitative Signal Intensity in Fluid-Attenuated Inversion Recovery and Treatment Effect in the WAKE-UP Trial

Background and Purpose—

Relative signal intensity of acute ischemic stroke lesions in fluid-attenuated inversion recovery (fluid-attenuated inversion recovery relative signal intensity [FLAIR-rSI]) magnetic resonance imaging is associated with time elapsed since stroke onset with higher intensities signifying longer time intervals. In the randomized controlled WAKE-UP trial (Efficacy and Safety of MRI-Based Thrombolysis in Wake-Up Stroke Trial), intravenous alteplase was effective in patients with unknown onset stroke selected by visual assessment of diffusion weighted imaging fluid-attenuated inversion recovery mismatch, that is, in those with no marked fluid-attenuated inversion recovery hyperintensity in the region of the acute diffusion weighted imaging lesion. In this post hoc analysis, we investigated whether quantitatively measured FLAIR-rSI modifies treatment effect of intravenous alteplase.

Methods—

FLAIR-rSI of stroke lesions was measured relative to signal intensity in a mirrored region in the contralesional hemisphere. The relationship between FLAIR-rSI and treatment effect on functional outcome assessed by the modified Rankin Scale (mRS) after 90 days was analyzed by binary logistic regression using different end points, that is, favorable outcome defined as mRS score of 0 to 1, independent outcome defined as mRS score of 0 to 2, ordinal analysis of mRS scores (shift analysis). All models were adjusted for National Institutes of Health Stroke Scale at symptom onset and stroke lesion volume.

Results—

FLAIR-rSI was successfully quantified in stroke lesions in 433 patients (86% of 503 patients included in WAKE-UP). Mean FLAIR-rSI was 1.06 (SD, 0.09). Interaction of FLAIR-rSI and treatment effect was not significant for mRS score of 0 to 1 ( P =0.169) and shift analysis ( P =0.086) but reached significance for mRS score of 0 to 2 ( P =0.004). We observed a smooth continuing trend of decreasing treatment effects in relation to clinical end points with increasing FLAIR-rSI.

Conclusions—

In patients in whom no marked parenchymal fluid-attenuated inversion recovery hyperintensity was detected by visual judgement in the WAKE-UP trial, higher FLAIR-rSI of diffusion weighted imaging lesions was associated with decreased treatment effects of intravenous thrombolysis. This parallels the known association of treatment effect and elapsing time of stroke onset.

Quantification of Skeletal and Soft Tissue Contributions to Thoracic Response in a Dynamic Frontal Loading Scenario

Thoracic injuries continue to be a major health concern in motor vehicle crashes. Previous thoracic research has focused on 50^th percentile males and utilized scaling techniques to apply results to different demographics. Individual rib testing offers the advantage of capturing demographic differences; however, understanding of rib properties in the context of the intact thorax is lacking. Therefore, the objective of this study was to obtain the data necessary to develop a transfer function between individual rib and thoracic response. A series of non-injurious frontal impacts were conducted on six PMHS, creating a loading environment commensurate to previously published individual rib testing. Each PMHS was tested in four tissue states: intact, intact with upper limbs removed, denuded, and eviscerated. Following eviscerated thoracic testing, eight individual mid-level ribs from each PMHS were removed and loaded to failure. A simplified model in which ribs of each thorax are treated as parallel springs was utilized to evaluate the ability of individual rib response data to predict each subject's eviscerated thoracic response. On average across subjects, denuded thoraces retained 89% and eviscerated thoraces retained 46% of intact force. Similarly, denuded thoraces retained 70% and eviscerated thoraces retained 30% of intact stiffness. The rib model did not adequately predict eviscerated thoracic response but provided a better understanding of the influence of connective tissue on a rib's behavior with-in the thorax. Results of this study could be used in conjunction with the database of individual rib test results to improve thoracic response targets and help assess biofidelity of current anthropomorphic test devices.

European Organisation for Research and Treatment of Cancer Soft Tissue and Bone Sarcoma Group Experience with Advanced/Metastatic Epithelioid Sarcoma Patients Treated in Prospective Trials: Clinical Profile and Response to Systemic Therapy

AIMS

Epithelioid sarcoma is a soft tissue sarcoma associated with a high rate of local recurrence after wide resection and high incidence of distant metastasis. Little is known about the clinical course and response to systemic treatments in epithelioid sarcoma patients. We carried out a retrospective analysis of clinical data from epithelioid sarcoma patients to provide a reference for the design of future epithelioid sarcoma-specific studies.

PATIENTS AND METHODS

Data from patients with epithelioid sarcoma entered in prospective multi-sarcoma phase II/III trials were pooled: EORTC trial 62012 (doxorubicin versus doxorubicin/ifosfamide), 62043 (pazopanib), 62072 (pazopanib versus placebo) and 62091 (doxorubicin versus trabectedin). Patients had either a local or a centrally confirmed diagnosis of epithelioid sarcoma, had inoperable/metastatic disease at study entry and were eligible for the according trial. Response was assessed according to RECIST 1.1. Progression-free survival (PFS) and overall survival were calculated from date of entry.

RESULTS

Among 976 patients with advanced sarcomas, 27 epithelioid sarcoma patients (2.8%) were eligible for the analysis (17 men, median age at diagnosis 50 years, range 19-72). Eighteen (66.7%) received chemotherapy as first-line treatment (five doxorubicin, eight doxorubicin/ifosfamide, two pazopanib, three trabectedin) and nine (33.3%) received pazopanib as second line or later. The primary tumour was located in the lower extremity (n = 8; 29.6%), upper extremity (n = 5; 18.5%), retro/intra-abdominal (n = 4; 14.8%) and in other locations (n = 10; 37.0%). At entry, metastases were mainly found in lung (n = 17; 63%), lymph nodes (n = 9; 33.3%), bone (n = 8; 29.6%) and soft tissue (n = 7; 25.9%). The best response for first-line patients was four partial responses (22.2%), 10 stable disease (55.6%) and four progressive disease (22.2%). In subsequent lines, pazopanib achieved one partial response (11.1%), four stable disease (44.4%) and four progressive disease (44.4%). All patients but one progressed on treatment. The median PFS and overall survival were 3.8 (95% confidence interval 2.2-4.8) and 10.8 months (95% confidence interval 8.1-21.3), respectively. Five patients were still alive at the time of the according trial analysis.

CONCLUSION

With all limitations of such a rare disease and small data set, objective response and survival outcomes are similar in epithelioid sarcoma to non-selected sarcoma populations. The clinical testing of novel systemic treatments for epithelioid sarcoma remains an unmet medical need and a high priority.

COMPARISON OF A HEAD MOUNTED IMPACT MEASUREMENT DEVICE TO THE HYBRID III ANTHROPOMORPHIC TESTING DEVICE IN A CONTROLLED LABORATORY SETTING

BACKGROUND

Reports estimate that 1.6 to 3.8 million cases of concussion occur in sports and recreation each year in the United States. Despite continued efforts to reduce the occurrence of concussion, the rate of diagnosis continues to increase. The mechanisms of concussion are thought to involve linear and rotational head accelerations and velocities. One method of quantifying the kinematics experienced during sport participation is to place measurement devices into the athlete's helmet or directly on the athlete's head.

PURPOSE

The purpose of this research to determine the accuracy of a head mounted device for measuring the head accelerations experienced by the wearer. This will be accomplished by identifying the error in Peak Linear Acceleration (PLA), Peak Rotational Acceleration (PRA) and Peak Rotational Velocity (PRV) of the device.

STUDY DESIGN

Laboratory study.

METHODS

A helmeted Hybrid III 50th percentile male headform was impacted via a pneumatic ram from the front, side, rear, front oblique and rear oblique at speeds from 1.5 to 5 m/s. The X2 Biosystems xPatch® (Seattle, WA) sensor was placed on the headform's right side at the approximate location of the mastoid process. Measures of PLA, PRA, PRV from the xPatch ® and Hybrid III were analyzed for Root Mean Square Error (RMSE), and Absolute and Relative Error (AE, RE).

RESULT

Seventy-six impacts were analyzed. All measures of correlation, fixed through the origin, were found to be strong: PLA R²=0.967 p<0.01, PRA R²=0.933 p<0.01, PRV R²=0.999 p<0.00. PLA RMSE was 34%, RE 31.0%±14.0, and AE 31.1%±13.7. PRA RMSE was 23.4%, RE -6.7 ± 22.4 and AE 18.9%±13.8. PRV RMSE was 2.2%, RE 0.1 ± 2.2, and AE 1.8 ± 1.3.

CONCLUSION

Without including corrections for effect of skin artifact, the xPatch® produces measurements highly correlated with the gold standard yet above the average error of testing devices in both PLA and PRA, but a low error in PRV. PLA measures from the xPatch® system demonstrated a high level of correlation with the PLA data from the Hybrid III mounted data collection system.

LEVEL OF EVIDENCE

3.

Observational study of the development and evaluation of a fertility preservation patient decision aid for teenage and adult women diagnosed with cancer: the Cancer, Fertility and Me research protocol

INTRODUCTION

Women diagnosed with cancer and facing potentially sterilising cancer treatment have to make time-pressured decisions regarding fertility preservation with specialist fertility services while undergoing treatment of their cancer with oncology services. Oncologists identify a need for resources enabling them to support women's fertility preservation decisions more effectively; women report wanting more specialist information to make these decisions. The overall aim of the 'Cancer, Fertility and Me' study is to develop and evaluate a new evidence-based patient decision aid (PtDA) for women with any cancer considering fertility preservation to address this unmet need.

METHODS AND ANALYSIS

This is a prospective mixed-method observational study including women of reproductive age (16 years +) with a new diagnosis of any cancer across two regional cancer and fertility centres in Yorkshire, UK. The research involves three stages. In stage 1, the aim is to develop the PtDA using a systematic method of evidence synthesis and multidisciplinary expert review of current clinical practice and patient information. In stage 2, the aim is to assess the face validity of the PtDA. Feedback on its content and format will be ascertained using questionnaires and interviews with patients, user groups and key stakeholders. Finally, in stage 3 the acceptability of using this resource when integrated into usual cancer care pathways at the point of cancer diagnosis and treatment planning will be evaluated. This will involve a quantitative and qualitative evaluation of the PtDA in clinical practice. Measures chosen include using count data of the PtDAs administered in clinics and accessed online, decisional and patient-reported outcome measures and qualitative feedback. Quantitative data will be analysed using descriptive statistics, paired sample t-tests and CIs; interviews will be analysed using thematic analysis.

ETHICS AND DISSEMINATION

Research Ethics Committee approval (Ref: 16/EM/0122) and Health Research Authority approval (Ref: 194751) has been granted. Findings will be published in open access peer-reviewed journals, presented at conferences for academic and health professional audiences, with feedback to health professionals and program managers. The Cancer, Fertility and Me patient decision aid (PtDA) will be disseminated via a diverse range of open-access media, study and charity websites, professional organisations and academic sources. External endorsement will be sought from the International Patient Decision Aid Standards (IPDAS) Collaboration inventory of PtDAs and other relevant professional organisations, for example, the British Fertility Society.

TRIAL REGISTRATION NUMBER

NCT02753296; pre-results.

Comparisons of Modeled and Observed Reflectivities and Fall Speeds for Snowfall of Varied Riming Degrees during Winter Storms on Long Island, New York

Derived radar reflectivities and fall speeds for four Weather Research and Forecasting (WRF) Model bulk microphysical parameterizations (BMPs) run at 1.33-km grid spacing are compared with ground-based, vertically pointing Ku-band radar, scanning S-band radar, and in situ measurements at Stony Brook, New York. Simulations were partitioned into periods of observed riming degree as determined manually using a stereo microscope and camera during nine winter storms. Simulations were examined to determine whether the selected BMPs captured the effects of varying riming intensities, provided a reasonable match to the vertical structure of radar reflectivity or fall speed, and whether they produced reasonable surface fall speed distributions. Schemes assuming nonspherical mass-diameter relationships yielded reflectivity distributions closer to observed values. All four schemes examined in this study provided a better match to the observed, vertical structure of reflectivity during moderate riming than light riming periods. The comparison of observed and simulated snowfall speeds had mixed results. One BMP produced episodes of excessive cloud water at times, resulting in fall speeds that were too large. However, most schemes had frequent periods of little or no cloud water during moderate riming periods and thus underpredicted the snowfall speeds at lower levels. Short, 1-4-h periods with relatively steady snow conditions were used to compare BMP and observed size and fall speed distributions. These limited data suggest the examined BMPs underpredict fall speeds of cold-type snow habits and underrepresent aggregates larger than 4-mm diameter.

How young people describe the impact of living with and beyond a cancer diagnosis: feasibility of using social media as a research method

OBJECTIVE

Young people with cancer exhibit unique needs. During a time of normal physical and psychological change, multiple disease and treatment-related symptoms cause short and long-term physical and psychosocial effects. Little is known about how young people cope with the impact of cancer and its treatment on daily routines and their strategies to manage the challenges of cancer and treatments. We aimed to determine how young people describe these challenges through a social media site.

METHODS

Using the principles of virtual ethnography and watching videos on a social media site we gathered data from young people describing their cancer experience. Qualitative content analysis was employed to analyse and interpret the narrative from longitudinal 'video diaries' by 18 young people equating to 156 films and 27 h and 49 min of recording. Themes were described then organized and clustered into typologies grouping commonalities across themes.

RESULTS

Four typologies emerged reflective of the cancer trajectory: treatment and relenting side effects, rehabilitation and getting on with life, relapse, facing more treatment and coming to terms with dying.

CONCLUSIONS

This study confirms the need for young people to strive towards normality and creating a new normal, even where uncertainty prevailed. Strategies young people used to gain mastery over their illness and the types of stories they choose to tell provide the focus of the main narrative. Social Media sites can be examined as a source of data, to supplement or instead of more traditional routes of data collection known to be practically challenging with this population. Copyright © 2016 John Wiley & Sons, Ltd.

Use of a telestroke service for evaluation of non-stroke neurological cases

Telemedicine is a growing field in many medical specialties. Within clinical neurosciences one of its largest applications is in acute stroke care. However, little is known about its value and effect in general neurology, despite stroke. In a retrospective survey of 1500 teleconsultations over a time period of 12 months from October 2008 to September 2009, from a large telestroke network in Germany, we evaluated 352 cases with a non-stroke diagnosis. Duration and methods of teleconsultation as well as neurological consultations at bedside and discharge diagnosis were analyzed and compared to stroke cases. Discharge diagnosis was not identical to teleconsultation diagnosis in 48.9% of all non-stroke cases compared to 12.5% of all stroke cases. Duration of teleconsultation was 26.5 min in non-stroke cases compared to 14.3 min for stroke cases. In non-stroke cases other parts of the neurological examination were added to the pure administration of a stroke scale. There were no significant differences between non-stroke cases with correct and incorrect consultation diagnoses concerning in-hospital mortality (4.6 vs. 5.0%) and length of hospital stay (8.3 vs. 7.6 days). We conclude that diagnostic accuracy and protocol routine is not as exact in non-stroke cases compared to acute stroke cases. Other neurologic conditions may need different algorithms for a telemedicine service. Thus experience from a telestroke service cannot be transferred to other neurologic conditions on a routine basis.

Game changer: the topology of creativity

This article examines the sociological factors that explain why some creative teams are able to produce game changers--cultural products that stand out as distinctive while also being critically recognized as outstanding. The authors build on work pointing to structural folding--the network property of a cohesive group whose membership overlaps with that of another cohesive group. They hypothesize that the effects of structural folding on game changing success are especially strong when overlapping groups are cognitively distant. Measuring social distance separately from cognitive distance and distinctiveness independently from critical acclaim, the authors test their hypothesis about structural folding and cognitive diversity by analyzing team reassembly for 12,422 video games and the career histories of 139,727 video game developers. When combined with cognitive distance, structural folding channels and mobilizes a productive tension of rules, roles, and codes that promotes successful innovation. In addition to serving as pipes and prisms, network ties are also the source of tools and tensions.

ENCCA WP17-WP7 consensus paper on teenagers and young adults (TYA) with bone sarcomas

Teenagers and young adults (TYA) cancer contributes substantially to morbidity and mortality in a population with much to offer society. TYA place distinct challenges upon cancer care services, many reporting feeling marginalized and their needs not being met in adult or paediatric cancer services. Bone tumours such as osteosarcoma and Ewing sarcoma, because of their age at presentation and the complexity of their care, are where challenges in managing (TYA) with cancer have often been most readily apparent. Bone sarcomas may be managed by paediatric or medical oncologists, and require fastidious attention to protocol. A lack of recent improvement in survival in TYA with bone tumours may be linked to a lack of specialist care, poor concordance with therapy in some situations and TYA-specific pharmacology. Participation in clinical trials, particularly of young adults, is low, hindering progress. All these requirements may be best met by a concerted effort to create collaborative care between adult and paediatric experts in bone sarcoma, working together to meet TYA patients' needs.

Informing future research priorities into the psychological and social problems faced by cancer survivors: a rapid review and synthesis of the literature

PURPOSE

To establish what is known regarding the psychological and social problems faced by adult cancer survivors (people who are living with and beyond a diagnosis of cancer) and identify areas future research should address.

METHOD

A rapid search of published literature reviews held in electronic data bases was under taken. Inclusion and exclusion criteria, and removal of duplicated papers, reduced the initial number of papers from 4051 to 38. Twenty-two review papers were excluded on grounds of quality and 16 review papers were selected for appraisal.

RESULTS

The psychological and social problems for cancer survivors are identified as depression, anxiety, distress, fear of recurrence, social support/function, relationships and impact on family, and quality of life. A substantial minority of people surviving cancer experience depression, anxiety, and distress or fear associated with recurrence or follow up. There is some indication that social support is positively associated with better outcomes. Quality of life for survivors of cancer appears generally good for most people, but an important minority experience a reduction in quality of life, especially those with more advanced disease and reduced social and economic resources. The majority of research knowledge is based on women with breast cancer. The longer term implications of cancer survival have not been adequately explored.

CONCLUSIONS

Focussing well designed research in the identified areas where less is already known about the psychological and social impact of cancer survival is likely to have the greatest impact on the wellbeing of people surviving cancer.

Subtype distribution of Blastocystis isolates identified in a Sydney population and pathogenic potential of Blastocystis

Blastocystis is one of the most common enteric parasites present in humans. There is still much uncertainty about the pathogenic potential of this parasite, and it was suggested that its pathogenicity could be subtype-related. This report aimed to study 98 Blastocystis isolates found in human stool specimens to identify the subtypes present and carry out phylogenetic analysis on these isolates. This study also aimed to show the relationship between subtype and symptoms. Five-hundred and thirteen stool samples were submitted to five different diagnostic techniques for the detection of Blastocystis. Polymerase chain reaction (PCR)-positive samples were then sequenced and the small subunit (SSU) rDNA sequences were aligned and submitted to phylogenetic analysis. Ninety-eight samples were positive by any of the diagnostic methods for Blastocystis and 96 were positive by PCR. There were seven different subtypes (1, 2, 3, 4, 6, 7 and 8) identified by PCR and sequencing. This is the first large-scale study to examine the occurrence of Blastocystis in Australia. This study reports the high incidence of subtype 3 (44 %) in this population and discusses the emerging idea of subtype-dependent pathogenicity.

Comparing school environments with and without legislation for the prevention and management of anaphylaxis

BACKGROUND

  School personnel in contact with students with life-threatening allergies often lack necessary supports, creating a potentially dangerous situation. Sabrina's Law, the first legislation in the world designed to protect such children, requires all Ontario public schools to have a plan to protect children at risk. Although it has captured international attention, the differences a legislative approach makes have not been identified. Our study compared the approaches to anaphylaxis prevention and management in schools with and without legislation.

METHODS

  Legislated (Ontario) and nonlegislated (Alberta, British Columbia, Newfoundland and Labrador, and Quebec) environments were compared. School board anaphylaxis policies were assessed for consistency with Canadian anaphylaxis guidelines. Parents of at-risk children and school personnel were surveyed to determine their perspectives on school practices. School personnel's EpiPen5 technique was assessed.

RESULTS

  Consistency of school board policies with anaphylaxis guidelines was significantly better in a legislated environment (P=0.009). Parents in a legislated environment reported more comprehensive anaphylaxis emergency forms (P<0.001), while school personnel in nonlegislated environments reported more comprehensive forms (P=0.004). Despite school personnel in both environments receiving EpiPen5 training (>80%), suboptimal technique was commonly observed. However, school personnel in the legislated environment had better technique (P<0.001).

CONCLUSION

  Our results suggest that school boards in legislated environments have made greater efforts to support students at risk for anaphylaxis compared to nonlegislated environments. However, significant gaps exist in both environments, especially with respect to EpiPen5 administration, content, and distribution of anaphylaxis emergency forms, and awareness of school procedures by school personnel and parents.

Accelerated BEP: a phase I trial of dose-dense BEP for intermediate and poor prognosis metastatic germ cell tumour

Background:

We used bleomycin, etoposide, cisplatin (BEP), the most effective regimen in the treatment of germ cell tumours (GCTs) and increased dose-density by using pegfilgrastim to shorten cycle length. Our aim was to assess safety and tolerability.

Methods:

Sixteen male patients with intermediate or poor prognosis metastatic GCT were treated with four cycles of 3-day BEP with G-CSF on a 14-day cycle for a planned relative dose-density of 1.5 compared with standard BEP.

Results:

Eleven intermediate and five poor prognosis patients were treated. In all, 14 of 16 patients completed the study treatment. Toxicities were comparable to previous studies using standard BEP, except for mucositis and haematological toxicity that were more severe. The overall relative dose-density for all 16 patients was mean 1.38 (range 0.72–1.5; median 1.46). Complete response was achieved after chemotherapy alone in two patients (13%) and following chemotherapy plus surgery in nine additional patients (56%). Four patients (25%) had a partial response and normalised their marker levels. At a median follow-up of 4.4 years (range 2.1–6.8) the estimated 5-year progression-free survival probability is 81% (95% CI 64–100%).

Conclusion:

Accelerated BEP is tolerable without major additional toxicity. A randomised controlled trial will be required to obtain comparative efficacy data.

A simple practical patient-reported clinic satisfaction measure for young adults

Background:

The development of practical patient-reported outcome measures (PROM) to assess the user view of health programmes is increasingly important. Valid, shorter instruments are more likely to be used and completed than extensive questionnaires.

Methods:

Consecutive adult outpatient attendees who were long-term survivors of childhood cancer completed the 16-item Patient Satisfaction with Communication Questionnaire (PSCQ). These data were used to develop a three-item questionnaire. The brief PROM was validated against data from a second, independent survey conducted in a similar fashion.

Results:

In all, 93 individuals contributed PSCQ data, a response rate of 63%. The brief PROM was highly correlated with the original PSCQ in derivation (ρ=0.87, P<0.001) and validation (ρ=0.82, P<0.001) data sets. Using a cutoff of scores <9 to indicate dissatisfaction showed fair discrimination in derivation (sensitivity 85%, specificity 80%) and validation data sets (sensitivity 75%, specificity 78%).

Conclusion:

It is possible to quickly and efficiently assess satisfaction with follow-up clinics with three questions. This brief PROM could prove useful in monitoring services quality by allowing clinic users to provide timely feedback on their care.

Pharmacokinetics and safety of subcutaneous immune globulin (human), 10% caprylate/chromatography purified in patients with primary immunodeficiency disease

Subcutaneous administration of intravenous immunoglobulin G (IgG) preparations provides an additional level of patient convenience and more options for patients with poor venous access or a history of intravenous IgG reactions. An open-label, pharmacokinetic trial (n = 32) determined the non-inferiority of the subcutaneous versus intravenous route of 10% caprylate/chromatography purified human immune globulin intravenous (IGIV-C; Gamunex®) administration by comparing the steady-state area under the concentration-versus-time curve (AUC) of total plasma IgG in patients with primary immunodeficiency disease. Patients on stable IGIV-C received two intravenous infusions (administered 3 or 4 weeks apart). Seven to 10 days after the second intravenous infusion, all patients switched to a weekly infusion of subcutaneous IGIV-C, with the dose equal to 137% of the previous weekly equivalent intravenous dose, for up to 24 weeks. Samples for pharmacokinetic analysis were collected during steady state for intravenous and subcutaneous IGIV-C treatments. The AUC(0-) τ geometric least-squares mean ratio was 0·89 (90% confidence interval, 0·86-0·92) and met the criteria for non-inferiority. The overall mean steady-state trough concentration of plasma total IgG with subcutaneous IGIV-C was 11·4 mg/ml, 18·8% higher than intravenous IGIV-C (9·6 mg/ml). Subcutaneous IGIV-C was safe and well tolerated. Subcutaneous IGIV-C infusion-site reactions were generally mild/moderate and the incidence decreased over time. No serious bacterial infections were reported. Weekly subcutaneous IGIV-C infusion using 137% of the weekly equivalent intravenous immunoglobulin dose provides an AUC comparable to intravenous administration, thus allowing patients to maintain the same IgG preparation/formulation if switching between intravenous and subcutaneous infusions.

Importance of nonenteric protozoan infections in immunocompromised people

There are many neglected nonenteric protozoa able to cause serious morbidity and mortality in humans, particularly in the developing world. Diseases caused by certain protozoa are often more severe in the presence of HIV. While information regarding neglected tropical diseases caused by trypanosomatids and Plasmodium is abundant, these protozoa are often not a first consideration in Western countries where they are not endemic. As such, diagnostics may not be available in these regions. Due to global travel and immigration, this has become an increasing problem. Inversely, in certain parts of the world (particularly sub-Saharan Africa), the HIV problem is so severe that diseases like microsporidiosis and toxoplasmosis are common. In Western countries, due to the availability of highly active antiretroviral therapy (HAART), these diseases are infrequently encountered. While free-living amoebae are rarely encountered in a clinical setting, when infections do occur, they are often fatal. Rapid diagnosis and treatment are essential to the survival of patients infected with these organisms. This paper reviews information on the diagnosis and treatment of nonenteric protozoal diseases in immunocompromised people, with a focus on patients infected with HIV. The nonenteric microsporidia, some trypanosomatids, Toxoplasma spp., Neospora spp., some free-living amoebae, Plasmodium spp., and Babesia spp. are discussed.

Cancer incidence among the south Asian and non-south Asian population under 30 years of age in Yorkshire, UK

Background:

Few studies have examined epidemiological differences between ethnic groups for children and young adults with cancer.

Methods:

Subjects aged 0–29 years, diagnosed between 1990 and 2005 in the former Yorkshire Regional Health Authority, were included in the analysis. Ethnicity (south Asian or not) was assigned using name analysis program and Hospital Episode Statistics data. Differences in incidence (per 1 000 000 person-years) rates and trends were analysed using joinpoint and Poisson regression analysis.

Results:

Overall cancer incidence was similar for south Asians (12.1, 95% CI: 10.7–13.5; n=275) and non-south Asians (12.6, 95% CI: 12.2–13.1; n=3259). Annual incidence rates increased significantly by 1.9% per year on average (95% CI: 1.2–2.6%), especially for south Asians (7.0% 95% CI: 4.2–9.9%).

Conclusion:

If present trends continue, the higher rate of increase seen among south Asians aged 0–29 years in Yorkshire will result in three times higher cancer incidence than non-south Asians by 2020.

Management of anaphylaxis in primary care: Canadian expert consensus recommendations

BACKGROUND

Anaphylaxis is often managed inadequately. We used findings from a systematic review of gaps in anaphylaxis management to develop evidence-based recommendations for gaps rated as clinically important by a panel of Canadian allergy experts.

METHODS

The nominal group technique (NGT) consensus methodology was used to develop evidence-based recommendations for the management of anaphylaxis in primary care. Physician-specific gaps from our systematic review were prioritized by consensus meeting participants in two rounds, which involved the rating, discussion, and re-rating of gaps. Using current anaphylaxis guidelines, recommendations were then developed for each category of gaps that were identified by the panel as clinically important.

RESULTS

Thirty unique physician gaps from the systematic review were categorized according to gaps of knowledge and anaphylaxis practice behaviors. The panel rated diagnosis of anaphylaxis, and when and how to use epinephrine auto-injectors as clinically important knowledge gaps; and rated infrequent or delayed epinephrine administration, low rate of auto-injector prescription, and infrequent or no referrals to allergy specialists after a reaction as important practice behavior gaps. Evidence from four guidelines was used to support the consensus recommendation statements for three resulting categories of gap themes: anaphylaxis management, epinephrine use, and follow-up care.

CONCLUSION

We used an NGT consensus methodology to develop an educational resource for primary care physicians and allergists to better understand how to manage patients with anaphylaxis. Next steps include testing our findings against observed data in primary care settings and to develop other strategies or tools to overcome gaps in anaphylaxis management.