QI initiative to reduce the number of inpatient falls in an acute hospital Trust

Inpatient falls are one of the most frequent concerns to patient safety within the acute hospital environment, equating to 1700 falls per year in an 800-bed general hospital. They are predicted to cost approximately £2600 per patient, however, this estimate does not capture the costs and impact that inpatient falls have on the wider health and social care system. It also does not take into the account loss of confidence and delays in functional recovery.This report shares the learning from a quality improvement (QI) initiative that took place in a District General Hospital (DGH) in the UK. The initiative started in February 2020, was paused November 2020 due to wave 2 of the pandemic and restarted in March 2021. Improvement was achieved in January 2021.Data for falls within the Trust identified that falls were within common cause variation. A system change was needed to achieve an improvement.A QI project was commenced with the aim to achieve a 5% reduction in falls per 1000 bed days in a care of the elderly ward.Two primary drivers were identified: recognising patients at high risk of falls and preventing them from falling. Change ideas to address these primary drivers were tested using Plan Do Study Act (PDSA) cycles. Changes tested included: the development of an assessment tool to identify patients at high risk of falls, use of a wristband to identify patients at high risk of a fall, and increased observation.Change ideas achieved some success with the process measures but did not achieve an improvement with the outcome measures. A Trust wide change idea relating to the falls prevention service did lead to a sustained improvement in falls reduction.The barriers to the improvement included changing Trust priorities during the pandemic, and limited opportunities to fully engage the ward-based team with systems thinking and changing mental models.

A new direction for tackling phosphorus inefficiency in the UK food system

The UK food system is reliant on imported phosphorus (P) to meet food production demand, though inefficient use and poor stewardship means P is currently accumulating in agricultural soils, wasted or lost with detrimental impacts on aquatic environments. This study presents the results of a detailed P Substance Flow Analysis for the UK food system in 2018, developed in collaboration with industry and government, with the key objective of highlighting priority areas for system interventions to improve the sustainability and resilience of P use in the UK food system. In 2018 the UK food system imported 174.6 Gg P, producing food and exportable commodities containing 74.3 Gg P, a P efficiency of only 43%. Three key system hotspots for P inefficiency were identified: Agricultural soil surplus and accumulation (89.2 Gg P), loss to aquatic environments (26.2 Gg P), and waste disposal to landfill and construction (21.8 Gg P). Greatest soil P accumulation occurred in grassland agriculture (85% of total accumulation), driven by loadings of livestock manures. Waste water treatment (12.5 Gg P) and agriculture (8.38 Gg P) account for most P lost to water, and incineration ashes from food system waste (20.3 Gg P) accounted for nearly all P lost to landfill and construction. New strategies and policy to improve the handling and recovery of P from manures, biosolids and food system waste are therefore necessary to improve system P efficiency and reduce P accumulation and losses, though critically, only if they effectively replace imported mineral P fertilisers.

Management of humeral impending or pathological fractures with intramedullary nailing: reaming versus non reaming technique-a retrospective comparative study

PURPOSE

To compare reamed intramedullary nailing (RIM) versus un-reamed intramedullary nailing (URIM) for the treatment of impending and pathological fractures of the humeral shaft in terms of 24-h postoperative pain, blood transfusion requirements, surgical time, surgical complications, medical complications, length of stay and consolidation rates.

METHODS

A retrospective comparative study between January 2013 and December 2018 was conducted. Student's t test, Mann-Whitney U and Chi-square tests were used to detect differences within the two study groups. Multiple linear regression was done to adjust for possible confounders.

RESULTS

A total of 53 patients (33 RIM vs. 20 URIM) underwent humeral nailing. Fifteen (28%) were impending fractures (7 RIM vs. 8 URIM). Multiple myeloma (49%) and metastatic carcinoma (39.6%) were the most common etiologies. Pain score (5.13 ± 0.68 RIM vs. 6.78 ± 0.62 URIM; p = 0.082) and total dose of opioids (33.125 ± 27.6 RIM vs. 33.3 ± 22.28 URIM; p = 0.462) showed similar results. Blood transfusion was more prevalent within RIM group (34.48% RIM vs. 20% URIM; p = 0.044) with a clinical tendency of higher blood loss (207.86 ± 150.83RIM vs. 127.00 ± 179.98 URIM; p = 0.092). There was a consolidation rate of 71.05% (27/38) with no statistical difference (73.08% (19/26) RIM vs. 66.67% (8/12) URIM; p = 0.685).

CONCLUSION

Our study suggests possible benefit of URIM in terms of less blood transfusions with no difference in consolidation rates. Even though without significance, a tendency to less blood loss, less events of systemic complication and lower length of stay was observed with URIM. Despite its limitations, this study can be used to design future prospective ventures that quantify patient-reported outcomes and provide more clear evidence.

Ensuring scientific reproducibility in bio-macromolecular modeling via extensive, automated benchmarks

Each year vast international resources are wasted on irreproducible research. The scientific community has been slow to adopt standard software engineering practices, despite the increases in high-dimensional data, complexities of workflows, and computational environments. Here we show how scientific software applications can be created in a reproducible manner when simple design goals for reproducibility are met. We describe the implementation of a test server framework and 40 scientific benchmarks, covering numerous applications in Rosetta bio-macromolecular modeling. High performance computing cluster integration allows these benchmarks to run continuously and automatically. Detailed protocol captures are useful for developers and users of Rosetta and other macromolecular modeling tools. The framework and design concepts presented here are valuable for developers and users of any type of scientific software and for the scientific community to create reproducible methods. Specific examples highlight the utility of this framework, and the comprehensive documentation illustrates the ease of adding new tests in a matter of hours.

Designed, highly expressing, thermostable dengue virus 2 envelope protein dimers elicit quaternary epitope antibodies

Dengue virus (DENV) is a worldwide health burden, and a safe vaccine is needed. Neutralizing antibodies bind to quaternary epitopes on DENV envelope (E) protein homodimers. However, recombinantly expressed soluble E proteins are monomers under vaccination conditions and do not present these quaternary epitopes, partly explaining their limited success as vaccine antigens. Using molecular modeling, we found DENV2 E protein mutations that induce dimerization at low concentrations (<100 pM) and enhance production yield by more than 50-fold. Cross-dimer epitope antibodies bind to the stabilized dimers, and a crystal structure resembles the wild-type (WT) E protein bound to a dimer epitope antibody. Mice immunized with the stabilized dimers developed antibodies that bind to E dimers and not monomers and elicited higher levels of DENV2-neutralizing antibodies compared to mice immunized with WT E antigen. Our findings demonstrate the feasibility of using structure-based design to produce subunit vaccines for dengue and other flaviviruses.

Transmyocardial extraction of endothelin-1 correlates with increased microvascular resistance following percutaneous coronary intervention

Introduction

Coronary microvascular dysfunction (CMD) can persist following successful percutaneous coronary intervention (PCI). Endothelin-1 (ET-1) is a potent vasoconstrictor and may be an important mediator of CMD. We sought to assess the trans-myocardial gradient (TMG – coronary sinus minus coronary root levels) of ET-1 and its precursor - Big ET-1 and assess the correlation with pressure-wire indices of CMD: coronary flow reserve (CFR) and index of microvascular resistance (IMR).

Methods

Paired blood samples from the aortic root and coronary sinus were collected before and after pressure wire guided PCI from patients with stable angina. Plasma was then analysed using specific enzyme linked immunosorbent assay (ELISA) for quantification of ET-1 and Big ET-1 and correlated with pressure-wire data.

Results

Samples were analysed from 66 patients. Both mean ET-1 and Big ET-1 concentrations increased post-PCI in both the aorta (ET-1: 1.0±0.4 pg/ml to 1.4±0.4 pg/ml, p&lt;0.0001 and Big ET-1: 2.8±1.3 pg/ml to 3.4±1.6 pg/ml, p&lt;0.0001) and coronary sinus (ET-1: 1.0±0.3 pg/ml to 1.2±0.3 pg/ml, p=0.03 and Big ET-1: 3.2±1.7 pg/ml to 3.8±1.5 pg/ml, p=0.01). TMG extraction of ET-1 increased following PCI: 0.05±0.25 pg/ml vs.-0.20±0.41 pg/ml, p=0.01. In contrast, there was TMG release of Big ET-1 before and after PCI: 0.46±1.26 pg/ml vs. 0.38±1.03 pg/ml, p=0.52. ET-1 extraction correlated with IMR post-PCI (Pearson's r=0.293, p=0.02). Patients with CFR&lt;2 post-PCI demonstrated a numerical trend towards higher mean ET-1 extraction than those with preserved CFR post-PCI (0.30±0.51 pg/ml vs. 0.16±0.42 pg/ml, p=0.31) as did those with criteria for Type 4a Myocardial Infarction compared with those without (0.39±0.57 vs. 0.15±0.41, p=0.11).

Conclusions

ET-1 and Big ET-1 significantly increase post-PCI. Trans-myocardial extraction of ET-1 increases post-PCI and correlates with post-PCI CMD.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Jon Moulton Charity Trust.NIHR Cambridge Biomedical Research Centre Biomedical Resources Grant. TMG of ET-1 and Big ET-1ET-1 extraction and post-PCI IMR

PyRosetta Jupyter Notebooks Teach Biomolecular Structure Prediction and Design

Biomolecular structure drives function, and computational capabilities have progressed such that the prediction and computational design of biomolecular structures is increasingly feasible. Because computational biophysics attracts students from many different backgrounds and with different levels of resources, teaching the subject can be challenging. One strategy to teach diverse learners is with interactive multimedia material that promotes self-paced, active learning. We have created a hands-on education strategy with a set of sixteen modules that teach topics in biomolecular structure and design, from fundamentals of conformational sampling and energy evaluation to applications like protein docking, antibody design, and RNA structure prediction. Our modules are based on PyRosetta, a Python library that encapsulates all computational modules and methods in the Rosetta software package. The workshop-style modules are implemented as Jupyter Notebooks that can be executed in the Google Colaboratory, allowing learners access with just a web browser. The digital format of Jupyter Notebooks allows us to embed images, molecular visualization movies, and interactive coding exercises. This multimodal approach may better reach students from different disciplines and experience levels as well as attract more researchers from smaller labs and cognate backgrounds to leverage PyRosetta in their science and engineering research. All materials are freely available at https://github.com/RosettaCommons/PyRosetta.notebooks.

How to increase the value of self-reported health service data by using data linkage: a case study

Background

This is a case study for recurrent stroke prevention. Lifestyle factors account for about 80% of the risk of recurrent stroke. Most health services studies examining stroke prevention rely on stroke survivors' self-reported lifestyle behaviour data. How can researchers increase the value of collected self-reported data to provide additional information for more comprehensive assessments?

Methods

45 and Up Study is the largest ongoing study in the Southern Hemisphere focusing on the health of people aged 45 years and older living in NSW, Australia. This case study linked self-reported longitudinal lifestyle data in the 45 and Up Study, with corresponding mortality data (i.e. NSW Registry of Births, Deaths and Marriages & NSW Cause of Death Unit Record File) and hospital data (i.e. NSW Admitted Patient Data Collection) via the Centre for Health Record Linkage (CHeReL). The main outcome measures are health services, clinical outcomes, and mortality rates for stroke care. The analyses will include descriptive analysis, multivariate regression analysis, and survival analysis.

Results

A total of 8410 stroke survivors who participated in the 45 and Up Study were included in this data linkage study. From January 2006 to December 2015, 99249 hospital claims (mean: 13 times admission to hospital per person) and 2656 death registration records have been linked to these participants. The mean age of the stroke survivors was 72 (SD = 11) years, with 56% being males. These results are preliminary and more analyses will be conducted by using quality of life status, clinical diagnosis, comorbidities, and procedures.

Conclusions

Data linkage enables researchers to generate comprehensive findings on health services studies and gain a more holistic understanding of the determinants and outcomes of stroke prevention with lower data collection costs and less burden on participants.

Key messages

Data linkage brings about a new opportunity for self-reported data on health services utilisation. It is a cost-effective way to enhance existing self-reported data via the data linkage approach to increase its usefulness for informing health service planning.

Macromolecular modeling and design in Rosetta: recent methods and frameworks

The Rosetta software for macromolecular modeling, docking and design is extensively used in laboratories worldwide. During two decades of development by a community of laboratories at more than 60 institutions, Rosetta has been continuously refactored and extended. Its advantages are its performance and interoperability between broad modeling capabilities. Here we review tools developed in the last 5 years, including over 80 methods. We discuss improvements to the score function, user interfaces and usability. Rosetta is available at http://www.rosettacommons.org.

Computational stabilization of T cell receptors allows pairing with antibodies to form bispecifics

Recombinant T cell receptors (TCRs) can be used to redirect naïve T cells to eliminate virally infected or cancerous cells; however, they are plagued by low stability and uneven expression. Here, we use molecular modeling to identify mutations in the TCR constant domains (Cα/Cβ) that increase the unfolding temperature of Cα/Cβ by 20 °C, improve the expression of four separate α/β TCRs by 3- to 10-fold, and improve the assembly and stability of TCRs with poor intrinsic stability. The stabilizing mutations rescue the expression of TCRs destabilized through variable domain mutation. The improved stability and folding of the TCRs reduces glycosylation, perhaps through conformational stabilization that restricts access to N-linked glycosylation enzymes. The Cα/Cβ mutations enables antibody-like expression and assembly of well-behaved bispecific molecules that combine an anti-CD3 antibody with the stabilized TCR. These TCR/CD3 bispecifics can redirect T cells to kill tumor cells with target HLA/peptide on their surfaces in vitro.

Human S-cone electroretinograms obtained by silent substitution stimulation

We used triple silent substitution stimuli to characterize human S-cone electroretinograms (ERGs) in normal trichromats. Short-wavelength-cone (S-cone) ERGs were found to have different morphological features and temporal frequency response characteristics compared to ERGs derived from L-cones, M-cones, and rod photoreceptors in normal participants. Furthermore, in two cases of retinal pathology, blue cone monochromatism (BCM) and enhanced S-cone syndrome (ESCS), S-cone ERGs elicited by our stimuli were preserved and enhanced, respectively. The results from both normal and pathological retinae demonstrate that triple silent substitution stimuli can be used to generate ERGs that provide an assay of human S-cone function.

The impact of daycare attendance on outdoor free play in young children

Background

Outdoor free play is important for healthy growth and development in early childhood. Recent studies suggest that the majority of time spent in daycare is sedentary. The objective of this study was to determine whether there was an association between daycare attendance and parent-reported outdoor free play.

Methods

Healthy children aged 1-5 years recruited to The Applied Research Group for Kids! (TARGet Kids!), a primary care research network, were included. Parents reported daycare use, outdoor free play and potential confounding variables. Multivariable linear regression was used to determine the association between daycare attendance and outdoor free play, adjusted for age, sex, maternal ethnicity, maternal education, neighborhood income and season.

Results

There were 2810 children included in this study. Children aged 1 to <3 years (n = 1388) and ≥3 to 5 years (n = 1284) who attended daycare had 14.70 min less (95% CI -20.52, -8.87; P < 0.01) and 9.44 min less (95% CI -13.67, -5.20; P < 0.01) per day of outdoor free play compared with children who did not attend daycare, respectively.

Conclusions

Children who spend more time in daycare have less parent-reported outdoor free play. Parents may be relying on daycare to provide opportunity for outdoor free play and interventions to promote increased active play opportunities outside of daycare are needed.

CNGB3 mutations cause severe rod dysfunction

PURPOSE

Congenital achromatopsia or rod monochromatism is a rare autosomal recessive condition defined by a severe loss of cone photoreceptor function in which rods purportedly retain normal or near-to-normal function. This report describes the results of electroretinography in two siblings with CNGB3-associated achromatopsia.

METHODS

Full field light- and dark-adapted electroretinograms (ERGs) were recorded using standard protocols detailed by the International Society for Clinical Electrophysiology of Vision (ISCEV). We also examined rod-mediated ERGs using series of stimuli that varied over a 6 log unit range of retinal illuminances (-1.9-3.5 log scotopic trolands).

RESULTS

Dark-adapted ERGs in achromatopsia patients exhibited severely reduced b-wave amplitudes with abnormal b:a ratios (1.3 and 0.6). In comparison, the reduction in a-wave amplitude was less marked. The rod-mediated ERG took on an electronegative appearance at high-stimulus illuminances.

CONCLUSION

Although the defect that causes achromatopsia is primarily in the cone photoreceptors, our results reveal an accompanying disruption of rod function that is more severe than has previously been reported. The differential effects on the b-wave relative to the a-wave points to an inner-retinal locus for the disruption of rod function in these patients.

Three year Experience of Non-Melanoma Skin Cancer in a General Practice

We report 85 lesions of non-melanoma skin cancer in 58 patients, representing 9% of the minor surgical workload of a single general practitioner. Cases were studied in order to describe pathology, management and outcomes. Eighteen percent of lesions were referred, mainly because of central facial site and larger size. Of the lesions treated in the surgery, all but four were treated surgically. Quantitative margins of lateral and deep excision were reported for 50% and 30% of specimens respectively. Lateral histological margins of clearance were narrower for head and neck lesions. Incomplete excision occurred in 4%. There was one recurrent lesion after two years of follow-up. A majority of non-melanoma skin cancers at this clinic were managed safely without referral to secondary care. Quantitative reporting of tumour free margins for skin cancer is lacking.

The morphology of human rod ERGs obtained by silent substitution stimulation

Purpose

To record transient ERGs from the light-adapted human retina using silent substitution stimuli which selectively reflect the activity of rod photoreceptors. We aim to describe the morphology of these waveforms and examine how they are affected by the use of less selective stimuli and by retinal pathology.

Methods

Rod-isolating stimuli with square-wave temporal profiles (250/250 ms onset/offset) were presented using a 4 primary LED ganzfeld stimulator. Experiment 1: ERGs were recorded using a rod-isolating stimulus (63 ph Td, rod contrast, C_rod = 0.25) from a group (n = 20) of normal trichromatic observers. Experiment 2: Rod ERGs were recorded from a group (n = 5) using a rod-isolating stimulus (C_rod = 0.25) which varied in retinal illuminance from 40 to 10,000 ph Td. Experiment 3: ERGs were elicited using 2 kinds of non-isolating stimuli; (1) broadband and (2) rod-isolating stimuli which contained varying degrees of L- and M-cone excitation. Experiment 4: Rod ERGs were recorded from two patient groups with rod monochromacy (n = 3) and CSNB (type 1; n = 2).

Results

The rod-isolated ERGs elicited from normal subjects had a waveform with a positive onset component followed by a negative offset. Response amplitude was maximal at retinal illuminances <100 ph Td and was virtually abolished at 400 ph Td. The use of non-selective stimuli altered the ERG waveform eliciting more photopic-like ERG responses. Rod ERGs recorded from rod monochromats had similar features to those recorded from normal trichromats, in contrast to those recorded from participants with CSNB which had an electronegative appearance.

Conclusions

Our results demonstrate that ERGs elicited by silent substitution stimuli can selectively reflect the operation of rod photoreceptors in the normal, light-adapted human retina.

The Generalizability of the Paediatric Developmental Passport: A Multi-Site Randomized Controlled Trial

BACKGROUND: The Pediatric Developmental Passport (passport) is an innovative tracking tool for families of children with autism spectrum disorder (ASD). It provides a mechanism for clearly communicating appropriate regional developmental services, an opportunity track progress in accessing these developmental services and a valuable summary of the developmental care received by that child for pediatrician. A qualitative study with parents and health professionals (developmental pediatricians, developmental nurses, pediatricians) lead to the design and iterative review of the passport.

OBJECTIVES: The objective of this study was to determine the general-izability and effectiveness of the passport compared to placebo in a multi-site pragmatic randomized control trial.

DESIGN/METHODS: A pragmatic multi-site randomized controlled trial was conducted with families of children between 0-6 years of age diagnosed with ASD. Families from two different models of developmental care were enrolled into the study. One site was a sub-urban developmental consultation clinic and the second site was a shared-care model between developmental pediatricians and general pediatricians in an urban resource restricted area. All families included in the study were randomized to receive the passport or placebo (blank card). Agencies providing Autism specific behaviour therapy (ABA) within each site were contacted directly to obtain accurate contact and access status of recommended developmental services. To determine passport effectivenes a pearson’s chi square test was conducted using a significant p value of &lt;0.05.

RESULTS: Forty children with ASD were included and followed in this study. The passport proved to be significantly more effective in aiding families to contact developmental services than the placebo (blank card). A significantly larger portion of families (90.5%) with the passport contacted agencies for ABA (applied behaviour analysis) therapy compared to families with the placebo (61.9%, (p value significant at &lt;0.05). More families with the passport tended to contact ABA in less than 2 months (48%) than the placebo group (35%), but this was not statistically significant.

CONCLUSION: The pediatric developmental passport enables families of children newly diagnosed with Autism to contact necessary behavioural services more often than those who did not receive the passport after diagnosis.

The Relationship between Milk Fat Content, Vitamin D and Adiposity in Early Childhood

BACKGROUND: Fortified cow’s milk is the main dietary source of vitamin D and an important source of dietary fat for North American children. Current guidelines recommend reduced milk fat consumption to reduce childhood obesity, yet the relationship between lower milk fat, vitamin D stores and adiposity is unclear.

OBJECTIVES: The objective of this study was to determine the association between percent fat content of milk and both zBMI and 25-hydroxyvi-tamin D; secondly, to explore if volume of milk consumed modified this relationship.

DESIGN/METHODS: A cross-sectional study of healthy urban children 12-72 months of age was conducted. Bivariate multiple linear regression was used to test the association between percent milk fat content and child 25-hydroxyvitamin D and zBMI concurrently. The interaction between volume of milk consumed and percent milk fat content was examined to explore how milk volume might modify these relationships.

RESULTS: 2745 children were included in the analysis. Percent fat content of milk was positively associated with 25-hydroxyvitamin D (p=0.006), and negatively associated with zBMI (p&lt;0.0001). Children who drank homogenized milk (3.25% fat) had 6.6 nmol/L (95% CI 5.49 to 7.71) higher median 25(OH)D concentration and 0.72 lower (95% CI 0.68 to 0.76) zBMI score than children who drank skim milk (0.1% fat). Volume of milk consumed potentiated the effect of percent fat content of milk on 25-hydroxyvitamin D (p=0.003) but not on zBMI (p=0.77). Children who drank 1 cup of homogenized milk each day had a similar 25-hydroxyvita-min D as children who drank 2.85 cups (95% CI 2.71 to 2.99) of skim milk, but had zBMI score 0.78 (95% CI 0.63, 0.93) units lower.

CONCLUSION: Homogenized milk may be more appropriate than reduced fat milk in maximizing serum 25-hydroxyvitamin D and minimizing adiposity in early childhood. Current guidelines for reduced milk fat consumption in childhood may require further study to achieve desired outcomes.

How Well Does the Nipissing District Developmental Screen (NDDS) Identify Communication Problems in Infants?

BACKGROUND: Communication problems are often the first presenting problem in infants with developmental disabilities. With early detection, intervention can start. The 18-month Nipissing District Developmental Screen (NDDS) was created as a developmental checklist for use in primary care. The Infant Toddler Checklist (ITC) is a validated questionnaire for detecting communication problems. Our objective was to examine how well the 18-month NDDS identifies communication problems. We therefore assessed the convergent validity of the 18-month NDDS with the ITC as a gold standard.

OBJECTIVES: To examine how well the 18-month NDDS identifies communication problems. To compare parents’ answers to a similar question, “How many different words does your child use?”, on both checklists.

DESIGN/METHODS: Healthy children (n = 348, 55% male, mean age 18.6 months, SD 0.7) were recruited during scheduled health supervision visits. Parents completed both the 18-months NDDS and ITC. We assessed the convergent validity of the 18-month NDDS with the ITC as a gold standard. Correlation (Spearman) and the level of agreement (Cohen’s kappa, sensitivity, specificity) were calculated. For our secondary outcome, we compared the percentage of agreement between the answers to the same question on both instruments.

RESULTS: On the NDDS, 138 (39.7%) children had “one or more flags” (+1 NDDS) and 54 (15.8%) children had “two or more flags” (+2 NDDS). 13 (3.7%) infants had a concern on the total ITC score, 31 (8.9%) a speech-, 9 (2.6%) a social -, and 14 (4.0%) a symbolic concern.The +2 NDDS had a medium correlation (Spearman’s rho 0.42) and a fair agreement (Cohen’s kappa 0.32) with the ITC. Sensitivity and specificity of the NDDS using the +1 and + 2 flag cut-offs in detecting concerns compared with the ITC are shown in the table.The similar question about number of words spoken by 18-month old infants revealed agreement between the NDDS and ITC; 24.4% versus 30.8% of the 18-month old infants did not speak 20 words or more respectively.

CONCLUSION: Infants with a severe overall communication delay were identified with the 18-months NDDS. The low sensitivity of the 2+ NDDS flag in detecting speech and social concerns suggests that infants who could benefit from early interventions may not be identified.The low specificity of the 1+ NDDS flag may cause unnecessary concerns for parents.For the early identification of all levels of communicationdelays, we recommend using a standardized questionnaire like the ITC.

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Screening for Risk of Developmental Delay in a primary care setting using the Nippising District Developmental Screen

BACKGROUND: Early growth and development in the first five years of life is strongly associated with health outcomes. The Nipissing District Developmental Screen (NDDS) is a free parent-reported screening tool recommended by the Canadian Pediatric Society as one of the tools for developmental screening in children

OBJECTIVES: To determine the prevalence of a positive screen for risk of developmental delay in a cohort of healthy children at 18-months and 5 years. To identify risk factors (child, socio-demo-graphic and home environment) associated with a positive screen for risk of developmental delay.

DESIGN/METHODS: A cross-sectional study of healthy Canadian children attending 18-months and 5 year well-child visits between June 2008 and February 2015 was conducted through the TARGet Kids! practice-based research network. Multivariable logistic regression was used to identify risk factors associated with a positive screen for developmental delay. Risk factors of development delay identified from literature were:, male sex, low birth weight, low income, low maternal education, maternal unemployment, non-industrialized immigrant status, single parent family, only child and older maternal age.

RESULTS: 1086 children (53% male) at 18 months and 575 children (51% male) at 5 years were included in the final analysis. At 18 months, 341 (31.4%) of children (95% CI, 28.7% - 34.3%) and at 5 years 166 (28.9%) (95% CI, 25.2% -32.8%) were screen positive base on 1+ flag NDDS. At 18 months, children with a low birthweight (OR=1.66; 95% CI 1.22-2.28), with a mother with low education (OR=1.75; 95% CI 1.07-2.85), and those from non-industrialized immigrant families (OR=1.85; 95% CI 1.37-2.49) were associated with an increased odds of a positive screen for developmental delay based on the 1+ NDDS flag. A female child (OR=0.74; 95% CI 0.57-0.96) and an only child (OR=0.76; 95% CI 0.57-0.99) were associated with a decreased odds of a positive screen for developmental delay. At 5 years, factors associated with a positive screen for developmental delay based on the 1+ NDDS flag were: low maternal education (OR 2.24; 95% CI 1.14-4.39) (children had 2.24 times greater odds of a positive screen for developmental delay) and older maternal age (OR 1.05; 95% CI 1.00-1.09) (every 1-year increase in maternal age, children had 1.05 times greater odds of a positive screen for developmental delay). A female child was associated with a decreased odds of a positive screen for developmental delay (OR=0.66; 95% CI 0.46-0.96) based on the 1+ NDDS flag.

CONCLUSION: In a population of healthy urban children the NDDS identified 30% at both 18 month and 5 years at risk for developmental delay. Risk factors for developmental delay were associated with a positive NDDS screen.

SOCCAR: A randomised phase II trial comparing sequential versus concurrent chemotherapy and radical hypofractionated radiotherapy in patients with inoperable stage III Non-Small Cell Lung Cancer and good performance status

BACKGROUND

Cure of lung cancer is impossible without local tumour control. This can be compromised by accelerated repopulation of tumour cells during radiotherapy and chemotherapy. A strategy to minimise accelerated repopulation might improve local control. We investigated whether concurrent chemo-radiotherapy could be given safely over four weeks.

METHODS

We conducted a randomised phase II trial in which patients with inoperable Stage III Non-Small Cell Lung Cancer (NSCLC) received a radical radiation dose over four weeks rather than conventional fractionation. Treatment was given either sequentially or concurrently with three to four cycles of cisplatinum and vinorelbine. 130 patients with inoperable stage III NSCLC and PS 0-1 were randomised to receive cisplatinum and vinorelbine with either sequential or concurrent chemo-radiation using 55Gy in 20 fractions over four weeks. The primary end-point was treatment related mortality. Secondary end-points were toxicity and survival.

FINDINGS

Treatment related mortality was: 2.9% (exact 95% confidence interval [CI] 0.36-10.2%) and 1.7% (exact 95% CI 0.043-9.1%) for the Concurrent and Sequential group respectively; relative risk (RR) 1.25; (95% CI 0.55, 2.84). Toxicity was similar between arms; grade 3 or worse oesophagitis was 8.8% versus 8.5%; RR 1.02 (95% CI 0.58, 1.79). OS HR was 0.92; 95% CI (0.60-1.39; p=0.682). The 2 year overall survival rates were: 50% versus 46%; RR 1.06 (95% CI 0.77, 1.46) for Concurrent versus Sequential.

INTERPRETATION

A strategy to minimise the effects of accelerated repopulation using accelerated hypofractionated radiotherapy with chemotherapy is feasible, and reasonably safe for patients with stage III NSCLC. The reported two year survival is promising and suggests that a four week regime of radiotherapy should be compared with conventionally fractionated radiotherapy in an adequately powered randomised controlled phase III trial.

Emotion and mood adaptations in the peripartum female:complementary contributions of GABA and oxytocin

Peripartum hormones and sensory cues from young modify the maternal brain in ways that can render females either at risk for, or resilient to, elevated anxiety and depression. The neurochemical systems underlying these aspects of maternal emotional and mood states include the inhibitory neurotransmitter GABA and the neuropeptide oxytocin (OXT). Data from laboratory rodents indicate that increased activity at the GABA(A) receptor contributes to the postpartum suppression of anxiety-related behaviour that is mediated by physical contact with offspring, whereas dysregulation in GABAergic signalling results in deficits in maternal care, as well as anxiety- and depression-like behaviours during the postpartum period. Similarly, activation of the brain OXT system accompanied by increased OXT release within numerous brain sites in response to reproductive stimuli also reduces postpartum anxiety- and depression-like behaviours. Studies of peripartum women are consistent with these findings in rodents. Given the similar consequences of elevated central GABA and OXT activity on maternal anxiety and depression, balanced and partly reciprocal interactions between these two systems may be essential for their effects on maternal emotional and mood states, in addition to other aspects of postpartum behaviour and physiology.