Psychosocial outcomes after varying risk management strategies in women at increased familial breast cancer risk: a mixed methods study of patient and partner outcomes

INTRODUCTION

Female carriers of BRCA1/2 genes have an increased lifetime risk of breast cancer. Options for managing risk include imaging surveillance or risk-reducing surgery (RRS). This mixed methods study aimed to identify factors affecting risk-management decisions and the psychosocial outcomes of these decisions for high-risk women and their partners.

METHODS

Semi-structured qualitative interviews were performed with women at high breast cancer risk who had faced these choices. Partners were also interviewed. Analysis used a framework approach. A bespoke questionnaire was developed to quantify and explore associations.

RESULTS

A total of 32 women were interviewed. Of these, 27 had partners of whom 7 (26%) agreed to be interviewed. Four main themes arose: perception of risk and impact of increased risk; risk-management strategy decision-making; impact of risk-management strategy; support needs and partner relationship issues. The questionnaire response rate was 36/157 (23%). Decision satisfaction was high in both surveillance and RRS groups. Relationship changes were common but not universal. Common causes of distress following RRS included adverse body image changes. Both groups experienced generalised and cancer-specific anxiety. Drivers for surgery included having children, deaths of close family from breast cancer and higher levels of cancer anxiety.

CONCLUSIONS

Levels of psychosocial and decision satisfaction were high for women choosing both RRS and surveillance but, for a minority, risk-reducing measures result in long-term psychosocial morbidity. Efforts to recognise women at increased risk of psychological morbidity may allow targeted support.

Associations between religious/spiritual beliefs and behaviours and dietary patterns: analysis of the parental generation in a prospective cohort study (ALSPAC) in Southwest England

OBJECTIVE

Religious/spiritual beliefs and behaviours (RSBB) have been associated with health outcomes, with diet a potential mediator of this relationship. We therefore explored whether RSBB were associated with differences in diet.

DESIGN

Dietary patterns and nutrient intakes were derived from food frequency questionnaire completed by pregnant women in 1991-1992 (mean age = 28·3 years, range = 15-46) and by the mothers and partners 4 years post-partum (mothers mean age = 32·3, range = 19-49; partners mean age = 34·5, range = 18-74). RSBB exposures measured in pregnancy included religious belief, affiliation and attendance. We first explored whether RSBBs were associated with dietary patterns in confounder-adjusted linear regression models. If associations were found, we examined whether RSBB were associated with nutrient intake (linear regression) and following nutrient intake guidelines (logistic regression).

SETTING

Prospective birth cohort study in Southwest England (Avon Longitudinal Study of Parents and Children; ALSPAC).

PARTICIPANTS

13 689 enrolled mothers and their associated partners.

RESULTS

In pregnant women, RSBB were associated with higher 'traditional' (i.e. 'meat and two veg') and lower 'vegetarian' dietary pattern scores. Religious attendance and non-Christian religious affiliation were associated with higher 'health-conscious' dietary pattern scores. Religious attendance was associated with increased micronutrient intake and following recommended micronutrient intake guidelines, with weaker effects for religious belief and affiliation. Comparable patterns were observed for mothers and partners 4 years post-partum, although associations between RSBB and nutrient intakes were weaker for partners.

CONCLUSIONS

RSBBs are associated with broad dietary patterns and nutrient intake in this cohort. If these reflect causal relationships, diet may potentially mediate the pathway between RSBB and health.

Demographic and socioeconomic predictors of religious/spiritual beliefs and behaviours in a prospective cohort study (ALSPAC) in Southwest England: Results from the parental generation

Background: We explored associations between possible demographic and socioeconomic causes of religious/spiritual beliefs and behaviours (RSBB) in the parental generation of the Avon Longitudinal Study of Parents and Children (ALSPAC). Methods : We used a prospective birth cohort study (ALSPAC) in Southwest England with 14,157 enrolled mothers and 14,154 associated partners. Three RSBB outcome measures collected during pregnancy were examined: religious belief (belief in God/a divine power; yes/not sure/no), religious affiliation (Christian/none/other) and religious attendance (frequency of attendance at a place of worship). Multiple demographic and socioeconomic exposures were assessed (23 in mothers and 22 in partners). We explored age-adjusted associations between each exposure and outcome using multinomial regression, in addition to exposure-age interactions. Results: Many demographic and socioeconomic factors were associated with RSBB, including age, ethnicity, marital status, education, income and deprivation. Overall, higher socioeconomic position was associated with increased levels of RSBB, particularly regarding religious attendance. For instance, compared to mothers with the lowest level of educational attainment, a degree-level education was associated with a six-fold increase in the relative risk ratio of religious attendance at least once a week, relative to not attending at all (RRR=5.90; 95% CI=[4.44; 7.86]). The magnitude of these associations often varied by outcome, e.g., income was associated with religious attendance, but only weakly with religious affiliation. Although results were demographically and socially patterned, overall effect sizes were relatively small, with a largest pseudo- R 2 value of 2.4%. Patterns of association were similar for mothers and partners. Conclusion: The observed positive association between socioeconomic position and RSBB is contrary to much previous theoretical and empirical work. Potential reasons for these differences are discussed, including cross-cultural variation in religiosity and state support, and differences between RSBB measures. This descriptive paper can also help inform future studies using these data regarding the consideration of appropriate confounders.

Demographic and socioeconomic predictors of religious/spiritual beliefs and behaviours in a prospective cohort study (ALSPAC) in Southwest England: Results from the parental generation

Background: We explored associations between possible demographic and socioeconomic causes of religious/spiritual beliefs and behaviours (RSBB) in the parental generation of the Avon Longitudinal Study of Parents and Children (ALSPAC). Methods : We used a prospective birth cohort study (ALSPAC) in Southwest England with 14,157 enrolled mothers and 14,154 associated partners. Three RSBB outcome measures collected during pregnancy were examined: religious belief (belief in God/a divine power; yes/not sure/no), religious affiliation (Christian/none/other) and religious attendance (frequency of attendance at a place of worship). Multiple demographic and socioeconomic exposures were assessed (23 in mothers and 22 in partners). We explored age-adjusted associations between each exposure and outcome using multinomial regression, in addition to exposure-age interactions. Results: Many demographic and socioeconomic factors were associated with RSBB, including age, ethnicity, marital status, education, income and deprivation. Overall, higher socioeconomic position was associated with increased levels of RSBB, particularly regarding religious attendance. For instance, compared to mothers with the lowest level of educational attainment, a degree-level education was associated with a six-fold increase in the relative risk ratio of religious attendance at least once a week, relative to not attending at all (RRR=5.90; 95% CI=[4.44; 7.86]). The magnitude of these associations often varied by outcome, e.g., income was associated with religious attendance, but only weakly with religious affiliation. Although results were demographically and socially patterned, overall effect sizes were relatively small, with a largest pseudo- R 2 value of 2.4%. Patterns of association were similar for mothers and partners. Conclusion: The observed positive association between socioeconomic position and RSBB is contrary to much previous theoretical and empirical work. Potential reasons for these differences are discussed, including cross-cultural variation in religiosity and state support, and differences between RSBB measures. This descriptive paper can also help inform future studies using these data regarding the consideration of appropriate confounders.

Demographic and socioeconomic predictors of religious/spiritual beliefs and behaviours in a prospective cohort study (ALSPAC) in Southwest England: Results from the offspring generation

Background: We explored associations between possible demographic and socioeconomic causes of religious/spiritual beliefs and behaviours (RSBB) in the offspring generation of the Avon Longitudinal Study of Parents and Children (ALSPAC). Methods: We examined approximately 4,450 offspring aged 28 years with RSBB data from a prospective birth cohort study (ALSPAC) in Southwest England. Three RSBB outcome measures were assessed: religious belief (belief in God/a divine power; yes/not sure/no), religious affiliation (Christian/none/other) and religious attendance (frequency of attendance at a place of worship). We explored age- and sex-adjusted associations between 35 demographic and socioeconomic exposures and each of the three RSBB outcomes using multinomial regression. Exposure-sex interactions were also examined. Results: Some sociodemographic factors were associated with RSBB in this cohort; for instance, being female and from an ethnicity other than White were associated with increased religiosity across all domains. For many other exposures, however, associations were frequently null or inconsistent, often depending on the specific exposure and outcome combination. As an example, higher educational attainment was associated with higher rates of religious attendance, but not with religious belief or affiliation; in contrast, higher income was associated with lower levels of religiosity. No consistent interactions between sex and the exposures on RSBB were found. Effect sizes were also rather weak, with most pseudo-R2 values below 0.5% and a maximum of 1.2%. Conclusions: The results highlight that several demographic and socioeconomic factors are associated with RSBB in this cohort. However, the number of these associations, and their magnitude, is smaller than comparable results from the parental generation of these offspring, suggesting that patterns of sociodemographic factors associated with RSBB differ between these generations. In addition to describing these associations, this paper will help inform future studies using these data, particularly regarding the choice of potential sociodemographic confounders.

X-ray pulse generation with ultra-fast flipping of its orbital angular momentum

A method to temporally tailor the properties of X-ray radiation carrying Orbital Angular Momentum (OAM) is presented. In simulations, an electron beam is prepared with a temporally modulated micro-bunching structure which, when radiating at the second harmonic in a helical undulator, generates OAM light with a corresponding temporally modulated intensity. This method is shown to generate attosecond pulse trains of OAM light without the need for any additional external optics, making the wavelength range tunable. In addition to the OAM pulse train, the method can be adapted to generate radiation where the handedness of the OAM mode may also be temporally modulated (flipped).

Religious/spiritual beliefs and behaviours and study participation in a prospective cohort study (ALSPAC) in Southwest England

Background Longitudinal studies are key to understanding risk factors for health, well-being, and disease, yet associations may be biased if study invitation and participation are non-random. Religious/spiritual beliefs and behaviours (RSBB) are increasingly recognised as having potentially important relationships with health. However, it is unclear whether RSBB is associated with study participation. We examine whether RSBB is associated with participation in the longitudinal birth cohort ALSPAC (Avon Longitudinal Study of Parents and Children). Methods Three RSBB factors were used: religious belief (belief in God/a divine power; yes/not sure/no), religious affiliation (Christian/none/other), and religious attendance (frequency of attendance at a place of worship). Participation was measured in three ways: i) total number of questionnaires/clinics completed; ii) completion of the most recent questionnaire (in 2020); and iii) length of participation. Analyses were repeated for the ALSPAC mothers, their partners, and the study children, and were adjusted for relevant socio-demographic confounders. Results Religious attendance was positively associated with participation in all adjusted models in all three cohorts. For example, study mothers who attended a place of worship at least once a month on average completed two more questionnaires (out of a possible 50), had 50% greater odds of having completed the most recent questionnaire, and had 25% reduced risk of drop-out, relative to those who did not attend a place of worship. In the adjusted analyses, religious belief and attendance were not associated with participation. However, the majority of unadjusted models showed associations between RSBB and participation. Conclusion After adjusting for confounders, religious attendance –  not religious belief or affiliation – was associated with participation in ALSPAC. These results indicate that use of RSBB variables (and religious attendance in particular) may result in selection bias and spurious associations; these potential biases should be explored and discussed in future studies using these data.

Are tomorrow's doctors prepared to prevent dementia? A cross-sectional study of Tasmanian medical students' knowledge of dementia risk factors

Tomorrow's doctors are unprepared to prevent dementia. This cross-sectional study invited medical students enrolled in the University of Tasmania 5-year medical degree (MBBS) to participate in an online questionnaire during 2019. This study measured students' recall of risk factors, prompted and unprompted, for dementia and cardiovascular disease (CVD), and Dementia Knowledge Assessment Scale (DKAS) score. Data were collected via an online survey comprising the DKAS, and risk factor questions adapted from the Alzheimer's Research UK National Monitor Survey, with questions on CVD risk factors added for comparison. Medical students (n = 82) proffered fewer unprompted risk factors for dementia than for CVD and were less proficient at recognizing dementia risk factors from a prompted list. Knowledge of vascular risk factors for dementia was particularly limited. Their broader dementia knowledge was generally adequate and DKAS scores were at the level of a qualified doctor by final year. Whilst medical students' general knowledge of dementia was satisfactory, their knowledge of modifiable risk factors of dementia was limited. If replicated elsewhere, this raises concerns about whether the future medical workforce is equipped to take a necessary lead role in managing dementia risk reduction. As dementia incidence rises worldwide, and 40% cases are attributable to modifiable risk factors, educational programs may need to urgently address these deficiencies.

EP.TH.602Exploring decision-making of healthcare professionals in patients with benign large non-pedunculated colonic polyps (BLNPCP) virtually using combined focus group and nominal group technique

Aim

We aimed to elicit key factors that influence healthcare professional decision-making when deciding treatment for BLNPCP.

Background

Benign large non-pedunculated colonic polyps (BLNPCP) may harbour covert malignancy and opinions differ about the optimal treatment modality. There are several options available, including endoscopic mucosal resection, endoscopic submucosal resection, combined endoscopic laparoscopic surgery and surgical resection. Despite widespread availability of endoscopic resection techniques, there are high rates of surgery in the UK.

Methods

Three focus groups of healthcare professionals, comprised of either consultant colorectal surgeons, nurse endoscopists and consultant gastroenterologists, were conducted virtually utilising the Nominal Group Technique. Meetings were recorded and transcribed verbatim. Themes were devolved using the framework approach for qualitative analysis. A priority-ranked list of factors influencing healthcare professional decision-making in this setting was generated.

Results

Five main themes were identified as influencing decision-making: Shared decision making (patient preference, informed consent); Patient factors (co-morbidity, age, life-expectancy); Polyp factors (Location, size, morphology, risk of cancer); Healthcare professionals (skill-set, personal preference); System factors (techniques availability locally, regional referral networks). Nominal Group Technique generated 55 items across the three focus groups. Nurses and gastroentologists ranked patient factors (particularly drug history and tolerance of procedure) and shared decision making (patient preference) more highly then surgeons. Surgeons placed greater emphasis on polyp factors particularly location and the risk of submucosal invasive carcinoma.

Conclusion

Decision making is complex and multifactorial. These results support the benefits of complex polyp MDTs and patient involvement in the decision-making. The complexity of decision-making may underpin wide variation in practice.

626 Barriers Faced by Female Surgical Trainees – A Qualitative Study

Aim

Today women make up 56% of medical students, yet just 12% of surgical consultants, a number that has remained static since 2013. This qualitative study aimed to explore the barriers to female success in modern surgery.

Method

Semi-structured qualitative interviews were undertaken primarily with female surgical trainees to determine the barriers they face. Male trainees and Training Programme Directors were also interviewed for triangulation.

Results

Nineteen interviews were performed (15 female trainees, 3 male trainees and 1 TPD) between October 2019 and March 2020. Family pressures and becoming a mother were significant barriers for women training in surgery, a barrier that did not apply to male trainees who were fathers, often resulting in women choosing to train less than full time (LTFT). Unfortunately, LTFT training presents further obstacles for female trainees. The set-up of the National training programme in surgery provides many non-gender specific barriers, chiefly moving hospital every 6 months resulting in disrupted training and long commutes. Sexism and discrimination are still common, both from colleagues and patients. Many participants perceived inherent differences between genders in communication and methods for coping with stress.

Conclusions

Greater gender equality in surgery may be achieved by changes in the structure and organisation of training to reduce the tension between the professional role and the predominantly female-led role of raising children. Better equality and diversity training and awareness at all levels in surgery may help to mitigate some of the conscious and unconscious bias that still exists.

Bridging the age gap in breast cancer: cluster randomized trial of two decision support interventions for older women with operable breast cancer on quality of life, survival, decision quality, and treatment choices

BACKGROUND

Rates of surgery and adjuvant therapy for breast cancer vary widely between breast units. This may contribute to differences in survival. This cluster RCT evaluated the impact of decision support interventions (DESIs) for older women with breast cancer, to ascertain whether DESIs influenced quality of life, survival, decision quality, and treatment choice.

METHODS

A multicentre cluster RCT compared the use of two DESIs against usual care in treatment decision-making in older women (aged at least ≥70 years) with breast cancer. Each DESI comprised an online algorithm, booklet, and brief decision aid to inform choices between surgery plus adjuvant endocrine therapy versus primary endocrine therapy, and adjuvant chemotherapy versus no chemotherapy. The primary outcome was quality of life. Secondary outcomes included decision quality measures, survival, and treatment choice.

RESULTS

A total of 46 breast units were randomized (21 intervention, 25 usual care), recruiting 1339 women (670 intervention, 669 usual care). There was no significant difference in global quality of life at 6 months after the baseline assessment on intention-to-treat analysis (difference -0.20, 95 per cent confidence interval (C.I.) -2.69 to 2.29; P = 0.900). In women offered a choice of primary endocrine therapy versus surgery plus endocrine therapy, knowledge about treatments was greater in the intervention arm (94 versus 74 per cent; P = 0.003). Treatment choice was altered, with a primary endocrine therapy rate among women with oestrogen receptor-positive disease of 21.0 per cent in the intervention versus 15.4 per cent in usual-care sites (difference 5.5 (95 per cent C.I. 1.1 to 10.0) per cent; P = 0.029). The chemotherapy rate was 10.3 per cent at intervention versus 14.8 per cent at usual-care sites (difference -4.5 (C.I. -8.0 to 0) per cent; P = 0.013). Survival was similar in both arms.

CONCLUSION

The use of DESIs in older women increases knowledge of breast cancer treatment options, facilitates shared decision-making, and alters treatment selection. Trial registration numbers: EudraCT 2015-004220-61 (https://eudract.ema.europa.eu/), ISRCTN46099296 (http://www.controlled-trials.com).

Long-term outcomes of latissimus dorsi flap breast reconstructions: A single-centre observational cohort study with up to 12 years of follow up

INTRODUCTION

The Latissimus Dorsi Myocutaneous Flap (LDMF) is used in post-mastectomy reconstruction. This study has evaluated long-term (up to 12 years) surgical- and patient-reported outcomes from LDMF procedures.

METHOD

A retrospective analysis of consecutive LDMF procedures in two UK hospitals, performed between 2006 and 2016. Case notes were reviewed for indications and outcomes. Patients were sent the BREAST-Q^Ⓡ survey by post. Outcomes, including surgical adverse events, revision, and implant loss rates, were correlated with patient risk factors.

RESULTS

A BREAST-Q was posted to 199/248 LDMF patients in 2018, (excluding 49 patients due to death, reduced cognitive function and incorrect coding) of whom 77 patients responded (38.7%). In 188 cases (representing 208 LDMFs), surgical outcomes were assessable. Median time since LDMF surgery was 7 years (range 2-12). Rates of acute implant loss were 9/139 (6.4%), flap necrosis 7/208 (3.4%), shoulder stiffness 4/208 (1.9%), chronic pain 24/208 (11.5%) and unplanned revision surgery 13/208 (7%). Median satisfaction levels were high with 78% of patients satisfied with treatment outcomes, 65% of patients satisfied with their breasts, 71% of patients satisfied psychosocially and 75% of patients satisfied with their chest. Receipt of radiotherapy was not associated with a higher risk of flap necrosis or capsule formation.

CONCLUSION

Long-term follow-up of a large cohort of LDMF reconstruction patients show relatively low levels of adverse events and unplanned revision surgery and high patient satisfaction, which demonstrates how temporally robust the technique is. With the rise in popularity of acellular dermal matrix reconstructions, the LDMF has relatively fallen out of favour but its potential in primary and delayed reconstruction is demonstrated.

The burden and epidemiology of hepatitis B and hepatitis D in Georgia: findings from the national seroprevalence survey

OBJECTIVES

The burden of hepatitis B virus (HBV) and hepatitis D virus (HDV) infections is unknown in Georgia. This analysis describes the prevalence of hepatitis B and coinfection with HDV and the demographic characteristics and risk factors for persons with HBV infection in Georgia.

STUDY DESIGN

This is a cross-sectional seroprevalence study.

METHODS

A cross-sectional, nationwide survey to assess hepatitis B prevalence among the general adult Georgian population (age ≥18 years) was conducted in 2015. Demographic and risk behavior data were collected. Blood specimens were screened for anti-hepatitis B core total antibody (anti-HBc). Anti-HBc-positive specimens were tested for hepatitis B surface antigen (HBsAg). HBsAg-positive specimens were tested for HBV and HDV nucleic acid. Nationally weighted prevalence estimates and adjusted odds ratios (aORs) for potential risk factors were determined for anti-HBc and HBsAg positivity.

RESULTS

The national prevalence of anti-HBc and HBsAg positivity among adults were 25.9% and 2.9%, respectively. Persons aged ≥70 years had the highest anti-HBc positivity (32.7%), but the lowest HBsAg positivity prevalence (1.3%). Anti-HBc positivity was associated with injection drug use (aOR = 2.34; 95% confidence interval [CI] = 1.46-3.74), receipt of a blood transfusion (aOR = 1.68; 95% CI = 1.32-2.15), and sex with a commercial sex worker (aOR = 1.46; 95% CI = 1.06-2.01). HBsAg positivity was associated with receipt of a blood transfusion (aOR = 2.72; 95% CI = 1.54-4.80) and past incarceration (aOR = 2.72; 95% CI = 1.25-5.93). Among HBsAg-positive persons, 0.9% (95% CI = 0.0-2.0) were HDV coinfected.

CONCLUSIONS

Georgia has an intermediate to high burden of hepatitis B, and the prevalence of HDV coinfection among HBV-infected persons is low. Existing infrastructure for hepatitis C elimination could be leveraged to promote hepatitis B elimination.

Effectiveness of Community Based Interventions in Reducing Maternal Mortality in Sub-Saharan Africa: A Systematic Review

Background & Aim: Maternal mortality ratio for sub- Saharan Africa in 2010 was estimated to be about 600 per 100,000 live births, which is approximately higher than what is obtainable in advanced countries. To this end, several community-based interventions have been put in place by governments and developmental partners in the region to address the situation. This review aimed to seek evidence from existing literature on the level of effectiveness of these interventions in improving maternal health outcomes in the region. The literature search process resulted in retrieval of six full text studies that were written in English, published between 2000 and 2019 and were focused on intervention based at the community level which resulted in the reduction of maternal deaths in some sub-Saharan African countries. The Critical Appraisal Skills Programme (CASP) tool was used to critically review retrieved literature. Findings: Findings from the articles reviewed show that community based interventions with direct reduction on maternal mortality were implemented in Ethiopia and Nigeria and were effective since maternal mortality declined by 64% and 43.5% respectively. Other community based interventions did not directly address reduction in maternal mortality but rather addressed leading causes of maternal mortality such as home and unskilled birth attendance, low Ante-Natal Care (ANC) & Post-Natal Care (PNC) services utilization, Eclampsia, delay in accessing care  and Postpartum Hemorrhage (PPH). Such interventions were implemented in Nigeria, Zambia, Tanzania and the Democratic Republic of Congo and were proved to be effective in reducing maternal mortality. Conclusions and Recommendations: Based on the literatures reviewed, it was concluded that community based interventions were effective in reducing maternal mortality in Sub-Saharan Africa. The following recommendations were made based on gaps observed in the implementation of some interventions. Introduction of emergency transport scheme in countries where they do not exist as despite the existence of maternity waiting homes and dedicated maternity ambulances in Zambia, many expectant mothers still had difficulty reaching the health facilities in time to deliver, Engagement and training of more health workers so as to avoid human resources challenges that may be associated with increased demand for health facility deliveries.

How do parents perceive and utilize knowledge of their infant's mental health? A systematic review

Infant mental health (IMH) is a growing area of practice for health, education and social care practitioners, as links are increasingly made between experiences in the early years and subsequent child development, mental health and well-being. It is unclear how parents perceive IMH and use knowledge relating to IMH with their children. We conducted a systematic review, the aim of which was to determine parents' perceptions of IMH and how they utilize this knowledge with their infants. We undertook a search of relevant databases and journals and from an initial list of 4147 potential papers, identified 16 for the review. Original data were extracted and presented in a table, and the content of all papers was analysed thematically and presented in narrative form. Three main themes emerged from the available research: knowledge and understanding of child development, influences of society and culture, and interpretation of emotions and expressions. Our results indicate that research is limited in terms of parental perspectives of IMH and how they obtain and use this knowledge. Further research is needed to investigate this topic to maximize mental well-being in infancy and later life.

Mobilization of iron from ferritin: new steps and details

Much evidence indicates that iron stored in ferritin is mobilized through protein degradation in lysosomes, but concerns about this process have lingered, and the mechanistic details of its aspects are lacking. In the studies presented here, ⁵⁹Fe-labeled ferritin was induced by preloading hepatic (HepG2) cells with radiolabeled Fe. Placing these cells in a medium containing desferrioxamine resulted in the loss of ferritin-⁵⁹Fe, but adding high concentrations of reducing agents or modulating the internal GSH concentration failed to alter the rates of ferritin-⁵⁹Fe release. Confocal microscopy showed that Fe deprivation increased the movement of ferritin into lysosomes and hyperaccumulation was observed when lysosomal proteolysis was inhibited. It also resulted in the rapid movement of DMT1 to lysosomes, which was inhibited by bafilomycin. Ferrihydrite crystals isolated from purified rat liver/spleen ferritin were solubilized at pH 5 and 7 by GSH, ascorbate, citrate and lysosomal fluids obtained from livers and J774a.1 macrophages. The inhibition of DMT1/Nramp2 and siRNA knockdown of Nramp1 each reduced the transfer of ⁵⁹Fe from lysosomes to the cytosol; and hepatocyte-specific knockout of DMT1 in mice prevented the release of Fe from the liver responding to EPO treatment, but did not inhibit lysosomal ferritin degradation. We conclude that ferritin-Fe mobilization does not occur through changes in cellular concentrations of reducing/chelating agents but by the coordinated movement of ferritin and DMT1 to lysosomes, where the ferrihydrite crystals exposed by ferritin degradation dissolve in the lysosomal fluid, and the reduced iron is transported back to the cytosol via DMT1 in hepatocytes, and by both DMT1 and Nramp1 in macrophages, prior to release into the blood or storage in ferritin.

A validated severity score for haemorrhoids as an essential prerequisite for future haemorrhoid trials

BACKGROUND

There is a lack of standardised outcomes for haemorrhoidal disease making comparison between trials difficult. A need for a very well validated severity score is essential to facilitate meta-analysis of comparative studies, enabling evidence-based clinical practice.

METHODS

The Hubble trial provides a large cohort of patients with haemorrhoidal disease randomised to rubber band ligation (RBL) or haemorrhoidal artery ligation. The haemorrhoid severity score (HSS) was collected on each patient at baseline, 6 weeks and 1 year after intervention. This allows for the responsiveness of the HSS instrument to be examined and compared with a more specific instrument, the Vaizey incontinence score (also collected). Responsiveness was tested using four methods (effect size, standardised response means (SRM), significance of change, and responsiveness statistic).

RESULTS

The four tests of responsiveness demonstrated that the HSS was more responsive to changes in the patient's health status following both of the interventions compared to the Vaizey questionnaire. For example, between baseline and 6 weeks, the RBL intervention effect size scores and SRM calculations indicated a non-significant small amount of change (0.20 and 0.16 respectively). However, using the HSS, the effect size and SRM demonstrated a large magnitude of change (1.12 and 1.01, respectively) which was significant. Similar results were observed at 1 year. Significance of change scores and the index of responsiveness were also higher for the HSS questionnaire than the Vaizey across both treatment modalities.

CONCLUSIONS

The HSS is a highly responsive tool for the detection of changes in haemorrhoid symptoms. It should form an essential patient-reported outcome tool for future studies on haemorrhoidal disease.

Prolonged and large outbreak of invasive group A Streptococcus disease within a nursing home: repeated intrafacility transmission of a single strain

OBJECTIVES

Multiple invasive group A Streptococcus (GAS) infections were reported to public health by a skilled nursing facility (facility A) in Illinois between May 2014 and August 2016. Cases continued despite interventions including antibiotic prophylaxis for all residents and staff. Two other geographically close facilities reported contemporaneous outbreaks of GAS. We investigated potential reasons for ongoing transmission.

METHODS

We obtained epidemiologic data from chart review of cases and review of facility and public health records from previous investigations into the outbreak. Infection control practices at facility A were observed and evaluated. Whole genome sequencing followed by phylogenetic analysis was performed on available isolates from the three facilities.

RESULTS

From 2014 to 2016, 19 invasive and 60 noninvasive GAS infections were identified at facility A occurring in three clusters. Infection control evaluations during clusters 2 and 3 identified hand hygiene compliance rates of 14% to 25%, appropriate personal protective equipment use in only 33% of observed instances, and deficient wound-care practices. GAS isolates from residents and staff of all three facilities were subtype emm89.0; on phylogenetic analysis, facility A isolates were monophyletic and distinct.

CONCLUSIONS

Inadequate infection control and improper wound-care practices likely led to this 28-month-long outbreak of severe infections in a skilled nursing facility. Whole genome sequencing and phylogenetic analysis suggested that intrafacility transmission of a single highly transmissible GAS strain was responsible for the outbreak in facility A. Integration of genomic epidemiology tools with traditional epidemiology and infection control assessments was helpful in investigation of a facility-wide outbreak.

Controlled comparison of two crisis resolution and home treatment teams

Aims and method

To compare an existing crisis resolution service with a new crisis resolution team (CRT) in Wales. The impact of the new team was measured by changes in bed days and admissions. A random sample of patients from each service was assessed for service satisfaction, social functioning and quality of life after first presentation.

Results

The total number of bed days was reduced following the introduction of the new CRT (27.3%). The frequency and duration of compulsory admissions increased by 31% in the CRT between the first and second years and by 7% in the control service, offset by a greater reduction in informal admissions in the CRT (23.5%) compared with the control group (13.3%); overall bed usage was unchanged. Service satisfaction, social functioning and quality of life showed no important differences between the services.

Clinical implications

Crisis resolution teams may reduce informal admissions in the short term but at the cost of more compulsory admissions later.