The sexuality of women with cervical cancer undergoing definitive radiotherapy in Ghana

INTRODUCTION

The purpose of this study was to assess the sexuality of cervical cancer patients undergoing radiotherapy at a major cancer treatment center in Ghana. This is an area of interest as globally; cervical cancer kills approximately 342,000 people per annum with an estimated number of 604,000 new cases in 2020. Acknowledging the World Health Organization's definition of sexual health as a state of physical, mental and social well-being in relation to sexuality, this paper sheds light on how these dimensions affect the quality of life of cervical cancer patients.

METHODS

This was a longitudinal study, which assessed the impact of radiotherapy on the sexuality of both premenopausal and postmenopausal cervical cancer patients presenting for primary treatment with chemoradiation from April to July, 2021 at a major cancer treatment centre in Ghana. The Female Sexual Function Index and Body Image Scale questionnaires were respectively used to evaluate the sexual functions scores among the cervical cancer patients, and to assess the impact of the treatment on their body image. MATLAB software was used for data analysis.

RESULTS

Most of the cervical cancer patients sampled were postmenopausal (57 %). About 79 % premenopausal and 96 % postmenopausal cervical cancer patients were sexually inactive during radiotherapy (day 15). Also, 48 % premenopausal and 24 % postmenopausal patients were very dissatisfied with their bodies at the onset of treatment. The frequency of orgasm in cervical cancer patients declined after treatment causing a deterioration in their sexual function. The patients' sexuality was influenced by age and menopausal status. The decreased sexual desire of the patients resulted in emotional distancing from their partners, which invariably induced changes in their partners' level of sexual interest. This study established significant differences between premenopausal and postmenopausal cervical cancer patients who were generally very dissatisfied with their sexual relationships with their partners on day 1 (p = 0.02) and on day 15 (p = 0.00) of treatment.

CONCLUSION

The majority of patients who presented for treatment for cervical cancer in this study were postmenopausal. Their interest in sexual activity was more influenced by their menopausal status than their antineoplastic treatment. This study indicates that cervical cancer patients are more likely to develop sexual health problems which could substantially worsen over the course of their treatment and beyond.

IMPLICATION FOR PRACTICE

The study will contribute within the oncology team by assisting personnel in putting in place measures that will guide the treatment of cervical cancer patients and improve quality of care.

Systematic review of the effectiveness of remifentanil in term breech pregnancies undergoing external cephalic version

BACKGROUND

External cephalic version (ECV) is a moderately painful procedure used to turn a fetus from a non-vertex to cephalic position. This systematic review and meta-analysis compared intravenous remifentanil with other analgesia or no analgesia or placebo on the success rate and associated pain of ECV.

METHODS

Systematic searches for randomised controlled trials using remifentanil during ECV for non-cephalic term singleton pregnancies were conducted in EMBASE, MEDLINE and Cochrane Library to October 2021. The primary outcomes were successful ECV and maternal pain; secondary outcomes included mode of delivery and adverse effects. The Cochrane Risk of Bias tool was used and meta-analysis undertaken if there were ≥2 comparable studies.

RESULTS

Four trials were identified, three placebo-controlled and one vs no analgesia, totalling 482 participants. Comparisons against nitrous oxide or neuraxial anaesthesia were not analysed. Two studies had a low overall risk of bias, and two had some concern for bias. Remifentanil compared with placebo increased the success of ECV by 43% (risk ratio [RR] 1.43; 95% confidence interval [CI] 1.14 to 1.78). Pain scores (0-10) were lower (mean difference -1.97; 95% CI -2.49 to -1.46) whilst there was no impact on caesarean delivery rate (RR 0.97; 95% CI 0.81 to 1.17). Adverse events were rare, with fetal bradycardia observed less often with remifentanil than placebo.

CONCLUSIONS

Remifentanil increases the procedural success of ECV and reduces pain compared with placebo. Trials were at low risk of bias and contained a sufficient number of participants to have reasonable confidence in this finding.

Reasons for missed opportunities to screen and test for TB in healthcare facilities

Missed opportunities for TB screening and/or passive testing in clinics continues to contribute to the number of missed cases. To understand reasons for these missed opportunities, we conducted focus group discussions with clinic-based nurses. Nurses described low indices of suspicion, prioritization of seemingly more urgent ailments and clinic operational challenges as barriers to TB screening and testing. To improve TB screening and testing in clinics, standard patients should be used to identify real-time factors that impact nurses' clinical decision-making and engage in real-time feedback and discussion with nurses to help optimize opportunities for TB screening and testing.

An analysis of the influence of atrial wall thickness on the protective effects of proactive esophageal cooling during high-power short-duration radiofrequency ablation

Background

The use of proactive esophageal cooling using a dedicated cooling device during radiofrequency (RF) left atrial ablation has increased, with endoscopic studies showing reductions in esophageal lesions using medium power ablation settings. With no atrioesophageal fistula yet identified using esophageal cooling, and clinical practice increasingly shifting to high-power short-duration (HPSD) ablation, additional data on the protective potential of this technique in HPSD ablation may help guide RF ablation strategies. In particular, a better understanding of the effects of anatomical variations in myocardial thickness on cooling efficacy is warranted.

Purpose

We sought to evaluate the influence of atrial wall thickness on the protective effects of proactive esophageal cooling during HPSD ablation.

Methods

Using a computer model of the left atrium and esophagus, we analyzed the esophageal damage that occurs under two HPSD ablation conditions (50 W for 10 s and 90 W for 4 s) with and without proactive esophageal cooling while varying atrial wall thickness. Injury to the esophagus was quantified using the Arrhenius equation as well as by determining the percentage of tissue reaching a 50°C lethal isotherm. Atrial thickness was varied between 0.6 mm to 2.0 mm. Esophageal cooling was set to the recommended 4°C coolant temperature.

Results

Using 50 W power settings in control (non-cooled) conditions, esophageal lesion transmurality ranged from 75% to 82% as calculated by the Arrhenius equation, with decreased transmurality seen as atrial wall thickness increased. With the addition of proactive cooling, lesion transmurality decreased to less than 43% in the thinnest atrial wall sections, and to less than 25% in the thickest atrial wall sections. Using 90 W power settings, control conditions showed esophageal lesion transmurality ranging from 52% to 63%, with the greatest damage seen in the middle-range atrial thicknesses (1 and 1.5 mm). Active esophageal cooling reduced this esophageal injury to less than 12% transmurality through the esophagus in all anatomic scenarios.

Conclusions

Modeling suggests that the use of proactive esophageal cooling significantly reduces esophageal lesion transmurality under HPSD ablation conditions across a range of typical atrial wall thicknesses, including in very thin myocardium, where the risk of esophageal injury is greatest.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Attune

Patient age, gender, and early outcome after PVI atrial ablation: analysis of a large regional database

Background

Demographics such as patient age and gender have been inconsistently found to be associated with outcome after ablation to achieve pulmonary vein isolation (PVI). A database created by the Dallas-Fort Worth Hospital Council (DFWHC) includes a collaboration of 90 member hospitals in North Texas reporting data on procedures, diagnoses, and discharges. All patients in this system can be followed longitudinally via unique identification number. The availability of this large, regional database offers opportunities to better characterize trends.

Objective

Characterize the association between age, gender, and 60-day outcome in patients receiving PVI over a 7-year time span.

Methods

Using the DFWHC database, all PVI procedures performed from January 2013 to December 2019 were identified. Follow up visits for this cohort of patients were then obtained, and outcomes recorded. Early mortalities (occurring less than 60 days from PVI), mean age and patient gender were determined for each of the groups and compared.

Results

A total of 11,880 unique PVI procedures were performed over this 7 year timeframe. Mean patient age was 64±10 years, with 66% male and 34% female. A total of 130 mortalities at any time after PVI occurred (1.1%), with 19 (0.16%) occurring within 60 days of the procedure. In multivariate analysis, the risk of 60-day mortality increased with year of procedure (OR 1.07, 95% CI 0.85 to 1.4) and female gender (OR 1.43, 95% CI 0.57 to 3.6), and decreased with age (OR 0.99, 95% CI 0.95 to 1.03); however no variable demonstrated statistically significant association with outcome.

Conclusions

Although trends towards increasing mortality over time and in female patients were seen, the total number of events remained low, and no statistically significant associations between age, gender, and early mortality were identified in this large regional database.

Funding Acknowledgement

Type of funding sources: None.

Managing an adult CF population in the COVID-19 pandemic-1 year on

BACKGROUND

The advent of the COVID-19 pandemic in 2020 required an alteration in the routine care of people with CF (pwCF), deemed to be extremely vulnerable.

AIM

We wished to report the alterations in clinical practice, including the introduction of remote video-assisted clinics, made to manage the adult pwCF attending our large centre.

METHODS

We studied clinical records over a period of 2 years (March 2019 to February 2021) by comparing 19th March to 20th February (Y1) with 20th March to 21st February (Y2).

RESULTS

We have shown out of hospital Multi Disciplinary Team (MDT) support increased and a greater proportion of IV therapy was administered at home. The VAC model of care increased clinical activity while reducing clinic non-attendance rates, suggesting more individuals engage with their carers.

CONCLUSIONS

This new model of care has allowed greater engagement with pwCF.

Causes of loss to follow-up from drug-resistant TB treatment in Khayelitsha, South Africa

Patients initiated on drug-resistant TB(DR-TB) treatment in 2019 in Khayelitsha, South Africa, with a loss to follow-up outcome were evaluated to better understand reasons for loss to follow-up and to determine if any had returned to care. Of a total of 187 patients, 28 (15%) were lost to follow-up (LTFU), 24 (86%) of whom were traced: 20/24 (83%) were found when they re-presented to facilities and 8/28 (29%) were linked back to DR-TB care. People with DR-TB continue to seek care even after being LTFU; thus better coordination between different components of the healthcare system are required to re-engage with these patients. Interventions to mitigate the socio-economic challenges of people on DR-TB treatment are needed. Many people who were LTFU and symptomatic were willing to re-engage with DR-TB care, which highlights the importance of for compassionate interventions to welcome them back.

Influence of tissue thickness on thermal latency during high-power short-duration radiofrequency ablation with proactive esophageal cooling

Funding Acknowledgements

Type of funding sources: None.

Background

Thermal latency, or delayed heating, is increasingly recognized as an important factor in the formation of both intentional and unintentional lesions during radiofrequency (RF) ablation for the treatment of atrial fibrillation (AF). High-power short-duration (HPSD) ablation appears to have greater thermal latency than low or medium power ablation. Proactive esophageal cooling (PEC) has been shown to reduce esophageal lesion formation under a variety of conditions by directly reducing the effects of thermal latency, but the influence of anatomic dimensions on the protective efficacy of cooling during HPSD ablation has not been investigated.

Purpose

Determine the impact of changes in pericardial tissue thickness on thermal latency in order to quantify the protective efficacy of PEC across a range of anatomic dimensions.

Methods

We created a mathematical model of the left atrium undergoing HPSD ablation, both with and without a PEC device in place, using a range of pericardial tissue thicknesses (0.5, 0.75, and 1 mm). HPSD ablation was set at 50 W for 10 s, or 90 W for 4 s. We then examined the temperature dynamics at a range of thickness, focusing on the layer of mostly fatty tissue between the atrial and esophageal walls by varying the thickness of this layer while quantifying the degree of esophageal damage using the Arrhenius equation to determine the fraction of damage after peak heating has occurred.

Results

Under control conditions, the growth of lesions from RF ablation at both 50 W and 90 W was found to continue for greater than 10 seconds beyond the cessation of RF energy application. Esophageal lesion formation ranged from 71% to 96% transmurality after 50 W ablation for 10 s, and from 50% to 72% transmurality after 90 W ablation for 4 s. With PEC in place, esophageal lesion transmurality was markedly reduced, with a maximum transmurality ranging from 12% to 32% with 50 W ablation, and from 2% to 20% with 90 W ablation (Figure). Increasing thickness of pericardial tissue (with simulations of 0.5, 0.75, and 1 mm) resulted in decreasing esophageal lesion transmurality (67%, 74%, and 83% at 50 W power, and 72%, 82%, and 96% at 90 W power, respectively, with the 0.5, 0.75, and 1 mm simulations).

Conclusions

Thermal latency with HPSD ablation contributes to lesion growth and can cause esophageal injury. Proactive esophageal cooling counteracts this effect across a range of pericardial tissue thicknesses, and reduces esophageal lesion transmurality by an average of 79%.

Early mortality during rifampicin-resistant TB treatment

BACKGROUND: Data suggest that treatment with newer TB drugs (linezolid [LZD], bedaquiline [BDQ] and delamanid [DLM]), used in Khayelitsha, South Africa, since 2012, reduces mortality due to rifampicin-resistant TB (RR-TB).METHODS: This was a retrospective cohort study to assess 6-month mortality among RR-TB patients diagnosed between 2008 and 2019.RESULTS: By 6 months, 236/2,008 (12%) patients died; 12% (78/651) among those diagnosed in 2008-2011, and respectively 8% (49/619) and 15% (109/738) with and without LZD/BDQ/DLM in 2012-2019. Multivariable analysis showed a small, non-significant mortality reduction with LZD/BDQ/DLM use compared to the 2008-2011 period (aOR 0.79, 95% CI 0.5-1.2). Inpatient treatment initiation (aOR 3.2, 95% CI 2.4-4.4), fluoroquinolone (FQ) resistance (aOR 2.7, 95% CI 1.8-4.2) and female sex (aOR 1.5, 95% CI 1.1-2.0) were also associated with mortality. When restricted to 2012-2019, use of LZD/BDQ/DLM was associated with lower mortality (aOR 0.58, 95% CI 0.39-0.87).CONCLUSIONS: While LZD/BDQ/DLM reduced 6-month mortality between 2012 and 2019, there was no significant effect overall. These findings may be due to initially restricted LZD/BDQ/DLM use for those with high-level resistance or treatment failure. Additional contributors include increased treatment initiation among individuals who would have otherwise died before treatment due to universal drug susceptibility testing from 2012, an effect that also likely contributed to higher mortality among females (survival through to care-seeking).

RhD negative women transfused RhD positive blood: Alloimmunization prophylaxis protocol and experiences

Introduction/Objective

Preventing allomiunization from D-mismatched transfusions, i.e., transfusion RhD positive (RhD+) red blood cells (RBC) to an RhD negative (RhD–) individual, is not well established. We describe our hospital protocol and experiences managing RhD– young women who received emergency release D-mismatched transfusions.

Methods/Case Report

The pathologists evaluate all patients who received D-mismatched blood transfusions. The inclusion criteria for alloimmunization prophylaxis protocol include: RhD– females; <50 years old; No current or historical Anti-D; and received ≥1 unit of RhD+ blood.

The prophylaxis protocol depends on the RBC volume (RBCV) transfused. Patients who receive RBCV <20% of their total blood volume (TBV) are eligible to receive high dose RhIg, calculated based on the volume transfused. Those who received RBCV ≥20% of TBV would be eligible for red cell exchange (RBCX) followed by RhIg.

Results (if a Case Study enter NA)

Since 2016, four eligible patients received RhIg prophylaxis protocol and none met the criteria for RBCX. All the patients started the prophylaxis protocol within 24 hours of transfusion and completed it within 72 hours. One patient developed post treatment hemolysis and significant drop in hemoglobin requiring blood transfusion. Passive anti-D post treatment was confirmed in three patients, and one had passive anti C. Three of the four patients had follow up antibody screens >6 months post treatment that were negative for RhD alloimmunization.

Conclusion

Our therapeutic plan, the first well established protocol, involves identifying eligible patients based on set criteria and protocols. Our experience demonstrates that this protocol is effective in reducing/preventing RhD alloimmunization.

977 The Role of Telephone Triage in Head and Neck Cancer Care in a Teaching Hospital

Introduction

NHS England sets standards to ensure prompt specialist review, diagnosis, and treatment of cancer. Patients with suspected cancer should receive specialist review within 14 days of referral, diagnosis by day 28 and first treatment by day 62. To reduce transmission during the SARS-CoV-2 pandemic, the NHS recommended telephone triage as the first specialist appointment. The effect of telephone triage on head and neck cancer timeframes in an NHS teaching hospital was assessed.

Method

Four head and neck cancer telephone triage clinics during July 2020 were selected at random. Clinical correspondence and the electronic patient records were reviewed for each patient and cancer pathway timeframes were analysed.

Results

31 patients were referred for telephone triage and 100% received specialist review within 14 days. Subsequently 17 (55%) patients were investigated, 12 (71%) of which received a diagnosis within 28 days. 4 patients received a cancer diagnosis, but none received first treatment within 62 days. 24 (77%) patients were seen in a face-to-face clinic after telephone triage on average 7 days after telephone triage.

Conclusions

In this sample, telephone triage allowed safe initial specialist review by meeting the 14-day standard. However, the 28-day diagnosis and 62-day treatment standards were not adhered to. Telephone triage does not largely reduce overall patient contact, with 77% of patients subsequently reviewed in a patient-facing setting. The addition of telephone triage delayed first clinical examination by a specialist by an average of 7 days, which may be a contributing factor to the delays seen in diagnosis and treatment.

Pathophysiology of aniridia-associated keratopathy: Developmental aspects and unanswered questions

Aniridia, a rare congenital disease, is often characterized by a progressive, pronounced limbal insufficiency and ocular surface pathology termed aniridia-associated keratopathy (AAK). Due to the characteristics of AAK and its bilateral nature, clinical management is challenging and complicated by the multiple coexisting ocular and systemic morbidities in aniridia. Although it is primarily assumed that AAK originates from a congenital limbal stem cell deficiency, in recent years AAK and its pathogenesis has been questioned in the light of new evidence and a refined understanding of ocular development and the biology of limbal stem cells (LSCs) and their niche. Here, by consolidating and comparing the latest clinical and preclinical evidence, we discuss key unanswered questions regarding ocular developmental aspects crucial to AAK. We also highlight hypotheses on the potential role of LSCs and the ocular surface microenvironment in AAK. The insights thus gained lead to a greater appreciation for the role of developmental and cellular processes in the emergence of AAK. They also highlight areas for future research to enable a deeper understanding of aniridia, and thereby the potential to develop new treatments for this rare but blinding ocular surface disease.

POS1472-HPR CLINICIANS’ PERSPECTIVES ON PSYCHOLOGICAL DISTRESS AND MEETING PATIENTS’ SUPPORT NEEDS IN RHEUMATOLOGY CARE SETTINGS

Background:

People with inflammatory rheumatic diseases (IRDs) face challenges that include fluctuations in pain, fatigue and flares of disease activity, complex medical regimens, and decisions about when to seek clinical help with symptoms [1,2]. Evidence suggests levels of anxiety and depression are higher in people with IRDs compared to the general population [3]. Rheumatology teams report that psychologically distressed patients can have additional support needs and require more time. Patients’ concerns include health-related anxiety and difficulty accepting the diagnosis. This group can have poor outcomes and poor adherence to treatments. However, little is currently known about optimal ways to meet these patients’ support needs.

Objectives:

To understand rheumatology clinicians’ perspectives on psychological distress in care settings with the long-term aim to develop a proposed model/pathway of support.

Methods:

Telephone interviews were conducted with members of UK rheumatology teams who have clinical experience with patients experiencing distress. The semi-structured interviews explored both ‘what happens now’ (current clinical practice) and ‘what should happen’ (acceptable models of future psychological support provision). The semi-structured format provided flexibility to probe more deeply and develop new lines of enquiry based on participants’ responses.

Results:

Fourteen interviews were conducted with rheumatology clinicians including 2 consultants, 4 nurses, 1 physiotherapist, 4 occupational therapists, 2 clinical psychologists and 1 podiatrist. Inductive thematic analysis was used to analyse the data. Two main themes represent the data (Table 1).

Table 1.Main ThemeSub-themes1. ‘No one shoe fits all’ – the many manifestations of distress in patients.‘I pick up on distress as increased emotion…tearfulness and sadness I suppose, but also frustration, anger...A lot of helplessness comments’1. ‘Distress can be quite emotive and quite obvious, but then it can also hide away’2. ‘They’re [patients] trying to manage their own conditions, but they’re also trying to manage life’2. ‘If Rheumatology could be interwoven with psychological principles’ – the need to attend to the psychological impact of IRDs, alongside the physical impact.‘The physical and mental health side of things are so closely linked because one affects the other…after a while they [patients] don’t really know what’s affecting what’1. ‘Prioritising physical health…sometimes the stress gets not thought about’2. ‘Make best use of everyone in the team to work with patients who are struggling’3. ‘For the psychological side of things we don’t measure anything about that at all’

Conclusion:

Distress can be obvious or hidden and cause issues for both patient and clinician. It can lead to poor engagement with care provision. Clinicians differ in their perceptions of distress and in their thresholds for dealing with distress and have described the inconsistency of support offered for distressed patients. They described the powerful link between physical and mental distress, the vicious cycle that can develop, and the benefits of incorporating a psychological approach to treatment. This study suggests psychological support should be embedded within the team as it is felt there is a need for speciality understanding and for patients’ emotional wellbeing to consistently be given equal priority to their physical wellbeing.

References:

[1]Gettings L. Psychological well-being in rheumatoid arthritis: a review of the literature. Musculoskeletal care 2010;8(2):99-106. doi: 10.1002/msc.171 [published Online First: 2010/03/17]

[2]Homer D. Addressing psychological and social issues of rheumatoid arthritis within the consultation: a case report. Musculoskeletal care 2005;3(1):54-9. doi: 10.1002/msc.26 [published Online First: 2006/10/17]

[3]Isik A, Koca SS, Ozturk A, et al. Anxiety and depression in patients with rheumatoid arthritis. Clinical rheumatology 2007;26(6):872-8. doi: 10.1007/s10067-006-0407-y [published Online First: 2006/08/31]

Disclosure of Interests:

None declared

Uterine artery embolisation or myomectomy for women with uterine fibroids wishing to avoid hysterectomy: a cost-utility analysis of the FEMME trial

OBJECTIVES

To assess the cost-effectiveness of uterine artery embolisation (UAE) and myomectomy for women with symptomatic uterine fibroids wishing to avoid hysterectomy.

DESIGN

Economic evaluation alongside the FEMME randomised controlled trial.

SETTING

29 UK hospitals.

POPULATION

Premenopausal women who had symptomatic uterine fibroids amenable to UAE or myomectomy wishing to avoid hysterectomy. 254 women were randomised to UAE (127) and myomectomy (127).

METHODS

A within-trial cost-utility analysis was conducted from the perspective of the UK NHS.

MAIN OUTCOME MEASURES

Quality-adjusted life years (QALYs) measured using the EuroQoL EQ-5D-3L, combined with costs to estimate cost-effectiveness over 2 and 4 years of follow-up.

RESULTS

Over a 2-year time horizon, UAE was associated with higher mean costs (difference £645; 95% CI -1381 to 2580) and lower QALYs (difference -0.09; 95% CI -0.11 to -0.04) when compared with myomectomy. Similar results were observed over the 4-year time horizon. Thus, UAE was dominated by myomectomy. Results of the sensitivity analyses were consistent with the base case results for both years. Over 2 years, UAE was associated with higher costs (difference £456; 95% CI -1823 to 3164) and lower QALYs (difference -0.06; 95% CI -0.11 to -0.02).

CONCLUSIONS

Myomectomy is a cost-effective option for the treatment of uterine fibroids. The differences in costs and QALYs are small. Women should be fully informed and have the option to choose between the two procedures.

Dichloroacetate as a possible treatment for endometriosis-associated pain: a single-arm open-label exploratory clinical trial (EPiC)

Background

Endometriosis (where endometrial-like tissue is found outside the uterus) affects ~ 176 million women worldwide and can lead to debilitating pelvic pain. There is an unmet need for new medical treatment options for endometriosis. Pelvic peritoneal mesothelial cells of women with endometriosis exhibit detrimental metabolic reprogramming that creates an environment favouring the formation and survival of endometriosis lesions. We have generated powerful preclinical proof-of-concept data to show that it is possible to correct this metabolic phenotype using dichloroacetate (DCA), a non-hormonal compound previously used to treat rare metabolic disorders in children. We plan a single-arm, open-label, single site exploratory clinical trial to inform the design of a future randomised controlled trial (RCT) to determine the efficacy of DCA for the treatment of endometriosis-associated pain.

Methods

We will recruit 30 women with endometriosis-associated pain over a 6-month period. All participants will receive approximately 6.25 mg/kg oral DCA capsules twice daily for 6 weeks, with a dose increase to approximately 12.5 mg/kg twice daily for a further 6 weeks if their pain has not been adequately controlled on this dose regime and side-effects are acceptable. If pain is adequately controlled with minimal side-effects, the lower dose will be continued for a further 6 weeks. The primary objective is to determine whether it is possible to achieve acceptable recruitment and retention rates within the defined exclusion and inclusion criteria. Secondary objectives are to determine the acceptability of the trial to participants, including the proposed methods of recruitment, treatment, follow-up frequency and number of questionnaires. The recruitment rate will be determined by the proportion of patients recruited from the pool of eligible women. The retention rate will be determined by the proportion of participants who attended the final trial visit.

Discussion

This is a feasibility study to explore effectiveness and acceptability of the proposed field methodology (recruitment, retention, study processes and compliance with treatment). The results will be used to inform the design of a future RCT.

Trial registration

ClinicalTrials.gov, NCT04046081 Registered 6 August 2019

Practitioner review: health anxiety in children and young people in the context of the COVID-19 pandemic

Health-related fear is a normal and common response in the face of the global pandemic of COVID-19. Children and young people are frequently being exposed to messages about the threat to health, including from the media and authorities. Whilst for most, their anxiety will be proportionate to the threat, for some, existing pre-occupation with physical symptoms and illness will become more problematic. There is a growing body of evidence that health anxiety may occur in childhood, however much of the literature is taken from research using adult samples. This practitioner review aims to give an overview of the assessment and treatment of health-related worries in children and young people in the context of the COVID-19 pandemic. This review is based on the limited existing evidence in this population and the more substantial evidence base for treating health anxiety in adults. We consider the adaptations needed to ensure such interventions are developmentally appropriate.

Brief Enhanced Partner Notification and Risk Reduction Counseling to Prevent Sexually Transmitted Infections, Cape Town, South Africa

BACKGROUND

Evidence-based interventions are needed to stem sexually transmitted infections (STIs). Clinic-delivered counseling remains an important avenue for effective STI prevention.

METHODS

A 3-arm randomized clinical trial compared (a) STI health education control condition, (b) risk reduction counseling, and (c) enhanced partner notification counseling. Men and women (n = 1050) were recruited from an STI clinic in Cape Town, South Africa. After baseline assessments, participants were randomly allocated to receive 1 of the 3 single-session counseling interventions and were followed up for 9 months of behavioral assessments and 12 months of electronic medical records abstraction for STI clinic services.

RESULTS

Sexual risk reduction counseling reported greater condom use than did the other 2 conditions during the 3 and 6 months follow-ups. In addition, women receiving risk reduction counseling were significantly less likely to have returned for STI clinic services but did not differ in the number of STI clinic visits over the year.

CONCLUSIONS

Brief single-session STI prevention counseling demonstrates significant targeted outcomes. The findings suggest that counseling approaches to both increase condom use and enhance partner notification may offer more robust and sustained outcomes and should be tested in future research.

Crop production in the USA is frequently limited by a lack of pollinators

Most of the world's crops depend on pollinators, so declines in both managed and wild bees raise concerns about food security. However, the degree to which insect pollination is actually limiting current crop production is poorly understood, as is the role of wild species (as opposed to managed honeybees) in pollinating crops, particularly in intensive production areas. We established a nationwide study to assess the extent of pollinator limitation in seven crops at 131 locations situated across major crop-producing areas of the USA. We found that five out of seven crops showed evidence of pollinator limitation. Wild bees and honeybees provided comparable amounts of pollination for most crops, even in agriculturally intensive regions. We estimated the nationwide annual production value of wild pollinators to the seven crops we studied at over $1.5 billion; the value of wild bee pollination of all pollinator-dependent crops would be much greater. Our findings show that pollinator declines could translate directly into decreased yields or production for most of the crops studied, and that wild species contribute substantially to pollination of most study crops in major crop-producing regions.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Effects of enhanced STI partner notification counselling and provider-assisted partner services on partner referral and the incidence of STI diagnosis in Cape Town, South Africa: randomised controlled trial

Objectives

We investigated the effects of an enhanced partner notification (PN) counselling intervention with the offer of provider-assisted referral among people diagnosed with STI in a Cape Town public clinic.

Methods

Participants were adults diagnosed with STI at a community clinic. After the standard STI consultation, participants were randomly allocated in a 1:1:1 ratio to (1) ‘HE’: 20 min health education; (2) ‘RR’: 45 min risk reduction skills counselling; or (3) ‘ePN’: 45 min enhanced partner notification communication skills counselling and the offer of provider-assisted referral. The primary outcome was the incidence of repeat STI diagnoses during the 12 months after recruitment, and the secondary outcome was participants’ reports 2 weeks after diagnosis of notifying recent partners. Incidence rate ratios (IRRs) were used to compare the incidence rates between arms using a Poisson regression model.

Results

The sample included 1050 participants, 350 per group, diagnosed with STI between June 2014 and August 2017. We reviewed 1048 (99%) participant records, and identified 136 repeat STI diagnoses in the ePN arm, 138 in the RR arm and 141 in the HE arm. There was no difference in the annual incidence of STI diagnosis between the ePN and HE arms (IRR: 1.0; 95% CI 0.7 to 1.3), or between the RR and HE arms (IRR: 0.9; 95% CI 0.7 to 1.2). There was a greater chance of a partner being notified in the ePN condition compared with the HE condition, 64.3% compared with 53.8%, but no difference between the RR and HE arms.

Conclusions

PN counselling and education with provider-assisted services has the potential to change the behaviour of people diagnosed with STIs, increasing the number of partners they notify by more than 10%. However, these changes in behaviour did not lead to a reduction of repeat STI diagnoses.

Trial registration number

PACTR201606001682364.

Petawatt Laser Guiding and Electron Beam Acceleration to 8 GeV in a Laser-Heated Capillary Discharge Waveguide

Guiding of relativistically intense laser pulses with peak power of 0.85 PW over 15 diffraction lengths was demonstrated by increasing the focusing strength of a capillary discharge waveguide using laser inverse bremsstrahlung heating. This allowed for the production of electron beams with quasimonoenergetic peaks up to 7.8 GeV, double the energy that was previously demonstrated. Charge was 5 pC at 7.8 GeV and up to 62 pC in 6 GeV peaks, and typical beam divergence was 0.2 mrad.

EMERGENCE OF BEDAQUILINE RESISTANCE AFTER COMPLETION OF BEDAQUILINE-BASED DRUGRESISTANT TB TREATMENT: A CASE STUDY FROM SOUTH AFRICA

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Missed opportunities for earlier diagnosis of rifampicin-resistant tuberculosis despite access to Xpert® MTB/RIF

OBJECTIVE

To assess the proportion of rifampicin-resistant tuberculosis (RR-TB) patients with potential earlier RR-TB diagnoses in Khayelitsha, South Africa.

DESIGN

We conducted a retrospective analysis among RR-TB patients diagnosed from 2012 to 2014. Patients were considered to have missed opportunities for earlier diagnosis if 1) they were incorrectly screened according to the Western Cape diagnostic algorithm; 2) the first specimen was not tested using Xpert® MTB/RIF; 3) no specimen was ever tested; or 4) the initial Xpert test showed a negative result, but no subsequent specimen was sent for follow-up testing in human immunodeficiency virus-positive patients.

RESULTS

Among 543 patients, 386 (71%) were diagnosed with Xpert and 112 (21%) had had at least one presentation at a health care facility within the 6 months before the presentation at which RR-TB was diagnosed. Overall, 95/543 (18%) patients were screened incorrectly at some point: 48 at diagnostic presentation only, 38 at previous presentation only, and 9 at both previous and diagnostic presentations.

CONCLUSIONS

These data show that a significant proportion of RR-TB patients might have been diagnosed earlier, and suggest that case detection could be improved if diagnostic algorithms were followed more closely. Further training and monitoring is required to ensure the greatest benefit from universal Xpert implementation.

Assessing the impact of a waiting time survey on reducing waiting times in urban primary care clinics in Cape Town, South Africa

A waiting time survey (WTS) conducted in several clinics in Cape Town, South Africa provided recommendations on how to shorten waiting times (WT). A follow-up study was conducted to assess whether WT had reduced. Using a stratified sample of 22 clinics, a before and after study design assessed changes in WT. The WT was measured and perceptions of clinic managers were elicited, about the previous survey's recommendations. The overall median WT decreased by 21 minutes (95%CI: 11.77-30.23), a 28% decrease from the previous WTS. Although no specific factor was associated with decreases in WT, implementation of recommendations to reduce WT was 2.67 times (95%CI: 1.33-5.40) more likely amongst those who received written recommendations and 2.3 times (95%CI: 1.28-4.19) more likely amongst managers with 5 or more years' experience. The decrease in WT found demonstrates the utility of a WTS in busy urban clinics in developing country contexts. Experienced facility managers who timeously receive customised reports of their clinic's performance are more likely to implement changes that positively impact on reducing WT.

Adjuvant psychological therapy in long-term endocrine conditions

Consideration of psychological distress in long-term endocrine conditions is of vital importance given the prevalence of anxiety and depression in such disorders. Poor mental health can lead to compromised self-care, higher utilization of health services, lower rates of adherence, reduced quality of life and ultimately poorer outcomes. Adjuvant psychological therapy offers an effective resource to reduce distress in endocrine conditions. While the vast majority of work in this area has focused on psychological screening and intervention in diabetes, identification and recognition of psychological distress are equally important in other endocrinological conditions, with supportive evidence in polycystic ovary syndrome and Addison's disease. Referral pathways and recommendations set out by UK guidelines and the Department of Health mandate requires greater attention across a wider range of long-term endocrine conditions to facilitate improved quality of life and health outcome.

A Quantitative Trait Locus Associated With Cognitive Ability in Children

Quantitative trait loci (QTLs) associated with general cognitive ability ( g) were investigated for several groups of children selected for very high or for average cognitive functioning. A DNA marker in the gene for insulin-like growth factor-2 receptor (IGF2R) on Chromosome 6 yielded a significantly greater frequency of a particular form of the gene (allele) in a high- g group (.303; average IQ = 136, N = 51) than in a control group (.156; average IQ = 103, N = 51). This association was replicated in an extremely-high- g group (all estimated IQs > 160, N = 52) as compared with an independent control group (average IQ = 101, N = 50), with allelic frequencies of .340 and .169, respectively. Moreover, a high-mathematics-ability group ( N = 62) and a high-verbal-ability group ( N = 51) yielded results that were in the same direction but only marginally significant ( p = .06 and .08, respectively).

Multistage coupling of independent laser-plasma accelerators

Laser-plasma accelerators (LPAs) are capable of accelerating charged particles to very high energies in very compact structures. In theory, therefore, they offer advantages over conventional, large-scale particle accelerators. However, the energy gain in a single-stage LPA can be limited by laser diffraction, dephasing, electron-beam loading and laser-energy depletion. The problem of laser diffraction can be addressed by using laser-pulse guiding and preformed plasma waveguides to maintain the required laser intensity over distances of many Rayleigh lengths; dephasing can be mitigated by longitudinal tailoring of the plasma density; and beam loading can be controlled by proper shaping of the electron beam. To increase the beam energy further, it is necessary to tackle the problem of the depletion of laser energy, by sequencing the accelerator into stages, each powered by a separate laser pulse. Here, we present results from an experiment that demonstrates such staging. Two LPA stages were coupled over a short distance (as is needed to preserve the average acceleration gradient) by a plasma mirror. Stable electron beams from a first LPA were focused to a twenty-micrometre radius--by a discharge capillary-based active plasma lens--into a second LPA, such that the beams interacted with the wakefield excited by a separate laser. Staged acceleration by the wakefield of the second stage is detected via an energy gain of 100 megaelectronvolts for a subset of the electron beam. Changing the arrival time of the electron beam with respect to the second-stage laser pulse allowed us to reconstruct the temporal wakefield structure and to determine the plasma density. Our results indicate that the fundamental limitation to energy gain presented by laser depletion can be overcome by using staged acceleration, suggesting a way of reaching the electron energies required for collider applications.

Active Plasma Lensing for Relativistic Laser-Plasma-Accelerated Electron Beams

Compact, tunable, radially symmetric focusing of electrons is critical to laser-plasma accelerator (LPA) applications. Experiments are presented demonstrating the use of a discharge-capillary active plasma lens to focus 100-MeV-level LPA beams. The lens can provide tunable field gradients in excess of 3000 T/m, enabling cm-scale focal lengths for GeV-level beam energies and allowing LPA-based electron beams and light sources to maintain their compact footprint. For a range of lens strengths, excellent agreement with simulation was obtained.

Outcome in fetal lower urinary tract obstruction: a prospective registry study

OBJECTIVE

To describe influences on decision-making and prognostic variables in the prenatal management of fetal lower urinary tract obstruction (LUTO).

METHODS

This was a prospective registry study of pregnant women with a male fetus with LUTO from centers within the British Isles and The Netherlands. Women and/or their clinicians were given the treatment option of either conservative management or vesicoamniotic shunting (VAS). Baseline characteristics of women in the registry, reasons for entry to the registry and pregnancy outcomes were assessed. The main study outcomes were survival to 28 days after delivery, further survival to 2 years and renal function. Logistic regression analysis was used to examine prognostic variables that affected outcome. Results were compared with those of women in a randomized controlled trial (RCT) who were allocated randomly to a treatment option.

RESULTS

Forty-five women were registered, of whom 78% (35/45) underwent conservative management. Twenty-seven women entered the registry owing to their clinician's preference for management and 18 because of their own preference. Compared to the conservative-management group of the RCT, a higher proportion of women in the registry opting for conservative management had a normal amniotic fluid volume at diagnosis (P = 0.05) and a diagnosis of LUTO ≥ 24 weeks' gestation (P = 0.003). On multivariable logistic regression analysis, these variables showed a significant association with perinatal survival (P < 0.001). Survival to 28 days after delivery was higher in the conservative-management group, at 69% (24/35), compared to 40% (4/10) in the VAS group (P = 0.02) but this difference had limited statistical significance owing to small study size (relative risk, 0.58 (95% CI, 0.26-1.29); P = 0.14).

CONCLUSION

In our prospective registry, the majority of fetuses with LUTO received conservative management, which was associated with better short- and long-term outcomes. A significant proportion of these pregnancies had normal amniotic fluid volume and a gestational age at diagnosis of ≥ 24 weeks, characteristics shown to be associated with improved survival.