The accuracy of prehospital triage decisions in English trauma networks - a case-cohort study

BACKGROUND

Care for injured patients in England is provided by inclusive regional trauma networks. Ambulance services use triage tools to identify patients with major trauma who would benefit from expedited Major Trauma Centre (MTC) care. However, there has been no investigation of triage performance, despite its role in ensuring effective and efficient MTC care. This study aimed to investigate the accuracy of prehospital major trauma triage in representative English trauma networks.

METHODS

A diagnostic case-cohort study was performed between November 2019 and February 2020 in 4 English regional trauma networks as part of the Major Trauma Triage Study (MATTS). Consecutive patients with acute injury presenting to participating ambulance services were included, together with all reference standard positive cases, and matched to data from the English national major trauma database. The index test was prehospital provider triage decision making, with a positive result defined as patient transport with a pre-alert call to the MTC. The primary reference standard was a consensus definition of serious injury that would benefit from expedited major trauma centre care. Secondary analyses explored different reference standards and compared theoretical triage tool accuracy to real-life triage decisions.

RESULTS

The complete-case case-cohort sample consisted of 2,757 patients, including 959 primary reference standard positive patients. The prevalence of major trauma meeting the primary reference standard definition was 3.1% (n=54/1,722, 95% CI 2.3 - 4.0). Observed prehospital provider triage decisions demonstrated overall sensitivity of 46.7% (n=446/959, 95% CI 43.5-49.9) and specificity of 94.5% (n=1,703/1,798, 95% CI 93.4-95.6) for the primary reference standard. There was a clear trend of decreasing sensitivity and increasing specificity from younger to older age groups. Prehospital provider triage decisions commonly differed from the theoretical triage tool result, with ambulance service clinician judgement resulting in higher specificity.

CONCLUSIONS

Prehospital decision making for injured patients in English trauma networks demonstrated high specificity and low sensitivity, consistent with the targets for cost-effective triage defined in previous economic evaluations. Actual triage decisions differed from theoretical triage tool results, with a decreasing sensitivity and increasing specificity from younger to older ages.

Obesity is South Africa's new HIV epidemic

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Haemodynamic response to pre-hospital emergency anaesthesia in trauma patients within an urban helicopter emergency medical service

PURPOSE

Pre-hospital emergency anaesthesia is routinely used in the care of severely injured patients by pre-hospital critical care services. Anaesthesia, intubation, and positive pressure ventilation may lead to haemodynamic instability. The aim of this study was to identify the frequency of new-onset haemodynamic instability after induction in trauma patients with a standardised drug regime.

METHODS

A retrospective database analysis was undertaken of all adult patients treated by a physician-led urban pre-hospital care service over a 6-year period. The primary outcome measure was the frequency of new haemodynamic instability following pre-hospital emergency anaesthesia. The association of patient characteristics and drug regimes with new haemodynamic instability was also analysed.

RESULTS

A total of 1624 patients were included. New haemodynamic instability occurred in 231 patients (17.4%). Patients where a full-dose regime was administered were less likely to experience new haemodynamic instability than those who received a modified dose regime (9.7% vs 24.8%, p < 0.001). The use of modified drug regimes became more common over the study period (p < 0.001) but there was no change in the rates of pre-existing (p = 0.22), peri-/post-anaesthetic (p = 0.36), or new haemodynamic instability (p = 0.32).

CONCLUSION

New haemodynamic instability within the first 30 min following pre-hospital emergency anaesthesia in trauma patients is common despite reduction of sedative drug doses to minimise their haemodynamic impact. It is important to identify non-drug factors that may improve cardiovascular stability in this group to optimise the care received by these patients.

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

BACKGROUND

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

METHODS

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

FINDINGS

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

INTERPRETATION

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

FUNDING

Boehringer Ingelheim and Eli Lilly.

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

BACKGROUND

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

METHODS

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

FINDINGS

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

INTERPRETATION

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

FUNDING

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

Ferromagnetic resonators synthesized by metal-organic decomposition epitaxy

Metal-organic decomposition epitaxy is an economical wet-chemical approach suitable to synthesize high-quality low-spin-damping films for resonator and oscillator applications. This work reports the temperature dependence of ferromagnetic resonances and associated structural and magnetic quantities of yttrium iron garnet nanofilms that coincide with single-crystal values. Despite imperfections originating from wet-chemical deposition and spin coating, the quality factor for out-of-plane and in-plane resonances approaches 600 and 1000, respectively, at room temperature and 40 GHz. These values increase with temperature and are 100 times larger than those offered by commercial devices based on complementary metal-oxide semiconductor voltage-controlled oscillators at comparable production costs.

An extension of the BioAssay Ontology to include pharmacokinetic/pharmacodynamic terminology for the enrichment of scientific workflows

With the capacity to produce and record data electronically, Scientific research and the data associated with it have grown at an unprecedented rate. However, despite a decent amount of data now existing in an electronic form, it is still common for scientific research to be recorded in an unstructured text format with inconsistent context (vocabularies) which vastly reduces the potential for direct intelligent analysis. Research has demonstrated that the use of semantic technologies such as ontologies to structure and enrich scientific data can greatly improve this potential. However, whilst there are many ontologies that can be used for this purpose, there is still a vast quantity of scientific terminology that does not have adequate semantic representation. A key area for expansion identified by the authors was the pharmacokinetic/pharmacodynamic (PK/PD) domain due to its high usage across many areas of Pharma. As such we have produced a set of these terms and other bioassay related terms to be incorporated into the BioAssay Ontology (BAO), which was identified as the most relevant ontology for this work. A number of use cases developed by experts in the field were used to demonstrate how these new ontology terms can be used, and to set the scene for the continuation of this work with a look to expanding this work out into further relevant domains. The work done in this paper was part of Phase 1 of the SEED project (Semantically Enriching electronic laboratory notebook (eLN) Data).

Definitions matter: detection rates and perinatal outcome for infants classified prenatally as having late fetal growth restriction using SMFM biometric vs ISUOG/Delphi consensus criteria

OBJECTIVES

Fetal growth restriction (FGR) is often secondary to placental dysfunction and is suspected prenatally based on biometric or circulatory abnormalities detected on ultrasound. The aims of this study were to compare the screening performance of the Society for Maternal-Fetal Medicine (SMFM) biometric criteria (estimated fetal weight (EFW) or abdominal circumference (AC) < 10th centile) with that of the International Society of Ultrasound in Obstetrics and Gynecology (ISUOG)-endorsed Delphi consensus criteria for late FGR for delivery of a small-for-gestational-age (SGA) infant at term, emergency Cesarean section (CS) for non-reassuring fetal status (NRFS), perinatal mortality and composite severe neonatal morbidity.

METHODS

We classified retrospectively non-anomalous singleton infants as having late FGR (diagnosed ≥ 32 weeks) according to SMFM and ISUOG/Delphi criteria in a cohort of women who had been referred to the Mater Mother's Hospital, Brisbane, Australia and who delivered at term between January 2014 and December 2020. The study outcomes were delivery of a SGA infant (birth weight (BW) < 10th or < 3rd centile), emergency CS for NRFS, perinatal mortality (defined as stillbirth or neonatal death within 28 days of a live birth) and a composite of severe neonatal morbidity. We assessed the screening performance of various ultrasound variables by calculating the sensitivity, specificity, positive (PPV) and negative (NPV) predictive values, false-positive and false-negative rates, positive likelihood ratio (LR+) and negative likelihood ratio.

RESULTS

The SMFM and ISUOG/Delphi consensus criteria collectively classified 1030 cases as having late FGR. Of these, 400 cases were classified by both SMFM and ISUOG/Delphi criteria, whilst 548 cases were classified using only SMFM criteria and 82 cases were classified only by ISUOG/Delphi criteria. Prenatal detection of late FGR by SMFM and ISUOG/Delphi criteria was associated with increased odds of delivery of an infant with BW < 10th centile (SMFM: adjusted odds ratio (aOR), 133.0 (95% CI, 94.7-186.6); ISUOG/Delphi: aOR, 69.5 (95% CI, 49.1-98.2)) or BW < 3rd centile (SMFM: aOR, 348.7 (95% CI, 242.6-501.2); ISUOG/Delphi: aOR, 215.4 (95% CI, 148.4-312.7)). Compared with the SMFM criteria, the ISUOG/Delphi criteria were associated with lower odds (aOR, 0.5 (95% CI, 0.3-0.8)) of predicting a SGA infant with BW < 10th centile, but higher odds of predicting emergency CS for NRFS (aOR, 2.30 (95% CI, 1.14-4.66)) and composite neonatal morbidity (aOR, 1.22 (95% CI, 1.05-1.41)). Both SMFM and ISUOG/Delphi criteria were associated with high LR+, specificity, PPV and NPV for the prediction of infants with BW < 10th and BW < 3rd centile. However, both methods functioned much less efficiently for the prediction of composite severe neonatal morbidity or emergency CS for NRFS, with LR+ < 10. The SMFM biometric criteria alone, particularly AC < 3rd centile, had the highest LR+ values for the prediction of perinatal mortality.

CONCLUSION

Both the SMFM and ISUOG/Delphi criteria had strong screening potential for the detection of infants with BW < 10th or < 3rd centile but not for adverse neonatal outcome. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Central tropical Pacific convection drives extreme high temperatures and surface melt on the Larsen C Ice Shelf, Antarctic Peninsula

Northern sections of the Larsen Ice Shelf, eastern Antarctic Peninsula (AP) have experienced dramatic break-up and collapse since the early 1990s due to strong summertime surface melt, linked to strengthened circumpolar westerly winds. Here we show that extreme summertime surface melt and record-high temperature events over the eastern AP and Larsen C Ice Shelf are triggered by deep convection in the central tropical Pacific (CPAC), which produces an elongated cyclonic anomaly across the South Pacific coupled with a strong high pressure anomaly over Drake Passage. Together these atmospheric circulation anomalies transport very warm and moist air to the southwest AP, often in the form of "atmospheric rivers", producing strong foehn warming and surface melt on the eastern AP and Larsen C Ice Shelf. Therefore, variability in CPAC convection, in addition to the circumpolar westerlies, is a key driver of AP surface mass balance and the occurrence of extreme high temperatures.

Control of complex behavior by astrocytes and microglia

Evidence that glial cells influence behavior has been gaining a steady foothold in scientific literature. Out of the five main subtypes of glial cells in the brain, astrocytes and microglia have received an outsized share of attention with regard to shaping a wide spectrum of behavioral phenomena and there is growing appreciation that the signals intrinsic to these cells as well as their interactions with surrounding neurons reflect behavioral history in a brain region-specific manner. Considerable regional diversity of glial cell phenotypes is beginning to be recognized and may contribute to behavioral outcomes arising from circuit-specific computations within and across discrete brain nuclei. Here, we summarize current knowledge on the impact of astrocyte and microglia activity on behavioral outcomes, with a specific focus on brain areas relevant to higher cognitive control, reward-seeking, and circadian regulation.

Mechanisms associated with the rapid decline in sea ice cover around a stranded ship in the Lazarev Sea, Antarctica

In the satellite data era starting from 1979, the extent of Antarctic sea ice increased moderately for the first 37 years. However, the extent decreased to record low levels from 2016 to 2020, with the drop being greatest in the Weddell and Lazarev Seas of the Southern Ocean. An important question for the scientific fraternity and policymakers is to understand what ocean-atmospheric processes triggered such a rapid decline in sea ice. We employ in-situ, satellite, and atmospheric reanalysis data to examine the causative mechanism of anomalous sea ice variability in the Lazarev Sea at a time of ice growth in the annual cycle (March-April 2019), when a cargo ship was stuck in extensive ice cover and freed following the unusual decline in sea ice. High-resolution Sentinel-1 synthetic aperture radar captured a distinct view of the ship location and track within extensive ice cover of fast sea ice, dense pack ice, and icebergs in the Lazarev Sea on 27 March 2019. Subsequently, the sea ice cover declined and reached the fourth lowest extent in the entire satellite record during April 2019 which was 25.6% lower than the long-term mean value of 2.65 × 10⁶ km². We show that the anomalous sea ice variability was due to the occurrence of eastward-moving polar cyclones, including a quasi-stationary explosive development that impacted sea ice through extreme changes in ocean-atmospheric conditions. The cyclone-induced dynamic (poleward propagation of ocean waves and ice motion) and thermodynamic (heat and moisture plumes from midlatitudes, ocean mixed layer warming) processes coupled with high tides provided a conducive environment for an exceptional decline in sea ice over the region of ship movement.

Gut Microbiota of Wild Fish as Reporters of Compromised Aquatic Environments Sleuthed through Machine Learning

Human-generated negative impacts on aquatic environments are rising. Despite wild fish playing a key role in aquatic ecologies and comprising a major global food source, physiological consequences of these impacts to them are poorly understood. Here we address the issue through the lens of interrelationship between wild fish and their gut microbiota, hypothesizing that fish microbiota are reporters of the aquatic environs. Two geographically separate teleost wild-fish species were studied (Lake Erie, Ohio and Caribbean Sea, US Virgin Islands). At each geo-location, fresh fecal samples were collected from fish in areas of presence or absence of known aquatic compromise. Gut microbiota was assessed via microbial 16S-rRNA gene sequencing and represents the first complete report for both fish species. Despite marked differences in geography, climate, water type, fish species, habitat, diet and gut microbial compositions, the pattern of shifts in microbiota shared by both fish species was nearly identical due to aquatic compromise. Next, these data were subjected to Machine Learning (ML) to examine reliability for using the fish-gut microbiota as an eco-marker for anthropogenic aquatic impacts. Independent of geo-location, ML predicted aquatic compromise with remarkable accuracy (>90%). Overall, this study represents the first multi-species stress-related comparison of its kind and demonstrates the potential of artificial intelligence via ML as a tool for bio-monitoring and detecting compromised aquatic conditions.

Adaptive strategies of sponges to deoxygenated oceans

Ocean deoxygenation is one of the major consequences of climate change. In coastal waters, this process can be exacerbated by eutrophication, which is contributing to an alarming increase in the so-called 'dead zones' globally. Despite its severity, the effect of reduced dissolved oxygen has only been studied for a very limited number of organisms, compared to other climate change impacts such as ocean acidification and warming. Here, we experimentally assessed the response of sponges to moderate and severe simulated hypoxic events. We ran three laboratory experiments on four species from two different temperate oceans (NE Atlantic and SW Pacific). Sponges were exposed to a total of five hypoxic treatments, with increasing severity (3.3, 1.6, 0.5, 0.4 and 0.13 mg O₂  L^-1 , over 7-12-days). We found that sponges are generally very tolerant of hypoxia. All the sponges survived in the experimental conditions, except Polymastia crocea, which showed significant mortality at the lowest oxygen concentration (0.13 mg O₂  L^-1 , lethal median time: 286 h). In all species except Suberites carnosus, hypoxic conditions do not significantly affect respiration rate down to 0.4 mg O₂  L^-1 , showing that sponges can uptake oxygen at very low concentrations in the surrounding environment. Importantly, sponges displayed species-specific phenotypic modifications in response to the hypoxic treatments, including physiological, morphological and behavioural changes. This phenotypic plasticity likely represents an adaptive strategy to live in reduced or low oxygen water. Our results also show that a single sponge species (i.e., Suberites australiensis) can display different strategies at different oxygen concentrations. Compared to other sessile organisms, sponges generally showed higher tolerance to hypoxia, suggesting that sponges could be favoured and survive in future deoxygenated oceans.

Predictors of suicide attempts in male UK gamblers seeking residential treatment

BACKGROUND

Disordered gambling can have serious negative consequences for the individual and those around them. Previous research has indicated that disordered gamblers are at an increased risk of suicidal thoughts, ideation and attempts. The current study sought to utilise data from a clinical sample to identify factors that are associated with prior suicide attempts.

METHODS

The sample included 621 patients entering a gambling-specific residential facility in the UK. A series of Chi-Square analyses and binary logistic regressions were run to identify clinical and sociodemographic variables associated with suicide attempts.

RESULTS

Of the 20 variables analysed using Chi-square statistics, five were significantly associated with the outcome variable (lifetime attempted suicide): loss of family relationships, loss of home, prior depression, prior suicidal thoughts, and medication use. Regression analysis showed that individuals were more likely to have reported suicide attempts if they had experienced loss of family relationships (1.65 times), loss of a home (1.87 times), prior depression (3.2 times), prior suicidal thoughts (6.14 times), or were taking medication (1.95 times) compared to those not reporting such individual events.

CONCLUSIONS

Disordered gamblers are vulnerable to suicide; a number of factors have been identified in the current study that predict an increased likelihood of attempted suicide. The factors mainly revolve around loss: not financial loss, but rather disintegration of an individual's support network and deterioration in the individual's mental health. Findings indicate that isolation and negative affect associated with gambling are most influential in attempted suicide and should therefore be more strongly considered when creating and providing the legislative, educational and treatment environments for those experiencing gambling related harm.

A193 PERCEIVED BARRIERS TO GLUTEN-FREE FOOD ACCESS ON-CAMPUS EXPERIENCED BY STUDENTS FROM DIFFERENT CANADIAN UNIVERSITIES AND COLLEGES

Background

Students with gluten-related disorders (GRD), a spectrum of conditions including celiac disease (CeD) and non-celiac wheat sensitivity (NCWS), often experience challenges when accessing gluten-free (GF) foods.

Aims

To identify barriers perceived by students with GRD to access GF products on-campus of universities and colleges across Canada.

Methods

We conducted a cross sectional survey using the RedCap platform and distributed it to the Canadian Celiac Association community. We included students who reported adopting a GFD for various reasons including CeD and other GRD. We collected data on adherence to the GFD using a validated questionnaire (CDAT), presence of perceived barriers to follow a GFD while dining on campus, persistent symptoms, and altered quality of life. Continuous data are expressed as median (IQR), and categorical data as proportions of patients. Mann-Whitney U and Chi2 with Fisher correction were used to assess differences between groups.

Results

Seventy nine students responded to the survey (5% male and median age = 25 yrs) and 78 had complete data for analysis. Of the 78 students, 52 (66.6%) reported a diagnosis of CeD, while 26 were adopting a GFD for other reasons (non-CeD). The majority were enrolled in university programs (72/78) and 18% were living on-campus. Almost 90% reported difficulties maintaining a GFD while dining on-campus. Similar proportion of CeD and non-CeD reported eating gluten accidentally (75% vs 80%), while 15% reported eating gluten intentionally on-campus at least a few times per week. This was observed more frequently in non-CeD compared with students with CeD (61% vs 17%; p=0.04). Barriers identified in CeD versus non-CeD groups were related to a reduced GF-food variety (48% vs 69%), lack of availability of GF food (21% vs 46%) and increased cost (46% vs 81%) compared with gluten-containing counterparts. The majority of participants were concerned whether the food available on-campus was truly GF (80% vs 54%) as they reported foods not properly labelled. The majority of participants considered their overall health (79%) and quality of life (65%) was fair to terrible while dining on campus. During the pandemic, 76% of them perceived that it was easier to stick to a GF diet.

Conclusions

Students from various universities and colleges across Canada experience barriers to access GF food on-campus. This has a significant impact on their overall health and quality of life. Proper food labeling, GF certification and improving the variety of GF food on-campus are options for improvement.

Funding Agencies

None

Safety Evaluation for Restorin® NMN, a NAD+ Precursor

NAD+ is an abundant molecule in the body and vital to all living cells. NAD+ levels decline with age, and this decline correlates with age-related diseases. Therefore, sustaining NAD+ levels offers potential benefits to healthspan and longevity. Here we conducted toxicity studies to evaluate the safety of Restorin® NMN, a high purity form of the direct NAD+ precursor, β-nicotinamide mononucleotide (NMN). Based on the preliminary toxicity study and a 14-days repeated dose toxicity study at a higher dose level exposure, Restorin® NMN was administered orally to Sprague-Dawley rats for 91 days followed by a 14-days recovery period. The oral doses of 500, 1,000, and 2000 mg/kg/day were compared. There were no test item-related findings that could be considered adverse events in animals dosed at 500 mg/kg/day. The findings in the Restorin® NMN high dose group (2000 mg/kg/day) were similar to the reference item (Nicotinamide Riboside Chloride) dosed at 1740 mg/kg/day: reduced body weight, reductions in body weight gains, and diminished food consumption. In conclusion, the No-Observed-Adverse-Effect-Level (NOAEL) for Restorin® NMN is 1,000 mg/kg/day in female rats and 500 mg/kg/day in male rats, and the Low-Observed-Adverse-Effect-Level (LOAEL) for Resotrin® NMN is 2000 mg/kg/day.

Protection outcomes for fish trophic groups across a range of management regimes

Understanding how Marine Protected Areas (MPAs) improve conservation outcomes across anthropogenic pressures can improve the benefits derived from them. Effects of protection for coral reefs in the western and central Indian Ocean were assessed using size-spectra analysis of fish and the relationships of trophic group biomass with human population density. Length-spectra relationships quantifying the relative abundance of small and large fish (slope) and overall productivity of the system (intercept) showed inconsistent patterns with MPA protection. The results suggest that both the slopes and intercepts were significantly higher in highly and well-protected MPAs. This indicates that effective MPAs are more productive and support higher abundances of smaller fish, relative to moderately protected MPAs. Trophic group biomass spanning piscivores and herbivores, decreased with increasing human density implying restoration of fish functional structure is needed. This would require addressing fisher needs and supporting effective MPA management to secure ecosystem benefits for coastal communities.

Vulnerability of Temperate Mesophotic Ecosystems (TMEs) to environmental impacts: Rapid ecosystem changes at Lough Hyne Marine Nature Reserve, Ireland

Temperate Mesophotic Ecosystems (TMEs) are stable habitats, usually dominated by slow-growing, long-lived sessile invertebrates and sciaphilous algae. Organisms inhabiting TMEs can form complex three-dimensional structures and support many commercially important species. However, TMEs have been poorly studied, with little known about their vulnerability to environmental impacts. Lough Hyne Marine Nature Reserve (Ireland) supports TMEs in shallower waters (12-40 m) compared with other locations (30-150+ m) as a result of the unusual hydrodynamic conditions. Here, we report changes that have occurred on the sponge-dominated cliffs at Lough Hyne between 1990 and 2019, providing insights into TME long-term stability and vulnerability to environmental impacts. Our main finding was a marked decline in most three-dimensional sponges at the internal sites of the lough. This was likely the result of one or more mass mortality events that occurred between 2010 and 2015. We also found an increase in ascidians, which might have been more tolerant and benefited from the space freed by the sponge mortality. Finally, in the most recent surveys, we found a high abundance of sponge recruits, indicating that a natural recovery may be underway. The possible factors involved in these community changes include eutrophication, increased temperature, and a toxic event due to an anomaly in the oxycline breakdown. However, the absence of comprehensive monitoring of biotic and abiotic variables makes it impossible to identify the cause with certainty. Our Lough Hyne example shows the potential vulnerability of TMEs to short-term disturbance events, highlighting the importance of monitoring these habitats globally to ensure they are appropriately conserved.

Crystallization by Amorphous Particle Attachment: On the Evolution of Texture

Crystallization by particle attachment (CPA) is a gradual process where each step has its own thermodynamic and kinetic constrains defining a unique pathway of crystal growth. An important example is biomineralization of calcium carbonate through amorphous precursors that are morphed into shapes and textural patterns that cannot be envisioned by the classical monomer-by-monomer approach. Here, a mechanistic link between the collective kinetics of mineral deposition and the emergence of crystallographic texture is established. Using the prismatic ultrastructure in bivalve shells as a model, a fundamental leap is made in the ability to analytically describe the evolution of form and texture of biological mineralized tissues and to design the structure and crystallographic properties of synthetic materials formed by CPA.

37 Improving the Management of Post-Operative Hypocalcaemia in Thyroid Surgery

Introduction

Hypocalcaemia is a frequent, and potentially dangerous, complication of total thyroidectomy [1, 2]. This quality improvement (QI) project was undertaken in a large ENT department in the East of England over a year. The project improved postoperative guideline compliance by optimising the recognition and management of patients at risk of hypocalcaemia. This process focussed on improving parathyroid hormone (PTH) and calcium blood testing, appropriate prescribing and the monitoring and management of hypocalcaemia.

Method

Following a baseline audit the QI process subsequently involved the introduction of a new intraoperative PTH pathway and the amendment of trust guidelines. In addition, there was a focus on improving clinician awareness of guidelines, junior doctor education, communication between operating surgeons and junior doctors and the optimisation of patient handover.

Results

The measurement of PTH at four hours improved from 42.5% to 52.2%. The project saw a significant improvement in the monitoring of hypocalcaemia (from 22.2% to 83.3% for patients with an intermediate risk of hypocalcaemia) and in the prescribing of prophylactic calcium supplements from 7.5% to 43.5%.

Conclusions

By optimising postoperative care this QI project improved patient safety as well as impacting on the duration, and overall cost, of inpatient stay.

A33 MEALTIME SUPPORT: A PILOT COHORT STUDY OF AN EFFECTIVE, COST-SAVING OUTPATIENT HUNGER-BASED FEEDING PROGRAM FOR TUBE DEPENDENCY

Background

Tube dependency is an under recognized complication of long-term enteral feeding in young children. Many children struggle to progress to full oral feeds even with sufficient oral motor skills and swallowing ability. Tube dependency greatly impacts the quality of life of children and families and is a significant burden to the health care system. Economic challenges, increased burden of care and psychosocial issues all reinforce the need for timely tube removal.

Aims

We aimed to examine the efficacy of a multidisciplinary child-led, hunger-based approach called “Mealtime Support” at the Stollery Children’s Hospital in Edmonton. Nutritional outcomes, parental satisfaction and cost implications were evaluated. As a secondary aim we sought to determine the rates of gastrostomy tube insertions in the pediatric age range across Canada as a potential indicator of increasing need for long term tube feeding, hence the need for cost effective tube weaning programs to be developed in Canada.

Methods

The ambulatory program was delivered 2–3 times a day, for 2 weeks, by an occupational therapist and dietitian, under medical supervision. Hunger was promoted by reducing tube fed calories by 80% prior to commencement. Top-up tube feeds were given immediately after feeding sessions if needed. Caregivers completed 12-question subjective surveys pre and post intervention. Micro-costing methods compared costs between the program and ongoing tube feeding. The number of pediatric hospital admissions and gastrostomy tube insertions from 2008–2019, per province, was collected from the Canadian Institute for Health Information (CIHI).

Results

From 2016 - 2017, 6 children who had been tube fed from 7 to 21 months in total were enrolled and 5 completed the program. At 1-month post intervention, 4/5 of the children were 100% orally fed. Parents reported improvement in mealtime struggles (p-value = 0.005), reduction in worry about their child’s eating (p-value = 0.005) and improvement in their child’s appetite/variety foods eaten (p-value = 0.004). Over a year the potential cost savings were estimated at $42,471.24. By 6-months, all feeding tubes were removed. Based on the CIHI data, the number of gastrostomy tubes inserted per 100,000 children varied significantly between provinces, but highest in Nova Scotia, Saskatchewan and Alberta with increases seen from 2008–2018.

Conclusions

The transition from tube feeding to oral feeding is difficult for children who are tube dependent and poses several economic and psychosocial challenges. Mealtime Support was safe and successful in reducing tube dependency and cost-effective compared to no intervention or hospital based programs. There is a need to develop and fund Canadian outpatient feeding programs.

Funding Agencies

The Stollery Children’s Foundation

Outcomes following emergency colorectal cancer presentation in the elderly

AIM

Colorectal cancer is predominantly a disease of the elderly and up to 30% of these patients will present as an emergency. We compared the outcomes of 'elderly' patients presenting to our unit with a colorectal cancer emergency over a 10-year period with those of a 'younger' cohort.

METHODS

A single centre retrospective review of colorectal cancer emergencies between 1 April 2007 and 1 April 2017 was performed. Patients were separated into two cohorts: 'young' (< 75 years) and 'elderly' (≥ 75 years). Data collected included demographics, disease status, treatment and outcomes.

RESULTS

A total of 341 patients (< 75 years: n = 154; ≥ 75 years: n = 187) presented as a colorectal cancer emergency. Significantly fewer 'elderly' patients underwent curative surgical procedures (72% vs 49%, P < 0.0001) or received adjuvant chemotherapy (56% vs 21%, P < 0.0001). 'Elderly' patients had significantly more postoperative cardio-respiratory complications (7% vs 36%, P < 0.0001), but despite this there was no significant difference in 30-day mortality (7% vs 12%) and survival rates at 1 year (75% vs 74%) or 3 years (56% vs 49%). Elderly patients treated with best supportive care had a median overall survival of just 62 (range 1-955) days.

CONCLUSION

Patients ≥ 75 years presenting as a colorectal cancer emergency were significantly less likely to undergo emergency curative surgery or receive adjuvant chemotherapy than those < 75 years. However, the 30-day mortality, 1- and 3-year survival rates for patients undergoing curative surgery were comparable.

piNET: a versatile web platform for downstream analysis and visualization of proteomics data

Rapid progress in proteomics and large-scale profiling of biological systems at the protein level necessitates the continued development of efficient computational tools for the analysis and interpretation of proteomics data. Here, we present the piNET server that facilitates integrated annotation, analysis and visualization of quantitative proteomics data, with emphasis on PTM networks and integration with the LINCS library of chemical and genetic perturbation signatures in order to provide further mechanistic and functional insights. The primary input for the server consists of a set of peptides or proteins, optionally with PTM sites, and their corresponding abundance values. Several interconnected workflows can be used to generate: (i) interactive graphs and tables providing comprehensive annotation and mapping between peptides and proteins with PTM sites; (ii) high resolution and interactive visualization for enzyme-substrate networks, including kinases and their phospho-peptide targets; (iii) mapping and visualization of LINCS signature connectivity for chemical inhibitors or genetic knockdown of enzymes upstream of their target PTM sites. piNET has been built using a modular Spring-Boot JAVA platform as a fast, versatile and easy to use tool. The Apache Lucene indexing is used for fast mapping of peptides into UniProt entries for the human, mouse and other commonly used model organism proteomes. PTM-centric network analyses combine PhosphoSitePlus, iPTMnet and SIGNOR databases of validated enzyme-substrate relationships, for kinase networks augmented by DeepPhos predictions and sequence-based mapping of PhosphoSitePlus consensus motifs. Concordant LINCS signatures are mapped using iLINCS. For each workflow, a RESTful API counterpart can be used to generate the results programmatically in the json format. The server is available at http://pinet-server.org, and it is free and open to all users without login requirement.

Creation of skyrmions in van der Waals ferromagnet Fe3GeTe2 on (Co/Pd) n superlattice

Magnetic skyrmions are topological spin textures, which usually exist in noncentrosymmetric materials where the crystal inversion symmetry breaking generates the so-called Dzyaloshinskii-Moriya interaction. This requirement unfortunately excludes many important magnetic material classes, including the recently found two-dimensional van der Waals (vdW) magnetic materials, which offer unprecedented opportunities for spintronic technology. Using photoemission electron microscopy and Lorentz transmission electron microscopy, we investigated and stabilized Néel-type magnetic skyrmion in vdW ferromagnetic Fe₃GeTe₂ on top of (Co/Pd) _n in which the Fe₃GeTe₂ has a centrosymmetric crystal structure. We demonstrate that the magnetic coupling between the Fe₃GeTe₂ and the (Co/Pd) _n could create skyrmions in Fe₃GeTe₂ without the need of an external magnetic field. Our results open exciting opportunities in spintronic research and the engineering of topologically protected nanoscale features by expanding the group of skyrmion host materials to include these previously unknown vdW magnets.

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.

LINCS Data Portal 2.0: next generation access point for perturbation-response signatures

The Library of Integrated Network-Based Cellular Signatures (LINCS) is an NIH Common Fund program with the goal of generating a large-scale and comprehensive catalogue of perturbation-response signatures by utilizing a diverse collection of perturbations across many model systems and assay types. The LINCS Data Portal (LDP) has been the primary access point for the compendium of LINCS data and has been widely utilized. Here, we report the first major update of LDP (http://lincsportal.ccs.miami.edu/signatures) with substantial changes in the data architecture and APIs, a completely redesigned user interface, and enhanced curated metadata annotations to support more advanced, intuitive and deeper querying, exploration and analysis capabilities. The cornerstone of this update has been the decision to reprocess all high-level LINCS datasets and make them accessible at the data point level enabling users to directly access and download any subset of signatures across the entire library independent from the originating source, project or assay. Access to the individual signatures also enables the newly implemented signature search functionality, which utilizes the iLINCS platform to identify conditions that mimic or reverse gene set queries. A newly designed query interface enables global metadata search with autosuggest across all annotations associated with perturbations, model systems, and signatures.

Exascale applications: skin in the game

As noted in Wikipedia, skin in the game refers to having 'incurred risk by being involved in achieving a goal', where 'skin is a synecdoche for the person involved, and game is the metaphor for actions on the field of play under discussion'. For exascale applications under development in the US Department of Energy Exascale Computing Project, nothing could be more apt, with the skin being exascale applications and the game being delivering comprehensive science-based computational applications that effectively exploit exascale high-performance computing technologies to provide breakthrough modelling and simulation and data science solutions. These solutions will yield high-confidence insights and answers to the most critical problems and challenges for the USA in scientific discovery, national security, energy assurance, economic competitiveness and advanced healthcare. This article is part of a discussion meeting issue 'Numerical algorithms for high-performance computational science'.

A113 COST SAVINGS OF SEROLOGIC VERSUS BIOPSY PROVEN DIAGNOSIS OF PEDIATRIC CELIAC DISEASE

Background

Celiac disease (CD) affects approximately one percent of the population in Canada and the United States. At present, endoscopic diagnosis (ED) of CD remains the gold standard in North America, despite mounting evidence and validated European guidelines for serologic diagnosis (SD). Within publicly funded healthcare systems there is pressure to ensure optimal resource utilization and cost efficiency, including for endoscopic services. At Stollery Children’s Hospital, Edmonton, Canada, we have adopted serologic diagnosis as routine practice since 2016.

Aims

The aim of this study is to estimate cost savings, i.e. hard dollar savings and capacity improvements, to the health care system as well as impacts on families in regard to reduced work days lost and missing child school days for SD versus ED. Initial cost saving data is presented.

Methods

Micro-costing methods were used to determine health care resource use in patients undergoing ED or SD from 2017–2018. SD testing included anti-tissue glutaminase antibody (aTTG) ≥200IU/mL (on two occasions), human leukocyte antigen (HLA) DQA5/DQ2, blood sampling, transport and laboratory costs. ED diagnosis included gastroenterologist, anesthetist, OR equipment, staff, overhead and histopathology. Cost of each unit of resource was obtained from the schedule of medical benefits (Alberta) and reported average ambulatory cost for day hospital endoscopy for Stollery Children’s Hospital determined in 2016; reported in CAN$.

Results

Between March 2017-December 2018, 473 patients were referred for diagnosis of CD; 233 had ED and 127 SD. Estimated cost for ED was $1240 per patient; for SD was $85 per patient (6.8% of ED cost). Based on 127 patients not requiring endoscopy and a cost saving of $1155 per patient there was a total cost savings of $146,685 over 22 months.

Conclusions

A SD approach presents a significant cost savings to the public health care system. It also frees up valuable endoscopic resources, and limits exposure of children to the immediate and long-term risks associated with anesthesia and biopsy. SD also decreases time to diagnosis and the cost of the process to families (lost days of school/work, travel costs etc.). Our costing data can be used in combination with mounting evidence on the test performance of SD versus ED to determine cost-effectiveness of serological diagnosis for pediatric CD. Given the potential for cost saving and more efficient operating room utilization, SD for pediatric CD warrants further investigation in North America.

Funding Agencies

None

A134 RATES OF PARENTERAL NUTRITION-ASSOCIATED CHOLESTASIS/LIVER DISEASE AND GROWTH PRE- AND POST-SMOFLIPID INTRODUCTION IN NEONATES AND INFANTS WITH INTESTINAL FAILURE

Background

Parenteral nutrition (PN) is essential for survival in infants with intestinal failure (IF). PN-associated cholestasis (PNAC) and liver disease (PNALD) are life-threatening complications of long-term PN use. SMOFlipid (soybean oil, medium-chain triglycerides, olive oil, and fish oil) has recently been approved as an off-label alternative to the conventional soy-based lipid emulsion (Intralipid). It is thought to have anti-cholestatic properties due to its more diverse lipid composition. Due to its’ recent approval in Canada (2013) and the USA (2016), data remains sparse.

Aims

We aim to determine if infants with IF receiving SMOFlipid had significantly lower rates of PNAC and improved growth compared to those receiving Intralipid.

Methods

All patients (≤1 year old at start of PN therapy) who received PN of any duration at two tertiary pediatric hospitals in Edmonton (2010–2018) were identified from the shared pharmacy database. Those with IF who received one type of PN continuously for ≥6 weeks total were included. Individuals with an initial serum conjugated bilirubin &gt;50 µmol/L and/or who had PN interruptions &gt;5 days were excluded. Data on liver parameters, growth, and complications were collected. Non-parametric tests (Mann-Whitney U test for continuous variables and χ2 test for categorical variables) were used to compare PNAC/PNALD (serum conjugated bilirubin &gt;34umol/L during PN) and growth (weight/length/head circumference z-scores) between SMOFlipid and Intralipid.

Results

1777 patients were reviewed; 40 infants (55% male), median age 4 weeks (range 0–48 weeks) at the time of PN initiation, met the inclusion criteria. Reasons for exclusion (n=1737) were receiving PN &lt;6 weeks total (n=1485), duplicate patients (n=154), receiving multiple types of PN with each less than 6 weeks total (n=62), an initial serum conjugated bilirubin &gt;50umol/L (n=21), more than 5 consecutive days off of PN (n=12), and older than 1 year old at time of PN initiation (n=3). Twenty-one patients (53%) received SMOFlipid, 15 (38%) Intralipid, and 4 (10%) Omegaven for ≥6 weeks. The majority (92%) were in an intensive care unit (neonatal or pediatric). No patients were septic when starting PN. Individuals received PN over a median of 7.9 weeks (range 6–27 weeks).

Conclusions

As expected, neonatal onset intestinal failure is rare in Edmonton. In our tertiary pediatric institutions, 2010–2018, SMOFLipid was the predominant lipid choice for infants with intestinal failure, followed by Intralipid. Omegaven was used rarely. This dataset will now allow us to compare the rates of PNAC at six weeks post-PN initiation and differences in growth between infants with IF receiving SMOFlipid versus the traditional Intralipid in our Canadian setting. Analysis is currently underway.

Funding Agencies

Women and Children’s Health Research Institute (WCHRI) at the University of Alberta

7 Stop Falling Before it Starts: Increasing Access to Multifactorial Falls and Fracture Risk Assessment and Intervention for Older People At Risk of Falls or Early in Their Falls Career Via Proactive Case Finding

Background

Target population: patients from 6 (of 43) Newcastle upon Tyne General Practices, age 65 – 75, mild frailty on electronic frailty index, who had fallen or noticed a balance problem in the previous year.

Introduction

Usually multifactorial falls and fracture prevention services target frailer older people and intervention begins after a fall or fracture has occurred. There is limited provision of community-based strength and balance exercise.

Intervention

New service model ‘Stop Falling Before It Starts (SFBIS)’: proactive case finding by postal questionnaire; multifactorial falls and fracture risk assessment by specialist nurse; interventions recommended to General Practitioner (GP); community-based exercise offered to all, predominantly new 15 week ‘Steady On’ strength and balance classes suitable for fitter older people.

Methods

Data collection: patient characteristics, physical performance (Timed up and Go (TUG), 30 second sit to stand (STS)) before starting and on completion of Steady On classes, service process measures, patient and GP experience.

Results

157 patients assessed. 80 (51%) fallen in previous year. 9 (6%) history of syncope / pre-syncope. 18 (11%) orthostatic hypotension. 124 (79%) culprit medications. Recommendations: GP review of history 6 (4%) or medications 13 (8%); referral to secondary care falls service 1 (0.5%); optician assessment 58 (37%); DXA 13 (8%). 131 (83%) referred to Steady On; 119 (91%) attended first class, 61 (51%) completed classes. Mean initial TUG 11 seconds, mean improvement 3 seconds. Mean initial STS 11 repetitions, mean improvement 3 repetitions. Mean patient feedback score 14.6/15 (15 best). GP feedback positive.

Conclusions

SFBIS was effective in identifying the target population and engaging them in community-based strength and balance exercise classes. Meaningful improvements in physical performance were demonstrated. A smaller number of additional risk factors were identified. There was a high level of satisfaction from patients and GPs. Wider implementation would increase participation in evidence-based community exercise.

Correction to: Predictors of Dropout in Disordered Gamblers in UK Residential Treatment

The original version of this article contained errors in Table 1. The numbers (N) and percentages (%) in the 'completed treatment' column were incorrect. It is now corrected with this erratum.

Determinants of diagnostic discordance for non-diabetic hyperglycaemia and Type 2 diabetes using paired glycated haemoglobin measurements in a large English primary care population: cross-sectional study

AIM

To investigate factors influencing diagnostic discordance for non-diabetic hyperglycaemia and Type 2 diabetes.

METHODS

Some 10 000 adults at increased risk of diabetes were screened with HbA_1c and fasting plasma glucose (FPG). The 2208 participants with initial HbA_1c ≥ 42 mmol/mol (≥ 6.0%) or FPG ≥ 6.1 mmol/l were retested after a median 40 days. We compared the first and second HbA_1c results, and consequent diagnoses of non-diabetic hyperglycaemia and Type 2 diabetes, and investigated predictors of discordant diagnoses.

RESULTS

Of 1463 participants with non-diabetic hyperglycaemia and 394 with Type 2 diabetes on first testing, 28.4% and 21.1% respectively had discordant diagnoses on repeated testing. Initial diagnosis of non-diabetic hyperglycaemia and/or impaired fasting glucose according to both HbA_1c and FPG criteria, or to FPG only, made reclassification as Type 2 diabetes more likely than initial classification according to HbA_1c alone. Initial diagnosis of Type 2 diabetes according to both HbA_1c and FPG criteria made reclassification much less likely than initial classification according to HbA_1c alone. Age, and anthropometric and biological measurements independently but inconsistently predicted discordant diagnoses and changes in HbA_1c .

CONCLUSIONS

Diagnosis of non-diabetic hyperglycaemia or Type 2 diabetes with a single measurement of HbA_1c in a screening programme for entry to diabetes prevention trials is unreliable. Diagnosis of non-diabetic hyperglycaemia and Type 2 diabetes should be confirmed by repeat testing. FPG results could help prioritise retesting. These findings do not apply to people classified as normal on a single test, who were not retested.

Psychological intervention (ConquerFear) for treating fear of cancer recurrence: mediators and moderators of treatment efficacy

PURPOSE

ConquerFear is an efficacious intervention for fear of cancer recurrence (FCR) that demonstrated greater improvements than an attention control (relaxation training) in a randomized controlled trial. This study aimed to determine mediators and moderators of the relative treatment efficacy of ConquerFear versus relaxation.

METHODS

One hundred and fifty-two cancer survivors completed 5 therapy sessions and outcome measures before and after intervention and at 6 months' follow-up. We examined theoretically relevant variables as potential mediators and moderators of treatment outcome. We hypothesized that metacognitions and intrusions would moderate and mediate the relationship between treatment group and FCR level at follow-up.

RESULTS

Only total FCR score at baseline moderated treatment outcome. Participants with higher levels of FCR benefited more from ConquerFear relative to relaxation on the primary outcome. Changes in metacognitions and intrusive thoughts about cancer during treatment partially mediated the relationship between treatment group and FCR.

CONCLUSIONS

These results show that ConquerFear is relatively more effective than relaxation for those with overall higher levels of FCR. The mediation analyses confirmed that the most likely mechanism of treatment efficacy was the reduction in unhelpful metacognitions and intrusive thoughts during treatment, consistent with the theoretical framework underpinning ConquerFear.

IMPLICATIONS FOR CANCER SURVIVORS

ConquerFear is a brief, effective treatment for FCR in cancer survivors with early-stage disease. The treatment works by reducing intrusive thoughts about cancer and changing beliefs about worry and is particularly helpful for people with moderate to severe FCR.

Helical van der Waals crystals with discretized Eshelby twist

The ability to manipulate the twisting topology of van der Waals structures offers a new degree of freedom through which to tailor their electrical and optical properties. The twist angle strongly affects the electronic states, excitons and phonons of the twisted structures through interlayer coupling, giving rise to exotic optical, electric and spintronic behaviours^1-5. In twisted bilayer graphene, at certain twist angles, long-range periodicity associated with moiré patterns introduces flat electronic bands and highly localized electronic states, resulting in Mott insulating behaviour and superconductivity^3,4. Theoretical studies suggest that these twist-induced phenomena are common to layered materials such as transition-metal dichalcogenides and black phosphorus^6,7. Twisted van der Waals structures are usually created using a transfer-stacking method, but this method cannot be used for materials with relatively strong interlayer binding. Facile bottom-up growth methods could provide an alternative means to create twisted van der Waals structures. Here we demonstrate that the Eshelby twist, which is associated with a screw dislocation (a chiral topological defect), can drive the formation of such structures on scales ranging from the nanoscale to the mesoscale. In the synthesis, axial screw dislocations are first introduced into nanowires growing along the stacking direction, yielding van der Waals nanostructures with continuous twisting in which the total twist rates are defined by the radii of the nanowires. Further radial growth of those twisted nanowires that are attached to the substrate leads to an increase in elastic energy, as the total twist rate is fixed by the substrate. The stored elastic energy can be reduced by accommodating the fixed twist rate in a series of discrete jumps. This yields mesoscale twisting structures consisting of a helical assembly of nanoplates demarcated by atomically sharp interfaces with a range of twist angles. We further show that the twisting topology can be tailored by controlling the radial size of the structure.

Deliberating performance targets workshop: Potential paths for emerging PM2.5 and O3 air sensor progress

The United States Environmental Protection Agency held an international two-day workshop in June 2018 to deliberate possible performance targets for non-regulatory fine particulate matter (PM_2.5) and ozone (O₃) air sensors. The need for a workshop arose from the lack of any market-wide manufacturer requirement for Ozone documented sensor performance evaluations, the lack of any independent third party or government-based sensor performance certification program, and uncertainty among all users as to the general usability of air sensor data. A multi-sector subject matter expert panel was assembled to facilitate an open discussion on these issues with multiple stakeholders. This summary provides an overview of the workshop purpose, key findings from the deliberations, and considerations for future actions specific to sensors. Important findings concerning PM_2.5 and O₃ sensors included the lack of consistent performance indicators and statistical metrics as well as highly variable data quality requirements depending on the intended use. While the workshop did not attempt to yield consensus on any topic, a key message was that a number of possible future actions would be beneficial to all stakeholders regarding sensor technologies. These included documentation of best practices, sharing quality assurance results along with sensor data, and the development of a common performance target lexicon, performance targets, and test protocols.

Health concerns of cancer survivors after primary anti-cancer treatment

PURPOSE

Cancer survivors experience significant health concerns compared to the general population. Sydney Survivorship Clinic (SSC) is a multi-disciplinary clinic aiming to help survivors treated with curative intent manage side effects, and establish a healthy lifestyle. Here, we determine the health concerns of survivors post-primary treatment.

METHODS

Survivors completed questionnaires assessing symptoms, quality of life (QOL), distress, diet, and exercise before attending SSC, and a satisfaction survey after. Body mass index (BMI), clinical findings and recommendations were reviewed. Descriptive statistical methods were used.

RESULTS

Overall, 410 new patients attended SSC between September 2013 and April 2018, with 385 survivors included in analysis: median age 57 years (range 18-86); 69% female; 43% breast, 31% colorectal and 19% haematological cancers. Median time from diagnosis, 12 months. Common symptoms of at least moderate severity: fatigue (45%), insomnia (37%), pain (34%), anxiety (31%) and with 56% having > 5 moderate-severe symptoms. Overall, 45% scored distress ≥ 4/10 and 62% were rated by clinical psychologist as having 'fear of cancer recurrence'. Compared to population mean of 50, mean global QOL T-score was 47.2, with physical and emotional well-being domains most affected. Average BMI was 28.2 kg/m² (range 17.0-59.1); 61% overweight/obese. Only 31% met aerobic exercise guidelines. Overall, 98% 'agreed'/'completely agreed' attending the SSC was worthwhile, and 99% would recommend it to others.

CONCLUSION

Distress, fear of cancer recurrence, fatigue, obesity and sedentary lifestyle are common in cancer survivors attending SSC and may best be addressed in a multi-disciplinary Survivorship Clinic to minimise longer-term effects. This model is well-rated by survivors.

The effect of temperature, farm density and foot-and-mouth disease restrictions on the 2007 UK bluetongue outbreak

In 2006, bluetongue (BT), a disease of ruminants, was introduced into northern Europe for the first time and more than two thousand farms across five countries were affected. In 2007, BT affected more than 35,000 farms in France and Germany alone. By contrast, the UK outbreak beginning in 2007 was relatively small, with only 135 farms in southeast England affected. We use a model to investigate the effects of three factors on the scale of BT outbreaks in the UK: (1) place of introduction; (2) temperature; and (3) animal movement restrictions. Our results suggest that the UK outbreak could have been much larger had the infection been introduced into the west of England either directly or as a result of the movement of infected animals from southeast England before the first case was detected. The fact that air temperatures in the UK in 2007 were marginally lower than average probably contributed to the UK outbreak being relatively small. Finally, our results indicate that BT movement restrictions are effective at controlling the spread of infection. However, foot-and-mouth disease restrictions in place before the detection and control of BT in 2007 almost certainly helped to limit BT spread prior to its detection.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.