COVID-19 vaccines and adverse events of special interest: A multinational Global Vaccine Data Network (GVDN) cohort study of 99 million vaccinated individuals

BACKGROUND

The Global COVID Vaccine Safety (GCoVS) Project, established in 2021 under the multinational Global Vaccine Data Network™ (GVDN®), facilitates comprehensive assessment of vaccine safety. This study aimed to evaluate the risk of adverse events of special interest (AESI) following COVID-19 vaccination from 10 sites across eight countries.

METHODS

Using a common protocol, this observational cohort study compared observed with expected rates of 13 selected AESI across neurological, haematological, and cardiac outcomes. Expected rates were obtained by participating sites using pre-COVID-19 vaccination healthcare data stratified by age and sex. Observed rates were reported from the same healthcare datasets since COVID-19 vaccination program rollout. AESI occurring up to 42 days following vaccination with mRNA (BNT162b2 and mRNA-1273) and adenovirus-vector (ChAdOx1) vaccines were included in the primary analysis. Risks were assessed using observed versus expected (OE) ratios with 95 % confidence intervals. Prioritised potential safety signals were those with lower bound of the 95 % confidence interval (LBCI) greater than 1.5.

RESULTS

Participants included 99,068,901 vaccinated individuals. In total, 183,559,462 doses of BNT162b2, 36,178,442 doses of mRNA-1273, and 23,093,399 doses of ChAdOx1 were administered across participating sites in the study period. Risk periods following homologous vaccination schedules contributed 23,168,335 person-years of follow-up. OE ratios with LBCI > 1.5 were observed for Guillain-Barré syndrome (2.49, 95 % CI: 2.15, 2.87) and cerebral venous sinus thrombosis (3.23, 95 % CI: 2.51, 4.09) following the first dose of ChAdOx1 vaccine. Acute disseminated encephalomyelitis showed an OE ratio of 3.78 (95 % CI: 1.52, 7.78) following the first dose of mRNA-1273 vaccine. The OE ratios for myocarditis and pericarditis following BNT162b2, mRNA-1273, and ChAdOx1 were significantly increased with LBCIs > 1.5.

CONCLUSION

This multi-country analysis confirmed pre-established safety signals for myocarditis, pericarditis, Guillain-Barré syndrome, and cerebral venous sinus thrombosis. Other potential safety signals that require further investigation were identified.

Radiology reporting of incidental osteoporotic vertebral fragility fractures present on CT studies: results of UK national re-audit

AIM

To describe a UK-wide re-audit of the 2019 Royal College of Radiologists (RCR) audit evaluating patient-related data and organisational infrastructure in the radiological reporting of vertebral fragility fractures (VFFs) on computed tomography (CT) studies and to assess the impact of a series of RCR interventions, initiated to raise VFF awareness, on reporting practice and outcomes.

MATERIALS AND METHODS

Patient specific and organisational questionnaires largely replicated those utilised in 2019. The patient questionnaire involved retrospective analysis of between 50 and 100 consecutive, non-traumatic CT studies which included the thoracolumbar spine. All RCR radiology audit leads were invited to participate. Data collection commenced from 1 April 2022.

RESULTS

Data were supplied by 129/194 (67%) departments. One thousand five hundred and eighty-six of 7,316 patients (21.7%) had a VFF on auditor review. Overall improvements were demonstrated in key initial/provisional reporting results; comment on spine/bone (93.2%, 14.4% improvement, p<0.0002); fracture severity assessment (34.7%, 8.5% improvement, p=0.0007); use of recommended terminology (67.8%, 7.5% improvement, p=0.0034); recommendations for further management (11.7%, 9.1% improvement, p<0.0002).

CONCLUSIONS

The 2022 national re-audit confirms improvements in diagnostic performance and practice in VFF reporting. Continuing work is required to build on this improvement and to further embed best practice.

Family-systems interventions for families of people with an intellectual disability or who are autistic: a systematic review

BACKGROUND

Family-systems interventions have been proposed as one way of supporting families of people with an intellectual disability (ID) or who are autistic. This systematic review aimed to summarise what family-systems interventions have been studied with this population, what evidence there is for their effectiveness and families' experiences of the interventions.

METHODS

The review was preregistered on PROSPERO (CRD42022297516). We searched five electronic databases, identified 6908 records and screened 72 full texts. Study quality was evaluated using the Mixed Methods Appraisal Tool, and a narrative synthesis was used.

RESULTS

We identified 13 eligible articles with 292 participating families. Most studies reported positive effects of the interventions on wellbeing and family relationships, and families reported positive experiences. However, research quality was poor and there are no any sufficiently powered randomised controlled trials demonstrating family-systems interventions' effectiveness for this population.

CONCLUSIONS

There is a need for higher-quality research to establish whether family-systems interventions are beneficial for families of people who have an ID or who are autistic.

Analysis of the distal urinary tract in larval and adult zebrafish reveals homology to the human system

Little is known about the distal excretory component of the urinary tract in Danio rerio (zebrafish). This component is affected by many human diseases and disorders of development. Here, we undertook multi-level analyses to determine the structure and composition of the distal urinary tract in the zebrafish. In silico searches identified uroplakin 1a, 2-like and 3-like genes in the zebrafish genome (orthologues to genes that encode urothelium-specific proteins in humans). In situ hybridization demonstrated uroplakin-1a expression in the zebrafish pronephros and cloaca from 96 hours post-fertilisation. H&E sectioning of adult zebrafish demonstrated two mesonephric ducts uniting into a urinary bladder which leads to a distinct urethral opening. Immunohistochemistry identified Uroplakin 1a and 2 expression and Gata3 expression in zebrafish urinary bladder cell layers that match human urothelial expression. Fluorescent dye injections demonstrated zebrafish urinary bladder function, including urine storage, intermittent micturition, and a urethral orifice separate from the larger anal canal and rectum. Our findings reveal homology between the urinary tracts of zebrafish and humans and offer the former as a model system to study disease.

A150 MODERATE AGREEMENT IN ENDOSCOPIC DISEASE SCORING OF PEDIATRIC EOSINOPHILIC ESOPHAGITIS AMONG PEDIATRIC GASTROENTEROLOGISTS IN CANADA

Background

Endoscopy is an important tool in assessing the severity of gastrointestinal diseases including Eosinophilic Esophagitis (EoE). Agreement regarding endoscopy outcomes is important when using tools such as the Endoscopic Reference Score for EoE (EREFS).

Purpose

Our goal was to determine interrater and intrarater agreement of EREFS among Canadian pediatric gastroenterologists.

Method

Survey-based study of interrater and intrarater reliability amongst pediatric gastroenterologists with interest in pediatric EoE. Participants were sourced from the Canadian Pediatric EoE Network. Participants were asked how many years of training they’ve had with endoscopy for pediatric EoE and their comfort in disease scoring for pediatric EoE. Pediatric EoE cases were identified from the pediatric EoE registry at the Stollery Children’s Hospital with an endoscopic video associated with each case. Participants were asked to score each video using the EREFS questionnaire for the proximal, middle and distal segments of the esophagus. 15 endoscopic videos were evaluated, with 3 cases provided each week over a period of 5 weeks. Additional data included ratings of the video quality and endoscopy quality. Of 15 cases, 12 were unique cases, distributed evenly in severity between no active disease to severe disease. 3 cases were repeated to assess intrarater reliability. The maximum grade of the proximal, middle and distal segments of the esophagus for each component endoscopic finding (edema, rings, exudates, furrows, strictures) were used for reliability calculations. Fleiss Kappa was calculated for all EREFS items and for each component endoscopic finding. Cohen’s Kappa was calculated to assess intrarater reliability.

Result(s)

Fifteen participants were recruited for the study. The participants had a median of 12 years (IQR: 7, 19) of clinical experience in endoscopy for pediatric EoE. The majority of participants were “comfortable” (i.e., 4 on 5-point scale) with EREFS scoring for pediatric EoE. Fleiss Kappa for all EREFS items was 0.481. For each component endoscopic finding (edema, rings, exudates, furrows, strictures), Fleiss Kappa was 0.365, 0.293, 0.548, 0.263, 0.445 respectively. Cohen’s Kappa had a median of 0.620 (IQR: 0.593, 0.704). The majority of raters rated video quality and endoscopy quality as “good” (i.e., 4 on 5-point scale).

Conclusion(s)

There is moderate interrater reliability in EREFS scoring for pediatric EoE. Interrater reliability was between fair to moderate for each component endoscopic finding. Intrarater reliability was good. This study shows there is room for improvement in disease scoring for pediatric EoE. This could be in the form of additional training, expert-defined conventions, or centralized reading which have reduced variability in endoscopic reporting for adult GI disease in past studies and could be used in a follow-up study to attempt to improve agreement. Additionally, incorporating EREFS into routine clinical practice may increase agreement amongst endoscopists.

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Disclosure of Interest

None Declared

995 MULTIPLE ORGANISATIONAL FACTORS IMPROVE MULTI-DISCIPLINARY CARE DELIVERY TO PATIENTS WITH HIP FRACTURES: A QUALITATIVE STUDY

Introduction

Hip fractures are devastating injuries which incur high healthcare costs. Despite national standards and guidelines, there is substantial variation in hospital delivery of hip fracture care and in patient outcomes. This study aimed to understand organisational processes that facilitate successful delivery of hip fracture services.

Method

Forty qualitative interviews were conducted with healthcare professionals involved in delivering hip fracture care at four English hospitals. Interview data were supplemented with documentary analysis of 23 anonymised British Orthopaedic Association hospital-initiated peer-review reports of services. Data were analysed thematically, with themes transposed onto key components of the care pathway.

Results

We identified multiple aspects of service organisation that facilitated good care delivery. At admission, standardisation of training in nerve block administration impacted care delivery. During hospital stays, service delivery was improved by integrated, shared-care between orthopaedics and orthogeriatrics, and by strategies to improve trauma list efficiency. Adequately staffed orthogeriatric services and the ‘right’ skills and seniority mix were important to holistic care provision. Placing patients on designated hip fracture wards concentrated staff expertise. Collaborative working was achieved through multi-disciplinary team (MDT) meetings between key staff, protocols and care pathways that defined roles and responsibilities, MDT documentation, ‘joined-up’ IT systems within hospitals and with primary care, and shared working spaces such as shared offices and onwards. Trauma and hip fracture coordinators organised care processes and provided a valuable central point of contact within teams. Nominated leads, representing diverse specialties, worked together in MDT planning meetings to develop joint protocols, establish audit priorities, and agree shared goals. Routine, comprehensive monitoring and evaluation of service delivery, with findings shared throughout the MDT, was beneficial.

Conclusion

Our study has characterised potentially modifiable elements of successful hip fracture service delivery. Findings are intended to help services overcome organisational barriers towards delivery of high-quality hip fracture services.

946 MULTIPLE ORGANISATIONAL FACTORS ARE ASSOCIATED WITH ADVERSE PATIENT OUTCOMES POST HIP FRACTURE IN HOSPITALS IN ENGLAND & WALES

Introduction

Older adults who sustain a hip fracture require complex multidisciplinary care, which can challenge organisational structures within hospitals. Despite standards and guidelines, substantial variation remains in hip fracture care delivery across the UK. We aimed to determine which hospital-level organisational factors predict adverse patient outcomes in the post injury period.

Method

A cohort of 178,757 patients aged 60+ years in England and Wales (2016–19) who sustained a hip fracture was examined. Patient-level Hospital Episodes Statistics, National Hip Fracture Database, and mortality data were linked to metrics from 18 hospital-level organisational audits/reports/series. Multilevel models determined the organisational factors, independent of patient case-mix, associated with three patient outcomes: length of hospital stay (LOS), 30-day all-cause mortality, and emergency 30-day readmission.

Results

Overall LOS was mean 21 days (standard deviation, 20); 13,126 (7.3%) died within 30-days; and 25,239 (15.3%) were readmitted. 25 organisational factors independently predicted LOS: for example, a hospital’s ability to promptly mobilise ≥90% of patients was associated with a 2-day (95%CI:1.3–2.7) shorter LOS, and hospitals where all patients received orthogeriatric assessment within 72 hours of admission had mean 1.5-day (95%CI:0.6–2.3) shorter LOS. Ten organisational factors independently predicted 30-day mortality: providing prompt surgery (≤36 hours from admission) to &gt;80% patients was associated with the same 10% reduction in mortality (95%CI:4–15%), as was discussion of ‘patient experience’ feedback at clinical governance meetings (95%CI:5–15%). Nine organisational factors independently predicted readmission: knowledge of time from discharge to start of community therapy was associated with 17% (95%CI:9–24%) lower readmission rates. Organisational delivery of clinical governance, surgery, and physiotherapy were associated with all outcomes.

Conclusion

Multiple, potentially modifiable, organisational factors are associated with important patient outcomes post-hip fracture. These factors, if causal, indicate auditable components of hospital care where interventions can be targeted to reduce variability in hip fracture care delivery, to improve patient outcomes.

Characteristics and Outcomes of Recipients of Heart Transplant with Coronarvirus Disease 2019 Who Received Casirivimab Plus Imdevimab Infusion

Purpose

Heart transplant (HT) recipient are at increased risk of adverse outcomes following COVID-19 infection and may benefit from monoclonal antibody infusion to mitigate progression to clinically severe disease. The aim of this study is to describe the outcomes of HT patients who experienced mild to moderate coronavirus disease 2019 (COVID-19), with subsequent administration of casirivimab plus imdevimab administration.

Methods

A retrospective review of all HT recipients who were infected with COVID-19, and subsequently infused with monoclonal antibodies in a large academic medical center between January 1, 2021 to September 1, 2021.

Results

14 HT patients were included in the analysis. The median age was 57.5 (interquartile range [IQR], 41.5-64) years, 10 (71%) were men, and median time from HT was 3.48 (IQR, 1.00-11.82) years. Comorbid conditions included hypertension in 6 patients (43%), diabetes in 4 (29%), and chronic kidney disease in 6 (43%). Eight patients (57%) were previously vaccinated, predominantly with the Pfizer-BioNTech vaccine. Three participants (21%) were admitted after clinical progression of COVID-19. Among patients managed at the study institution, mycophenolate mofetil was discontinued in two patients (14%) and calcineurin inhibitor was maintained at previous levels in all fourteen patients (100%). Of the admitted patients, 1 was treated with high dose corticosteroids alone and 2 were treated with corticosteroids plus remdesivir. No patient required intubation. All 3 patients were discharged home and no patients in this cohort died.

Conclusion

In this single-center case series, HT patients with mild-moderate COVID-19 who were treated with monoclonal antibody infusion had a hospitalization rate of 21% and 100% survival. Further studies are required to optimize management of COVID-19 infection in the HT population.

Dapiglutide, a novel dual GLP-1 and GLP-2 receptor agonist, attenuates intestinal insufficiency in a murine model of short bowel

BACKGROUND

Extensive intestinal resection may lead to short bowel (SB) syndrome, resulting in intestinal insufficiency or intestinal failure (IF). Intestinal insufficiency and IF involve deficiency of the proglucagon-derived hormones glucagon-like peptide-1 (GLP-1) and GLP-2. Two major problems of SB are epithelial surface loss and accelerated transit. Standard treatment now targets intestinal adaptation with a GLP-2 analogue to enlarge absorptive surface area. It is possible that additional benefit can be gained from a combination of GLP-1 and GLP-2 activity, with the aim to enlarge intestinal surface area and slow intestinal transit.

METHODS

The GLP-1- and GLP-2-specific effects of the novel dual GLP-1 receptor (GLP-1R) and GLP-2 receptor (GLP-2R) agonist dapiglutide (rINN) were characterized in rodents. Furthermore, in a murine SB model of intestinal insufficiency with 40% ileocecal resection, the influence of dapiglutide on intestinal growth, body weight, food intake, volume status, and stool water content was tested against vehicle and sham-operated male mice.

RESULTS

Dapiglutide significantly improves oral glucose tolerance, reduces intestinal transit time, and promotes intestinal growth. In the SB mouse model, dapiglutide promotes body weight recovery, despite unchanged intake of liquid diet. Dapiglutide promotes significant intestinal growth, as indicated by significantly increased villus height as well as intestinal length. Furthermore, dapiglutide reduces stool water losses, resulting in reduced plasma aldosterone.

CONCLUSION

Dapiglutide possesses specific and potent GLP-1R and GLP-2R agonist effects in rodents. In the murine SB model, combined unimolecular GLP-1R and GLP-2R stimulation with dapiglutide potently attenuates intestinal insufficiency and potentially also IF.

Sex related differences in exercise performance in patients with hypertrophic cardiomyopathy: hemodynamic insights through non-invasive pressure volume analysis

Background

Women with HCM have worse cardiopulmonary exercise performance compared to men. We used non-invasive pressure-volume (PV) analysis to delineate sex related hemodynamic differences in HCM.

Methods

PV loops were constructed from echocardiograms using left ventricular (LV) volumes indexed to body surface area, Doppler estimates of LV end-diastolic pressure and blood pressure. The end-systolic PV relationship (ESPVR) and end-diastolic PV relationship (EDPVR) were derived from validated single-beat techniques. The area between the ESPVR and EDPVR (isovolumetric PV area), was indexed to an LV end-diastolic pressure of 30mmHg (PVAiso30), as the integrated metric of LV function. LV volume at an end-diastolic pressure of 30mmHg (V30) indexed ventricular capacity.

Results

202 patients were included, 56 women. Women were older (51 vs 44 yrs, p=0.012) and had reduced exercise capacity (5.6 vs 6.9 METs, p&lt;0.001). Only 32 patients (16%) had a peak gradient &gt;30mmHg at rest with no sex differences. Women had significantly lower indexed PVAiso30 (6577 vs 7767 mmHg·mL/m2, p&lt;0.001) driven by reduced ventricular capacitance (V30 54 vs 62 ml/m2, p&lt;0.001). In multivariable linear regression indexed V30 was an independent predictor of exercise capacity.

Conclusion

Impaired exercise capacity in women with HCM appears strongly related to abnormalities in passive diastolic properties, suggesting a unique pathophysiology compared to men, and a potential difference in viable therapeutic molecular targets

Funding Acknowledgement

Type of funding sources: None.

Remote Monitoring of Heart Transplant Recipients during the COVID-19 Pandemic

Purpose

The COVID-19 pandemic created significant challenges in monitoring heart transplant (HT) recipients for rejection due to efforts to minimize contact with the hospital setting. The aim of this study was to evaluate the safety and efficacy of transitioning HT patients to home phlebotomy and a monitoring protocol based on gene expression profiling (GEP) and donor derived cell free DNA (ddcfDNA).

Methods

A single-center cohort study that prospectively enrolled consecutive HT patients who were transitioned to a remote monitoring protocol employing home phlebotomy and non-invasive surveillance for rejection. Patients were enrolled starting at 2 months post-HT. Positive GEP values were defined as ≥32 (up to 6 months post-HT) and ≥34 (> 6 months post-HT). A positive ddcfDNA score was defined as >0.12%. A positive biopsy was defined as grade ≥1B/1R

Results

246 HT patients were enrolled and followed for a minimum of 3 months. Mean age was 56±14, 71.5% were male, and median time from transplant was 2.7 years. The average distance of patients from the hospital was 25.6 miles. 359 blood tests were drawn for detection of GEP and ddcfDNA and 102 biopsies performed (Figure). Among 32 patients who had negative results on both tests and had a biopsy, 0 had a positive biopsy. Of 25 patients who had positive results on both tests and had a biopsy, 3 (12%) had a positive biopsy. The biopsy positivity rate in patients who were GEP+/ddcfDNA- was 6% and in patients who were GEP-/ddcfDNA+ was 8%. None of the positive biopsies were associated with hemodynamic compromise. 15 (6%) of patients were admitted due to allograft rejection during the study period. There were no deaths.

Conclusion

Using a remote monitoring protocol with home phlebotomy and noninvasive rejection surveillance was feasible and safe in HT recipients. In this cohort, the combination of negative GEP and ddcfDNA scores was accurate at predicting a lack of allograft rejection.

A14 WIDE VARIATION IN CLINICAL MANAGEMENT OF PAEDIATRIC EOSINOPHILIC ESOPHAGITIS: A CANADIAN EXPERIENCE

Background

Eosinophilic esophagitis (EoE) is a chronic disorder treated by food elimination diet (FED), topical steroids and/or proton-pump inhibitors (PPI). Serial endoscopies and biopsies assess response to therapy. EoE management has evolved as guidelines are updated.

Aims

To identify practice variation among Canadian paediatric gastroenterologists (PG) who care for children with EoE.

Methods

An online survey using REDCap about decision-making in children with EoE was distributed to PG in Canada in November 2020.

Results

62 PG completed the survey (response rate 69%, 62/94). The majority work in academic centres (92%). 3 centers indicated an accrual of &gt;50 new patients per year; 9/16 centres have &gt;100 patients in follow-up. An EoE Clinic is present in 5 centres.

Diagnosis: Familiarity with the 2018 AGREE and 2020 AGA EoE guidelines was found to be 57% and 67% respectively. Criteria required to diagnose EoE according to current guidelines were correctly indicated by 42% of PG. (Figure 1).

Endoscopy: The majority of PG (95%) adhere to guidelines in terms of required number and location of biopsies for the initial diagnosis. Ideal timing of repeat endoscopy after change in therapy in patients who are not in histological remission was 8–12 weeks by 67% of PG, timing in stable patients on maintenance therapy varied (33% only if patient is symptomatic). 25% used the EREFS Score in reporting endoscopic findings.

Therapy: Improvement of symptoms was the highest ranked goal (64%), followed by remission of histologic findings (30%). A treatment algorithm was in place in 4 centers. The majority routinely assess adherence to therapy (73%) and consult a dietitian for FED (77%). Most (87%) do not consult an allergist for initial management. Preferred choices of 1st-line therapy varied among PG (Figure 2). When FED was selected, 32% of PG started with 1 food, 32% started with 2 foods, most frequently excluding dairy, followed by wheat. 14 (26%) start with ≥6 FED. Prescription of budesonide slurry was consistent among PG with doses of 1 and 2 mg/day in children &lt;10 and &gt;10 years, respectively.

Conclusions

The is the first Canadian study to assess the variation in management of children with EoE by PG. Overall, PG demonstrated good adherence to the guidelines in terms of initial diagnosis, but differences in maintenance therapy choice and timing of endoscopies. The results highlight a need for standardized management algorithms to deliver uniform care to this growing group. Grounding these guidelines in evidence will warrant a significant investment in further paediatric EoE research.

Funding Agencies

None

Nomogram Predicting Bladder Cancer-specific Mortality After Neoadjuvant Chemotherapy and Radical Cystectomy for Muscle-invasive Bladder Cancer: Results of an International Consortium

BACKGROUND

Cisplatin-based neoadjuvant chemotherapy (NAC) for muscle-invasive bladder cancer (MIBC) is associated with improved overall and cancer-specific survival. The post-NAC pathological stage has previously been reported to be a major determinant of outcome.

OBJECTIVE

To develop a postoperative nomogram for survival based on pathological and clinical parameters from an international consortium.

DESIGN, SETTING, AND PARTICIPANTS

Between 2000 and 2015, 1866 patients with MIBC were treated at 19 institutions in the USA, Canada, and Europe. Analysis was limited to 640 patients with adequate follow-up who had received three or more cycles of NAC.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

A nomogram for bladder cancer-specific mortality (BCSM) was developed by multivariable Cox regression analysis. Decision curve analysis was used to assess the model's clinical utility.

RESULTS AND LIMITATIONS

A total of 640 patients were identified. Downstaging to non-MIBC (ypT1, ypTa, and ypTis) occurred in 271 patients (42 %), and 113 (17 %) achieved a complete response (ypT0N0). The 5-yr BCSM was 47.2 % (95 % confidence interval [CI]: 41.2-52.6 %). On multivariable analysis, covariates with a statistically significant association with BCSM were lymph node metastasis (hazard ratio [HR] 1.90 [95% CI: 1.4-2.6]; p < 0.001), positive surgical margins (HR 2.01 [95 % CI: 1.3-2.9]; p < 0.001), and pathological stage (with ypT0/Tis/Ta/T1 as reference: ypT2 [HR 2.77 {95 % CI: 1.7-4.6}; p < 0.001] and ypT3-4 [HR 5.9 {95 % CI: 3.8-9.3}; p < 0.001]). The area under the curve of the model predicting 5-yr BCSM after cross validation with 300 bootstraps was 75.4 % (95 % CI: 68.1-82.6 %). Decision curve analyses showed a modest net benefit for the use of the BCSM nomogram in the current cohort compared with the use of American Joint Committee on Cancer staging alone. Limitations include the retrospective study design and the lack of central pathology.

CONCLUSIONS

We have developed and internally validated a nomogram predicting BCSM after NAC and radical cystectomy for MIBC. The nomogram will be useful for patient counseling and in the identification of patients at high risk for BCSM suitable for enrollment in clinical trials of adjuvant therapy.

PATIENT SUMMARY

In this report, we looked at the outcomes of patients with muscle-invasive bladder cancer in a large multi-institutional population. We found that we can accurately predict death after radical surgical treatment in patients treated with chemotherapy before surgery. We conclude that the pathological report provides key factors for determining survival probability.

Determination of Lead in Wine by Graphite Furnace Atomic Absorption Spectrophotometry: Interlaboratory Study

An interlaboratory study of a graphite furnace atomic absorption spectrophotometry (GFAAS) method for the determination of lead in wine was conducted. Seventeen laboratories from France, United States, and the United Kingdom, using a variety of GFAAS instruments, took part in the study. The method incorporated a novel matrix-matching procedure to minimize matrix effects between standards and samples. Six wine test materials were prepared and sent to participants as 12 blind duplicate or split level samples. There was good agreement between results obtained from participants and target values (24–279 μg/L) obtained with an inductively coupled plasma-mass spectrometry method. The precision of the GFAAS method was well within the range predicted by the Horwitz equation for the 6 test materials analyzed. Repeatability standard deviations ranged from 3 to 17%. Reproducibility standard deviations were in the range of 10 to 30%. The method is recommended for use for official purposes.

Evaluation of the Assurance GDS® for Salmonella Method in Foods and Environmental Surfaces: Multilaboratory Collaborative Study

A multilaboratory collaborative study was conducted to compare the detection of Salmonella by the Assurance GDS® for Salmonella method and the Reference culture methods. Six foods, representing a variety of low microbial and high microbial load foods were analyzed. Seventeen laboratories in the United States and Canada participated in this study. No statistical differences (P &lt; 0.05) were observed between the Assurance GDS for Salmonella and the Reference culture methods for any inoculation level of any food type or naturally contaminated food, except for pasta, for which the Assurance GDS method had a higher number of confirmed test portions for Salmonella compared to the Reference method.

Liquid Chromatographic Method for the Quantification of Zearalenone in Baby Food and Animal Feed: Interlaboratory Study

An interlaboratory trial for determination of zearalenone (ZON) in baby food and animal feed was conducted. The study involved 39 participants in 16 European Union member states, as well as Turkey, Uruguay, and China, representing a cross-section of industry, and official food control and research institutes. The method is based on immunoaffinity column cleanup followed by high-performance liquid chromatography using fluorimetry (HPLC-Fl). The test portion of the sample is extracted with methanolwater (75 + 25, v/v). The sample extract is filtered, diluted, and passed over an immunoaffinity column. ZON is eluted with methanol. The separation and determination of ZON is performed by reversed-phase HPLC-Fl with an excitation wavelength of 274 nm and an emission wavelength of 446 nm. Test portions of the samples were spiked at levels of 20 and 30 g/kg ZON in baby food and at levels of 100 and 150 g/kg ZON in animal feed. Mean recoveries from each participant ranged from 78 to 119 with an average value of 92 for baby food and from 51 to 122 with an average value of 74 for animal feed. Based on results for spiked samples (blind duplicates at 2 levels), as well as naturally contaminated samples (blind duplicates at 3 levels), the relative standard deviation for repeatability (RSDr) in baby food ranged from 2.8 to 9.0. For animal feed, this value ranged from 5.7 to 9.5. The relative standard deviation for reproducibility (RSDR) in baby food ranged from 8.2 to 13.3, and for animal feed this value ranged from 15.5 to 21.4. The Horwitz ratio (HorRat) in baby food ranged from 0.3 to 0.4, and for animal feed this value ranged from 0.6 to 0.9. The method showed acceptable within-and between-laboratory precision for each matrix, as required by European legislation.

Determination of Zearalenone in Barley, Maize and Wheat Flour, Polenta, and Maize-Based Baby Food by Immunoaffinity Column Cleanup with Liquid Chromatography: Interlaboratory Study

An interlaboratory study was performed on behalf of the UK Food Standards Agency to evaluate the effectiveness of an affinity column cleanup liquid chromatography (LC) method for the determination of zearalenone (ZON) in a variety of cereals and cereal products at proposed European regulatory limits. The test portion is extracted with acetonitrile:water. The sample extract is filtered, diluted, and applied to an affinity column. The column is washed, and ZON is eluted with acetonitrile. ZON is quantified by reversed-phase LC with fluorescence detection. Barley, wheat and maize flours, polenta, and a maize-based baby food naturally contaminated, spiked, and blank (very low level) were sent to 28 collaborators in 9 European countries and 1 collaborator in New Zealand. Participants were asked to spike test portions of all samples at a ZON concentration equivalent to 100 μg/kg. Average recoveries ranged from 91–111%. Based on results for 4 artificially contaminated samples (blind duplicates) and 1 naturally contaminated sample (blind duplicate), the relative standard deviation for repeatability (RSDr) ranged from 6.9–35.8%, and the relative standard deviation for reproducibility (RSDR) ranged from 16.4–38.2%. The method showed acceptable within- and between-laboratory precision for all 5 matrixes, as evidenced by HorRat values &lt;1.7.

Determination of Ochratoxin A in Currants, Raisins, Sultanas, Mixed Dried Fruit, and Dried Figs by Immunoaffinity Column Cleanup with Liquid Chromatography: Interlaboratory Study

An interlaboratory study was performed on behalf of the Food Standards Agency to evaluate the effectiveness of an affinity column cleanup liquid chromatographic (LC) method for the determination of ochratoxin A in a variety of dried fruit at European regulatory limits. To ensure homogeneity before analysis, laboratory samples are normally slurried with water in the ratio of 5 parts fruit to 4 parts water, and test materials in this form were used in the study. The test portion was extracted with acidified methanol. The extract was filtered, diluted with phosphate-buffered saline, and applied to an affinity column. The column was washed and ochratoxin A was eluted with methanol. Ochratoxin A was quantified by reversed-phase LC. The use of post-column pH shift to enhance the fluorescence of ochratoxin A by the addition of 1.1M ammonia solution to the column eluant is optional. Determination was by fluorescence. Currants, sultanas, raisins, figs, and mixed fruit (comprising dried pineapple, papaya, sultanas, prunes, dates, and banana chips), both naturally contaminated and blank (very low level), were sent to 24 collaborators in 7 European countries. Participants were asked to spike test portions of all test samples at a level equivalent to 5 ng/g ochra toxin A. Average recoveries ranged from 69 to 74%. Based on results for 5 naturally contaminated test samples (blind duplicates) the relative standard deviation for repeatability (RSDr) ranged from 4.9 to 8.7%, and the relative standard deviation for reproducibility (RSDR)rangedfrom14to28%. The method showed acceptable within-and be-tween-laboratory precision for all 5 matrixes, as evidenced by HORRAT values &lt;1.3.

Arts for the Blues - a new creative psychological therapy for depression: a pilot workshop report

INTRODUCTION

Research over the last decade has identified both strengths and limitations in the use of routinely prescribed psychological therapies for depression. More recently, a focus on how creative art therapies and 'arts on prescription' are developing a growing recognition of their potential additional therapeutic mechanisms for depression.

AIM

In an attempt to develop a new therapeutic intervention for depression, this research aligned both the evidence base surrounding the arts on prescription movement, collating these with client-reported helpful factors and preferences for therapeutic interventions.

METHODS

We developed a framework for a new pluralistic 'meta-approach' of therapy for depression, based on; an interdisciplinary thematic synthesis of active ingredients, considered specific features implemented in therapy, and client-reported helpful factors considered to be the broad features or experiences in therapy from both talking therapies and creative approaches. This framework contributed to the development of a pilot workshop entitled Arts for the Blues - A New Creative Psychological Therapy for Depression. An outline of, and evaluation from this workshop is presented in this article. Workshop participants were recruited via a voluntary workshop taking place at a North West Higher Education Institution Arts and Health conference ( N = 15).

RESULTS

The workshop was evaluated using quantitative measures, with results indicating around a 70% overall satisfaction, followed up with qualitative commentary around areas of good practice and areas for development. These included the positive reflection on the application of creative arts and the multimodal nature of the approach, while others reflected on the potential overwhelming nature of utilising multimodal methods for individuals with depression.

CONCLUSION

Overall feedback from the pilot workshop is discussed in relation to prior research, giving credence to the potential for incorporating arts into therapy.

A comparison of the cost-effectiveness of intramedullary nail fixation and locking plate fixation in the treatment of adult patients with an extra-articular fracture of the distal tibia: economic evaluation based on the FixDT trial

Aims

The aim of this study was to compare the cost-effectiveness of intramedullary nail fixation and 'locking' plate fixation in the treatment of extra-articular fractures of the distal tibia.

Patients and Methods

An economic evaluation was conducted from the perspective of the United Kingdom National Health Service (NHS) and personal social services (PSS), based on evidence from the Fixation of Distal Tibia Fractures (UK FixDT) multicentre parallel trial. Data from 321 patients were available for analysis. Costs were collected prospectively over the 12-month follow-up period using trial case report forms and participant-completed questionnaires. Cost-effectiveness was reported in terms of incremental cost per quality adjusted life year (QALY) gained, and net monetary benefit. Sensitivity analyses were conducted to test the robustness of cost-effectiveness estimates.

Results

Mean NHS and PSS costs were significantly lower for patients treated with an intramedullary nail than for those treated with a locking plate (-£970, 95% confidence interval (CI) -1685 to -256; p = 0.05). There was a small increase in QALYs gained in the nail fixation group (0.01, 95% CI -0.03 to 0.06; p = 0.52). The probability of cost-effectiveness for nail fixation exceeded 90% at cost-effectiveness thresholds as low as £15 000 per additional QALY. The cost-effectiveness results remained robust to several sensitivity analyses.

Conclusion

This trial-based economic evaluation suggests that nail fixation is a cost-effective alternative to locking plate fixation. Cite this article: Bone Joint J 2018;100-B:624-33.

Sexual Harassment Policies and Training in State Legislatures

(1) Sexual harassment is a violation of The Civil Rights Act of 1964. (2) Most states do not require employers to conduct sexual harassment training. (3) Most sexual harassment training for state legislators occurs at their orientation.