Flares of acute graft-versus-host disease: a Mount Sinai Acute GVHD International Consortium analysis

ABSTRACT

The absence of a standardized definition for graft-versus-host disease (GVHD) flares and data on its clinical course are significant concerns. We retrospectively evaluated 968 patients across 23 Mount Sinai Acute GVHD International Consortium (MAGIC) transplant centers who achieved complete response (CR) or very good partial response (VGPR) within 4 weeks of treatment. The cumulative incidence of flares within 6 months was 22%, and flares were associated with a higher risk of nonrelapse mortality (NRM; adjusted hazard ratio [aHR], 4.84; 95% confidence interval [CI], 3.19-7.36; P < .001). Flares were more severe (grades 3/4, 41% vs 16%; P < .001) and had more frequent lower gastrointestinal (LGI) involvement (55% vs 32%; P < .001) than the initial GVHD. At CR/VGPR, elevated MAGIC biomarkers predicted the future occurrence of a flare, along with its severity and LGI involvement. In multivariate analyses, higher Ann Arbor (AA) biomarker scores at CR/VGPR were significant risk factors for flares (AA2 vs AA1: aHR, 1.81 [95% CI, 1.32-2.48; P = .001]; AA3 vs AA1: aHR, 3.14 [95% CI, 1.98-4.98; P < .001]), as were early response to initial treatment (aHR, 1.84; 95% CI, 1.21-2.80; P = .004) and HLA-mismatched unrelated donor (aHR, 1.74; 95% CI, 1.00-3.02; P = .049). MAGIC biomarkers also stratified the risk of NRM both at CR/VGPR and at the time of flare. We conclude that GVHD flares are common and carry a significant mortality risk. The occurrence of future flares can be predicted by serum biomarkers that may serve to guide adjustment and discontinuation of immunosuppression.

Amphiregulin, ST2,and REG3α Biomarker Risk Algorithms as Predictors of Non-Relapse Mortality in Patients with Acute GVHD

Graft-vs-host disease (GVHD) is a major cause of non-relapse mortality (NRM) following allogeneic hematopoietic cell transplant (HCT). Algorithms containing either the GI GVHD biomarker amphiregulin (AREG) or a combination of two GI GVHD biomarkers, (ST2+REG3α) when measured at GVHD diagnosis are validated predictors of NRM risk, but have never been assessed in the same patients using identical statistical methods. We measured serum concentrations of ST2, REG3, and AREG by ELISA at the time of GVHD diagnosis in 715 patients divided by date of transplant into training (2004-2015) and validation (2015-2017) cohorts. The training cohort (n=341) was used to develop algorithms for predicting probability of 12 month NRM that contained all possible combinations of 1-3 biomarkers and a threshold corresponding to the concordance probability was used to stratify patients for risk of NRM. Algorithms were compared to each other based on several metrics including the area under the receiver operating characteristics curve (AUC), proportion of patients correctly classified, sensitivity, and specificity using only the validation cohort (n=374). All algorithms were strong discriminators of 12 month NRM, whether or not patients were systemically treated (n=321). An algorithm containing only ST2+REG3α had the highest AUC (0.757), correctly classified the most patients (75%), and more accurately risk stratified those who developed Minnesota standard risk GVHD and for patients who received post-transplant cyclophosphamide-based prophylaxis. An algorithm containing only AREG more accurately risk stratified patients with Minnesota high risk GVHD. Combining ST2, REG3α, and AREG into a single algorithm did not improve performance.

The MAGIC algorithm probability predicts treatment response and long-term outcomes to second-line therapy for acute GVHD

The significance of biomarkers at second-line treatment for acute graft-versus-host disease (GVHD) is not well characterized. We analyzed clinical data and serum samples at initiation of second-line systemic treatment of acute GVHD from 167 patients from 17 centers of the Mount Sinai Acute GVHD International Consortium (MAGIC) between 2016 and 2021. Sixty-two patients received ruxolitinib-based therapy while 102 received other systemic agents. In agreement with prospective trials, ruxolitinib resulted in higher day 28 (D28) ORR compared to non-ruxolitinib therapies (55% vs 31%, P=0.003) and patients who received ruxolitinib had significantly lower non-relapse mortality (NRM) than those who received non-ruxolitinib therapies (point estimates at 2-year: 35% vs 61%, p=0.002). Biomarker analyses demonstrated that the benefit from ruxolitinib was observed only in patients with low MAGIC algorithm probabilities (MAPs) at the start of second-line treatment. Among patients with a low MAP, those who received ruxolitinib experienced significantly lower NRM than those who received non-ruxolitinib therapies (point estimates at 2-year: 12% vs 41%, p=0.016). However, patients with a high MAP experienced high NRM regardless of treatment with ruxolitinib or non-ruxolitinib therapies (point estimates at 2-year: 67% vs 80%, p=0.65). A landmark analysis demonstrated that the relationship between D28 response and NRM largely depends on the MAP level at initiation of second-line therapy. In conclusion, the MAP measured at second-line systemic treatment for acute GVHD predicts treatment response and NRM. Outcomes of patients with high MAP are poor, regardless of treatment choice, and ruxolitinib appears to primarily benefit patients with low MAP.

Molecular biology of cholangiocarcinoma and its implications for targeted therapy in patient management

Cholangiocarcinoma (CCA) remains a devastating malignancy and a significant challenge to treat. The majority of CCA patients are diagnosed at an advanced stage, making the disease incurable in most cases. The advent of high-throughput genetic sequencing has significantly improved our understanding of the molecular biology underpinning cancer. The identification of 'druggable' genetic aberrations and the development of novel targeted therapies against them is opening up new treatment strategies. Currently, 3 targeted therapies are approved for use in CCA; Ivosidenib in patients with IDH1 mutations and Infigratinib/Pemigatinib in those with FGFR2 fusions. As our understanding of the biology underpinning CCA continues to improve it is highly likely that additional targeted therapies will become available in the near future. This is important, as it is thought up to 40 % of CCA patients harbour a potentially actionable mutation. In this review we provide an overview of the molecular pathogenesis of CCA and highlight currently available and potential future targeted treatments.

Observation of Seven Astrophysical Tau Neutrino Candidates with IceCube

We report on a measurement of astrophysical tau neutrinos with 9.7 yr of IceCube data. Using convolutional neural networks trained on images derived from simulated events, seven candidate ν_{τ} events were found with visible energies ranging from roughly 20 TeV to 1 PeV and a median expected parent ν_{τ} energy of about 200 TeV. Considering backgrounds from astrophysical and atmospheric neutrinos, and muons from π^{±}/K^{±} decays in atmospheric air showers, we obtain a total estimated background of about 0.5 events, dominated by non-ν_{τ} astrophysical neutrinos. Thus, we rule out the absence of astrophysical ν_{τ} at the 5σ level. The measured astrophysical ν_{τ} flux is consistent with expectations based on previously published IceCube astrophysical neutrino flux measurements and neutrino oscillations.

Implementation of a Program for Appendicitis MRI in a Pediatric Hospital

MRI is increasingly used as an alternate to CT for the evaluation of suspected appendicitis in pediatric patients presenting to the emergency department (ED) with abdominal pain, when further imaging is needed after an initial ultrasound examination. The available literature shows a similar diagnostic performance of MRI and CT in this setting. At the authors' institution, to evaluate for appendicitis in children in the ED, MRI is performed using a rapid three-sequence free-breathing protocol without IV contrast media. Implementation of an MRI program for appendicitis in children involves multiple steps, including determination of imaging resource availability, collaboration with other services to develop imaging pathways, widespread educational efforts, and regular quality review. Such programs can face numerous practice-specific challenges, such as those involving scanner capacity, costs, and buy-in of impacted groups. Nonetheless, through careful consideration of these factors, MRI can be used to positively impact the care of children presenting to the ED with suspected appendicitis. This Clinical Perspective aims to provide guidance on the development of a program for appendicitis MRI in children, drawing on one institution's experience while highlighting the advantages of MRI and practical strategies for overcoming potential barriers.

A Day 14 Endpoint for Acute GVHD Clinical Trials

The overall response rate (ORR) 28 days after treatment has been adopted as the primary endpoint for clinical trials of acute graft versus host disease (GVHD). However, physicians often need to modify immunosuppression earlier than day (D) 28, and non-relapse mortality (NRM) does not always correlate with ORR at D28. We studied 1144 patients that received systemic treatment for GVHD in the Mount Sinai Acute GVHD International Consortium (MAGIC) and divided them into a training set (n=764) and a validation set (n=380). We used a recursive partitioning algorithm to create a Mount Sinai model that classifies patients into favorable or unfavorable groups that predicted 12 month NRM according to overall GVHD grade at both onset and D14. In the Mount Sinai model grade II GVHD at D14 was unfavorable for grade III/IV GVHD at onset and predicted NRM as well as the D28 standard response model. The MAGIC algorithm probability (MAP) is a validated score that combines the serum concentrations of suppression of tumorigenicity 2 (ST2) and regenerating islet-derived 3-alpha (REG3α) to predict NRM. Inclusion of the D14 MAP biomarker score with the D14 Mount Sinai model created three distinct groups (good, intermediate, poor) with strikingly different NRM (8%, 35%, 76% respectively). This D14 MAGIC model displayed better AUC, sensitivity, positive and negative predictive value, and net benefit in decision curve analysis compared to the D28 standard response model. We conclude that this D14 MAGIC model could be useful in therapeutic decisions and may offer an improved endpoint for clinical trials of acute GVHD treatment.

A Validated Risk Stratification That Incorporates MAGIC Biomarkers Predicts Long-Term Outcomes in Pediatric Patients with Acute GVHD

Acute graft versus host disease (GVHD) is a common and serious complication of allogeneic hematopoietic cell transplantation (HCT) in children but overall clinical grade at onset only modestly predicts response to treatment and survival outcomes. Two tools to assess risk at initiation of treatment were recently developed. The Minnesota risk system stratifies children for risk of nonrelapse mortality (NRM) according to the pattern of GVHD target organ severity. The Mount Sinai Acute GVHD International Consortium (MAGIC) algorithm of 2 serum biomarkers (ST2 and REG3α) predicts NRM in adult patients but has not been validated in a pediatric population. We aimed to develop and validate a system that stratifies children at the onset of GVHD for risk of 6-month NRM. We determined the MAGIC algorithm probabilities (MAPs) and Minnesota risk for a multicenter cohort of 315 pediatric patients who developed GVHD requiring treatment with systemic corticosteroids. MAPs created 3 risk groups with distinct outcomes at the start of treatment and were more accurate than Minnesota risk stratification for prediction of NRM (area under the receiver operating curve (AUC), .79 versus .62, P = .001). A novel model that combined Minnesota risk and biomarker scores created from a training cohort was more accurate than either biomarkers or clinical systems in a validation cohort (AUC .87) and stratified patients into 2 groups with highly different 6-month NRM (5% versus 38%, P < .001). In summary, we validated the MAP as a prognostic biomarker in pediatric patients with GVHD, and a novel risk stratification that combines Minnesota risk and biomarker risk performed best. Biomarker-based risk stratification can be used in clinical trials to develop more tailored approaches for children who require treatment for GVHD.

Split-bolus single-phase versus single-bolus split-phase CT acquisition protocols for staging in patients with testicular cancer: A retrospective study

INTRODUCTION

Computed tomography (CT) imaging has become indispensable in the management of medical oncology patients. Risks associated with high cumulative effective dose (CED) are relevant in testicular cancer patients. Split-bolus protocols, whereby the contrast medium injection is divided into two, followed by combining the required phase images in a single scan acquisition has been shown to provide images of comparable image quality and less radiation dose compared to single-bolus split-phase CT for various indications. We retrospectively evaluated the performance of split-bolus and single-bolus protocols in patients having follow-up CT imaging for testicular cancer surveillance.

METHODS

45 patients with testicular cancer undergoing surveillance CT imaging of the thorax, abdomen, and pelvis who underwent split-bolus and single-bolus protocols were included. Quantitative image quality analysis was conducted by placing region of interests in pre-defined anatomical sub-structures within the abdominal cavity. The signal-to-noise ratio (SNR) and radiation dose in the form of dose length product (DLP) and effective dose (ED) were recorded.

RESULTS

The DLP and ED for the single-bolus, split-phase acquisition was 506 ± 89 mGy cm and 7.59 ± 1.3 mSv, respectively. For the split-bolus, single-phase acquisition, 397 ± 94 mGy∗cm and 5.95 ± 1.4 mSv, respectively (p < 0.000). This represented a 21.5 % reduction in radiation dose exposure. The SNR for liver, muscle and fat for the single-bolus were 7.4, 4.7 and 8, respectively, compared to 5.5, 3.8 and 7.4 in the split-bolus protocol (p < 0.001).

CONCLUSION

In a testicular cancer patient cohort undergoing surveillance CT imaging, utilization of a split-bolus single-phase acquisition CT protocol enabled a significant reduction in radiation dose whilst maintaining subjective diagnostic acceptability.

IMPLICATIONS FOR PRACTICE

Use of split-bolus, single-phase acquisition has the potential to reduce CED in surveillance of testicular cancer patients.

HIV incidence among non-migrating persons following a household migration event: a population-based, longitudinal study in Uganda

Background

The impact of migration on HIV risk among non-migrating household members is poorly understood. We measured HIV incidence among non-migrants living in households with and without migrants in Uganda.

Methods

We used four survey rounds of data collected from July 2011-May 2018 from non-migrant participants aged 15-49 years in the Rakai Community Cohort Study, an open, population-based cohort. Non-migrants were individuals with no evidence of migration between surveys or at the prior survey. The primary exposure, household migration, was assessed using census data and defined as ≥1 household member migrating in or out of the house from another community between surveys (∼18 months). Incident HIV cases tested positive following a negative result at the preceding visit. Incidence rate ratios (IRR) with 95% confidence intervals were estimated using Poisson regression with generalized estimating equations and robust standard errors. Analyses were stratified by gender, migration into or out of the household, and the relationship between non-migrants and migrants (i.e., any household migration, spouse, child).

Findings

Overall, 11,318 non-migrants (5,674 women) were followed for 37,320 person-years. 28% (6,059/21,370) of non-migrant person-visits had recent migration into or out of the household, and 240 HIV incident cases were identified in non-migrating household members. Overall, non-migrants in migrant households were not at greater risk of acquiring HIV. However, HIV incidence among men was significantly higher when the spouse had recently migrated in (adjIRR:2·12;95%CI:1·05-4·27) or out (adjIRR:4·01;95%CI:2·16-7·44) compared to men with no spousal migration. Women with in- and out-migrant spouses also had higher HIV incidence, but results were not statistically significant.

Interpretation

HIV incidence is higher among non-migrating persons with migrant spouses, especially men. Targeted HIV testing and prevention interventions such as pre-exposure prophylaxis could be considered for those with migrant spouses.

Funding

National Institutes of Health, US Centers for Disease Control and Prevention.

Research in context

We searched PubMed for studies focused on HIV acquisition, prevalence or sexual behaviors among non-migrants who lived with migrants in sub-Saharan Africa (SSA) using search terms such as "HIV", "Emigration and Immigration", "family", "spouses", "household", "parents", and "children". Despite high levels of migration and an established association with HIV risk in SSA, there is limited data on the broader societal impacts of migration on HIV acquisition risk among non-migrant populations directly impacted by it.There has been only one published study that has previously evaluated impact of migration on HIV incidence among non-migrating persons in sub-Saharan Africa. This study, which exclusively assessed spousal migration, was conducted in Tanzania more than two decades earlier prior to HIV treatment availability and found that non-migrant men with long-term mobile partners were more than four times as likely to acquire HIV compared to men who had partners that were residents. To the best of our knowledge, this is the first study to examine the effect of non-spousal migration, including any household migration and child migration, on HIV incidence among non-migrants.

Added value of this study

In this study, we used data from the Rakai Community Cohort Study (RCCS), a population-based HIV surveillance cohort to measure the impact of migration on HIV incidence for non-migrant household members. The RCCS captures HIV incident events through regular, repeat HIV testing of participants and migration events through household censuses. Our study adds to the current literature by examining the general effect of migration in the household on HIV incidence in addition to child, and spousal migration. Using data from over 11,000 non-migrant individuals, we found that spousal, but not other types of household migration, substantially increased HIV risk among non-migrants, especially among men. Taken together, our results suggest that spousal migration may be associated with an increased risk of HIV acquisition in the period surrounding and immediately after spousal migration.

Implications of all the available evidence

Our findings suggest that spousal migration in or out of the household is associated with greater HIV incidence. Targeted HIV testing and prevention interventions such as pre-exposure prophylaxis could be considered for men with migrant spouses.

Phase 2 study of natalizumab plus standard corticosteroid treatment for high-risk acute graft-versus-host disease

Graft-versus-host disease (GVHD) of the gastrointestinal (GI) tract is the main cause of nonrelapse mortality (NRM) after allogeneic hematopoietic cell transplantation. Ann Arbor (AA) scores derived from serum biomarkers at onset of GVHD quantify GI crypt damage; AA2/3 scores correlate with resistance to treatment and higher NRM. We conducted a multicenter, phase 2 study using natalizumab, a humanized monoclonal antibody that blocks T-cell trafficking to the GI tract through the α4 subunit of α4β7 integrin, combined with corticosteroids as primary treatment for patients with new onset AA2/3 GVHD. Seventy-five patients who were evaluable were enrolled and treated; 81% received natalizumab within 2 days of starting corticosteroids. Therapy was well tolerated with no treatment emergent adverse events in >10% of patients. Outcomes for patients treated with natalizumab plus corticosteroids were compared with 150 well-matched controls from the MAGIC database whose primary treatment was corticosteroids alone. There were no significant differences in overall or complete response between patients treated with natalizumab plus corticosteroids and those treated with corticosteroids alone (60% vs 58%; P = .67% and 48% vs 48%; P = 1.0, respectively) including relevant subgroups. There were also no significant differences in NRM or overall survival at 12 months in patients treated with natalizumab plus corticosteroids compared with controls treated with corticosteroids alone (38% vs 39%; P = .80% and 46% vs 54%; P = .48, respectively). In this multicenter biomarker-based phase 2 study, natalizumab combined with corticosteroids failed to improve outcome of patients with newly diagnosed high-risk GVHD. This trial was registered at www.clinicaltrials.gov as # NCT02133924.

3D Printing as an Effective Quality Assurance Implementation in Massive-Scale SARS-CoV-2 Testing at a SwabSeq Next-Generation Sequencing Laboratory

Massive-scale SARS-CoV-2 testing using the SwabSeq diagnostic platform came with quality assurance challenges due to the novelty and scale of sequencing-based testing. The SwabSeq platform relies on accurate mapping between specimen identifiers and molecular barcodes to match a result back to a patient specimen. To identify and mitigate mapping errors, we instituted quality control using placement of negative controls within a rack of patient samples. We designed 2-dimensional paper templates to fit over a 96-position rack of specimens with holes to show the control tube placements. We designed and 3-dimensionally printed plastic templates that fit onto 4 racks of patient specimens and provide accurate indications of the correct control tube placements. The final plastic templates dramatically reduced plate mapping errors from 22.55% in January 2021 to less than 1% after implementation and training in January 2021. We show how 3D printing can be a cost-effective quality assurance tool to mitigate human error in the clinical laboratory.

A new method for trans-vaginal extraction of an impacted vaginal calculus: A case report

INTRODUCTION

Vaginal stones are a rare pathology, with no clear guidelines on management and optimal removal techniques.

PRESENTATION OF CASE

We report a novel surgical technique, leading to safe transvaginal extraction of the largest reported impacted vaginal stone. In this case we removed an 11 cm struvite stone transvaginally from a 46 year old patient. This was achieved by hollowing it out with surgical drills, allowing safe collapse of the outer cortex and complete removal.

DISCUSSION

Our technique allowed for the safe, minimally invasive removal of the largest stone to be reported so far in the literature, preventing further complications for the patient. A full description of our technique is outlined to allow other clinicians utilisation of this for similar cases in the future.

CONCLUSION

Future vaginal calculi could be managed using this technique, preventing the need for laparotomy or vaginal trauma.

Incidence, clinical presentation, risk factors, outcomes, and biomarkers in de novo late acute GVHD

Late acute graft-versus-host disease (GVHD) is defined as de novo acute GVHD presenting beyond 100 days after allogeneic hematopoietic cell transplantation (HCT) without manifestations of chronic GVHD. Data are limited regarding its characteristics, clinical course, and risk factors because of underrecognition and changes in classification. We evaluated 3542 consecutive adult recipients of first HCTs at 24 Mount Sinai Acute GVHD International Consortium (MAGIC) centers between January 2014 and August 2021 to better describe the clinical evolution and outcomes of late acute GVHD. The cumulative incidence of classic acute GVHD that required systemic treatment was 35.2%, and an additional 5.7% of patients required treatment for late acute GVHD. At the onset of symptoms, late acute GVHD was more severe than classic acute GVHD based on both clinical and MAGIC algorithm probability biomarker parameters and showed a lower overall response rate on day 28. Both clinical and biomarker grading at the time of treatment stratified the risk of nonrelapse mortality (NRM) in patients with classic and late acute GVHD, respectively, but long-term NRM and overall survival did not differ between patients with classic and late acute GVHD. Advanced age, female-to-male sex mismatch, and the use of reduced intensity conditioning were associated with the development of late acute GVHD, whereas the use of posttransplant cyclophosphamide-based GVHD prevention was protective mainly because of shifts in GVHD timing. Because overall outcomes were comparable, our findings, although not definitive, suggest that similar treatment strategies, including eligibility for clinical trials, based solely on clinical presentation at onset are appropriate.

Evaluating the usability of a co-designed power assisted exercise graphical user interface for people with stroke

BACKGROUND

Digital advancement of power assisted exercise equipment will advance exercise prescription for people with stroke (PwS). This article reports on the remote usability evaluation of a co-designed graphical user interface (GUI) and denotes an example of how video-conference software can increase reach to participants in the testing of rehabilitation technologies. The aim of this study was to evaluate the usability of two sequential versions of the GUI.

METHODS

We adopted a mixed methods approach. Ten professional user (PU) (2M/8F) and 10 expert user (EU) participants (2M/8F) were recruited. Data collection included a usability observation, a 'think aloud' walk through, task completion, task duration and user satisfaction as indicated by the Post Study System Usability Questionnaire (PSSUQ). Identification of usability issues informed the design of version 2 which included an additional submenu. Descriptive analysis was conducted upon usability issues and number of occurrences detected on both versions of the GUI. Inferential analysis enabled comparison of task duration and PSSUQ data between the PU and EU groups.

RESULTS

Analysis of the 'think aloud' walkthrough data enabled identification of 22 usability issues on version 1 from a total of 100 usability occurrences. Task completion for all tasks was 100%. Eight usability issues were directly addressed in the development of version 2. Two recurrent and 24 new usability issues were detected in version 2 with a total of 86 usability occurrences. Paired two tailed T-tests on task duration data indicated a significant decrease amongst the EU group for task 1.1 on version 2 (P = 0.03). The mean PSSUQ scores for version 1 was 1.44 (EU group) and 1.63 (PU group) compared with 1.40 (EU group) and 1.41 (PU group) for version 2.

CONCLUSIONS

The usability evaluation enabled identification of usability issues on version 1 of the GUI which were effectively addressed on the iteration of version 2. Testing of version 2 identified usability issues within the new submenu. Application of multiple usability evaluation methods was effective in identifying and addressing usability issues in the GUI to improve the experience of PAE for PwS. The use of video-conference software to conduct synchronous, remote usability testing is an effective alternative to face to face testing methods.

Post COVID-19 trends in simulation use within diagnostic radiography and radiation therapy education

PURPOSE

Simulation is used within medical radiation science training. Recent global events and simulation resource uptake has led to significant changes. The aim of this study was to capture post COVID-19 trends and activity of simulation-based education (SBE) in diagnostic radiography and radiation therapy.

METHODS

An online survey was designed to investigate the role of simulation within diagnostic radiography and radiation therapy education. Survey design was based on literature and experience within the research team. Questions were based around access and use of simulation, future trends and the effects of COVID-19. Participants were diagnostic radiography and/or radiation therapy educators. Data captured in this study was undertaken in March 2022 and compared with previous data from Bridge and colleagues (2021).

RESULTS

Sixty-seven responses were received across five continents (two from North/South America), Europe was the most widely represented (n = 58, 87%). Fifty-three (79%) of participants reported that they use simulation as part of their teaching and learning. Twenty-seven (51%) respondents reported that they had increased their use of simulation because of COVID-19. Sixteen (30%) respondents stated that they were now able to enrol more students because of the pandemic. Fixed models and immersive environments were the two most common simulation activities. Participants reported, to different degrees, that simulation was used across all parts of the curriculum.

CONCLUSIONS

Simulation is deeply embedded into diagnostic radiography and radiation therapy education. Evidence suggests that the growth of simulation may be slowing. Opportunities exist for the development of guidance, training and best practice resources around simulation.

IMPLICATIONS FOR PRACTICE

Simulation is a key pedagogical approach for diagnostic radiography and radiation therapy education. Key stakeholders now need to work collaboratively to define standards and best practices.

Reg3α concentrations at day of allogeneic stem cell transplantation predict outcome and correlate with early antibiotic use

Intestinal microbiome diversity plays an important role in the pathophysiology of acute gastrointestinal (GI) graft-versus-host disease (GVHD) and influences the outcome of patients after allogeneic stem cell transplantation (ASCT). We analyzed clinical data and blood samples taken preconditioning and on the day of ASCT from 587 patients from 7 German centers of the Mount Sinai Acute GVHD International Consortium, dividing them into single-center test (n = 371) and multicenter validation (n = 216) cohorts. Regenerating islet-derived 3α (Reg3α) serum concentration of day 0 correlated with clinical data as well as urinary 3-indoxylsulfate (3-IS) and Clostridiales group XIVa, indicators of intestinal microbiome diversity. High Reg3α concentration at day 0 of ASCT was associated with higher 1-year transplant-related mortality (TRM) in both cohorts (P < .001). Cox regression analysis revealed high Reg3α at day 0 as an independent prognostic factor for 1-year TRM. Multivariable analysis showed an independent correlation of high Reg3α concentrations at day 0 with early systemic antibiotic (AB) treatment. Urinary 3-IS (P = .04) and Clostridiales group XIVa (P = .004) were lower in patients with high vs those with low day 0 Reg3α concentrations. In contrast, Reg3α concentrations before conditioning therapy correlated neither with TRM nor disease or treatment-related parameters. Reg3α, a known biomarker of acute GI GVHD correlates with intestinal dysbiosis, induced by early AB treatment in the period of pretransplant conditioning. Serum concentrations of Reg3α measured on the day of graft infusion are predictive of the risk for TRM of ASCT recipients.

Radiographers' perspectives on clinical supervision of students in Ireland

INTRODUCTION

Optimising clinical education in radiography is crucial to ensure competent graduates provide safe and effective patient care. Radiographers play a vital role in student supervision undertaken in the complex clinical environment. A greater understanding of factors influencing their ability to undertake this role effectively is needed. The study aimed to explore radiographers' attitudes and perceptions of confidence in undertaking clinical supervision and perceived barriers in a 'real-life' clinical department.

METHODS

The lens of Bandura's social-cognitive theory was utilised to assist the exploration of the desired constructs. An anonymous online survey was developed and circulated among qualified radiographers in Ireland. Descriptive (frequencies and percentages) and inferential statistical testing was undertaken. Thematic analysis was conducted on optional free-text comments.

RESULTS

217 responses were received. Although most radiographers reported a positive attitude (73.3%), a significant minority reported not being confident across survey items related to the tasks required (ranging from 20.7%-29.1%). Time pressures from clinical workload, perceived lack of organisational support, and lack of guidance on expectations were highlighted challenges.

CONCLUSION

The survey has enabled first-hand identification of some challenges radiographers encounter in undertaking students' clinical supervision. Radiographers must be supported to optimise the clinical learning environment where both students and educators are valued.

IMPLICATIONS FOR PRACTICE

The findings highlight impact on educational support, practice, policy and future research. Effective clinical supervision is dependent on collaborative engagement and support being evident at all levels, including the clinical department, academic and healthcare institutions, and national organisations.

Effective treatment of low-risk acute GVHD with itacitinib monotherapy

The standard primary treatment for acute graft-versus-host disease (GVHD) requires prolonged, high-dose systemic corticosteroids (SCSs) that delay reconstitution of the immune system. We used validated clinical and biomarker staging criteria to identify a group of patients with low-risk (LR) GVHD that is very likely to respond to SCS. We hypothesized that itacitinib, a selective JAK1 inhibitor, would effectively treat LR GVHD without SCS. We treated 70 patients with LR GVHD in a multicenter, phase 2 trial (NCT03846479) with 28 days of itacitinib 200 mg/d (responders could receive a second 28-day cycle), and we compared their outcomes to those of 140 contemporaneous, matched control patients treated with SCSs. More patients responded to itacitinib within 7 days (81% vs 66%, P = .02), and response rates at day 28 were very high for both groups (89% vs 86%, P = .67), with few symptomatic flares (11% vs 12%, P = .88). Fewer itacitinib-treated patients developed a serious infection within 90 days (27% vs 42%, P = .04) due to fewer viral and fungal infections. Grade ≥3 cytopenias were similar between groups except for less severe leukopenia with itacitinib (16% vs 31%, P = .02). No other grade ≥3 adverse events occurred in >10% of itacitinib-treated patients. There were no significant differences between groups at 1 year for nonrelapse mortality (4% vs 11%, P = .21), relapse (18% vs 21%, P = .64), chronic GVHD (28% vs 33%, P = .33), or survival (88% vs 80%, P = .11). Itacitinib monotherapy seems to be a safe and effective alternative to SCS treatment for LR GVHD and deserves further investigation.

University stakeholders largely unaware and unsupportive of university pouring rights contracts with companies supplying sugar-sweetened beverages

Background: Pouring rights contracts are agreements in which beverage companies pay universities for exclusive marketing and rights to sell sugar-sweetened beverages (SSB) in campus. This study explored university stakeholder's awareness and opinions of university pouring rights contracts. Methods: Nine hundred fifteen university stakeholders self-reported their awareness and support of pouring rights contracts along with several possible determinants of support (age, gender, nutrition education, beliefs about SSBs, beverage intake). Results: About 64.2% of participants reported no awareness of pouring rights contracts whereas only 38% reported agreeing with university pouring rights contracts. Males, undergraduate students, and those who felt individuals are responsible for their SSB consumption were more likely to support pouring rights contracts. Conclusions: University stakeholders were largely unaware of and unsupportive of pouring rights contracts. Universities are encouraged to consider the health impacts and opinions of university stakeholders when deciding whether to enter into pouring rights contracts.

Mode of delivery following obstetric anal sphincter injury: a 7-year retrospective review and follow-up cohort survey

INTRODUCTION AND HYPOTHESIS

Limited evidence exists regarding long-term outcomes following birth after prior obstetric anal sphincter injury (OASI). This article set out to describe outcomes following birth after OASI by reviewing the grades of tear, endoanal ultrasound (EAUS) findings, subsequent delivery outcomes and long-term symptoms.

METHODS

This study was conducted in two parts. The first involved a retrospective review of all OASI at a tertiary hospital in Australia over 7 years (2013-2019 inclusive) where the patient underwent a subsequent delivery. Following this, a retrospective cohort survey of this group was performed.

RESULTS

There were 27,284 vaginal births and 828 OASIs (3.03%); 247 (29.8%) had at least one subsequent birth by January 2021. Vaginal delivery occurred in 68%; recurrence of OASI was 5.4%. There were 90 responses (36.4%) to the follow-up survey. EAUS had been performed in 87.5%; none demonstrated a defect. Vaginal birth was the preferred mode for 77.8%; this occurred in 64%. The majority had high levels of satisfaction, this related to communication rather than the mode of delivery itself. Ongoing faecal or flatal incontinence was reported by 12%. There was no statistically significant difference in St Mark's incontinence scores between modes of birth.

CONCLUSIONS

In our unit most women who sustain OASI will have a subsequent vaginal delivery in future pregnancies. The majority remain asymptomatic at long-term follow-up with no statistically significant difference in incontinence scores regardless of mode of delivery. The rate of recurrent OASI was 5.4%.

National audit of non-melanoma skin cancer excisions performed by plastic surgery in the UK

A national, multi-centre audit of non-melanoma skin cancer excisions by plastic surgery.

The influence of anastomotic techniques on postoperative anastomotic complications: Results of the Oesophago-Gastric Anastomosis Audit

BACKGROUND

The optimal anastomotic techniques in esophagectomy to minimize rates of anastomotic leakage and conduit necrosis are not known. The aim of this study was to assess whether the anastomotic technique was associated with anastomotic failure after esophagectomy in the international Oesophago-Gastric Anastomosis Audit cohort.

METHODS

This prospective observational multicenter cohort study included patients undergoing esophagectomy for esophageal cancer over 9 months during 2018. The primary exposure was the anastomotic technique, classified as handsewn, linear stapled, or circular stapled. The primary outcome was anastomotic failure, namely a composite of anastomotic leakage and conduit necrosis, as defined by the Esophageal Complications Consensus Group. Multivariable logistic regression modeling was used to identify the association between anastomotic techniques and anastomotic failure, after adjustment for confounders.

RESULTS

Of the 2238 esophagectomies, the anastomosis was handsewn in 27.1%, linear stapled in 21.0%, and circular stapled in 51.9%. Anastomotic techniques differed significantly by the anastomosis sites (P < .001), with the majority of neck anastomoses being handsewn (69.9%), whereas most chest anastomoses were stapled (66.3% circular stapled and 19.3% linear stapled). Rates of anastomotic failure differed significantly among the anastomotic techniques (P < .001), from 19.3% in handsewn anastomoses, to 14.0% in linear stapled anastomoses, and 12.1% in circular stapled anastomoses. This effect remained significant after adjustment for confounding factors on multivariable analysis, with an odds ratio of 0.63 (95% CI, 0.46-0.86; P = .004) for circular stapled versus handsewn anastomosis. However, subgroup analysis by anastomosis site suggested that this effect was predominantly present in neck anastomoses, with anastomotic failure rates of 23.2% versus 14.6% versus 5.9% for handsewn versus linear stapled anastomoses versus circular stapled neck anastomoses, compared with 13.7% versus 13.8% versus 12.2% for chest anastomoses.

CONCLUSIONS

Handsewn anastomoses appear to be independently associated with higher rates of anastomotic failure compared with stapled anastomoses. However, this effect seems to be largely confined to neck anastomoses, with minimal differences between techniques observed for chest anastomoses. Further research into standardization of anastomotic approach and techniques may further improve outcomes.

Radiographers' knowledge, attitudes and expectations of artificial intelligence in medical imaging

INTRODUCTION

Artificial intelligence (AI) is increasingly utilised in medical imaging systems and processes, and radiographers must embrace this advancement. This study aimed to investigate perceptions, knowledge, and expectations towards integrating AI into medical imaging amongst a sample of radiographers and determine the current state of AI education within the community.

METHODS

A cross-sectional online quantitative study targeting radiographers based in Europe was conducted over ten weeks. Captured data included demographical information, participants' perceptions and understanding of AI, expectations of AI and AI-related educational backgrounds. Both descriptive and inferential statistical techniques were used to analyse the obtained data.

RESULTS

A total of 96 valid responses were collected. Of these, 64% correctly identified the true definition of AI from a range of options, but fewer (37%) fully understood the difference between AI, machine learning and deep learning. The majority of participants (83%) agreed they were excited about the advancement of AI, though a level of apprehensiveness remained amongst 29%. A severe lack of education on AI was noted, with only 8% of participants having received AI teachings in their pre-registration qualification.

CONCLUSION

Overall positive attitudes towards AI implementation were observed. The slight apprehension may stem from the lack of technical understanding of AI technologies and AI training within the community. Greater educational programs focusing on AI principles are required to help increase European radiography workforce engagement and involvement in AI technologies.

IMPLICATIONS FOR PRACTICE

This study offers insight into the current perspectives of European based radiographers on AI in radiography to help facilitate the embracement of AI technology and convey the need for AI-focused education within the profession.

Textbook outcome following oesophagectomy for cancer: international cohort study

Background

Textbook outcome has been proposed as a tool for the assessment of oncological surgical care. However, an international assessment in patients undergoing oesophagectomy for oesophageal cancer has not been reported. This study aimed to assess textbook outcome in an international setting.

Methods

Patients undergoing curative resection for oesophageal cancer were identified from the international Oesophagogastric Anastomosis Audit (OGAA) from April 2018 to December 2018. Textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least 15 lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. A multivariable binary logistic regression model was used to identify factors independently associated with textbook outcome, and results are presented as odds ratio (OR) and 95 per cent confidence intervals (95 per cent c.i.).

Results

Of 2159 patients with oesophageal cancer, 39.7 per cent achieved a textbook outcome. The outcome parameter ‘no major postoperative complication’ had the greatest negative impact on a textbook outcome for patients with oesophageal cancer, compared to other textbook outcome parameters. Multivariable analysis identified male gender and increasing Charlson comorbidity index with a significantly lower likelihood of textbook outcome. Presence of 24-hour on-call rota for oesophageal surgeons (OR 2.05, 95 per cent c.i. 1.30 to 3.22; P = 0.002) and radiology (OR 1.54, 95 per cent c.i. 1.05 to 2.24; P = 0.027), total minimally invasive oesophagectomies (OR 1.63, 95 per cent c.i. 1.27 to 2.08; P &lt; 0.001), and chest anastomosis above azygous (OR 2.17, 95 per cent c.i. 1.58 to 2.98; P &lt; 0.001) were independently associated with a significantly increased likelihood of textbook outcome.

Conclusion

Textbook outcome is achieved in less than 40 per cent of patients having oesophagectomy for cancer. Improvements in centralization, hospital resources, access to minimal access surgery, and adoption of newer techniques for improving lymph node yield could improve textbook outcome.

Textbook outcome following oesophagectomy for cancer: international cohort study

BACKGROUND

Textbook outcome has been proposed as a tool for the assessment of oncological surgical care. However, an international assessment in patients undergoing oesophagectomy for oesophageal cancer has not been reported. This study aimed to assess textbook outcome in an international setting.

METHODS

Patients undergoing curative resection for oesophageal cancer were identified from the international Oesophagogastric Anastomosis Audit (OGAA) from April 2018 to December 2018. Textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least 15 lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. A multivariable binary logistic regression model was used to identify factors independently associated with textbook outcome, and results are presented as odds ratio (OR) and 95 per cent confidence intervals (95 per cent c.i.).

RESULTS

Of 2159 patients with oesophageal cancer, 39.7 per cent achieved a textbook outcome. The outcome parameter 'no major postoperative complication' had the greatest negative impact on a textbook outcome for patients with oesophageal cancer, compared to other textbook outcome parameters. Multivariable analysis identified male gender and increasing Charlson comorbidity index with a significantly lower likelihood of textbook outcome. Presence of 24-hour on-call rota for oesophageal surgeons (OR 2.05, 95 per cent c.i. 1.30 to 3.22; P = 0.002) and radiology (OR 1.54, 95 per cent c.i. 1.05 to 2.24; P = 0.027), total minimally invasive oesophagectomies (OR 1.63, 95 per cent c.i. 1.27 to 2.08; P < 0.001), and chest anastomosis above azygous (OR 2.17, 95 per cent c.i. 1.58 to 2.98; P < 0.001) were independently associated with a significantly increased likelihood of textbook outcome.

CONCLUSION

Textbook outcome is achieved in less than 40 per cent of patients having oesophagectomy for cancer. Improvements in centralization, hospital resources, access to minimal access surgery, and adoption of newer techniques for improving lymph node yield could improve textbook outcome.

Long-term efficacy and safety of addition of carboplatin with or without veliparib to standard neoadjuvant chemotherapy in triple-negative breast cancer: 4-year follow-up data from BrighTNess, a randomized phase 3 trial

BACKGROUND

Primary analyses of the phase 3 BrighTNess trial showed addition of carboplatin with/without veliparib to neoadjuvant chemotherapy significantly improved pathological complete response (pCR) rates with manageable acute toxicity in patients with triple-negative breast cancer (TNBC). Here, we report 4.5-year follow-up data from the trial.

DESIGN

Women with untreated stage II-III TNBC were randomized (2:1:1) to paclitaxel (weekly for 12 doses) plus either: (a) carboplatin (every 3 weeks for four cycles) plus veliparib (twice daily); (b) carboplatin plus veliparib placebo; or (c) carboplatin placebo plus veliparib placebo. All patients then received doxorubicin and cyclophosphamide (AC) every 2‒3 weeks for four cycles. The primary endpoint was pCR. Secondary endpoints included event-free survival (EFS), overall survival (OS), and safety. Since the co-primary endpoint of increased pCR with carboplatin plus veliparib with paclitaxel versus carboplatin with paclitaxel was not met, secondary analyses are descriptive.

RESULTS

Of 634 patients, 316 were randomized to carboplatin plus veliparib with paclitaxel, 160 to carboplatin with paclitaxel, and 158 to paclitaxel. With median follow-up of 4.5 years, the hazard ratio [HR] for EFS for carboplatin plus veliparib with paclitaxel versus paclitaxel was 0.63 (95% confidence interval [CI] 0.43‒0.92, P=0.02), but 1.12 (95% CI 0.72‒1.72, P=0.62) for carboplatin plus veliparib with paclitaxel versus carboplatin with paclitaxel. In post hoc analysis, HR for EFS was 0.57 (95% CI 0.36‒0.91, P=0.02) for carboplatin with paclitaxel versus paclitaxel. OS did not differ significantly between treatment arms, nor did rates of myelodysplastic syndromes, acute myeloid leukemia, or other secondary malignancies.

CONCLUSION

Improvement in pCR with addition of carboplatin was associated with long-term EFS benefit with a manageable safety profile, and without increasing the risk of second malignancies, while adding veliparib did not impact EFS. These findings support the addition of carboplatin to weekly paclitaxel followed by AC neoadjuvant chemotherapy for early stage TNBC.

The Exeter Activity Unlimited statement on physical activity and exercise for cystic fibrosis: methodology and results of an international, multidisciplinary, evidence-driven expert consensus

Background

The roles of physical activity (PA) and exercise within the management of cystic fibrosis (CF) are recognised by their inclusion in numerous standards of care and treatment guidelines. However, information is brief, and both PA and exercise as multi-faceted behaviours require extensive stakeholder input when developing and promoting such guidelines.

Method

On 30^th June and 1^st July 2021, 39 stakeholders from 11 countries, including researchers, healthcare professionals and patients participated in a virtual conference to agree an evidence-based and informed expert consensus about PA and exercise for people with CF. This consensus presents the agreement across six themes: (i) patient and system centred outcomes, (ii) health benefits, iii) measurement, (iv) prescription, (v) clinical considerations, and (vi) future directions. The consensus was achieved by a stepwise process, involving: (i) written evidence-based synopses; (ii) peer critique of synopses; (iii) oral presentation to consensus group and peer challenge of revised synopses; and (iv) anonymous voting on final proposed synopses for adoption to the consensus statement.

Results

The final consensus document includes 24 statements which surpassed the consensus threshold (>80% agreement) out of 30 proposed statements.

Conclusion

This consensus can be used to support health promotion by relevant stakeholders for people with CF.

Assessing the Acceptability of a Co-Produced Long COVID Intervention in an Underserved Community in the UK

BACKGROUND

The COVID-19 pandemic has disproportionately affected people from more deprived communities. The experience of Long COVID is similarly distributed but very few investigations have concentrated on the needs of this population. The aim of this project was to co-produce an acceptable intervention for people with Long COVID living in communities recognised as more deprived.

METHODS

The intervention was based on a multi-disciplinary team using approaches from sport and exercise medicine and functional rehabilitation. The co-production process was undertaken with a stakeholder advisory group and patient public involvement representation. This study identified participants by postcode and the indices of multiple deprivation (IMD); recruitment and engagement were supported by an existing health and wellbeing service. A virtual 'clinic' was offered with a team of professional practitioners who met participants three times each; to directly consider their needs and offer structured advice. The acceptability of the intervention was based on the individual's participation and their completion of the intervention.

RESULTS

Ten participants were recruited with eight completing the intervention. The partnership with an existing community health and wellbeing service was deemed to be an important way of reaching participants. Two men and six women ages ranging from 38 to 73 were involved and their needs were commonly associated with fatigue, anxiety and depression with overall de-conditioning. None reported serious hardship associated with the pandemic although most were in self-employment/part-time employment or were not working due to retirement or ill-health. Two older participants lived alone, and others were single parents and had considerable challenges associated with managing a household alongside their Long COVID difficulties.

CONCLUSIONS

This paper presents the needs and perspectives of eight individuals involved in the process and discusses the needs and preferences of the group in relation to their support for self- managed recovery from Long COVID.

Postoperative outcomes in oesophagectomy with trainee involvement

BACKGROUND

The complexity of oesophageal surgery and the significant risk of morbidity necessitates that oesophagectomy is predominantly performed by a consultant surgeon, or a senior trainee under their supervision. The aim of this study was to determine the impact of trainee involvement in oesophagectomy on postoperative outcomes in an international multicentre setting.

METHODS

Data from the multicentre Oesophago-Gastric Anastomosis Study Group (OGAA) cohort study were analysed, which comprised prospectively collected data from patients undergoing oesophagectomy for oesophageal cancer between April 2018 and December 2018. Procedures were grouped by the level of trainee involvement, and univariable and multivariable analyses were performed to compare patient outcomes across groups.

RESULTS

Of 2232 oesophagectomies from 137 centres in 41 countries, trainees were involved in 29.1 per cent of them (n = 650), performing only the abdominal phase in 230, only the chest and/or neck phases in 130, and all phases in 315 procedures. For procedures with a chest anastomosis, those with trainee involvement had similar 90-day mortality, complication and reoperation rates to consultant-performed oesophagectomies (P = 0.451, P = 0.318, and P = 0.382, respectively), while anastomotic leak rates were significantly lower in the trainee groups (P = 0.030). Procedures with a neck anastomosis had equivalent complication, anastomotic leak, and reoperation rates (P = 0.150, P = 0.430, and P = 0.632, respectively) in trainee-involved versus consultant-performed oesophagectomies, with significantly lower 90-day mortality in the trainee groups (P = 0.005).

CONCLUSION

Trainee involvement was not found to be associated with significantly inferior postoperative outcomes for selected patients undergoing oesophagectomy. The results support continued supervised trainee involvement in oesophageal cancer surgery.

The prevalence and safety of direct oral anticoagulants in patients with non-atrial fibrillation associated intra-cardiac thrombus

Background

The standard of care in management of intra-cardiac thrombus has been the use of vitamin K antagonists (VKAs). The emergence and use of direct oral anticoagulants (DOACs) in other conditions has led to the consideration of their use in patients with intra-cardiac thrombus. Thus far, case-reports have provided the majority of data regarding the efficacy of DOACs in this population.

Purpose

The aim of this observational study was to investigate the safety and efficacy of DOACs in intracardiac thrombus not associated with atrial fibrillation, compared to the current standard of care, VKAs.

Methods

An observational study was conducted between 10 hospitals in our region. The study was conducted between 2013 and 2019 in patients with a diagnosis of intracardiac thrombus. All left and right, atrial and ventricular thrombi were included. Patients with atrial fibrillation were excluded. Patient information was collected from the hospital electronic record. The primary endpoints were clinically significant bleeding requiring transfusion and thromboembolic events, excluding myocardial infarction.

Results

1153 patients had a diagnosis of intracardiac thrombus. 878 out of 1153 patients were discharged on warfarin and 275 were discharged on a DOAC. In the warfarin population 73 of 878 patients (8.3%) had clinically significant bleeding events compared to 21 of 275 patients (7.6%) in the DOAC population (p=0.801). The median ages were 60.5 and 58 respectively. The median time period to a bleeding event was 151 and 198 days respectively. In the warfarin population, 116 of 878 patients (13.2%) had thromboembolic disease versus 34 of 275 patients (12.4%) in the DOAC arm (p=0.759). The median ages were 62 and 62.5 respectively. The median time period to a thromboembolic event was 114 and 184 days respectively. In the warfarin arm, 3 patients had systemic thromboembolism and 113 patients had embolic strokes. In the DOAC arm, 2 patients had systemic thromboembolism, 32 patients had embolic strokes.

Conclusion

The data from this study suggests that DOACs may be a feasible alternative to warfarin in patients with intracardiac thrombus. There was no statistically significant difference in the rates of clinically significant bleeding or in incidence of thromboembolic disease. To our knowledge, this is the largest observational study to date on this topic. Randomized controlled trials are needed to fully establish the efficacy of DOACs in this patient population.

Funding Acknowledgement

Type of funding sources: None. Table 1

Effects of Vaccine-Related Conspiracy Theories on Chinese Young Adults' Perceptions of the HPV Vaccine: An Experimental Study

This online experiment used the Theory of Planned Behavior to examine the impact of exposure to conspiracy social media messages on Chinese young adults' perceptions of the HPV vaccine. Three major findings were identified. First, exposure to anti-vaccine conspiracy theories resulted in less favorable attitudes toward the HPV vaccine, less positive perceived norms regarding getting vaccinated, and weaker vaccination intentions. Second, people who were more knowledgeable about the HPV vaccine had more favorable attitudes, more positive norms, higher perceived behavioral control, and greater behavioral intentions. Finally, vaccine knowledge moderated the effect of exposure to anti-vaccine conspiracy theories. Our results suggest that, among Chinese young adult social media users, preexisting knowledge of the HPV vaccine may have a protective effect against exposure to online conspiracy theories.

Using nominal group technique to advance power assisted exercise equipment for people with stroke

BACKGROUND

Power assisted exercise is accessible and acceptable for people with stroke. The potential for technological advancement of the equipment to improve the user experience has been identified. Involvement of end users and service providers in the design of health technologies is essential in determining how said technology is perceived and adopted. This project invited people with stroke and service providers to influence design features and determine machine selection in the preliminary stages of a codesign research programme.

AIMS

To capture the perspectives of people with stroke and professionals working with people with stroke about proposed digitalisation of power assisted exercise equipment and select machines for prototype development.

METHODS

Nominal group technique was used to capture the perspectives, ideas, preferences and priorities of three stakeholder groups: people with stroke (n = 3, mean age 66 years), rehabilitation professionals (n = 3) and exercise scientists (n = 3). Two questions underpinned the structure of the events; 'What does an assistive exercise machine need to do to allow the person with stroke to engage in exercise?' and 'Which machines would you prioritise for use with People with Stroke?' Attendees were invited to cast votes to indicate their preferred machines.

FINDINGS

Synthesis of the data from the NGT identified four domains; software and interface, exercise programme, machine and accessories, setting and service. Three preferred machines from a range of nine were identified through vote counting.

CONCLUSION

Nominal group technique directed the selection of machines to be included in the development of the proposed technology. The vision shared by users during the structured discussion shaped the subsequent steps in the design and testing of the new technology.

PATIENT AND SERVICE PROVIDER CONTRIBUTION

The opinions and preferences of people with stroke, rehabilitation professionals and exercise scientists were central to key decisions which will shape the digitalisation of power assisted equipment, influence future research and guide implementation of the new technologies.

Evaluation of Elafin as a Prognostic Biomarker in Acute Graft-versus-Host Disease

Acute graft-versus-host disease (GVHD) is a major cause of mortality in patients undergoing hematopoietic cell transplantation (HCT) for hematologic malignancies. The skin is the most commonly involved organ in GVHD. Elafin, a protease inhibitor overexpressed in inflamed epidermis, was previously identified as a diagnostic biomarker of skin GVHD; however, this finding was restricted to a subset of patients with isolated skin GVHD. The main driver of nonrelapse mortality (NRM) in HCT recipients is gastrointestinal (GI) GVHD. Two biomarkers, Regenerating islet-derived 3a (REG3α) and Suppressor of tumorigenesis 2 (ST2), have been validated as biomarkers of GI GVHD that predict long-term outcomes in patients treated for GVHD. We undertook this study to determine the utility of elafin as a prognostic biomarker in the general population of acute GVHD patients in whom GVHD may develop in multiple organs. We analyzed serum elafin concentrations as a predictive biomarker of acute GVHD outcomes and compared it with ST2 and REG3α in a large group of patients treated at multiple centers. A total of 526 patients from the Mount Sinai Acute GVHD International Consortium (MAGIC) who had received corticosteroid treatment for skin GVHD and who had not been previously studied were analyzed. Serum concentrations of elafin, ST2, and REG3α were measured by ELISA in all patients. The patients were divided at random into equal training and validation sets, and a competing-risk regression model was developed to model 6-month NRM using elafin concentration in the training set. Additional models were developed using concentrations of ST2 and REG3α or the combination of all 3 biomarkers as predictors. Receiver operating characteristic (ROC) curves were constructed using the validation set to evaluate the predictive accuracy of each model and to stratify patients into high- and low-risk biomarker groups. The cumulative incidence of 6-month NRM, overall survival (OS), and 4-week treatment response were compared between the risk groups. Unexpectedly, patients in the low-risk elafin group demonstrated a higher incidence of 6-month NRM, although the difference was not statistically significant (17% versus 11%; P = .19). OS at 6 months (68% versus 68%; P > .99) and 4-week response (78% versus 78%; P = .98) were similar in the low-risk and high-risk elafin groups. The area under the ROC curve (AUC) was 0.55 for elafin and 0.75 for the combination of ST2 and REG3α. The addition of elafin to the other 2 biomarkers did not improve the AUC. Our data indicate that serum elafin concentrations measured at the initiation of systemic treatment for acute GVHD did not predict 6-month NRM, OS, or treatment response in a multicenter population of patients treated systemically for acute GVHD. As seen in previous studies, serum concentrations of the GI GVHD biomarkers ST2 and REG3α were significant predictors of NRM, and the addition of elafin levels did not improve their accuracy. These results underscore the importance of GI disease in driving NRM in patients who develop acute GVHD.

Users' experience of community-based power assisted exercise: a transition from NHS to third sector services

PURPOSE

Seated Power Assisted Exercise (PAE) equipment is an accessible exercise mode for people with limited mobility following stroke and is available at a small number of community-based venues. The purpose of this qualitative study was to understand the lived experience of using PAE amongst PwS in a community venue and identify recommendations for the development and advancement of PAE equipment.

METHOD

Semi-structured interviews were conducted with 8 participants (PwS) attending a community stroke venue where PAE equipment was available. Transcribed data were analysed using interpretative phenomenological analysis.

RESULTS

Three overarching themes emerged from the analysis; 1) Don't tell me I've plateaued; 2) PAE facilitates the transition into long-term recovery; 3) Reframing the experience of stroke. Participants associated the uptake of PAE alongside venue membership as a turning point in their adjustment to life following stroke. In addition, recommendations for future development of the equipment were identified.

CONCLUSION

These findings indicate that membership of a stroke venue alongside engagement with PAE facilitated transition from early stroke rehabilitation into longer term recovery. The results of this study have informed the need for future product design and highlighted PAE is an effective mode for continued rehabilitation in third-sector services.

Mortality from esophagectomy for esophageal cancer across low, middle, and high-income countries: An international cohort study

BACKGROUND

No evidence currently exists characterising global outcomes following major cancer surgery, including esophageal cancer. Therefore, this study aimed to characterise impact of high income countries (HIC) versus low and middle income countries (LMIC) on the outcomes following esophagectomy for esophageal cancer.

METHOD

This international multi-center prospective study across 137 hospitals in 41 countries included patients who underwent an esophagectomy for esophageal cancer, with 90-day follow-up. The main explanatory variable was country income, defined according to the World Bank Data classification. The primary outcome was 90-day postoperative mortality, and secondary outcomes were composite leaks (anastomotic leak or conduit necrosis) and major complications (Clavien-Dindo Grade III - V). Multivariable generalized estimating equation models were used to produce adjusted odds ratios (ORs) and 95% confidence intervals (CI95%).

RESULTS

Between April 2018 to December 2018, 2247 patients were included. Patients from HIC were more significantly older, with higher ASA grade, and more advanced tumors. Patients from LMIC had almost three-fold increase in 90-day mortality, compared to HIC (9.4% vs 3.7%, p < 0.001). On adjusted analysis, LMIC were independently associated with higher 90-day mortality (OR: 2.31, CI95%: 1.17-4.55, p = 0.015). However, LMIC were not independently associated with higher rates of anastomotic leaks (OR: 1.06, CI95%: 0.57-1.99, p = 0.9) or major complications (OR: 0.85, CI95%: 0.54-1.32, p = 0.5), compared to HIC.

CONCLUSION

Resections in LMIC were independently associated with higher 90-day postoperative mortality, likely reflecting a failure to rescue of these patients following esophagectomy, despite similar composite anastomotic leaks and major complication rates to HIC. These findings warrant further research, to identify potential issues and solutions to improve global outcomes following esophagectomy for cancer.

Comparison of short-term outcomes from the International Oesophago-Gastric Anastomosis Audit (OGAA), the Esophagectomy Complications Consensus Group (ECCG), and the Dutch Upper Gastrointestinal Cancer Audit (DUCA)

BACKGROUND

The Esophagectomy Complications Consensus Group (ECCG) and the Dutch Upper Gastrointestinal Cancer Audit (DUCA) have set standards in reporting outcomes after oesophagectomy. Reporting outcomes from selected high-volume centres or centralized national cancer programmes may not, however, be reflective of the true global prevalence of complications. This study aimed to compare complication rates after oesophagectomy from these existing sources with those of an unselected international cohort from the Oesophago-Gastric Anastomosis Audit (OGAA).

METHODS

The OGAA was a prospective multicentre cohort study coordinated by the West Midlands Research Collaborative, and included patients undergoing oesophagectomy for oesophageal cancer between April and December 2018, with 90 days of follow-up.

RESULTS

The OGAA study included 2247 oesophagectomies across 137 hospitals in 41 countries. Comparisons with the ECCG and DUCA found differences in baseline demographics between the three cohorts, including age, ASA grade, and rates of chronic pulmonary disease. The OGAA had the lowest rates of neoadjuvant treatment (OGAA 75.1 per cent, ECCG 78.9 per cent, DUCA 93.5 per cent; P < 0.001). DUCA exhibited the highest rates of minimally invasive surgery (OGAA 57.2 per cent, ECCG 47.9 per cent, DUCA 85.8 per cent; P < 0.001). Overall complication rates were similar in the three cohorts (OGAA 63.6 per cent, ECCG 59.0 per cent, DUCA 62.2 per cent), with no statistically significant difference in Clavien-Dindo grades (P = 0.752). However, a significant difference in 30-day mortality was observed, with DUCA reporting the lowest rate (OGAA 3.2 per cent, ECCG 2.4 per cent, DUCA 1.7 per cent; P = 0.013).

CONCLUSION

Despite differences in rates of co-morbidities, oncological treatment strategies, and access to minimal-access surgery, overall complication rates were similar in the three cohorts.

Surgical innovation revisited: A historical narrative of the minimally invasive “Agarwal sliding‐clip renorrhaphy” technique for partial nephrectomy and its application to an Australian cohort

Objective

To evaluate local clinical outcomes of sliding clip renorrhaphy, from inception to current utilization for open, laparoscopic, and robotically assisted partial nephrectomy.

Methods

We reviewed prospectively maintained databases of three surgeons performing partial nephrectomies with the sliding‐clip technique at teaching hospitals between 2005 and 2019. Baseline characteristics, operative parameters, including surgical approach, RENAL Nephrometry Score, and post‐operative outcomes, including Clavien‐Dindo classification of complications, were recorded for 76 consecutive cases. We compared perioperative and 90‐day events with patient and tumor characteristics, stratified by operative approach and case complexity, using Wilcoxon rank‐sum test for continuous variables and the Chi‐squared or Fisher's exact test, for binary and categorical variables, respectively.

Results

Open surgery (n = 15) reduced ischemia time and operative time, but increased hospital admission time. Pre‐ and post‐operative estimated glomerular filtration rates did not change significantly by operative approach. Older patients (P = .007) and open surgery (P = .003) were associated with a higher rate of complications (any‐grade). Six grade ≥3 complications occurred: these were associated with higher RENAL Nephrometry Score (P = .016) and higher pathological tumor stage (P = .045). Limits include smaller case volumes which incorporate the learning curve cases; therefore, these data are most applicable to lower volume teaching hospitals.

Conclusion

The sliding‐clip technique for partial nephrectomy was first described by Agarwal et al and has low complication rates, acceptable operative time, and preserves renal function across open and minimally invasive surgeries. This series encompasses the initial learning curve with developing the technique through to present‐day emergence as a routine standard of practice.