Dealing with complications in interventional radiology

It is widely accepted that most misadventures, which lead to harm have not occurred because of a single individual but rather due to a failure of process that results in healthcare workers making mistakes. This failure of process and the pervasiveness of adverse events is just as prevalent in Interventional Radiology (IR) as it is in other specialities. The true prevalence and prevailing aetiology of complications in IR are not exactly known as there is a paucity of investigative literature into this area; especially when compared with other more established disciplines such as Surgery. Some IR procedures have a higher risk profile than others. However, published data suggests that many adverse events in IR are preventable (55-84%) and frequently involve a device related complication such as improper usage or malfunction. This article aims to discuss factors that contribute to complications in IR along with tools and strategies for dealing with them to achieve optimal patient outcomes.

Providing men at risk of suicide with emotional support and advice with employment, housing and financial difficulties: a qualitative evaluation of the Hope service

BACKGROUND

Men at risk of suicide often face difficulties with finances, employment, or housing, yet support services are usually psychologically based. This study evaluated the Hope service which provides integrated psychosocial support alongside practical, financial and specialist advice.

AIMS

To examine how the Hope service supports men at risk of suicide and factors that influence its impact and usefulness.

METHODS

Twenty-six qualitative interviews with 16 service users, six Hope staff, two specialist money advice workers funded to work for Hope and two NHS referral staff, thematically analysed.

RESULTS

The Hope service provided an essential service for men at risk of suicide, with complex needs including addiction, job loss, homelessness, debt, relationship-breakdown and bereavement who often would otherwise have fallen through service provision gaps. Working in a person-centred, non-judgemental way elicited trust and specialist advice tackled problems such as housing needs, debt, benefit claims and employment, enabling men to regain a sense of control over their lives. Some men shared histories of abuse, for which specialist counselling was hard to access.

CONCLUSIONS

Hope provides an effective integrated support package for suicidal men. Funding for services like Hope are important to tackle structural issues such as homelessness and debt, alongside emotional support.

Management of chronic pain secondary to temporomandibular disorders: a systematic review and network meta-analysis of randomised trials

OBJECTIVE

We explored the comparative effectiveness of available therapies for chronic pain associated with temporomandibular disorders (TMD).

DESIGN

Systematic review and network meta-analysis of randomised clinical trials (RCTs).

DATA SOURCES

MEDLINE, EMBASE, CINAHL, CENTRAL, and SCOPUS were searched to May 2021, and again in January 2023.

STUDY SELECTION

Interventional RCTs that enrolled patients presenting with chronic pain associated with TMD.

DATA EXTRACTION AND SYNTHESIS

Pairs of reviewers independently identified eligible studies, extracted data, and assessed risk of bias. We captured all reported patient-important outcomes, including pain relief, physical functioning, emotional functioning, role functioning, social functioning, sleep quality, and adverse events. We conducted frequentist network meta-analyses to summarise the evidence and used the GRADE approach to rate the certainty of evidence and categorise interventions from most to least beneficial.

RESULTS

233 trials proved eligible for review, of which 153-enrolling 8713 participants and exploring 59 interventions or combinations of interventions-were included in network meta-analyses. All subsequent effects refer to comparisons with placebo or sham procedures. Effects on pain for eight interventions were supported by high to moderate certainty evidence. The three therapies probably most effective for pain relief were cognitive behavioural therapy (CBT) augmented with biofeedback or relaxation therapy (risk difference (RD) for achieving the minimally important difference (MID) in pain relief of 1 cm on a 10 cm visual analogue scale: 36% (95% CI 33 to 39)), therapist-assisted jaw mobilisation (RD 36% (95% CI 31 to 40)), and manual trigger point therapy (RD 32% (29 to 34)). Five interventions were less effective, yet more effective than placebo, showing RDs ranging between 23% and 30%: CBT, supervised postural exercise, supervised jaw exercise and stretching, supervised jaw exercise and stretching with manual trigger point therapy, and usual care (such as home exercises, self stretching, reassurance).Moderate certainty evidence showed four interventions probably improved physical functioning: supervised jaw exercise and stretching (RD for achieving the MID of 5 points on the short form-36 physical component summary score: 43% (95% CI 33 to 51)), manipulation (RD 43% (25 to 56)), acupuncture (RD 42% (33 to 50)), and supervised jaw exercise and mobilisation (RD 36% (19 to 51)). The evidence for pain relief or physical functioning among other interventions, and all evidence for adverse events, was low or very low certainty.

CONCLUSION

When restricted to moderate or high certainty evidence, interventions that promote coping and encourage movement and activity were found to be most effective for reducing chronic TMD pain.

REGISTRATION

PROSPERO (CRD42021258567).

Effect of HIV infection on plasma exposure to first-line TB drugs and target attainment in children

BACKGROUND: Whether HIV infection adversely affects exposure to first-line TB drugs in children is debatable. It is also not known whether HIV infection increases the risk of plasma underexposure or overexposure to TB drugs. This study sought to address these questions.DESIGN/METHODS: Children on TB treatment were enrolled. After 4 weeks on therapy, blood samples were collected at pre-dose, 1, 2, 4, 8, and 12 h post-dose for pharmacokinetic analysis. Plasma drug exposure below and above the lower and upper bounds of the 95% confidence intervals of the reference mean for children were considered underexposure and overexposure, respectively. The effect of HIV infection on drugs exposure and risk of underexposure were examined using multivariate analysis.RESULTS: Of 86 participants (median age: 4.9 years), 45 had HIV coinfection. HIV coinfection was associated with lower pyrazinamide (PZA) and ethambutol exposures in adjusted analysis. Patients with TB-HIV coinfection were three times more likely to have PZA underexposure than those with TB only. Underexposure of rifampin was common irrespective of HIV coinfection status.CONCLUSIONS: HIV coinfection was associated with a higher risk for PZA underexposure in children. This effect should be accounted for in models and simulations to determine optimal PZA dose for children.

Weeping sponge kidney: an unusual phenomenon that should be considered in cases of severe renal haemorrhage

AIM

To describe the clinical presentation, imaging evaluation, endovascular management, and outcomes of multifocal renal capsular haemorrhage, "weeping sponge kidney", and to identify associated risk factors and the pathophysiological mechanism behind this condition.

MATERIALS AND METHODS

This is a case series in which clinical information for each of the cases was collected retrospectively from electronic patient notes as well as the radiology information and picture archiving and communication systems.

RESULTS

Four consecutive cases were included in the series. All of the cases were treated successfully with embolisation. Three of the four patients had chronic renal failure with renal atrophy, which are patient factors that appear to be associated with multifocal renal capsular haemorrhage. Based on the procedural findings and the published literature, a pathophysiological mechanism is described to explain this condition and the relevance of the collateral arterial supply to the kidney in such cases is discussed.

CONCLUSION

Small subcapsular haematomas are usually self-limiting but in patients with renal failure, there may be an increased risk of developing a weeping sponge kidney, which can be life-threatening. The endovascular treatment for multifocal haemorrhage differs from that for a single bleeding point, especially if preservation of renal function is not a priority.

Magnetic Resonance Imaging Features and Prognostic Indicators of Local Recurrence after Curettage and Cementation of Atypical Cartilaginous Tumour in the Appendicular Skeleton

Objective: The aim of this study is to determine MRI features that may be prognostic indicators of local recurrence (LR) in patients treated with curettage and cementation of atypical cartilaginous tumours (ACTs) in the appendicular skeleton. Materials and Methods: This study is a retrospective review of adult patients with histologically confirmed appendicular ACT. The data collected included age, sex, skeletal location and histology from curettage, the presence of LR and oncological outcomes. The pre-operative MRI characteristics of the ACT reviewed by a specialist MSK radiologist included lesion location, lesion length, degree of medullary filling, bone expansion, cortical status and the presence of soft tissue extension. Results: A total of 43 patients were included, including 9 males and 34 females with a mean age of 42.8 years (range: 25-76 years). Tumours were located in the femur (n = 19), humerus (n = 15), tibia (n = 5), fibula (n = 2) and radius and ulna (n = 1 each). A total of 19 lesions were located in the diaphysis, 12 in the metadiaphysis, 6 in the metaphysis and 6 in the epiphysis. The mean tumour length was 61.0 mm (range: 12-134 mm). The mean follow up was 97.7 months (range: 20-157 months), during which 10 (23.3%) patients developed LR, 7 (70%) of which were asymptomatic and 3 (30%) of which presented with pain. Four patients required repeat surgery with no associated death or evidence of metastatic disease. LR was significantly commoner with tumours arising in the epiphysis or metadiaphysis, but no MRI features were predictive of LR. Conclusions: No relationship was found between the apparent 'aggressiveness' of an ACT of the appendicular skeleton on MRI and the development of LR following treatment with curettage and cementation.

Vascular Interventions in Oncology

Vascular interventions are an important and established tool in the management of the oncology patient. The goal of these procedures may be curative, palliative or adjunctive in nature. Some of the common vascular interventions used in oncology include transarterial embolisation or chemoembolisation, selective internal radiation therapy, chemosaturation, venous access lines, superior vena cava stenting and portal vein embolisation. We provide an overview of the principles, technology and approach of vascular techniques for tumour therapy in both the arterial and venous systems. Arterial interventions are currently mainly used in the management of hepatocellular carcinoma. Transarterial embolisation, chemoembolisation and selective internal radiation therapy deliver targeted catheter-delivered treatments with the aim of reducing tumour burden, controlling tumour growth or increasing survival in patients not eligible for transplantation. Chemosaturation is a regional chemotherapy technique that delivers high doses of chemotherapy directly to the liver via the hepatic artery, while reducing the risks of systemic effects. Venous interventions are more adjunctive in nature. Venous access lines are used to provide a means of delivering chemotherapy and other medications directly into the bloodstream. Superior vena cava stenting is a palliative procedure that is used to relieve symptoms of superior vena cava obstruction. Portal vein embolisation is a procedure that allows hypertrophy of a healthy portion of the liver in preparation for liver resection. Interventional radiology-led vascular interventions play an essential part of cancer management. These procedures are minimally invasive and provide a safe and effective adjunct to traditional cancer treatment methods. Appropriate work-up and discussion of each patient-specific problem in a multidisciplinary setting with interventional radiology is essential to provide optimum patient-centred care.

Grading of recommendations assessment, development, and evaluation concept article 5: addressing intransitivity in a network meta-analysis

OBJECTIVES

This article describes considerations for addressing intransitivity when assessing the certainty of the evidence from network meta-analysis (NMA) using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. Intransitivity is induced by effect modification, that is, when the magnitude of the effect between an intervention and outcome differs depending on the level of another factor.

STUDY DESIGN AND SETTING

To develop this GRADE concept paper, the lead authors conducted iterative discussions, computer simulations, and presentations to the GRADE project group and at GRADE working group meetings. The GRADE Working Group formally approved the article in July 2022.

RESULTS

NMA authors can have a higher or a lower threshold to rate down the certainty of the evidence due to intransitivity, which depends on the extent of their concerns regarding the trustworthiness of indirect comparisons, and their view of the relative problems with rating down excessively or insufficiently. NMA authors should consider three main factors when addressing intransitivity: the credibility of effect modification, the strength of the effect modification, and the distribution of effect modifiers across the direct comparisons. To avoid double counting limitations of the evidence, authors should consider the relationship between intransitivity and other GRADE domains.

CONCLUSION

NMA authors face theoretic and pragmatic challenges and in most situations need to assess intransitivity without the availability of empirical data. Thus, explicitness regarding perspective is crucial.

Genomic analyses of germline and somatic variation in high-grade serous ovarian cancer

BACKGROUND

High-grade serous ovarian cancers (HGSCs) display a high degree of complex genetic alterations. In this study, we identified germline and somatic genetic alterations in HGSC and their association with relapse-free and overall survival. Using a targeted capture of 557 genes involved in DNA damage response and PI3K/AKT/mTOR pathways, we conducted next-generation sequencing of DNA from matched blood and tumor tissue from 71 HGSC participants. In addition, we performed the OncoScan assay on tumor DNA from 61 participants to examine somatic copy number alterations (SCNA).

RESULTS

Approximately one-third of tumors had loss-of-function (LOF) germline (18/71, 25.4%) or somatic (7/71, 9.9%) variants in the DNA homologous recombination repair pathway genes BRCA1, BRCA2, CHEK2, MRE11A, BLM, and PALB2. LOF germline variants also were identified in other Fanconi anemia genes and in MAPK and PI3K/AKT/mTOR pathway genes. Most tumors harbored somatic TP53 variants (65/71, 91.5%). Using the OncoScan assay on tumor DNA from 61 participants, we identified focal homozygous deletions in BRCA1, BRCA2, MAP2K4, PTEN, RB1, SLX4, STK11, CREBBP, and NF1. In total, 38% (27/71) of HGSC patients harbored pathogenic variants in DNA homologous recombination repair genes. For patients with multiple tissues from the primary debulking or from multiple surgeries, the somatic mutations were maintained with few newly acquired point mutations suggesting that tumor evolution was not through somatic mutations. There was a significant association of LOF variants in homologous recombination repair pathway genes and high-amplitude somatic copy number alterations. Using GISTIC analysis, we identified NOTCH3, ZNF536, and PIK3R2 in these regions that were significantly associated with an increase in cancer recurrence and a reduction in overall survival.

CONCLUSIONS

From 71 patients with HGCS, we performed targeted germline and tumor sequencing and provided a comprehensive analysis of these 557 genes. We identified germline and somatic genetic alterations including somatic copy number alterations and analyzed their associations with relapse-free and overall survival. This single-site long-term follow-up study provides additional information on genetic alterations related to occurrence and outcome of HGSC. Our findings suggest that targeted treatments based on both variant and SCNA profile potentially could improve relapse-free and overall survival.

African American Prostate Cancer Displays Quantitatively Distinct Vitamin D Receptor Cistrome-transcriptome Relationships Regulated by BAZ1A

African American (AA) prostate cancer associates with vitamin D3 deficiency, but vitamin D receptor (VDR) genomic actions have not been investigated in this context. We undertook VDR proteogenomic analyses in European American (EA) and AA prostate cell lines and four clinical cohorts. Rapid immunoprecipitation mass spectrometry of endogenous protein (RIME) analyses revealed that nonmalignant AA RC43N prostate cells displayed the greatest dynamic protein content in the VDR complex. Likewise, in AA cells, Assay for Transposase-Accessible Chromatin using sequencing established greater 1α,25(OH)2D3-regulated chromatin accessibility, chromatin immunoprecipitation sequencing revealed significant enhancer-enriched VDR cistrome, and RNA sequencing identified the largest 1α,25(OH)2D3-dependent transcriptome. These VDR functions were significantly corrupted in the isogenic AA RC43T prostate cancer cells, and significantly distinct from EA cell models. We identified reduced expression of the chromatin remodeler, BAZ1A, in three AA prostate cancer cohorts as well as RC43T compared with RC43N. Restored BAZ1A expression significantly increased 1α,25(OH)2D3-regulated VDR-dependent gene expression in RC43T, but not HPr1AR or LNCaP cells. The clinical impact of VDR cistrome-transcriptome relationships were tested in three different clinical prostate cancer cohorts. Strikingly, only in AA patients with prostate cancer, the genes bound by VDR and/or associated with 1α,25(OH)2D3-dependent open chromatin (i) predicted progression from high-grade prostatic intraepithelial neoplasia to prostate cancer; (ii) responded to vitamin D3 supplementation in prostate cancer tumors; (iii) differentially responded to 25(OH)D3 serum levels. Finally, partial correlation analyses established that BAZ1A and components of the VDR complex identified by RIME significantly strengthened the correlation between VDR and target genes in AA prostate cancer only. Therefore, VDR transcriptional control is most potent in AA prostate cells and distorted through a BAZ1A-dependent control of VDR function.

Significance

Our study identified that genomic ancestry drives the VDR complex composition, genomic distribution, and transcriptional function, and is disrupted by BAZ1A and illustrates a novel driver for AA prostate cancer.

Abstract WMP73: Border Zone Infarct Pattern Predicts Early Recurrence In Symptomatic Intracranial Atherosclerotic Disease: A Systematic Review And Meta-analysis

Introduction: Stroke secondary to intracranial atherosclerosis (ICAD) results in three distinct infarct patterns: (a) border zone infarcts (BZI) due to impaired distal perfusion (b) territorial infarcts due to distal plaque/thrombus embolization, and (c) perforator infarcts due to plaque progression. Previous studies indicate higher stroke recurrence in ICAD patients with BZI.

Methods: This registered systematic review (CRD42021265230) comprised Medline and Web of Science search from inception to March 2022 for keywords (Intracranial Atherosclerosis OR Intracranial Stenosis) AND (Border zone OR Infarct Pattern) to identify papers and conference abstracts reporting initial infarct patterns and recurrence rates in patients with symptomatic ICAD. Sensitivity analyses were performed for studies including any BZI vs isolated BZI and those excluding posterior circulation strokes. The study outcome included neurological deterioration and/or stroke recurrence. For all outcome events, corresponding risk ratios (RR) and 95% confidence intervals (CI) were calculated. Risk of bias assessments will be presented.

Results: Literature search yielded 4478 studies,11 met inclusion criteria (n=1315 patients, 354 with BZI, weighted proportions summarized in figure). The meta-analysis of these studies with moderate heterogeneity (I 2 =38.7%) demonstrated that RR of outcomes in BZI group compared to non-BZI group was 2.10 (95% CI 1.52-2.90). Limiting analysis to studies including any BZI, RR (and 95% CI) was 2.32 (1.58-3.40), and 3.25 (2.09-5.07) for studies only including anterior circulation strokes with low heterogeneity for both (I 2 =0%). A non-significantly high outcome rate was seen with isolated BZI (RR 2.29, 95% CI 0.94-5.62) but with moderate heterogeneity across studies (I 2 =70.25%).

Conclusion: We demonstrate the presence of BZI secondary to symptomatic ICAD can be imaging biomarker to predict neurological deterioration and/or stroke recurrence.

Impact of site of occlusion in proximal splenic artery embolisation for blunt splenic trauma

Background

Proximal splenic artery embolisation (PSAE) can be performed in stable patients with Association for the Surgery of Trauma (AAST) grade III-V splenic injury. PSAE reduces splenic perfusion but maintains viability of the spleen and pancreas via the collateral circulation. The hypothesized ideal location is between the dorsal pancreatic artery (DPA) and great pancreatic artery (GPA). This study compares the outcomes resulting from PSAE embolisation in different locations along the splenic artery.

Materials and methods

Retrospective review was performed of PSAE for blunt splenic trauma (2015–2020). Embolisation locations were divided into: Type I, proximal to DPA; Type II, DPA-GPA; Type III, distal to GPA. Fifty-eight patients underwent 59 PSAE: Type I (7); Type II (27); Type III (25). Data was collected on technical and clinical success, post-embolisation pancreatitis and splenic perfusion. Statistical significance was assessed using a chi-squared test.

Results

Technical success was achieved in 100% of cases. Clinical success was 100% for Type I/II embolisation and 88% for Type III: one patient underwent reintervention and two had splenectomies for ongoing instability. Clinical success was significantly higher in Type II embolisation compared to Type III (p = 0.02). No episodes of pancreatitis occurred post-embolisation. Where post-procedural imaging was obtained, splenic perfusion remained 100% in Type I and II embolisation and 94% in Type III. Splenic perfusion was significantly higher in the theorized ideal Type II group compared to Type I and III combined (p = 0.01).

Conclusion

The results support the proposed optimal embolisation location as being between the DPA and GPA.

Abstract 3619: Vitamin D receptor function in African American prostate cancer is disrupted by reduced BAZ1A/SMARCA5

The biological drivers of prostate cancer (PCa) health disparities remain enigmatic. There are genomic differences, for example in the incidence of TMPRSS2 and ERG gene fusions which differ between European American (EA) and African American (AA) PCa. Accumulating epidemiological evidence suggests loss of vitamin D receptor VDR signaling contributes to AA PCa. Therefore, we investigated the VDR signaling in AA and EA prostate models. VDR protein levels were comparable between AA (RC43N, RC43T, RC77N, RC77T) and EA cells (HPr1AR, LNCaP) but RIME analyses identified significant AA-EA differences in VDR binding of coactivators (e.g. NCOA5), corepressors (e.g. HDAC2), and components of SWI/SNF and circadian rhythm complexes. ATAC-Seq identified 1α,25(OH)2D3-stimulated gain in nucleosome free (NF) regions was greatest in RC43N (non-malignant AA cells) and enriched for circadian rhythm transcription motifs (e.g. CLOCK). In RC43T AA PCa cells 1α,25(OH)2D3 led to a loss of NF free regions. Similarly, VDR ChIP-Seq revealed the cistrome was greater in AA cell models, and was dynamically altered in RC43N cells by 1α,25(OH)2D3 and overlapped with the SWI/SNF component SMARCA4, but 1α,25(OH)2D3 led to reduced VDR binding in RC43T cells. The 1α,25(OH)2D3-regulated transcriptome was largest in RC43N and RC43T but GSEA terms were frequently and oppositely enriched, for example Reactome S phase genes were negatively enriched in RC43N, but positively enriched in RC43T. Cistrome-transcriptome integration identified the most significant relationships between VDR binding and the magnitude of 1α,25(OH)2D3-regulated genes in RC43N. Global coregulator analyses identified significantly reduced BAZ1A/SMARCA5 in AA PCa in TCGA and a published cohort of ~1500 AA/EA tumors. Restoring BAZ1A expression in cells resulted in significantly enhanced 1α,25(OH)2D3-regulated transcriptome in RC43N and RC43T cells, and hypergeometric tests revealed the significant enrichment of direct VDR target genes. The footprint of altered AA VDR signaling was evident in three previously established clinical cohorts. Serum miRNA that predicted AA progression from HGPIN to PCa were enriched for 1α,25(OH)2D3-regulated VDR targets; AA tumors from a vitaminD3-treated chemotherapy trail were enriched for VDR-bound genes; and, tumors from men with low serum 25(OH)D3 levels were significantly enriched for VDR target genes identified in AA but not EA PCa. Together, these data suggest VDR transcriptional control is most potent and dynamic in AA prostate cells, and is primed to govern inflammatory and circadian pathways. Reduced BAZ1A/SMARCA5 expression and/or reduced environmental-regulated serum vitamin D3 levels most acutely suppress these actions in AA PCa. Therefore, the VDR axis lies at the cross-roads of biopsychosocial processes that contributes to PCa health disparities.

Citation Format: Shahid Hussain, Manjunath Siddappa, Sajad A. Wani, Hedieh Jafari, Jaimie S. Gray, Hsu-Chang Wu, Hancong Tang, Mark D. Long, Isra Elhussin, Balasubramanyam Karanam, Honghe Wang, Rebecca Morgan, Gary Hardiman, Isaacson B. Adelani, Rotimi Oladapo, Adam R. Murphy, James R. Marshall, Chanita Highes Halbert, Lara E. Sucheston-Campbell, Clayton Yates, Moray J. Campbell. Vitamin D receptor function in African American prostate cancer is disrupted by reduced BAZ1A/SMARCA5 [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 3619.

Defining core patient descriptors for perforated peptic ulcer research: international Delphi

BACKGROUND

Perforated peptic ulcer (PPU) remains a common condition globally with significant morbidity and mortality. Previous work has demonstrated variation in reporting of patient characteristics in PPU studies, making comparison of studies and outcomes difficult. The aim of this study was to standardize the reporting of patient characteristics, by creating a core descriptor set (CDS) of important descriptors that should be consistently reported in PPU research.

METHODS

Candidate descriptors were identified through systematic review and stakeholder proposals. An international Delphi exercise involving three survey rounds was undertaken to obtain consensus on key patient characteristics for future research. Participants rated items on a scale of 1-9 with respect to their importance. Items meeting a predetermined threshold (rated 7-9 by over 70 per cent of stakeholders) were included in the final set and ratified at a consensus meeting. Feedback was provided between rounds to allow refinement of ratings.

RESULTS

Some 116 clinicians were recruited from 29 countries. A total of 63 descriptors were longlisted from the literature, and 27 were proposed by stakeholders. After three survey rounds and a consensus meeting, 27 descriptors were included in the CDS. These covered demographic variables and co-morbidities, risk factors for PPU, presentation and pathway factors, need for organ support, biochemical parameters, prognostic tools, perforation details, and surgical history.

CONCLUSION

This study defines the core descriptive items for PPU research, which will allow more robust synthesis of studies.

Pediatric electric scooter injuries in the UK: Case series and review of literature

OBJECTIVE

Electric scooters are being used worldwide as a new means of transport and e-scooter shared schemes are currently being piloted in cities across the UK. At present, there is no data published looking at pediatric e-scooter injuries within the UK. We aim to assess if e-scooters pose a risk to children and the patterns and severity of orthopedic injuries related to their use.

METHODS

We performed a retrospective review of all orthopedic pediatric referrals relating to e-scooter use from January 1 to December 31, 2020 at two hospitals, including one pediatric Major Trauma Center in central London. Data including patient demographics, mechanism of injury, diagnosis, and treatment were collected.

RESULTS

Ten patients were identified in this series, of which 5 required orthopedic surgery. Four patients required admission to hospital from the emergency department. The median age was 15 (range 13-17 years) and all were male. All e-scooters were privately owned and all sustained a fall whilst riding the e-scooter. No patient was wearing a helmet. Six sustained lower limb injuries and four upper limb injuries. Two patients were trauma called and one patient sustained an open fracture. There were no mortalities at 30 days.

CONCLUSION

E-scooters pose a significant risk to children and can be associated with severe musculoskeletal injury. The risk they pose to the pediatric population should not be overlooked and these findings may inform public policy regarding the restriction of electric scooter use in children.

Preventing male suicide through a psychosocial intervention that provides psychological support and tackles financial difficulties: a mixed method evaluation

BACKGROUND

To help resolve high suicide rates in Bristol, North Somerset and South Gloucestershire, the charity Second Step was commissioned to roll-out the Hope service offering a psychosocial intervention for men, supporting them through acute distress and addressing financial difficulties. This study evaluated the impact of the Hope service on men at risk of suicide experiencing financial and other difficulties.

METHODS

Mixed methods study using: (i) a prospective cohort study design to compare depression, suicidal ideation and financial self-efficacy scores of men aged 30-64, referred to the service between October 2018 and July 2020, at baseline and 6 months follow-up and between low and moderate to high-intensity service users; and (ii) a qualitative interview study to evaluate the acceptability and impact of the Hope service to Hope service users.

RESULTS

There was a 49% reduction in depression score (mean reduction - 10.0, 95% CI - 11.7 to - 8.3) and in the proportion of service users with suicidal ideation (percent reduction - 52.5, 95% CI - 64.1% to - 40.9%) at 6 months follow-up compared to baseline. Financial self-efficacy scores increased by 26% (mean increase 2.9, 95% CI 1.8 to 3.9). Qualitative accounts illustrated how 'Hope saved my life' for several men interviewed; most respondents described being able to move forward and tackle challenges with more confidence following the Hope intervention. Professional advice to tackle financial and other difficulties such as housing helped to relieve anxiety and stress and enable practical issues to be resolved.

CONCLUSIONS

The Hope service offered practical and emotional support to men who have experienced suicidal feelings, redundancy, homelessness and poverty and occupies an important space between mental health and social care provision. Hope demonstrates the value of an intervention which cuts across traditional boundaries between psychiatric care and social advice agencies to provide, what is, in effect, an integrated care service.

Genetic taste sensitivity and dental caries in children and adolescents: A systematic review and meta-analysis

BACKGROUND

PROP test (6-n-propylthiouracil) for the identification of genetic sensitivity to caries in young individuals has emerged as a useful tool for caries risk assessment.

AIM

To systematically appraise available evidence on the association between genetic taste sensitivity, as detected by (PROP), and caries.

DESIGN

Seven databases, as of March 2020, were searched. Search terms included 'caries', 'taste predisposition', 'PROP'. Risk of bias assessment was performed using ROBINS-I tool, and the quality of evidence was assessed with GRADE. Random-effects meta-analyses were conducted to synthesize data, and pooled effects were estimated through standardized mean differences (SMDs) and associated confidence Intervals (95% CIs).

RESULTS

Of 92 articles initially retrieved, 12 were eligible for inclusion. Seven contributed to the meta-analyses. All were cross-sectional studies, with moderate-to-serious risk of bias. The non-tasters of PROP exhibited a significantly higher value for the DMFT compared with tasters (SMD: 1.23; 95% CI: 0.90, 1.56; P < .001), whereas the association for the DMFS was SMD: 1.34; 95% CI: 0.66, 2.01; P < .001 (non-tasters versus super-tasters). The quality of evidence was very low overall.

CONCLUSIONS

Within the limitations of this study, non-tasters to PROP exhibited higher caries experience, with subsequent clinical implications for follow-up and management of the 'high-susceptibility' individuals.

Long non-coding RNAs and their potential impact on diagnosis, prognosis, and therapy in prostate cancer: racial, ethnic, and geographical considerations

INTRODUCTION

Advances in high-throughput sequencing have greatly advanced our understanding of long non-coding RNAs (lncRNAs) in a relatively short period of time. This has expanded our knowledge of cancer, particularly how lncRNAs drive many important cancer phenotypes via their regulation of gene expression.

AREAS COVERED

Men of African descent are disproportionately affected by PC in terms of incidence, morbidity, and mortality. LncRNAs could serve as biomarkers to differentiate low-risk from high-risk diseases. Additionally, they may represent therapeutic targets for advanced and castrate-resistant cancer. We review current research surrounding lncRNAs and their association with PC. We discuss how lncRNAs can provide new insights and diagnostic biomarkers for African American men. Finally, we review advances in computational approaches that predict the regulatory effects of lncRNAs in cancer.

EXPERT OPINION

PC diagnostic biomarkers that offer high specificity and sensitivity are urgently needed. PC specific lncRNAs are compelling as diagnostic biomarkers owing to their high tissue and tumor specificity and presence in bodily fluids. Recent studies indicate that PCA3 clinical utility might be restricted to men of European descent. Further work is required to develop lncRNA biomarkers tailored for men of African descent.

Implementing a School-Based, Trauma-Informed Resilience Curriculum for Parents

"Families OverComing Under Stress" (FOCUS) Resilience Curriculum for Parents (FRC-P) is a trauma-informed group parenting program adapted for school social workers to deliver to parents of racial/ethnic minority urban public schoolchildren, an under-researched group of parents in the literature. The objective was to describe implementation of the pilot FRC-P in terms of possible effectiveness, feasibility, and acceptability. Social workers delivered FRC-P to parents at 16 schools. We analyzed (1) changes in parent well-being; (2) parent satisfaction; and (3) a focus group of participating social workers. Ninety-six of 261 parents (37%) who attended FRC-P completed pre and post surveys. Parents reported significant improvements (p < .01) in family functioning (Cohen's d = 0.41), parent connectedness (d = 0.71), and social support (d = 0.66). Social workers linked parents to needed services. Parents and social workers found FRC-P feasible and acceptable. With refinement, FRC-P could help schools foster resilience in under-resourced parents.

A systematic scoping review of racial, ethnic, and socioeconomic health disparities in pediatric dermatology

BACKGROUND/OBJECTIVES

Health disparities encompass a wide range of personal, societal, environmental, and system-based factors that contribute to inequitable health and health outcomes in vulnerable patient populations. The goal of this work was to scientifically summarize the existing published North American research on disparity as it pertains to pediatric dermatology.

METHODS

A systematic review was performed according to PRISMA guidelines. A medical librarian performed electronic searches from multiple electronic databases from their dates of inception to March 2021. Title and abstracts were reviewed by authors, identifying articles for full review. Data on article characteristics and identified disparities were then extracted and collected in a spreadsheet.

RESULTS

Fifty-one articles met final inclusion criteria, of which 25 highlighted disparities due to race/ethnicity, 13 highlighted disparities due to socioeconomic (SES), and 13 highlighted disparities due to both race/ethnicity and SES. The most frequent study designs were cross-sectional or survey, followed by retrospective cohort. Only two were prospective cohort studies. Disparities reported included reduced access to care and medications, increased school absenteeism, reduced knowledge about skin care including sun protection, increased hospitalizations and emergency department visits, and severe and persistent disease in the setting of minority race and poverty, among other indicators.

CONCLUSIONS

There are few, scattered research studies addressing disparity in pediatric dermatology. Greater focus will be needed in the future to improve knowledge of sources of disparity and its detrimental effects on the health of children, to rectify the notable disparity under-reporting of disparity research.

397 Seasonal Variation in Acute Cholecystitis; An Analysis to Predict Resources Allocation

Background

Acute cholecystitis accounts for 20% of Emergency General Surgical admissions. The concept of seasonal variation is still a developing concept in surgical literature. Whether acute cholecystitis also follows a seasonal trend remains to be established.

Aim

Given the struggle healthcare system has been facing towards resource and staff allocation to deliver best possible patient care, we thought this may be a step forward to predict North Wales demand of resources seasonally and make appropriate arrangements ahead of time.

Method

We performed a retrospective analysis of patients across North Wales who had a discharging diagnosis of acute cholecystitis from January 2010 to December 2019. Chi-square goodness-of-fit test was used to analyse seasonality of acute cholecystitis adjusting for variation in number of days between seasons. The number of days for seasons were taken as 92, 92, 91, and 90.25 for spring, summer, fall, and winter, respectively.

Results

Overall, 4100 patients presented to the three hospitals across North Wales with acute cholecystitis during the study period. The frequency of hospital admissions varied between months (minimum February n = 302, maximum July n = 373) and seasons (minimum winter n = 971, maximum spring n = 1067). After applying chi-square goodness-of-fit test to check significant seasonality, we did not find any significant seasonal variation in acute cholecystitis (p-value = 0.262).

Conclusions

Our data failed to show any significant seasonal variation in patients presenting with acute cholecystitis in North Wales. We recommend prospective collection of data at national level to validate our results.

Dark Energy Survey Year 1 Results: Cosmological Constraints from Cluster Abundances, Weak Lensing, and Galaxy Correlations

We present the first joint analysis of cluster abundances and auto or cross-correlations of three cosmic tracer fields: galaxy density, weak gravitational lensing shear, and cluster density split by optical richness. From a joint analysis (4×2pt+N) of cluster abundances, three cluster cross-correlations, and the auto correlations of the galaxy density measured from the first year data of the Dark Energy Survey, we obtain Ω_{m}=0.305_{-0.038}^{+0.055} and σ_{8}=0.783_{-0.054}^{+0.064}. This result is consistent with constraints from the DES-Y1 galaxy clustering and weak lensing two-point correlation functions for the flat νΛCDM model. Consequently, we combine cluster abundances and all two-point correlations from across all three cosmic tracer fields (6×2pt+N) and find improved constraints on cosmological parameters as well as on the cluster observable-mass scaling relation. This analysis is an important advance in both optical cluster cosmology and multiprobe analyses of upcoming wide imaging surveys.

Improving Patient- and Family-Centered Communication in Pediatrics: A Review of Simulation-Based Learning

Patient- and family-centered care focuses on relationships among patients, families, and health care providers that are mutually beneficial and improve health care outcomes and provider satisfaction. Building relationships is a key component of the provision of excellent health care and can be taught and enhanced through simulation-based communication skills training. This article reviews the available literature on simulation-based learning as used to improve patient- and family- centered communication in the discipline of pediatrics. In this narrative review, we examine the various methods, theories, and frameworks on which simulation-based learning for communication skills are built with the goal of assisting pediatric providers in using this powerful educational technique. [Pediatr Ann. 2021;50(1):e32-e38.].

Abstract PR05: Epigenetic disruption of vitamin D receptor signaling in African American prostate cancer alters circadian signaling networks

The current study aimed to define the genomic functions of the vitamin D receptor (VDR) in African American (AA) prostate cancer (PCa) compared to European American (EA) counterparts. VDR-dependent ChIP-Seq and RNA-Seq gene was undertaken in EA (non-malignant HPr1AR and malignant LNCaP) and AA (non-malignant RC43N and malignant RC43T) prostate models, combined with analyses of three PCa cohorts. In AA prostate models the VDR is highly expressed, binds more frequently, and is enriched in active and poised enhancers. Motif analyses revealed selective enrichment, including ZBTB33/KAISO in AA cells and ERG family members in EA cells and, similarly, GIGGLE analyses revealed AA VDR cistromes were significantly overlapped with core circadian rhythm transcription factors (e.g. NONO). Combining VDR-dependent ChIP-Seq and RNA-Seq established that AA cells displayed a significantly stronger transcriptional response, compared to EA cells, and was most responsive in non-malignant RC43N. For example, RC43N transcriptional responses were enriched for circadian rhythm (NES 2.7) and inflammation, whereas in RC43T the same gene networks were repressed. To reveal how VDR/1,25(OH)2D3 signaling is corrupted in AA PCa, we mined TCGA data and revealed that the BAZ1A/SMARCA5 chromatin remodeling complex was uniquely altered in TMPRSS2:ERG fusion negative AA PCa. We are currently examining the impact of BAZ1A on the 1,25(OH)2D3 responsiveness. We also identified miRNA associated with progression from HGPIN to PCa in AA men, and that ~30% were bound by VDR and regulated by 1,25(OH)2D3, although ~5% of EA progression miRNA were VDR-responsive. For example, VDR binds to miR-199b, is uniquely 1,25(OH)2D3 up-regulated in RC43N but repressed in RC43T, and associates with AA progression from HGPIN to PCa. MiR-199b regulates expression of NPAS2, a core circadian transcription factor. Finally, leveraging a previously analyzed cohort of 1,25(OH)2D3-treated PCa patients revealed that AA tumors were intrinsically more 1,25(OH)2D3-responsive than EA counterparts, reflecting the cell line analyses. 1,25(OH)2D3 regulated circadian transcriptional regulators (e.g. NOCT and MYBBP1A) and inflammatory signals. Together, these data suggest VDR transcriptional control in AA men is more dynamic than in EA men, and is primed to govern inflammatory and circadian rhythm pathways. This is frequently disrupted, including by altered BAZ1A/SMARCA5 expression and/or reduced environmental-regulated serum vitamin D3 levels, and leads to altered regulation of circadian rhythm process, and inflammatory signals. Therefore, the VDR axis lies at the cross-roads of biopsychosocial processes that contributes to PCa health disparities.

Citation Format: Manjunath Siddappa, Sajad D. Wani, Jaimie S. Gray, Mark D. Long, Hedieh Jafari, Hsuchang Wu, Honhe Wang, Rebecca Morgan, Gary Hardiman, James Marshall, Chanita Hughes-Halbert, Lara E. Sucheston-Campbell, Clayton L. Yates, Moray J. Campbell. Epigenetic disruption of vitamin D receptor signaling in African American prostate cancer alters circadian signaling networks [abstract]. In: Proceedings of the AACR Virtual Conference: Thirteenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2020 Oct 2-4. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(12 Suppl):Abstract nr PR05.

GRADE Guidelines 30: the GRADE approach to assessing the certainty of modeled evidence-An overview in the context of health decision-making

OBJECTIVES

The objective of the study is to present the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) conceptual approach to the assessment of certainty of evidence from modeling studies (i.e., certainty associated with model outputs).

STUDY DESIGN AND SETTING

Expert consultations and an international multidisciplinary workshop informed development of a conceptual approach to assessing the certainty of evidence from models within the context of systematic reviews, health technology assessments, and health care decisions. The discussions also clarified selected concepts and terminology used in the GRADE approach and by the modeling community. Feedback from experts in a broad range of modeling and health care disciplines addressed the content validity of the approach.

RESULTS

Workshop participants agreed that the domains determining the certainty of evidence previously identified in the GRADE approach (risk of bias, indirectness, inconsistency, imprecision, reporting bias, magnitude of an effect, dose-response relation, and the direction of residual confounding) also apply when assessing the certainty of evidence from models. The assessment depends on the nature of model inputs and the model itself and on whether one is evaluating evidence from a single model or multiple models. We propose a framework for selecting the best available evidence from models: 1) developing de novo, a model specific to the situation of interest, 2) identifying an existing model, the outputs of which provide the highest certainty evidence for the situation of interest, either "off-the-shelf" or after adaptation, and 3) using outputs from multiple models. We also present a summary of preferred terminology to facilitate communication among modeling and health care disciplines.

CONCLUSION

This conceptual GRADE approach provides a framework for using evidence from models in health decision-making and the assessment of certainty of evidence from a model or models. The GRADE Working Group and the modeling community are currently developing the detailed methods and related guidance for assessing specific domains determining the certainty of evidence from models across health care-related disciplines (e.g., therapeutic decision-making, toxicology, environmental health, and health economics).

Optimal Timing of CT Scanning in the Rapid Access Lung Cancer Clinic

Aims To investigate whether a ‘CT first’ approach to Rapid Access Lung Cancer Clinic (RALC) review could be feasible in an Irish context. Methods A retrospective review of our institution’s Lung Cancer Database was performed. All RALC first attendances from 2012-2018 were identified. Timing of CT was assessed as well as CT imaging findings. Results Total first attendances in this period were 2372, of whom 91% had CT thorax as part of their evaluation. 866 patients (37%) were diagnosed with lung cancer, all had an abnormal CT. 1290 patients (54%) underwent CT but did not have lung cancer after clinical work up. 34% of patients diagnosed with Lung Cancer had their CT scan post RALC. Time to diagnosis was longer in those who had post RALC CT (34.5 versus 21 days) Conclusion CT scanning plays a vital role in the RALC pathway. Initial delays in obtaining CT can result in delayed time to diagnosis. These findings warrant close consideration when devising future national lung cancer policy.

THU0475 THE EFFICACY OF ORAL GLUCOCORTICOSTEROIDS FOR PAIN IN RHEUMATOID ARTHRITIS: A PRELIMINARY REPORT OF A META-ANALYSIS

Background:

Glucocorticosteroids (GCs) are used to provide rapid relief of symptoms in people with active RA. Their use is recommended by most RA management guidelines and systematic reviews, although the magnitude of their benefit above placebo is uncertain. Persistent pain remains a problem in RA, even despite optimal immunomodulatory management. Systemic GC use may be associated with important adverse events.

Objectives:

To quantify the specific effects of oral GCs for RA pain.

Methods:

A systematic literature review was performed for RCTs using GCs in RA compared to inactive treatment. Trials were included whether or not participants received DMARD treatments, so long as a specific effect could be assigned to GCs. Medline, Embase and Cochrane databases were searched until November 2019 and 2 reviewers independently assessed titles, abstracts and full texts. Data for pain were synthesized in a meta-analysis. This study is part of a wider review (PROSPERO CRD42019111562).

For subgroup analyses, follow up time points of 0-3 months, >3 - 6 months and >6 months were selected to address duration of effect. Individual studies could contribute to each of the 3 follow up subgroups.

Meta-analysis was performed on standardized mean differences (SMDs, bodily pain data) and mean differences (MDs, 100mm VASpain only) of change from baseline (sd), using the Meta and Metafor packages in R. Heterogeneity was quantified using I2and tau statistics. Bias was assessed with a funnel plot and Eggers test.

Results:

15983 papers, 470 abstracts and 152 full texts were assessed. Pain data from 12 RCTs were suitable for the meta-analyses. The most common pain metric was the 100mm VASpain (9 trials).

Study populations ranged from n=12 to n=350 participants, 50% to 71% were female with mean ages from 43 to 66 years. Baseline scores for VASpain ranged from to 34 to 66 mm. Means were reported for DAS28 (from 4.9 to 5.8), ESR (25 to 60mm) and CRP (5 to 27mg/L).

Data synthesis at the reported primary time point/end point showed a statistically significant reduction in bodily pain in participants treated with GCs; SMD = -0.36 (10 studies, 1377 participants, 95% CI, -0.59 to -0.14, p=0.002) with significant heterogeneity (I2= 66%, tau = 0.27, p<0.01). The Funnel plot suggested asymmetry, favouring GCs (Eggers p = 0.007).

Subgroup analyses were used to investigate the time course of specific effects on pain. Efficacy displayed time-related decreases after initiation. From 0-3 months SMD= -0.56 (95% CI, -0.76 to -0.36, p<0.001, 9 studies, 936 participants, I2= 43%, Eggers p= 0.002). Efficacy was lower at >3 - 6 months (SMD= -0.32, 95%CI -0.52 to -0.11, p=0.002, 3 studies, 382 participants, I2=0%, Eggers p=0.75) and further reduced at >6 months (SMD= -0.07, 95%CI, -0.23 to 0.08, p=0.357, 4 studies, 665 participants, I2= 7%, Eggers p=0.43).

For trial data collected during concomitant oral GC dosage, mean difference (MDs) in 100mm VASpain was -14mm (95% CI, -20mm to -9mm) greater improvement in GC than control in the 0-3 month period (8 studies, 1047 participants, I2= 70%). For later follow ups, MDs at >3 to 6 months were -6mm (95% CI, -11mm to -1mm, 3 studies, 537 participants), and -1mm (95% CI, -6mm to 4mm, 3 studies, 369 participants) at >6 months.

Conclusion:

Oral GCs have efficacy for pain in RA but the mean effect is of borderline clinical importance, and greatest shortly after steroids are commenced. GCs were usually used alongside other treatments as part of a combination. Future research might determine who might gain most benefit from systemic GCs, and improve other treatments to reduce the burden of pain.

Acknowledgments:

Dr Douglas Grindley for help devising search strategy

Disclosure of Interests: :

Daniel McWilliams Grant/research support from: Grant support from Pfizer Ltd, Divya Thankaraj: None declared, Rheinallt Morgan: None declared, Julie Jones-Diette: None declared, David Walsh Grant/research support from: Grant support from Pfizer Ltd and Eli Lilly, Consultant of: Consultancy to Eli Lilly, Pfizer, Abbvie and GSK (all payments made to University of Nottingham). Consultancy to Love Productions(all payments made to the University of Nottingham).

EAN/ERS/ESO/ESRS statement on the impact of sleep disorders on risk and outcome of stroke

Sleep disorders are highly prevalent in the general population and may be linked in a bidirectional fashion to stroke, which is one of the leading causes of morbidity and mortality.Four major scientific societies established a task force of experts in neurology, stroke, respiratory medicine, sleep medicine and methodology, to critically evaluate the evidence regarding potential links and the impact of therapy. 13 research questions were evaluated in a systematic literature search using a stepwise hierarchical approach: first, systematic reviews and meta-analyses; second, primary studies post-dating the systematic reviews/meta-analyses. A total of 445 studies were evaluated and 88 included. Statements were generated regarding current evidence and clinical practice.Severe obstructive sleep apnoea (OSA) doubles the risk for incident stroke, especially in young to middle-aged patients. Continuous positive airway pressure (CPAP) may reduce stroke risk, especially in treatment-compliant patients. The prevalence of OSA is high in stroke patients and can be assessed by polygraphy. Severe OSA is a risk factor for recurrence of stroke and may be associated with stroke mortality, while CPAP may improve stroke outcome. It is not clear if insomnia increases stroke risk, while pharmacotherapy of insomnia may increase it. Periodic limb movements in sleep (PLMS), but not restless limb syndrome (RLS), may be associated with an increased risk of stroke. Preliminary data suggest a high frequency of post-stroke insomnia and RLS and their association with a less favourable stroke outcome, while treatment data are scarce.Overall, the evidence base is best for OSA relationship with stroke and supports active diagnosis and therapy. Research gaps remain especially regarding insomnia and RLS/PLMS relationships with stroke.

Gender dynamics in digital health: overcoming blind spots and biases to seize opportunities and responsibilities for transformative health systems

Much remains to ensure that digital health affirms rather than retrenches inequality, including for gender. Drawing from literature and from the SEARCH projects in this supplement, this commentary highlights key gender dynamics in digital health, including blind spots and biases, as well as transformative opportunities and responsibilities. Women face structural and social barriers that inhibit their participation in digital health, but are also frequently positioned as beneficiaries without opportunities to shape such projects to better fit their needs. Furthermore, overlooking gender relations and focussing on women in isolation can reinforce, rather than address, women’s exclusions in digital health, and worsen negative unanticipated consequences. While digital health provides opportunities to transform gender relations, gender is an intimate and deeply structural form of social inequality that rarely changes due to a single initiative or short-term project. Sustained support over time, across health system stakeholders and levels is required to ensure that transformative change with one set of actors is replicated and reinforced elsewhere in the health system. There is no one size prescriptive formula or checklist. Incremental learning and reflection is required to nurture ownership and respond to unanticipated reactions over time when transforming gender and its multiple intersections with inequality.

GRADE guidelines 26: informative statements to communicate the findings of systematic reviews of interventions

OBJECTIVES

Clear communication of systematic review findings will help readers and decision makers. We built on previous work to develop an approach that improves the clarity of statements to convey findings and that draws on Grading of Recommendations Assessment, Development and Evaluation (GRADE).

STUDY DESIGN AND SETTING

We conducted workshops including 80 attendants and a survey of 110 producers and users of systematic reviews. We calculated acceptability of statements and revised the wording of those that were unacceptable to ≥40% of participants.

RESULTS

Most participants agreed statements should be based on size of effect and certainty of evidence. Statements for low, moderate and high certainty evidence were acceptable to >60%. Key guidance, for example, includes statements for high, moderate and low certainty for a large effect on intervention x as: x results in a large reduction…; x likely results in a large reduction…; x may result in a large reduction…, respectively.

CONCLUSIONS

Producers and users of systematic reviews found statements to communicate findings combining size and certainty of an effect acceptable. This article provides GRADE guidance and a wording template to formulate statements in systematic reviews and other decision tools.