Performance and Return to Play After Surgery for Thoracic Outlet Syndrome in Professional Baseball Players: A Matched Cohort Analysis

BACKGROUND

Thoracic outlet syndrome (TOS) remains a rare diagnosis but is being recognized as a cause of upper extremity dysfunction in professional baseball players.

PURPOSE/HYPOTHESIS

The purpose was to determine performance and return-to-play (RTP) outcomes in professional baseball players after surgical treatment of TOS. The hypothesis was that there would be a high RTP rate in professional baseball players after TOS surgery with no statistical differences in performance between pitchers who had TOS surgery and matched controls.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

All professional baseball players who underwent surgical treatment of TOS between 2010 and 2017 were identified using the Major League Baseball Health and Injury Tracking System database. Demographic and performance data (before and after surgery) for each player were recorded. Performance variables were then compared between players who underwent TOS surgery and matched controls. The matching criteria were no history of previous surgeries on affected arm, age at time of surgery, throwing side, level of play (Major or Minor League Baseball), and years of experience playing professional baseball.

RESULTS

Overall, 52 players underwent surgery for TOS, of whom 46 (88%) were pitchers. The type of TOS was neurogenic in 69% and venous in 29%. One player had arterial TOS. After TOS surgery, 79% of players returned to play at the same or higher level (RTSP) by 9.5 months and played ≥3 years after surgery. No differences were found in RTSP rate based on the type of TOS. No statistical difference was found in RTP rates between major and minor league players. Pitchers had a 76% RTSP, which was similar to the natural attrition for control pitchers (P = .874). After TOS surgery, pitchers saw a decline in several performance metrics, but these declines were not different from those of control pitchers, indicating that the decline in performance after TOS surgery was no faster than is seen in healthy professional pitchers as they age.

CONCLUSION

The rate of RTSP after surgery for TOS in professional baseball players was 79%. There was no difference in RTP based on the type of TOS. Pitchers who underwent surgery for TOS had no significant differences in pitching performance metrics after surgery compared with matched controls.

Inconclusive decisions and error rates in forensic science

In recent years, there has been discussion and controversy relating to the treatment of inconclusive decisions in forensic feature comparison disciplines when considering the reliability of examination methods and results. In this article, we offer a brief review of the various viewpoints and suggestions that have been recently put forth, followed by a solution that we believe addresses the treatment of inconclusive decisions. We consider the issues in the context of method conformance and method performance as two distinct concepts, both of which are necessary for the determination of reliability. Method conformance relates to an assessment of whether the outcome of a method is the result of the analyst's adherence to the procedures that define the method. Method performance reflects the capacity of a method to discriminate between different propositions of interest (e.g., mated and non-mated comparisons). We then discuss implications of these issues for the forensic science community.

Supply and Demand for Radiation Oncologists in Canada: Workforce Planning Projections From 2020 to 2040

PURPOSE

The number of Canadians diagnosed with cancer, and subsequent demand for radiation therapy, are expected to increase over time. This study aimed to update our needs-based workforce planning model to ensure appropriate staffing levels in the future.

METHODS AND MATERIALS

The supply of radiation oncologists, by age group, sex, and full-time equivalent status, was projected from 2020 to 2040 using a recursive-aging, input-output model developed with seeding parameters derived from national sources. The demand for radiation oncologists until 2040 was estimated using referral patterns for radiation therapy and consultation workload metrics applied to projected annual cancer incident cases to calculate required full-time equivalent positions. Baseline model parameters were also applied to the 2005-2019 workforce and incident case data to evaluate preprojection supply and demand trends.

RESULTS

Preprojection trends for 2005 to 2019 revealed accelerated staffing growth that transitioned from a workforce shortage to a surplus state in 2014 followed by substantial growth slowdown in 2016. The model predicts a transient surplus of radiation oncologists until 2026 followed by a projected deficit in subsequent years. Sensitivity analyses using the plausible range for each parameter continued to favor an undersupply, suggesting a trainee shortage unable to meet workforce expansion needs. Considering possible future declining trends in radiotherapy utilization and workload, calculations to inform corrective efforts in resident numbers resulted in 25 entry positions per year, up from 21 per year currently. Geographic distribution of trainees, relative to workforce and cancer incidence distributions, could be improved with more residency positions in Canadian regions outside Ontario.

CONCLUSIONS

Demand for radiation therapy and radiation oncologists in Canada are expected to grow more quickly than future expansion in staffing levels. Our workforce planning model provides evidence for more trainee requirements to inform stakeholders of possible corrective actions to training programs and recruitment. Further research is needed to explore additional strategies to expand capacity and high-quality delivery of radiation therapy to meet the foreseeable increase in Canadian patients with cancer.

H. pylori predictors and outcomes among adults undergoing upper endoscopy at a Jamaican teaching hospital: A cross-sectional study

BACKGROUND

Recent data on the prevalence of H. pylori infection in Jamaica are lacking. It is postulated that there has been a decline in the prevalence of H. pylori infection and its associated complications. We determined sociodemographic characteristics, prevalence of H. pylori infection and clinical outcomes among adults undergoing esophagogastroduodenoscopy (EGD) and histology at the University Hospital of the West Indies (UHWI) between May 2018 and December 2020.

MATERIALS AND METHODS

A cross-sectional study of patients (≥18 years old), who underwent EGD and histological evaluation for H. pylori infection, was conducted. Associations of H. pylori positivity and gastric cancer with sociodemographic/clinical variables and endoscopic findings were determined by stepwise logistic regression using backward selection. Unadjusted and adjusted odds ratios with related 95% confidence intervals (Cis) were calculated for H. pylori positivity and gastric cancer status.

RESULTS

There were 323 participants (mean age 58.6 ± 17.8 years, 54.2% females). H. pylori prevalence was 22.2% (n = 70 of 315), 5.6% had gastric neoplasia (GN), 15.5% gastric atrophy, 11.4% intestinal metaplasia and 3.7% dysplasia on histology. Mucositis (64.5%), gastric ulcer (14.9%), and duodenal ulcer (13.9%) were the most common endoscopic findings. Participants with peptic ulcer disease (PUD) (unOR = 4.0; p = .017), gastric cancer (unOR = 9.5; p = .003), gastric atrophy (unOR = 12.8; p < .001), and intestinal metaplasia (unOR = 5.0; p < .001) had a significantly higher odds of being H. pylori positive, but after multivariable analyses only gastric atrophy remained significant (aOR = 27.3; p < .001). Participants with mucositis had a significantly lower odds of gastric cancer (unOR 0.1; p = .035) while participants with dysplasia had significantly higher odds (unOR 8.0; p = .042), but these were no longer significant after multivariable analyses (aOR = 0.2; p = .156 and aOR = 18.9; p = .070, respectively).

CONCLUSIONS

Histology based prevalence of H. pylori infection is lower than previously reported in Jamaica. Gastric atrophy is a significant predictor of H. pylori positivity.

770 Determining the Diagnostic Value of an Abdominal Ultrasound in Women Presenting with Right Iliac Fossa Pain in an Acute Surgical Unit

Aim

Right iliac fossa (RIF) pain is a common acute surgical presentation, with appendicitis being the main differential diagnosis. In women of childbearing age, abdominal and pelvic ultrasounds (USS) are often the imaging modality of choice and can be particularly useful when the diagnosis is unclear. We aimed to determine the diagnostic value of USS in patients of childbearing age, presenting with RIF pain.

Method

A single centre retrospective review, of women aged 14 to 45 years old, presenting with RIF pain and undergoing a subsequent USS, over a 6-month period. Investigation results, length of stay, white cell count (WCC) and C-reactive protein on admission, and treatment outcomes were all recorded.

Results

45 consecutive patients were reviewed, with a median age of 28 years (14–45). 37 USS were reported as normal and 8 illustrated gynaecological pathology. None could confirm appendicitis. 24 patients had a normal WCC and a CRP of &lt;5 on admission, none of which had radiological findings requiring surgical intervention. 3 did progress to laparoscopic appendicectomy, 66.6% of which returned with negative pathology. Conservatively managed patients, with a normal USS and normal inflammatory markers, accrued a combined hospital stay of 53 days.

Conclusion

Our results illustrate that in patients with RIF pain and normal inflammatory markers, an USS is unlikely to demonstrate pathology requiring surgical intervention and therefore is of limited positive diagnostic value. However, a negative USS may aid patient reassurance and facilitate earlier discharge in this cohort.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Global variation in early epidemic growth rates and reproduction number of seasonal influenza

INTRODUCTION

Little is known about global variation in early epidemic growth rates and effective reproduction numbers (R_e) of seasonal influenza. We aimed to estimate global variation in R_e of influenza type A and B during a single period.

METHODS

Country influenza detection time series from September 2017 through January 2019 were obtained from an international database. Type A and B epidemics by country were selected based on R_e estimates for a five-week moving window advanced by week. Associations of R_e with absolute latitude, Human Development Index, percent of the population aged <15 years and percent living rurally in each country were assessed.

RESULTS

Time series were included for 119 of 169 available countries. There were 100 countries with influenza A and 79 with B epidemics. Median R_e for both influenza A and B epidemics was 1.23 (ranges: A 1.10, 1.60; B 1.06, 1.58). R_e of influenza B, but not A, was independently associated with absolute latitude, increasing by 0.022 (95% CI 0.002, 0.043) per 10 degrees.

CONCLUSIONS

R_e of influenza A and B were similar. Only R_e of influenza B was associated with country characteristics; increasing with distance from the equator. The approach may be suitable for continuous R_e surveillance.

Employment Outcomes for Canadian Radiation Oncology Graduates: 2020 Assessment and Longitudinal Trends

Purpose

Canadian radiation oncology (RO) trainees have experienced employment challenges after residency training. The present study was conducted to evaluate current employment trends and perform comparisons to prior reported assessments.

Methods and Materials

A survey was administered to all 13 Canadian RO program directors requesting the employment status and location of their graduates during the past 3 years, and their perceptions on graduates’ employment challenges. Visa trainees were excluded. Findings were compared with surveys performed in 2014, 2016, and 2018.

Results

The response rate from RO program directors was 100%. There were 77 graduates identified who completed their residency training between 2017 and 2020. All had known employment status and location. Two (17%) 2020 graduates, 16 (84%) 2019 graduates, 17 (81%) 2018 graduates, and 24 (100%) 2017 graduates had staff employment. Of the 59 graduates with staff positions, 86% were in Canada. Some graduates (28%) obtained staff or locum employment in a province other than their training program. The proportion of graduates obtaining staff positions 1 year after residency increased to 84% from 46%-48% in prior assessments. Most program directors (62%) did not perceive any difficulties with their graduates finding staff employment or trainees transferring to training programs in other disciplines owing to perceived workforce challenges.

Conclusions

Compared with 3 prior employment outcome assessments, this study observed a higher proportion of graduates with staff positions in Canada, fewer total graduates, fewer graduates seeking staff employment or in fellowship positions, and a trend for fewer graduates seeking employment or fellowships abroad. These findings support the view that the Canadian RO job market continues to improve. Although employment challenges for newly certified, Canadian-trained radiation oncologists still exist, national corrective measures to regulate resident intake in 2011 appear to have had a positive effect on the employment outcomes of recent Canadian RO graduates.

Experiences of UK African-Caribbean prostate cancer survivors of discharge to primary care

Objective: Black men are three times more likely to develop prostate cancer (PCa), to do so at a younger age and to experience a more aggressive form than White men. This study aims to understand the experiences of African-Caribbean men with respect to their discharge to primary care following successful PCa treatment and the challenges associated with survivorship.Design: Eight African-Caribbean men, who had been successfully treated for PCa, were recruited through the charity BME Cancer Communities. They participated in a focus group, which took place on the premises of the charity and was audio-recorded. The recording was transcribed and the data were analysed employing thematic analysis.Results: Three overarching themes were developed: Discharge - misconceptions and uncertainties; Survivorship - challenges and ways of coping; Black men and PCa: real and potential discrimination. Participants expressed concerns regarding the lack of information and clarity about what discharge meant, the quality of follow-up care, especially the levels of specialist knowledge among GPs, and the impact of side-effects, particularly erectile dysfunction (ED). Participants linked ED with stereotypes of Black male sexuality, particularly in relation to difficulties of expressing their emotions and psychological distress. African-Caribbean men face particular challenges in dealing with the side-effects of treatment for PCa, which are linked to socially-constructed ideas of masculinity.Conclusion: There needs to be a greater focus in primary care on understanding these issues and providing individualised culturally-sensitive care. In particular, GPs should be aware of sensitivities concerning help-seeking related to culturally-mediated understandings of masculinity.

The Association between GDP and non-communicable disease mortality in the WHO European Region

Background

The WHO Europe Region consists of 53 countries, each of which has differences in mortality from cardiovascular (CVD), neurological, and chronic respiratory diseases. Such diverse metrics result from political, social, and economic events that have influenced the health performance of each European sub-region. From a public health perspective, an updated analysis of such metrics is required for policymakers and health system organisations to improve the overall population health outcomes.

Methods

This study utilised data between 1990-2017 from the Global Burden of Disease study 2017 to explore the association between GDP and NCD mortality in Western, Central, and Eastern Europe and Central Asia. The mortality data was already stratified by age and sex, and a fixed effected regression analysis was run to observe associations between both variables using STATA. Data completeness was 80-100% for GDP and 100% for mortality across the European region. The final results were reported as a rate per 100,000, with confidence intervals. The rate changes were calculated using an equation from the GBD.

Results

The most significant decrease per 100,000 of the population across all three NCDs as GDP increased was in Central Asia and Eastern Europe among both sexes. For every 1000 unit increase in GDP, we expect -12.13 [-13.60, -10.66] and -14.49 [-16.89, -12.29] less deaths in CVD in females and males per 100,000 of population, respectively. Western Europe had the lowest decrease per 100,000 of the population, as with every 1000 unit increase in GDP, we expect -2.42 [-2.59, -2.25] and -4.09 [-4.33, -3.84] fewer deaths in CVD in females and males, respectively.

Conclusions

The overall differential rate of mortality from the three NCDs is decreasing across all regions. However, there is a large disparity between the sexes. Males have a higher mortality rate across CVD and chronic respiratory diseases, whilst neurological disorders were highest among females.

Key messages

This study’s analysis has added to existing knowledge on chronic health patterns in the WHO European region. Governments in Eastern Europe and Central Asia should introduce health policies targeting unhealthy consumption of alcohol, smoking and diets, as seen in Western Europe.

Sub-organism (acetylcholinesterase activity), population (survival) and chemical concentration responses reinforce mechanisms of antagonism associated with malathion toxicity

Within human modified ecosystems the effects of individual stressors are difficult to establish amid co-occurring biological processes, environmental gradients and other stressors. Coupled examination of several endpoints across different levels of organisation may help elucidate the individual and combined effects of stressors and interactions. Malathion is a commonly used organophosphate pesticide that contaminates freshwaters and has strong negative effects on aquatic biota. However, both other stressors (e.g. increased sediment) and common ecosystem components (e.g. macrophytes and variable pH) can reduce the aqueous concentrations of malathion, reducing its toxic effects. We conducted a fully orthogonal bioassay to examine how pH (at 7 and 7.8) and sorptive processes (across two levels of kaoline clay 0 and 24 g L^-1) affected aqueous malathion concentrations and toxicity in an aquatic invertebrate genus. Survival and acetylcholinesterase activity as a sub-organism response were examined in the mayfly Coloburiscoides spp. (Ephemeroptera; Coluburiscidae). Measured aqueous malathion concentrations decreased with increased pH and in the presence of kaolin clay. Survival declined with increasing malathion concentrations and exposure period. Results further identify that antagonism of malathion toxicity was associated with both pH (alkaline hydrolysis) and effects associated with sediment independent of pH (driven by sorptive processes). However, model predictions varied associated with target and measured concentrations and concentrations examined. Antagonistic effects were most apparent using subset target malathion concentrations because of the dominant effect of malathion at high concentrations. Acetylcholinesterase activity, identified repression occurred across all treatments and did not identify antagonistic interactions, but these results were similar to survival responses at the time points examined (i.e. 120 h). Examination of chemistry, acetylcholinesterase, and survival, affords greater understanding of stressor effects and their interactions. Measured malathion concentrations may underestimate effects on aquatic biota; not because of synergism among stressors, but because of strong effects despite antagonism.

Tailor-made recombinant prokaryotic lectins for characterisation of glycoproteins

Development of biosimilars is costly, where glycan analysis is a significant constraint on time and money. This paper provides an in-depth characterisation of several novel recombinant prokaryotic lectins (RPLs), developed through directed evolution, displaying specific binding activities to α-mannose, β-galactose, fucose and sialic acid residues, tested against major biosimilar targets. The binding characterisation of all lectins was performed employing the principles of bio-layer interferometry (BLI), with help of the streptavidin-coated sensor with the biotinylated lectins. The binding activity of the RPLs and the specificity to a broad range of glycoproteins and glycoconjugates were evaluated and compared to those of equivalent plant-derived lectins. While exhibiting better or similar specificity, RPLs displayed significantly better binding in all cases. The binding mechanisms are explained with particular focus on the role hydrogen bonding plays in the change of specificity for a galactose specific lectin. Furthermore, different sets of RPLs and their plant equivalents were assayed against the different glycoprotein targets to evaluate the analytical parameters of the lectin-glycoprotein interaction. The obtained LoDs reached by the RPLs were lower than those of their plant counterparts apart from one, exhibiting RPL:PL LoD ratios of 0.8, 2.5, 14.2 and 380 for the sets of lectins specific to fucose, α-mannose, β-galactose and sialic acid, respectively. Such enhancement in analytical parameters of RPLs shows their applicability in protein purification and as bioanalytical tools for glycan analysis and biosensor development.

Targeted Therapies for Metabolic Myopathies Related to Glycogen Storage and Lipid Metabolism: a Systematic Review and Steps Towards a 'Treatabolome'

BACKGROUND

Metabolic myopathies are a heterogenous group of muscle diseases typically characterized by exercise intolerance, myalgia and progressive muscle weakness. Effective treatments for some of these diseases are available, but while our understanding of the pathogenesis of metabolic myopathies related to glycogen storage, lipid metabolism and β-oxidation is well established, evidence linking treatments with the precise causative genetic defect is lacking.

OBJECTIVE

The objective of this study was to collate all published evidence on pharmacological therapies for the aforementioned metabolic myopathies and link this to the genetic mutation in a format amenable to databasing for further computational use in line with the principles of the "treatabolome" project.

METHODS

A systematic literature review was conducted to retrieve all levels of evidence examining the therapeutic efficacy of pharmacological treatments on metabolic myopathies related to glycogen storage and lipid metabolism. A key inclusion criterion was the availability of the genetic variant of the treated patients in order to link treatment outcome with the genetic defect.

RESULTS

Of the 1,085 articles initially identified, 268 full-text articles were assessed for eligibility, of which 87 were carried over into the final data extraction. The most studied metabolic myopathies were Pompe disease (45 articles), multiple acyl-CoA dehydrogenase deficiency related to mutations in the ETFDH gene (15 articles) and systemic primary carnitine deficiency (8 articles). The most studied therapeutic management strategies for these diseases were enzyme replacement therapy, riboflavin, and carnitine supplementation, respectively.

CONCLUSIONS

This systematic review provides evidence for treatments of metabolic myopathies linked with the genetic defect in a computationally accessible format suitable for databasing in the treatabolome system, which will enable clinicians to acquire evidence on appropriate therapeutic options for their patient at the time of diagnosis.

Ixazomib for Chronic Graft-versus-Host Disease Prophylaxis following Allogeneic Hematopoietic Cell Transplantation

Chronic graft-versus-host disease (cGVHD) is major cause of morbidity and mortality following allogeneic hematopoietic cell transplantation (HCT). Ixazomib is an oral, second-generation, proteasome inhibitor that has been shown in preclinical models to prevent GVHD. We conducted a phase I/II trial in 57 patients to evaluate the safety and efficacy of ixazomib administration for cGVHD prophylaxis in patients undergoing allogeneic HCT. Oral ixazomib was administered on a weekly basis for a total of 4 doses, beginning days +60 through +90, to recipients of matched related donor (MRD, n = 25) or matched unrelated donor (MUD, n = 26) allogeneic HCT in phase II portion of the study, once the recommended phase II dose of 4 mg was identified in phase I (n = 6). All patients received peripheral blood graft and standard GVHD prophylaxis of tacrolimus and methotrexate. Ixazomib administration was safe and well tolerated, with thrombocytopenia, leukopenia, gastrointestinal complaints, and fatigue the most common adverse events (>10%). In phase II (n = 51), the cumulative incidence of cGVHD at 1 year was 36% (95% confidence interval [CI], 19% to 54%) in the MRD cohort and 39% (95% CI, 21% to 56%) in the MUD cohort. One-year cumulative incidence of nonrelapse mortality (NRM) and relapse was 0% and 20% (95% CI, 8% to 36%) in the MRD cohort, respectively. In the MUD cohort, the respective NRM and relapse rates were 4% (0% to 16%) and 34% (17% to 52%). The outcomes on the study were compared post hoc with contemporaneous matched Center for International Blood and Marrow Transplant Research (CIBMTR) controls. This post hoc analysis showed no significant improvement in cGVHD rates in both the MRD (hazard ratio [HR] = 0.85, P = .64) or MUD cohorts (HR = 0.68, P = .26) on the study compared with CIBMTR controls. B cell activating factor plasma levels were significantly higher after ixazomib dosing in those who remained cGVHD free compared with those developed cGVHD. This study shows that the novel strategy of short-course oral ixazomib following allogeneic HCT is safe but did not demonstrate significant improvement in cGVHD incidence in recipients of MRD and MUD transplantation compared with matched CIBMTR controls. This study is registered at www.clinicaltrials.gov as NCT02250300.

Why the Public Need a Say in How Patient Data are Used for Covid-19 Responses

The global coronavirus pandemic has clearly demonstrated the great urgency to collect and use patient data effectively to understand, track and manage the spread of Covid-19. The value of patient data in this pandemic is undeniable, however considerations around how - and by whom - such data should be collected, accessed and used, and for what purposes, remain to be fully debated and resolved. Who decides, and how such decisions are made remain unclear. We argue that public engagement and deliberation are essential for good governance and are key to establish and maintain a legitimate social licence for data practices around Covid-19.

Analysis of exhaled breath of lung cancer patients using infrared spectroscopy

e21037

Background: Currently low-dose computed tomography is used for lung cancer (LC) screening, but is limited by radiation exposure, cost, and a high false detection rate (1,2). An accurate, accessible and affordable screening technology is needed to improve detection of LC in high risk individuals. Methods: We conducted an unblinded, prospective cohort study on the effectiveness of a novel technology utilizing infrared absorption measurements via cavity ringdown spectroscopy (IR-CRDS) to differentiate the expired breath of treatment-naïve LC patients from controls without known cancer. Breath samples were taken from 100 LC patients and 98 control subjects but, only 62 non-small cell lung cancer (NSCLC) and 96 control samples were analyzed. Patients on treatment were eligible but, the protocol was amended to exclude these due to signal ambiguities. Samples were also excluded due to missing data, unclear histologic subtypes, or if they were classified as small cell LC samples to prevent obscuring the NSCLC signal. A piecewise cubic spline interpolation was used for the spectra with missing values (3). After first- and second-derivative spectra were computed to increase the information density, a one-dimensional local binary pattern extracted features from the spectra (4). Meaningful spectra-based features were selected using a minimum redundancy maximum relevance algorithm (5). Finally, a classification model was built using a support vector machine classifier (3). Results: The table below characterizes each cohort. The discriminant analysis differentiated between NSCLC and control cases with a cross validation accuracy of 86.1% (89.6% sensitivity and 80.7% specificity) using 20 selected spectra-based features. Conclusions: IR absorption measurements can be used to accurately discriminate between NSCLC and control participants. We continue to build our database to support more robust machine learning models. To our knowledge, this is the first time IR-CRDS has been used to differentiate between NSCLC and control cases. [Table: see text]

NIST Ballistics Toolmark Research Database

In 2009, a report by the National Academies called into question, amongst other issues, the objectivity of visual toolmark identification by firearms examiners. The National Academies recommended development of objective toolmark identification criteria and error rate estimates. Industry, academia, and government laboratories are pursuing two promising approaches towards this goal: 1) development of mathematical criteria and advanced algorithms for the objective and automated identification and scoring of potential matches, and 2) supplementing traditional reflectance microscopy images with three- dimensional surface topography measurement data. Development and validation of both these approaches to objective toolmark identification are hindered by a lack of access to toolmark data sets that 1) represent the large variety of ballistic toolmarks encountered by toolmark examiners, and 2) represent challenging identification scenarios, such as those posed by consecutively manufactured firearms components. The NIST Ballistics Toolmark Research Database enables researchers to test and validate new approaches to objective, mathematics-based, toolmark identification while easing the transition to three- dimensional surface topography data. The database will provide a foundation for a scientific knowledge base on the degree of similarity that can be found between marks made by different firearms and the variability in marks made by an individual firearm. The current, fairly limited, knowledge base is a fundamental barrier to the development and validation of objective mathematical similarity criteria, and associated confidence limits, applicable to a broad range of firearms and ammunition brands.

Indoor temperature and health: a global systematic review

OBJECTIVES

The objective of this study was to identify and appraise evidence on the direct and indirect impacts of high indoor temperatures on health; the indoor temperature threshold at which the identified health impacts are observed; and to summarise the evidence for establishing a maximum indoor temperature threshold for health.

STUDY DESIGN

This is a systematic literature review and narrative synthesis.

METHODS

A review of the published literature using MEDLINE, EMBASE, Global Health, PsycINFO, Maternity and Infant Care, Cochrane Library, CINAHL and GreenFILE databases was conducted. The search criteria were kept broad to capture evidence from all countries and contexts; no date or study design limits were applied, except English language limits. We included studies that specifically measured indoor temperature and examined its effect on physical or mental health outcomes. Evidence was graded using the National Institutes of Health framework.

RESULTS

Twenty-two articles were included in the review, including 11 observational, seven cross-sectional and three longitudinal cohort studies and one prospective case-control study. Eight main health effects were described: respiratory, blood pressure, core temperature, blood glucose, mental health and cognition, heat-health symptoms, physical functioning and influenza transmission. Five studies found respiratory symptoms worsened in warm indoor environments, with one reporting indoor temperatures higher than 26 °C, which was associated with increased respiratory distress calls being made to paramedics (odds ratio = 1.63, P = 0.056). Core symptoms of schizophrenia and dementia were found to be significantly exacerbated by indoor heat (the latter above a 26 °C cumulative exposure threshold). The absorption of insulin doses in people with type one diabetes was also significantly accelerated in hot indoor environments. Only five studies reported the temperatures at which health outcomes worsened, with thresholds ranging between 26 °C and 32 °C. However, owing to insufficient data and the heterogeneity of the included studies (design, population, setting, exposure measures, outcomes and location), meta-analysis and an upper threshold determination was not feasible.

CONCLUSIONS

High indoor temperatures affect aspects of human health, with the strongest evidence for respiratory health, diabetes management and core schizophrenia and dementia symptoms. Exacerbation of symptoms in warm indoor environments has clinical relevance to at-risk groups and those caring for them. Care staff and facility managers need to be vigilant of high temperatures in care environments and should incorporate indoor overheating into their risk management and sustainability and/or climate change adaptation plans. The indoor temperature threshold at which adverse effects begin to occur remains unclear as studies seldom report the exposure-response relationship over a temperature continuum. Until there is extensive scientific data to support a maximum indoor temperature threshold, 26 °C may be the most suitable indoor temperature for at-risk groups in keeping with the existing guidance documents.

A-77 Validity Testing with Youth Populations: D-KEFS Trail Making Test Conditions 4:2 Ratio as an Embedded Validity Indicator

Objective

The Trail Making Test B:A ratio is an embedded validity indicator (EVI) for neuropsychological assessment (NA; Ruffolo, Guilmette, & Willis, 2000). Recent literature supports D-KEFS Trail Making Test Conditions 4:2 (analogous to B:A) ratio (D-KEFS 4:2) as an EVI (Erdodi et al., 2018). The present study sought to assess the utility of D-KEFS 4:2 as an EVI for youth populations, using the Test of Memory Malingering (TOMM) to operationalize effort.

Method

102 children (81.2% male, Mage = 11.88) completed a NA, including D-KEFS 4:2 and TOMM. Receiver operator characteristics (ROC) curve analysis calculating Area Under the Curve (AUC) determined whether D-KEFS 4:2 accurately categorized participants’ effort (represented by TOMM performance).

Results

D-KEFS 4:2 (cut-off = 1.60: Erdodi et al., 2018) produced sensitivity of 9.09% and specificity of 91.25% in predicting TOMM performance on Trial 1 (TOMM1; AUC = 0.488) and 0.00% and 91.09% in predicting Trial 2 (TOMM2; AUC = 0.772). As a TOMM2 cut-off of 49 is suggested as more sensitive to inadequate effort, another analysis showed D-KEFS 4:2 yielded sensitivity of 33.33% and specificity of 91.92% (AUC = 0.710) in predicting TOMM2 performance with the more conservative cutoff.

Conclusions

This study suggests that D-KEFS 4:2 is an adequate EVI in predicting suboptimal effort when operationalized by TOMM performance, particularly when more conservative TOMM cutoffs are used. D-KEFS 4:2 detected true effortful performance with excellent specificity but exhibited poor detection of suboptimal performance. As a result, D-KEFS 4:2 has utility as an EVI in youth populations, but should not be used independently.

Identical and Nonidentical Twins: Risk and Factors Involved in Development of Islet Autoimmunity and Type 1 Diabetes

OBJECTIVE

There are variable reports of risk of concordance for progression to islet autoantibodies and type 1 diabetes in identical twins after one twin is diagnosed. We examined development of positive autoantibodies and type 1 diabetes and the effects of genetic factors and common environment on autoantibody positivity in identical twins, nonidentical twins, and full siblings.

RESEARCH DESIGN AND METHODS

Subjects from the TrialNet Pathway to Prevention Study (N = 48,026) were screened from 2004 to 2015 for islet autoantibodies (GAD antibody [GADA], insulinoma-associated antigen 2 [IA-2A], and autoantibodies against insulin [IAA]). Of these subjects, 17,226 (157 identical twins, 283 nonidentical twins, and 16,786 full siblings) were followed for autoantibody positivity or type 1 diabetes for a median of 2.1 years.

RESULTS

At screening, identical twins were more likely to have positive GADA, IA-2A, and IAA than nonidentical twins or full siblings (all P < 0.0001). Younger age, male sex, and genetic factors were significant factors for expression of IA-2A, IAA, one or more positive autoantibodies, and two or more positive autoantibodies (all P ≤ 0.03). Initially autoantibody-positive identical twins had a 69% risk of diabetes by 3 years compared with 1.5% for initially autoantibody-negative identical twins. In nonidentical twins, type 1 diabetes risk by 3 years was 72% for initially multiple autoantibody-positive, 13% for single autoantibody-positive, and 0% for initially autoantibody-negative nonidentical twins. Full siblings had a 3-year type 1 diabetes risk of 47% for multiple autoantibody-positive, 12% for single autoantibody-positive, and 0.5% for initially autoantibody-negative subjects.

CONCLUSIONS

Risk of type 1 diabetes at 3 years is high for initially multiple and single autoantibody-positive identical twins and multiple autoantibody-positive nonidentical twins. Genetic predisposition, age, and male sex are significant risk factors for development of positive autoantibodies in twins.

Biological interactions mediate context and species-specific sensitivities to salinity

Toxicants have both sub-lethal and lethal effects on aquatic biota, influencing organism fitness and community composition. However, toxicant effects within ecosystems may be altered by interactions with abiotic and biotic ecosystem components, including biological interactions. Collectively, this generates the potential for toxicant sensitivity to be highly context dependent, with significantly different outcomes in ecosystems than laboratory toxicity tests predict. We experimentally manipulated stream macroinvertebrate communities in 32 mesocosms to examine how communities from a low-salinity site were influenced by interactions with those from a high-salinity site along a gradient of salinity. Relative to those from the low-salinity site, organisms from the high-salinity site were expected to have greater tolerance and fitness at higher salinities. This created the potential for both salinity and tolerant-sensitive organism interactions to influence communities. We found that community composition was influenced by both direct toxicity and tolerant-sensitive organism interactions. Taxon and context-dependent responses included: (i) direct toxicity effects, irrespective of biotic interactions; (ii) effects that were owing to the addition of tolerant taxa, irrespective of salinity; (iii) toxicity dependent on sensitive-tolerant taxa interactions; and (iv) toxic effects that were increased by interactions. Our results reinforce that ecological processes require consideration when examining toxicant effects within ecosystems.This article is part of the theme issue 'Salt in freshwaters: causes, ecological consequences and future prospects'.