Novel Measurement of the Neutron Magnetic Form Factor from A=3 Mirror Nuclei

The electromagnetic form factors of the proton and neutron encode information on the spatial structure of their charge and magnetization distributions. While measurements of the proton are relatively straightforward, the lack of a free neutron target makes measurements of the neutron's electromagnetic structure more challenging and more sensitive to experimental or model-dependent uncertainties. Various experiments have attempted to extract the neutron form factors from scattering from the neutron in deuterium, with different techniques providing different, and sometimes large, systematic uncertainties. We present results from a novel measurement of the neutron magnetic form factor using quasielastic scattering from the mirror nuclei ^{3}H and ^{3}He, where the nuclear effects are larger than for deuterium but expected to largely cancel in the cross-section ratios. We extracted values of the neutron magnetic form factor for low-to-modest momentum transfer, 0.6 Collapse

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Co-delivery of HIV pre-exposure prophylaxis (PrEP) and HIV testing among publicly insured adolescents and young adults (AYA) receiving medication for opioid use disorder (MOUD)

BACKGROUND

Low rates of HIV pre-exposure prophylaxis (PrEP) prescribing contribute to the disproportionate burden of HIV in the United States. Among adolescent and young adults (AYA) with opioid use disorder, HIV testing and PrEP co-prescription rates are poorly characterized.

METHODS

We performed a retrospective analysis involving deidentified data from Philadelphia's Medicaid beneficiaries ages 16-29 years who were prescribed medication for opioid use disorder (MOUD) from 2015 to 2020 and continuously Medicaid-enrolled for ≥6 months prior to that prescription. After identifying the presence of a qualifying diagnosis signifying a PrEP indication, we examined the outcome of appropriate PrEP co-prescriptions and HIV testing using generalized estimating equations (GEE) modeling.

RESULTS

We identified 795 AYA Medicaid beneficiaries with 1269 qualified treatment episodes. We calculated a PrEP prescribing rate of 29.47 per 1000 person-years among AYA receiving MOUD. The HIV testing rate was 63.47 per 1000 person-years among AYA receiving MOUD. GEE modeling revealed that individuals receiving methadone were more likely (aOR=2.62, 95% CI=1.06-6.49) to receive HIV testing within 6 months after a PrEP-qualifying diagnosis compared to those receiving other MOUD medications. Those who only saw outpatient behavioral health providers were less likely (aOR=0.48, 95% CI=0.24-0.99) to have received an HIV test within 6 months after the PrEP-qualifying diagnosis compared to those receiving inpatient behavioral health services.

CONCLUSIONS

Co-prescription of PrEP and HIV testing among AYA receiving MOUD was rare in this large urban publicly insured population. Interventions are needed to increase HIV prevention services for this key population of AYA at risk for HIV infection.

Post-acute COVID-19 complications in UK doctors: results of a cross-sectional survey

BACKGROUND

As a consequence of their occupation, doctors and other healthcare workers were at higher risk of contracting coronavirus disease 2019 (COVID-19), and more likely to experience severe disease compared to the general population. However, systematic information on post-acute COVID complications in doctors is very limited.

AIMS

This study aimed to determine the symptoms, perceived determinants, health and occupational impact, and consequent needs relating to post-acute COVID complications in UK doctors.

METHODS

An online cross-sectional survey was distributed to UK doctors self-identifying as having Long COVID or other post-acute COVID complications.

RESULTS

Of 795 responses, 603 fulfilled the inclusion criteria of being a UK-based medical doctor experiencing one or more post-acute COVID complications. Twenty-eight per cent reported a lack of adequate Respiratory Protective Equipment at the time of contracting COVID-19. Eighteen per cent of eligible respondents reported that they had been unable to return to work since acquiring COVID.

CONCLUSIONS

Post-acute COVID (Long COVID) in UK doctors is a substantial burden for respondents to our questionnaire. The results indicated that insufficient respiratory protection could have contributed to occupational disease, with COVID-19 being contracted in the workplace, and resultant post-COVID complications. Although it may be too late to address the perceived determinants of inadequate protection for those already suffering with Long COVID, more investment is needed in rehabilitation and support of those afflicted.

Musculoskeletal injuries in UK Service Personnel and the impact of in-theatre rehabilitation during Cold Weather Warfare training: Exercise CETUS 2020

INTRODUCTION

The Royal Marines provide the lead Service for UK Defence Mountain and Cold Weather Warfare capability. This is the first prospective study addressing musculoskeletal injury rates sustained during Cold Weather Warfare training, with the aim of informing injury mitigation interventions and assist military medical planning with respect to delivering primary care rehabilitation in theatre.

METHODS

All musculoskeletal injuries were surveyed by the Forward Rehabilitation Team (Nov 2019-Mar 2020) during a Cold Weather Deployment to Norway (Ex CETUS 2019/20). The frequency, nature of injury (new or recurrent), onset (sudden or gradual), cause, location and exercise/treatment outcome were recorded.

RESULTS

Eleven per cent (n=136 cases) of the deployed population (n=1179) reported a musculoskeletal injury, which were mainly 'new' (62%), and with a 'sudden' onset (64%). Injury rate was 17.8 injuries per 10 000 personnel days. The majority of injuries occurred due to military training (88%), specifically during ski-related (61%) and load carriage (10%) activities.The average Service Person treated by the Forward Rehabilitation Team improved from 'injured with restricted duties' to 'fully fit', and with an improvement in their self-reported Musculoskeletal Health Questionnaire from 33 to 45 over an average of two rehabilitation sessions. One hundred and seventeen Service Personnel were able to continue on Ex CETUS with rehabilitation in theatre, thus negating the requirement for aeromedical evacuation for continuation of rehabilitation in the UK. Nineteen patients were unable to continue their Cold Weather Deployment due to the nature of their musculoskeletal injury and returned to the UK for continued care in firm base rehabilitation centres.

CONCLUSION

This study identifies the nature, causation and injury location. It demonstrates the effectiveness of in-theatre rehabilitation and the ability to treat patients when deployed. Recommendations are presented to support strategies to mitigate musculoskeletal injury risk during future Cold Weather Warfare deployments to Norway.

TROG 15.03/ANZUP International Multicenter Phase II Trial of Focal Ablative STereotactic RAdiotherapy for Cancers of the Kidney (FASTRACK II)

PURPOSE/OBJECTIVE(S)

Stereotactic body radiotherapy (SBRT) is an emerging non-invasive alternative for primary renal cell cancer (RCC) in patients unsuitable for surgery. The objective of the FASTRACK II clinical trial was to investigate the efficacy of SBRT for primary RCC.

MATERIALS/METHODS

This non-randomized, intergroup multi-institutional phase II study was activated in 7 Australian centers and 1 Dutch center, through the Trans Tasman Radiation Oncology Group (TROG) and the Australian and New Zealand Urogenital and Prostate Cancer Trials Group (ANZUP). Eligible patients had biopsy confirmed diagnosis of primary RCC with a single lesion within a kidney, ECOG performance ≤2 and were medically inoperable, high risk or declined surgery. For tumors ≤4 cm a single fraction of 26 Gy was prescribed, for tumors > 4 cm, 42 Gy in three fractions was prescribed. The primary outcome of the study was to estimate the efficacy of SBRT for primary RCC, defined as local control based on RECIST criteria. The study was powered assuming that 1-year local control would be 90%, with the null hypothesis of ≤80% considered undesirable and not worthy of proceeding to a future randomized controlled trial.

RESULTS

Between July 2016 and February 2020, 70 patients were enrolled with a median follow-up of 42 months. Median age was 77 years. Forty-nine patients were male (70%), median BMI was 32 and median Charlson comorbidity score was 7. The median [IQR] RENAL complexity score was 8 [7-10]. Biopsy confirmation was 100%. Twenty-three patients (33%) had T1a disease. The median (interquartile range [IQR]) tumor size was 4.6cm [3.7-5.5]; it was 3.3cm [3.0-3.6] in those receiving single fraction (n = 23), and 5.3cm [4.6-6.0] in those receiving 3-fraction SBRT (n = 47). During real-time pre-treatment quality assurance review, 10 cases (14.3%) required resubmission for protocol deviation, 2119 variables were assessed at final review, and final protocol compliance was 99.3%. Seven (10%) patients experienced grade 3 treatment-related adverse events, with no grade 4 or 5 events observed. Eleven (16%) patients reported no adverse events. Local control was 100% throughout the lifetime of the trial (p<0.001). Cancer-specific survival was also 100% throughout the lifetime of the trial. Freedom from distant failure (95% CIs) at 1 and 3 years was 99% (90-100%). Overall survival (95% CIs) at 1 and 3 years was 99% (90-100%) and 82% (70-89%), respectively. Baseline mean eGFR (95% CI) was 61.1 mLs/min (56.6; 65.6) and reduced by -10.8 mLs/min (-13.0; -8.6) by 1-year, by -14.6 mLs/min (-17.0; -12.2) by 2-years and plateaued thereafter.

CONCLUSION

In the first multicenter prospective trial of a non-surgical primary RCC cohort, enrolling mostly T1b+ disease, SBRT was an effective treatment strategy with no observed local failures. We observed an acceptable side effect profile and renal function after SBRT. These outcomes support the design of a future randomized clinical trial of SBRT versus surgery for primary RCC. The trial was registered with ID: NCT02613819.

Initial Report of a Randomized Trial Comparing Conventional vs. Novel Treatment Planning Technique to Ameliorate Immunosuppression from Lung SBRT

PURPOSE/OBJECTIVE(S)

SBRT is highly effective against early-stage non-small cell lung cancer. Radiation Therapy (RT) is known to modulate the immune system and contribute to the generation of anti-tumor T cells and stimulate T cell infiltration into tumors. However, this anti-tumor activity is offset by radiation-induced immunosuppression (RIIS) which results in lower tumor control and survival. Lymphocytes are highly radiosensitive and RIIS means destroying existing as well as newly created cytotoxic and helper T lymphocytes. We hypothesized that optimizing RT treatment planning by considering circulating blood and lymphatics as a critical Organ at Risk (OAR) may mitigate RIIS.

MATERIALS/METHODS

We conducted an IRB approved NCI funded clinical trial for 50 early-stage lung cancer patients treated with SBRT alone, from 2020 to 2023, to investigate the ability to reduce RIIS by reducing dose to circulating blood and lymphatics with the aid of a predictive algorithm. All SBRT plans adhered to treatment parameters from RTOG 0813 (central) or RTOG 0915 (peripheral). Patients were randomized to two arms: experimental optimization for RIIS (to reduce dose to blood and lymphatic rich organs) versus standard SBRT planning (without optimization for RIIS). Peripheral blood samples were collected at baseline, end of Tx, 4 weeks and 6 months post Tx. Patients with baseline absolute lymphocyte counts (ALC) less than 0.5x109 cells/L were ineligible for the trial. Data acquired for all blood cell types as well as lymphocyte sub populations CD3+, CD4+, CD8+, CD19+, CD56+. Two sample t-test was used to determine the statistical significance between the cohorts at the time points.

RESULTS

The standard arm had an ALC reduction of 28% at one week post Tx and a nadir at 4 weeks with a 34% reduction. Absolute percentage reductions in ALC from baseline in the optimized arm compared to the standard arm are: end of treatment point (13%, p = 0.03), 4 weeks (12%, p = 0.08), 6 months (15%, p = 0.1), and all three time points together 13% (p = 0.001). ALC recovery appears to be faster in the optimized arm. Radiation induced suppression of all blood cell types are also reduced in the optimized arm with respect to standard arm (relative percentages): ALC (34%), WBC (47%), RBC (46%), platelets (40%), monocytes (100%), and neutrophils (62%) at 4-week mark. Average percentage reductions on integral doses, and V5 (volume receiving a 5 Gy dose) of optimized compared to standard plans are: aorta: 26%, 41% heart: 8%, 33%, vena cava: 32%, 52%, T spine: 51%, 81%, lymph nodes: 35%, 57%, total lung- ITV: 1.6%, 1%, body: 10%, 14%.

CONCLUSION

For the first time, we have shown that it is possible to reduce RIIS in a statistically significant manner, compared to standard of care, via optimized RT planning using a predictive model. This has implications in increasing the efficacy of immunotherapy by preserving the existing tumor reactive T cells in the immune system to enhance anti-tumor activity, and in reducing hospitalizations and improving survival.

Determining the gluonic gravitational form factors of the proton

The proton is one of the main building blocks of all visible matter in the Universe¹. Among its intrinsic properties are its electric charge, mass and spin². These properties emerge from the complex dynamics of its fundamental constituents-quarks and gluons-described by the theory of quantum chromodynamics^3-5. The electric charge and spin of protons, which are shared among the quarks, have been investigated previously using electron scattering². An example is the highly precise measurement of the electric charge radius of the proton⁶. By contrast, little is known about the inner mass density of the proton, which is dominated by the energy carried by gluons. Gluons are hard to access using electron scattering because they do not carry an electromagnetic charge. Here we investigated the gravitational density of gluons using a small colour dipole, through the threshold photoproduction of the J/ψ particle. We determined the gluonic gravitational form factors of the proton^7,8 from our measurement. We used a variety of models^9-11 and determined, in all cases, a mass radius that is notably smaller than the electric charge radius. In some, but not all cases, depending on the model, the determined radius agrees well with first-principle predictions from lattice quantum chromodynamics¹². This work paves the way for a deeper understanding of the salient role of gluons in providing gravitational mass to visible matter.

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

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

Comparison of actionable events detected in cancer genomes by whole-genome sequencing, in silico whole-exome and mutation panels

Background

Next-generation sequencing is used in cancer research to identify somatic and germline mutations, which can predict sensitivity or resistance to therapies, and may be a useful tool to reveal drug repurposing opportunities between tumour types. Multigene panels are used in clinical practice for detecting targetable mutations. However, the value of clinical whole-exome sequencing (WES) and whole-genome sequencing (WGS) for cancer care is less defined, specifically as the majority of variants found using these technologies are of uncertain significance.

Patients and methods

We used the Cancer Genome Interpreter and WGS in 726 tumours spanning 10 cancer types to identify drug repurposing opportunities. We compare the ability of WGS to detect actionable variants, tumour mutation burden (TMB) and microsatellite instability (MSI) by using in silico down-sampled data to mimic WES, a comprehensive sequencing panel and a hotspot mutation panel.

Results

We reveal drug repurposing opportunities as numerous biomarkers are shared across many solid tumour types. Comprehensive panels identify the majority of approved actionable mutations, with WGS detecting more candidate actionable mutations for biomarkers currently in clinical trials. Moreover, estimated values for TMB and MSI vary when calculated from WGS, WES and panel data, and are dependent on whether all mutations or only non-synonymous mutations were used. Our results suggest that TMB and MSI thresholds should not only be tumour-dependent, but also be sequencing platform-dependent.

Conclusions

There is a large opportunity to repurpose cancer drugs, and these data suggest that comprehensive sequencing is an invaluable source of information to guide clinical decisions by facilitating precision medicine and may provide a wealth of information for future studies. Furthermore, the sequencing and analysis approach used to estimate TMB may have clinical implications if a hard threshold is used to indicate which patients may respond to immunotherapy.

•

Genome analysis revealed that treatment biomarkers are shared across solid tumours, highlighting repurposing opportunities.

•

Comprehensive panels detect most known biomarkers; however, WGS detects more biomarkers for treatments in clinical trials.

•

TMB is well correlated between sequencing methods, but absolute values vary and are dependent on mutation types considered.

Deeply Virtual Compton Scattering Cross Section at High Bjorken x_{B}

We report high-precision measurements of the deeply virtual Compton scattering (DVCS) cross section at high values of the Bjorken variable x_{B}. DVCS is sensitive to the generalized parton distributions of the nucleon, which provide a three-dimensional description of its internal constituents. Using the exact analytic expression of the DVCS cross section for all possible polarization states of the initial and final electron and nucleon, and final state photon, we present the first experimental extraction of all four helicity-conserving Compton form factors (CFFs) of the nucleon as a function of x_{B}, while systematically including helicity flip amplitudes. In particular, the high accuracy of the present data demonstrates sensitivity to some very poorly known CFFs.

OP0048 FIRST INTERIM ANALYSIS OF THE INTERNATIONAL X-LINKED HYPOPHOSPHATAEMIA (XLH) REGISTRY: ADULT POPULATION BASELINE CHARACTERISTICS

Background

X-Linked Hypophosphataemia (XLH) is a rare, progressive, lifelong, hereditary phosphate wasting disorder characterised by a pathological increase in fibroblast growth factor 23 concentration/activity.1 Despite XLH being increasingly recognised as a chronic progressive disease, there are few data documenting its natural history or the impact of treatment and other medical interventions on patient outcomes.2 The multicentre, international, XLH patient registry was established to address this lack of information in XLH to help inform future clinical practice.

Objectives

To report data from the first interim analysis of the International XLH Registry (NCT03193476), focusing on baseline characteristics of adults (aged ≥18 years [y]).

Methods

The International XLH Registry was initiated August 2017 to collect information on the natural history of XLH and will run for 10 years, aiming to recruit 1,200 people with XLH. Subjects diagnosed with XLH were enrolled from 81 sites in 16 countries (Last Patient In: 30/11/2020; Database Lock: 29/03/2021). Parameters collected at baseline included demographics, medical/treatment history, and clinical presentation.

Results

In total, 217 adults were eligible for inclusion in this analysis (18–<30y, n=56; 30–<50y, n=96; ≥50y, n=65); and 150 (69.1%) were female. Mean (SD) age was 41.9y (15.5y); median 41.1y. Mean height was 155.8 cm (n=79); mean weight, 70.0 kg (n=96); mean BMI 26.5 kg/m2 (n=48). Most subjects resided in the UK (50.7%, n=110) and in France (18.9%, n=41). Treatment data were available for 118 subjects: conventional therapy (phosphate salts and active vitamin D), 83.9% (99/118); burosumab, 11.0% (13/118); no treatment recorded 5.1% (6/118). Of 163 subjects with available data, a genetic test result was recorded for 68 (41.7%), of whom 62 (91.2%) had a confirmed PHEX mutation. Data on XLH family history were available for 187 subjects; 56/140 (40.0%) reported their biological mother was affected; and 22/141 (15.6%) reported their biological father was affected. The mean time to diagnosis from first symptoms was longer in older vs younger adults: 18–<30y, 25 months (mo) (n=21); 30–<50y, 21mo (n=21); ≥50y, 112mo (n=13).

Retrospective XLH clinical data were available at study entry for 110 adult subjects. Among these subjects, joint conditions were reported by 36.4% (40/110), with osteoarthritis of the knees (60%), hips (42.5%), and shoulders (22.5%) the most frequently affected. Skeletal abnormalities were noted for 71.8% (79/110) of subjects; most common conditions were genu varum 53.2% (42/79), genu valgum 26.6% (21/79), and enthesopathy 21.5% (17/79). Historical fracture data (“yes/no”) were available for 111 subjects; 41 were reported to have had a fracture. Femur fracture was reported for 22 subjects, and hip fractures for 5 subjects.

Details of historical orthopaedic surgery were reported for 99 adults; osteotomy was reported for 89 subjects, and hip replacements reported in 14 subjects.

Conclusion

The demographics and baseline characteristics of subjects in the International XLH Registry are as expected for adults with XLH. The shorter time to diagnosis in younger vs older adults may indicate improved recognition and diagnosis of XLH in recent years. The analysis of this young population treated with conventional therapy highlights the frequency of musculoskeletal involvement (osteoarthritis, enthesopathies, etc). The information collected within this rare-disease registry during these 10 years provides an exciting opportunity to integrate large-scale real-world evidence into clinical practice, with the aim of improving the care and quality of life of people living with this debilitating disease.

References

[1]Haffner D, et al. Nat Rev Nephrol 2019;15(7):435–455.

[2]Padidela R, et al. Orphanet J Rare Dis. 2020; 15:172.

Acknowledgements

The authors acknowledge the contribution of all members of the International XLH Registry Steering Committee.

Disclosure of Interests

Karine Briot Speakers bureau: Speakers bureau from KKI, Amgen, UCB, Alexion, Jonathan Liu Employee of: Employed by Kyowa Kirin International, Angela Williams Employee of: Employed by Kyowa Kirin International, Sue Wood Employee of: Employed by Kyowa Kirin International.

POS1155 THE INTERNATIONAL X-LINKED HYPOPHOSPHATAEMIA (XLH) REGISTRY: OVERVIEW OF THE DATA SET

Background

X-Linked Hypophosphataemia (XLH) is a rare, progressive, lifelong, hereditary renal tubule phosphate-wasting disorder characterised by a pathological increase in fibroblast growth factor 23 concentration/activity.1 Despite XLH being increasingly recognised as a chronic progressive disease, there are few data documenting its natural history or the impact of treatment on patient outcomes.2 The International XLH Registry was established to address this lack of information on XLH to help inform future clinical management. The Registry will collect data to characterise the treatment, burden of disease, disease progression and long-term outcomes of XLH.

Objectives

To provide an overview and status update of the International XLH Registry as of 31 December 2021.

Methods

The International XLH Registry (NCT03193476) was initiated in August 2017, aims to recruit 1,200 children and adults with XLH, and will run for 10 years. This Registry is an international, multicentre, non-interventional data collection programme and will provide the largest single dataset representing children and adults with XLH. To be eligible for inclusion in the registry, patients must meet all the following criteria:1) Male or female subjects of all ages; 2) Diagnosis of XLH with clinical, radiological, biochemical and/or genetic findings consistent with XLH. The Registry captures any treatment details and clinical outcome variables in patients with XLH and patients are followed for as long as informed consent (and assent, where applicable) and regulatory permissions are maintained. Only data collected during standard routine examinations are recorded within the Registry, and no specific examinations/data entries are mandated.

Parameters collected at baseline included demographics, medical and treatment history, and clinical presentation data. The conduct of the International XLH Registry is overseen by 17 Steering Committee physician members representing the region.

Results

As of 31 December 2021, 1,043 subjects diagnosed with XLH were enrolled from 88 hospital sites in 19 countries. The geographic distribution of subjects is as follows: Belgium n=29, Bulgaria n=7, Czech Republic n=8, Denmark n=23, France n=267, Germany n=79, Hungary n=11, Ireland n=5, Israel n=21, Italy n=88, The Netherlands n=26, Norway n=23, Portugal n=9, Slovakia n=5, Slovenia n=3, Spain n=55, Sweden n=43, Switzerland n=17, and the UK n=324. A further 30 sites are yet to enrol (including sites in Austria and Latvia). Overall, 400 adults (18–29y, n=116; 30–39y, n=81; 40–49y, n=95; 50–59y, n=58; ≥60y, n=50) and 620 paediatric subjects (<5y, n=138; 5–12y, n=321; 13–17y, n=161) have been enrolled (date of birth not reported, n=23). The majority of enrolled subjects are female (648 (62.1%), with 372 male (35.7%) and 23 for whom sex was not reported (2.2%). The quantity of data from the patients included in this Registry will enable ongoing snapshot and prospective analyses to be conducted over the coming years to answer research questions and inform clinical practice.

Conclusion

This International XLH Registry forms the largest dataset of subjects with XLH collected to date. Patients have been recruited from a wide geographical region and baseline demographics are consistent with a hereditary X-linked dominant disease. Information collected during the 10-year Registry duration will generate real-world evidence to help inform clinical practice throughout the region, with the aim of improving the care and quality of life of adults and children living with this debilitating disease.

References

[1]Haffner D, et al. Nat Rev Nephrol 2019;15(7):435–455.

[2]Padidela R, et al. Orphanet J Rare Dis. 2020; 15:172.

Acknowledgements

Authors acknowledge the contribution of all International XLH Registry Steering Committee members, and all the investigators participating in the International XLH Registry.

Disclosure of Interests

Gema Ariceta Speakers bureau: I have received honoraria for lectures, presentations, or educational events from Alexion Pharmaceuticals, Recordati Rare Disease, Advicenne, Chiesi, Kyowa Kirin, Consultant of: I have participated on Advisory Boards for Alexion Pharmaceuticals, Advicenne, Chiesi, Dicerna, and Alnylam., Jonathan Liu Employee of: Employee of Kyowa Kirin International, Angela Williams Employee of: Employee of Kyowa Kirin International, Sue Wood Employee of: Employee of Kyowa Kirin International, Dirk Schnabel Speakers bureau: I received an honorarium from various companies for scientific lectures (i.e. Ascendis, BioMarin, Ferring Pharma, Hexal / Sandoz, Ipsen Pharma, Kyowa Kirin, Merck Serono, Novo Nordisk), Consultant of: BioMarin, Kyowa Kirin

Measurement of the Nucleon F_{2}^{n}/F_{2}^{p} Structure Function Ratio by the Jefferson Lab MARATHON Tritium/Helium-3 Deep Inelastic Scattering Experiment

The ratio of the nucleon F_{2} structure functions, F_{2}^{n}/F_{2}^{p}, is determined by the MARATHON experiment from measurements of deep inelastic scattering of electrons from ^{3}H and ^{3}He nuclei. The experiment was performed in the Hall A Facility of Jefferson Lab using two high-resolution spectrometers for electron detection, and a cryogenic target system which included a low-activity tritium cell. The data analysis used a novel technique exploiting the mirror symmetry of the two nuclei, which essentially eliminates many theoretical uncertainties in the extraction of the ratio. The results, which cover the Bjorken scaling variable range 0.19<x<0.83, represent a significant improvement compared to previous SLAC and Jefferson Lab measurements for the ratio. They are compared to recent theoretical calculations and empirical determinations of the F_{2}^{n}/F_{2}^{p} ratio.

Determination of the ^{27}Al Neutron Distribution Radius from a Parity-Violating Electron Scattering Measurement

We report the first measurement of the parity-violating elastic electron scattering asymmetry on ^{27}Al. The ^{27}Al elastic asymmetry is A_{PV}=2.16±0.11(stat)±0.16(syst)  ppm, and was measured at ⟨Q^{2}⟩=0.02357±0.00010  GeV^{2}, ⟨θ_{lab}⟩=7.61°±0.02°, and ⟨E_{lab}⟩=1.157  GeV with the Q_{weak} apparatus at Jefferson Lab. Predictions using a simple Born approximation as well as more sophisticated distorted-wave calculations are in good agreement with this result. From this asymmetry the ^{27}Al neutron radius R_{n}=2.89±0.12  fm was determined using a many-models correlation technique. The corresponding neutron skin thickness R_{n}-R_{p}=-0.04±0.12  fm is small, as expected for a light nucleus with a neutron excess of only 1. This result thus serves as a successful benchmark for electroweak determinations of neutron radii on heavier nuclei. A tree-level approach was used to extract the ^{27}Al weak radius R_{w}=3.00±0.15  fm, and the weak skin thickness R_{wk}-R_{ch}=-0.04±0.15  fm. The weak form factor at this Q^{2} is F_{wk}=0.39±0.04.

Opportunities to improve the impact of two national clinical audit programmes: a theory-guided analysis

Background

Audit and feedback is widely used in healthcare improvement, with evidence of modest yet potentially important effects upon professional practice. There are approximately 60 national clinical audit programmes in the UK. These programmes often develop and adapt new ways of delivering feedback to optimise impacts on clinical practice. Two such programmes, the National Diabetes Audit (NDA) and the Trauma Audit Research Network (TARN), recently introduced changes to their delivery of feedback. We assessed the extent to which the design of these audit programmes and their recent changes were consistent with best practice according to the Clinical Performance Feedback Intervention Theory (CP-FIT). This comprehensive framework specifies how variables related to the feedback itself, the recipient, and the context operate via explanatory mechanisms to influence feedback success.

Methods

We interviewed 19 individuals with interests in audit and feedback, including researchers, audit managers, healthcare staff, and patient and public representatives. This range of expert perspectives enabled a detailed exploration of feedback from the audit programmes. We structured interviews around the CP-FIT feedback cycle and its component processes (e.g. Data collection and analysis, Interaction). Our rapid analytic approach explored the extent to which both audits applied features consistent with CP-FIT.

Results

Changes introduced by the audit programmes were consistent with CP-FIT. Specifically, the NDA’s increased frequency of feedback augmented existing strengths, such as automated processes (CP-FIT component: Data collection and analysis) and being a credible source of feedback (Acceptance). TARN’s new analytic tool allowed greater interactivity, enabling recipients to interrogate their data (Verification; Acceptance). We also identified scope for improvement in feedback cycles, such as targeting of feedback recipients (Interaction) and feedback complexity (Perception) for the NDA and specifying recommendations (Intention) and demonstrating impact (Clinical performance improvement) for TARN.

Conclusions

The changes made by the two audit programmes appear consistent with suggested best practice, making clinical improvement more likely. However, observed weaknesses in the feedback cycle may limit the benefits of these changes. Applying CP-FIT via a rapid analysis approach helps identify strengths and remediable weaknesses in the design of audit programmes that can be shared with them in a timely manner.

Form Factors and Two-Photon Exchange in High-Energy Elastic Electron-Proton Scattering

We present new precision measurements of the elastic electron-proton scattering cross section for momentum transfer (Q^{2}) up to 15.75  (GeV/c)^{2}. Combined with existing data, these provide an improved extraction of the proton magnetic form factor at high Q^{2} and double the range over which a longitudinal or transverse separation of the cross section can be performed. The difference between our results and polarization data agrees with that observed at lower Q^{2} and attributed to hard two-photon exchange (TPE) effects, extending to 8  (GeV/c)^{2} the range of Q^{2} for which a discrepancy is established at >95% confidence. We use the discrepancy to quantify the size of TPE contributions needed to explain the cross section at high Q^{2}.

Deep Exclusive Electroproduction of π^{0} at High Q^{2} in the Quark Valence Regime

We report measurements of the exclusive neutral pion electroproduction cross section off protons at large values of x_{B} (0.36, 0.48, and 0.60) and Q^{2} (3.1 to 8.4  GeV^{2}) obtained from Jefferson Lab Hall A experiment E12-06-014. The corresponding structure functions dσ_{T}/dt+εdσ_{L}/dt, dσ_{TT}/dt, dσ_{LT}/dt, and dσ_{LT^{'}}/dt are extracted as a function of the proton momentum transfer t-t_{min}. The results suggest the amplitude for transversely polarized virtual photons continues to dominate the cross section throughout this kinematic range. The data are well described by calculations based on transversity generalized parton distributions coupled to a helicity flip distribution amplitude of the pion, thus providing a unique way to probe the structure of the nucleon.

Delivering computationally-intensive digital patient applications to the clinic: An exemplar solution to predict femoral bone strength from CT data

BACKGROUND AND OBJECTIVE

Whilst fragility hip fractures commonly affect elderly people, often causing permanent disability or death, they are rarely addressed in advance through preventive techniques. Quantification of bone strength can help to identify subjects at risk, thus reducing the incidence of fractures in the population. In recent years, researchers have shown that finite element models (FEMs) of the hip joint, derived from computed tomography (CT) images, can predict bone strength more accurately than other techniques currently used in the clinic. The specialised hardware and trained personnel required to perform such analyses, however, limits the widespread adoption of FEMs in clinical contexts. In this manuscript we present CT2S (Computed Tomography To Strength), a system developed in collaboration between The University of Sheffield and Sheffield Teaching Hospitals, designed to streamline access to this complex workflow for clinical end-users.

METHODS

The system relies on XNAT and makes use of custom apps based on open source software. Available through a website, it allows doctors in the healthcare environment to benefit from FE based bone strength estimation without being exposed to the technical aspects, which are concealed behind a user-friendly interface. Clinicians request the analysis of CT scans of a patient through the website. Using XNAT functionality, the anonymised images are automatically transferred to the University research facility, where an operator processes them and estimates the bone strength through FEM using a combination of open source and commercial software. Following the analysis, the doctor is provided with the results in a structured report.

RESULTS

The platform, currently available for research purposes, has been deployed and fully tested in Sheffield, UK. The entire analysis requires processing times ranging from 3.5 to 8 h, depending on the available computational power.

CONCLUSIONS

The short processing time makes the system compatible with current clinical workflows. The use of open source software and the accurate description of the workflow given here facilitates the deployment in other centres.

An agenda for research and action toward diverse and just futures for life on Earth

Decades of research and policy interventions on biodiversity have insufficiently addressed the dual issues of biodiversity degradation and social justice. New approaches are therefore needed. We devised a research and action agenda that calls for a collective task of revisiting biodiversity toward the goal of sustaining diverse and just futures for life on Earth. Revisiting biodiversity involves critically reflecting on past and present research, policy, and practice concerning biodiversity to inspire creative thinking about the future. The agenda was developed through a 2-year dialogue process that involved close to 300 experts from diverse disciplines and locations. This process was informed by social science insights that show biodiversity research and action is underpinned by choices about how problems are conceptualized. Recognizing knowledge, action, and ethics as inseparable, we synthesized a set of principles that help navigate the task of revisiting biodiversity. The agenda articulates 4 thematic areas for future research. First, researchers need to revisit biodiversity narratives by challenging conceptualizations that exclude diversity and entrench the separation of humans, cultures, economies, and societies from nature. Second, researchers should focus on the relationships between the Anthropocene, biodiversity, and culture by considering humanity and biodiversity as tied together in specific contexts. Third, researchers should focus on nature and economies by better accounting for the interacting structures of economic and financial systems as core drivers of biodiversity loss. Finally, researchers should enable transformative biodiversity research and action by reconfiguring relationships between human and nonhuman communities in and through science, policy, and practice. Revisiting biodiversity necessitates a renewed focus on dialogue among biodiversity communities and beyond that critically reflects on the past to channel research and action toward fostering just and diverse futures for human and nonhuman life on Earth.

An agenda for research and action toward diverse and just futures for life on Earth

Decades of research and policy interventions on biodiversity have insufficiently addressed the dual issues of biodiversity degradation and social justice. New approaches are therefore needed. We devised a research and action agenda that calls for a collective task of revisiting biodiversity toward the goal of sustaining diverse and just futures for life on Earth. Revisiting biodiversity involves critically reflecting on past and present research, policy, and practice concerning biodiversity to inspire creative thinking about the future. The agenda was developed through a 2-year dialogue process that involved close to 300 experts from diverse disciplines and locations. This process was informed by social science insights that show biodiversity research and action is underpinned by choices about how problems are conceptualized. Recognizing knowledge, action, and ethics as inseparable, we synthesized a set of principles that help navigate the task of revisiting biodiversity. The agenda articulates 4 thematic areas for future research. First, researchers need to revisit biodiversity narratives by challenging conceptualizations that exclude diversity and entrench the separation of humans, cultures, economies, and societies from nature. Second, researchers should focus on the relationships between the Anthropocene, biodiversity, and culture by considering humanity and biodiversity as tied together in specific contexts. Third, researchers should focus on nature and economies by better accounting for the interacting structures of economic and financial systems as core drivers of biodiversity loss. Finally, researchers should enable transformative biodiversity research and action by reconfiguring relationships between human and nonhuman communities in and through science, policy, and practice. Revisiting biodiversity necessitates a renewed focus on dialogue among biodiversity communities and beyond that critically reflects on the past to channel research and action toward fostering just and diverse futures for human and nonhuman life on Earth.

"The use of bisphosphonates to treat skeletal complications in solid tumours"

The skeleton is the most common site of secondary disease in breast cancer and prostate cancer, with up to 80% of patients with advanced disease developing bone metastases (BM). The proportion is also substantial in advanced lung cancer (20%-40%). Because of the high prevalence of cancers of the breast, prostate and lung, these cancers account for more than 80% of cases of metastatic bone disease occurring in solid tumours. Metastatic bone disease is associated with greatly increased bone resorption by osteoclasts, leading to moderate to severe pain and other skeletal complications, with major impact on quality of life (QoL). Skeletal Related Events (SREs) have been defined as: pathological long bone or vertebral fractures; spinal cord compression; need for radiation for pain relief or to prevent fracture/spinal cord compression, need for surgery to bone and hypercalcaemia. More recently, Symptomatic Skeletal Events (SSEs) have been defined to monitor QoL. Although there are currently no curative treatments for metastatic bone disease, patients with breast or prostate cancer and BM are now surviving for several years and sometimes longer, and prevention of SREs is the key aim to optimization of QoL. Since their discovery 50 years ago and their introduction more than 30 years ago into the field of metastatic bone disease, a range of oral and intravenous bisphosphonate drugs have made a major contribution to prevention of SREs. Large trials have clearly demonstrated the clinical value of different bisphosphonate-based drugs (including the oral drugs ibandronate and clodronate and intravenous agents such as zoledronate and pamidronate), in treatment of hypercalcaemia of malignancy and the reduction of SREs and SSEs in a range of cancers. Despite the success of denosumab in reducing osteolysis, bisphosphonates also remain mainstay drugs for treatment of metastatic bone disease. Recognizing the 50th Anniversary of the discovery of bisphosphonates, this review focuses on their continuing value in BM treatment and their future potential, for example in providing a bone-targeting vehicle for cytotoxic drugs.

Potential applications of CRISPR/Cas for next-generation biomonitoring of harmful algae blooms: A review

Research on harmful algal and cyanobacterial blooms (HABs and CHABs) has risen dramatically due to their increasing global distribution, frequency, and intensity. These blooms jeopardize public health, ecosystem function, sustainability and can have negative economic impacts. Numerous monitoring programs have been established using light microscopy, liquid chromatography coupled to mass spectrometry (LC-MS), ELISA, and spectrophotometry to monitor HABs/CHABs outbreaks. Recently, DNA/RNA-based molecular methods have been integrated into these programs to replace or complement traditional methods through analyzing environmental DNA and RNA (eDNA/eRNA) with techniques such as quantitative polymerase chain reaction (qPCR), fluorescent in situ hybridization (FISH), sandwich hybridization assay (SHA), isothermal amplification methods, and microarrays. These have enabled the detection of rare or cryptic species, enhanced sample throughput, and reduced costs and the need for visual taxonomic expertise. However, these methods have limitations, such as the need for high capital investment in equipment or detection uncertainties, including determining whether organisms are viable. In this review, we discuss the potential of newly developed molecular diagnosis technology based on Clustered Regularly Interspaced Short Palindromic Repeats/Cas proteins (CRISPR/Cas), which utilizes the prokaryotic adaptative immune systems of bacteria and archaea. Cas12 and Cas13-based platforms can detect both DNA and RNA with attomolar sensitivity within an hour. CRISPR/Cas diagnostic is a rapid, inexpensive, specific, and ultrasensitive technology that, with some further development, will provide many new platforms that can be used for HABs/CHABs biomonitoring and research.

Ruling out Color Transparency in Quasielastic ^{12}C(e,e^{'}p) up to Q^{2} of 14.2 (GeV/c)^{2}

Quasielastic ^{12}C(e,e^{'}p) scattering was measured at spacelike 4-momentum transfer squared Q^{2}=8, 9.4, 11.4, and 14.2  (GeV/c)^{2}, the highest ever achieved to date. Nuclear transparency for this reaction was extracted by comparing the measured yield to that expected from a plane-wave impulse approximation calculation without any final state interactions. The measured transparency was consistent with no Q^{2} dependence, up to proton momenta of 8.5  GeV/c, ruling out the quantum chromodynamics effect of color transparency at the measured Q^{2} scales in exclusive (e,e^{'}p) reactions. These results impose strict constraints on models of color transparency for protons.

Commercial weight management programmes for patients living with overweight or obesity prior to elective orthopaedic surgery: an evidence review

BACKGROUND

Increased body mass index is associated with increased operative risk during elective joint replacement surgery. Commercial weight management programmes are designed to achieve weight loss. It is not known whether commercial weight management programmes are effective at achieving weight loss in patients awaiting planned hip or knee replacement surgery, or whether achieving significant planned weight loss prior to surgery is associated with changes in surgical outcome.

METHODS

A systematic literature search of seven databases was conducted. Reference lists and grey literature were searched, including commercial weight management programme and medical association websites. Four relevant primary interventional studies were identified.

RESULTS

There is weak, low-quality evidence from four small studies, of which three demonstrated that commercial weight management programmes initiated between 3 and 6 months prior to elective joint replacement surgery are associated with a statistically significant weight loss and body mass index reduction. There is a weak evidence from two studies that peri- and post-operative complications are similar between control and commercial weight management programme groups.

CONCLUSION

There is a paucity of studies investigating commercial weight management programmes aiming to reduce weight in patients living with overweight or obesity awaiting total joint replacement. Further, high-quality research is urgently needed.

The EurValve model execution environment

The goal of this paper is to present a dedicated high-performance computing (HPC) infrastructure which is used in the development of a so-called reduced-order model (ROM) for simulating the outcomes of interventional procedures which are contemplated in the treatment of valvular heart conditions. Following a brief introduction to the problem, the paper presents the design of a model execution environment, in which representative cases can be simulated and the parameters of the ROM fine-tuned to enable subsequent deployment of a decision support system without further need for HPC. The presentation of the system is followed by information concerning its use in processing specific patient cases in the context of the EurValve international collaboration.

Probing the Deuteron at Very Large Internal Momenta

We measure ^{2}H(e,e^{'}p)n cross sections at 4-momentum transfers of Q^{2}=4.5±0.5  (GeV/c)^{2} over a range of neutron recoil momenta p_{r}, reaching up to ∼1.0  GeV/c. We obtain data at fixed neutron recoil angles θ_{nq}=35°, 45°, and 75° with respect to the 3-momentum transfer q[over →]. The new data agree well with previous data, which reached p_{r}∼500  MeV/c. At θ_{nq}=35° and 45°, final state interactions, meson exchange currents, and isobar currents are suppressed and the plane wave impulse approximation provides the dominant cross section contribution. We compare the new data to recent theoretical calculations, where we observe a significant discrepancy for recoil momenta p_{r}>700  MeV/c.

Precision Measurement of the Beam-Normal Single-Spin Asymmetry in Forward-Angle Elastic Electron-Proton Scattering

A beam-normal single-spin asymmetry generated in the scattering of transversely polarized electrons from unpolarized nucleons is an observable related to the imaginary part of the two-photon exchange process. We report a 2% precision measurement of the beam-normal single-spin asymmetry in elastic electron-proton scattering with a mean scattering angle of θ_{lab}=7.9° and a mean energy of 1.149 GeV. The asymmetry result is B_{n}=-5.194±0.067(stat)±0.082 (syst) ppm. This is the most precise measurement of this quantity available to date and therefore provides a stringent test of two-photon exchange models at far-forward scattering angles (θ_{lab}→0) where they should be most reliable.

Tools for successful proliferation: diverse strategies of nutrient acquisition by a benthic cyanobacterium

Freshwater cyanobacterial blooms have increased worldwide, channeling organic carbon into these systems, and threatening animal health through the production of cyanotoxins. Both toxic and nontoxic Microcoleus proliferations usually occur when there are moderate concentrations of dissolved inorganic nitrogen, but when phosphorus is scarce. In order to understand how Microcoleus establishes thick biofilms (or mats) on riverbeds under phosphorus-limiting conditions, we collected Microcoleus-dominated biofilms over a 19-day proliferation event for proteogenomics. A single pair of nitrogen-dependent Microcoleus species were consistently present in relatively high abundance, although each followed a unique metabolic trajectory. Neither possessed anatoxin gene clusters, and only very low concentrations of anatoxins (~2 µg kg-1) were detected, likely originating from rarer Microcoleus species also present. Proteome allocations were dominated by photosynthesizing cyanobacteria and diatoms, and data indicate biomass was actively recycled by Bacteroidetes and Myxococcales. Microcoleus likely acquired nutrients throughout the proliferation event by uptake of nitrate, urea, and inorganic and organic phosphorus. Both species also harbored genes that could be used for inorganic phosphate solubilization with pyrroloquinoline quinone cofactors produced by cohabiting Proteobacteria. Results indicate that Microcoleus are equipped with diverse mechanisms for nitrogen and phosphorus acquisition, enabling them to proliferate and out-compete others in low-phosphorus waters.

The clinical efficacy of PSMA PET/MRI in biochemically recurrent prostate cancer compared with standard of care imaging modalities and confirmatory histopathology: results of a single-centre, prospective clinical trial

Prospective evidence for the clinical role and efficacy of prostate specific membrane antigen (PSMA) positron emission tomography (PET)/magnetic resonance imaging (MRI) combining MRI characterization and localization of lesions with PET avidity in comparison to conventional imaging is limited. In a prospective clinical trial, we aimed to evaluate the diagnostic yield and therapeutic impact of PSMA PET/MRI in men with biochemical recurrence (BCR) following curative therapy. A single-centre, prospective clinical trial at the Princess Alexandra Hospital recruited 30 patients with BCR. Patients underwent PSMA PET/MRI and concurrent conventional CT chest, abdomen, pelvis and whole-body bone scan. Biopsy was performed when safety possible for histological correlation of identified lesions. Clinical efficacy and impact of PSMA PET findings were evaluated. 30 patients with BCR were recruited (median PSA 0.69 ng/ml). PSMA avid lesions were present in 21 patients (70%). 23 patients were previously treated with definitive surgery, 6 patients received external beam radiotherapy and 1 patient had low dose rate brachytherapy. A total of 8 of 9 lesions biopsied were positive (88.9% histological correlation). PSMA PET/MRI detected local recurrence (p = 0.005) and pelvic lesions (p = 0.06) more accurately than conventional imaging. PSMA PET/MRI may be useful in staging men with biochemical recurrence, especially when PSA is low. Our data demonstrates a high detection rate, especially for locally recurrent disease, and highlights the role of this modality when PSA is low. This modality has the potential to significantly improve prostate cancer detection and may have implications for earlier salvage treatment, avoidance of futile local therapy and change patient management to lead to improved outcomes.

AB1203 INVESTIGATING THE VIEWS OF COMMUNITY PHARMACISTS ON THEIR ROLE IN THE MANAGEMENT OF RHEUMATOID ARTHRITIS

Background:

Medicines optimisation is essential in the long-term management of rheumatoid arthritis (RA), particularly when considering combinations of conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs). Community pharmacists are ideally placed to optimise medicines use including monitoring side effects, counselling on dose and frequency and improving medicines adherence; however, in some countries, such as the UK, there are currently no community pharmacy services that address csDMARD use and little is known about the role community pharmacists play in managing RA as a long-term condition.

Objectives:

The objectives of this qualitative study were to understand community pharmacists’ views of their training, knowledge and current role in the management of RA.

Methods:

We conducted 9 semi-structured, face-to-face or telephone interviews with community pharmacists based in the UK; all were transcribed verbatim. A topic guide, used to inform the interviews, covered four key areas: 1) knowledge and training, 2) pharmacological management 3) patients and services, 4) potential role. The transcriptions were then imported into NVivo for thematic analysis. A coding framework was developed from continual emerging themes and applied to the transcripts.

Results:

Five male/4 female participants, the median age was 39 years (range 27 to 42) with a median number of years qualified as a pharmacist of 12 years (range 5 to 20) were included. The participants covered a range of roles including: pharmacist non-manager, pharmacist manager, locum pharmacist, superintendent pharmacist and relief pharmacist.

In assessing the current role of community pharmacists, 4 main themes were identified: (1) access to information about the patient’s condition as a barrier, (2) their lack of knowledge in the management of RA, (3) providing practical advice about taking csDMARDs, and (4) exploring the reasons for non-adherence before taking further action. In assessing the potential role of community pharmacists, a further 2 themes were identified: improving access to information about the patient’s condition before the current role can be increased and other barriers to an additional role, including time and funding.

In the theme ‘access to information as a barrier’ the most common point made was about the lack of information available to pharmacists on the individual indication for medicines. Pharmacists said this posed a barrier both to current practice and their potential role. No participants suggested the potential for an additional service specifically for RA, but some suggested that current services could be expanded to include RA as a target group. Participants discussed side effect counselling and ensuring access to medicines in detail with patients, but only 2 briefly mentioned discussing the benefits of csDMARDs.

Conclusion:

This is the first in-depth exploration of the perspectives of community pharmacists on the management of RA in community pharmacy. This study has highlighted several important barriers both environmental and personal including time, education and resources that, if addressed, could allow community pharmacists to play a greater role in the management of RA.

Disclosure of Interests:

Sarah Wood: None declared, Kimme Hyrich Grant/research support from: Pfizer, UCB, BMS, Speakers bureau: Abbvie, Suzanne Verstappen Grant/research support from: BMS, Consultant of: Celltrion, Speakers bureau: Pfizer, Douglas Steinke: None declared

Probing Few-Body Nuclear Dynamics via ^{3}H and ^{3}He (e,e^{'}p)pn Cross-Section Measurements

We report the first measurement of the (e,e^{'}p) three-body breakup reaction cross sections in helium-3 (^{3}He) and tritium (^{3}H) at large momentum transfer [⟨Q^{2}⟩≈1.9  (GeV/c)^{2}] and x_{B}>1 kinematics, where the cross section should be sensitive to quasielastic (QE) scattering from single nucleons. The data cover missing momenta 40≤p_{miss}≤500  MeV/c that, in the QE limit with no rescattering, equals the initial momentum of the probed nucleon. The measured cross sections are compared with state-of-the-art ab initio calculations. Overall good agreement, within ±20%, is observed between data and calculations for the full p_{miss} range for ^{3}H and for 100≤p_{miss}≤350  MeV/c for ^{3}He. Including the effects of rescattering of the outgoing nucleon improves agreement with the data at p_{miss}>250  MeV/c and suggests contributions from charge-exchange (SCX) rescattering. The isoscalar sum of ^{3}He plus ^{3}H, which is largely insensitive to SCX, is described by calculations to within the accuracy of the data over the entire p_{miss} range. This validates current models of the ground state of the three-nucleon system up to very high initial nucleon momenta of 500  MeV/c.

Perspective: Advancing the research agenda for improving understanding of cyanobacteria in a future of global change

Harmful cyanobacterial blooms (=cyanoHABs) are an increasing feature of many waterbodies throughout the world. Many bloom-forming species produce toxins, making them of particular concern for drinking water supplies, recreation and fisheries in waterbodies along the freshwater to marine continuum. Global changes resulting from human impacts, such as climate change, over-enrichment and hydrological alterations of waterways, are major drivers of cyanoHAB proliferation and persistence. This review advocates that to better predict and manage cyanoHABs in a changing world, researchers need to leverage studies undertaken to date, but adopt a more complex and definitive suite of experiments, observations, and models which can effectively capture the temporal scales of processes driven by eutrophication and a changing climate. Better integration of laboratory culture and field experiments, as well as whole system and multiple-system studies are needed to improve confidence in models predicting impacts of climate change and anthropogenic over-enrichment and hydrological modifications. Recent studies examining adaptation of species and strains to long-term perturbations, e.g. temperature and carbon dioxide (CO₂) levels, as well as incorporating multi-species and multi-stressor approaches emphasize the limitations of approaches focused on single stressors and individual species. There are also emerging species of concern, such as toxic benthic cyanobacteria, for which the effects of global change are less well understood, and require more detailed study. This review provides approaches and examples of studies tackling the challenging issue of understanding how global changes will affect cyanoHABs, and identifies critical information needs for effective prediction and management.

ENACT: a protocol for a randomised placebo-controlled trial investigating the efficacy and mechanisms of action of adjunctive N-acetylcysteine for first-episode psychosis

Background

First-episode psychosis (FEP) may lead to a progressive, potentially disabling and lifelong chronic illness; however, evidence suggests that the illness course can be improved if appropriate treatments are given at the early stages. Nonetheless, the efficacy of antipsychotic medications is suboptimal, particularly for negative and cognitive symptoms, and more efficacious and benign treatments are needed. Previous studies have shown that the antioxidant amino acid N-acetylcysteine (NAC) reduces negative symptoms and improves functioning in chronic schizophrenia and bipolar disorder. Research is scarce as to whether NAC is beneficial earlier in the course of illness. The primary aim of this study is to determine the efficacy of treatment with adjunctive NAC (2 g/day for 26 weeks) compared with placebo to improve psychiatric symptoms in young people experiencing FEP. Secondary aims are to explore the neurobiological mechanisms underpinning NAC and how they relate to various clinical and functional outcomes at 26- and 52-week follow-ups.

Methods/design

ENACT is a 26-week, randomised controlled trial of adjunctive NAC versus placebo, with a 26-week non-treatment follow-up period, for FEP. We will be recruiting 162 young people aged 15–25 years who have recently presented to, and are being treated at, the Early Psychosis Prevention and Intervention Centre, Melbourne, Australia. The primary outcome is the Total Score on the Positive and Negative Syndrome Scale which will be administered at baseline, and weeks 4, 8, 12, 26 (primary endpoint), and 52 (end of study). Secondary outcomes include: symptomatology, functioning, quality of life, neurocognition, blood-derived measures of: inflammation, oxidative and nitrosative stress, and magnetic resonance spectroscopy measures of glutathione concentration.

Discussion

Targeted drug development for FEP to date has generally not involved the exploration of neuroprotective agents. This study has the potential to offer a new, safe, and efficacious treatment for people with FEP, leading to better treatment outcomes. Additionally, the neuroprotective dimension of this study may lead to a better long-term prognosis for people with FEP. It has the potential to uncover a novel treatment that targets the neurobiological mechanisms of FEP and, if successful, will be a major advance for psychiatry.

Trial registration

Australian New Zealand Clinical Trials Registry, ID: ACTRN12618000413224. Registered on 21 March 2018.

Visual Immunoprecipitate Assay Eight Hour Method for Detection of Enterohemorrhagic Escherichia coli O157:H7 in Raw and Cooked Beef (Modification of AOAC Official Method 996.09): Collaborative Study

AOAC Official Method 996.09, Visual Immunoprecipitate Assay (VIP®) for Escherichia coli O157:H7, was modified to incorporate a new enrichment protocol using BioControl EHEC8™ medium for testing raw and cooked beef. Foods were tested by VIP assay and the U.S. Department of Agriculture/Food Safety and Inspection Service (USDA/FSIS) enrichment procedure and the FDA Bacteriological Analytical Manual (BAM) isolation and confirmation techniques. A total of 15 collaborators participated. Raw and cooked ground beef were inoculated with E. coli O157:H7 at 2 different levels: a high level, where predominantly positive results were expect d, and a low level where fractional recovery was anticipated. Collaborators tested 396 test portions and controls by both methods, for a total of 792 test portions. Of the 396 paired test portions, 75 were positive and 230 were negative by both the VIP and culture methods. Eleven test portions were presumptively positive by VIP and could not be confirmed culturally; 32 were negative by VIP, but confirmed positive by culture; and 65 were negative by the culture method, but confirmed positive by the VIP method. There was no statistical difference between results obtained with the VIP for EHEC 8 h method and the culture method except for cooked beef, where the VIP had significantly higher recovery for one inoculation level.

Assurance® Enzyme Immunoassay Eight Hour Method for Detection of Enterohemorrhagic Escherichia coli O157:H7 in Raw and Cooked Beef (Modification of AOAC Official Method 996.10): Collaborative Study

AOAC Official Method 996.10, Assurance® Enzyme Immunoassay (EIA) for Escherichia coli O157:H7 (EHEC), was modified to incorporate a new enrichment protocol using BioControl EHEC8™ medium for testing raw and cooked beef. Foods were tested by EIA and the U.S. Department of Agriculture/Food Safety and Inspection Service (USDA/FSIS) enrichment conditions and the FDA Bacteriological Analytical Manual (BAM) isolation and confirmation techniques. A total of 14 collaborators participated. Raw and cooked ground beef were inoculated with E. coli O157:H7 at 2 different levels: a high level where predominantly positive results were expected, and a low level where fractional recovery was anticipated. Collaborators tested 378 test portions and controls by both the 8 h EIA and the USDA/FSIS enrichment methods, for a total of 756 test portions. Of the 378 paired test portions, 75 were positive and 212 were negative by both methods. Thirteen test portions were presumptively positive by EIA and could not be confirmed culturally; 30 were negative by EIA, but confirmed positive by culture; and 65 were negative by the culture method, but confirmed positive by the EIA method. There was no statistical difference between results obtained with the Assurance EIA for EHEC 8 h method and the culture method for raw ground beef. The Assurance EIA had a significantly higher recovery for cooked beef.

Unique Access to u-Channel Physics: Exclusive Backward-Angle Omega Meson Electroproduction

Backward-angle meson electroproduction above the resonance region, which was previously ignored, is anticipated to offer unique access to the three quark plus sea component of the nucleon wave function. In this Letter, we present the first complete separation of the four electromagnetic structure functions above the resonance region in exclusive ω electroproduction off the proton, ep→e^{'}pω, at central Q^{2} values of 1.60, 2.45  GeV^{2}, at W=2.21  GeV. The results of our pioneering -u≈-u_{min} study demonstrate the existence of a unanticipated backward-angle cross section peak and the feasibility of full L/T/LT/TT separations in this never explored kinematic territory. At Q^{2}=2.45  GeV^{2}, the observed dominance of σ_{T} over σ_{L}, is qualitatively consistent with the collinear QCD description in the near-backward regime, in which the scattering amplitude factorizes into a hard subprocess amplitude and baryon to meson transition distribution amplitudes: universal nonperturbative objects only accessible through backward-angle kinematics.

Variations in competencies needed to complete surgical training

Background

This study aimed to analyse the degree of relative variation in specialty-specific competencies required for certification of completion of training (CCT) by the UK Joint Committee on Surgical Training.

Methods

Regulatory body guidance relating to operative and non-operative surgical skill competencies required for CCT were analysed and compared.

Results

Wide interspecialty variation was demonstrated in the required minimum number of logbook cases (median 1201 (range 60-2100)), indexed operations (13 (5-55)), procedure-based assessments (18 (7-60)), publications (2 (0-4)), communications to learned associations (0 (0-6)) and audits (4 (1-6)). Mandatory courses across multiple specialties included: Training the Trainers (10 of 10 specialties), Advanced Trauma Life Support (6 of 10), Good Clinical Practice (9 of 10) and Research Methodologies (8 of 10), although no common accord was evident.

Discussion

Certification guidelines for completion of surgical training were inconsistent, with metrics related to minimum operative caseload and academic reach having wide variation.

Measurements of Nonsinglet Moments of the Nucleon Structure Functions and Comparison to Predictions from Lattice QCD for Q^{2}=4 GeV^{2}

We present extractions of the nucleon nonsinglet moments utilizing new precision data on the deuteron F_{2} structure function at large Bjorken-x determined via the Rosenbluth separation technique at Jefferson Lab Experimental Hall C. These new data are combined with a complementary set of data on the proton previously measured in Hall C at similar kinematics and world datasets on the proton and deuteron at lower x measured at SLAC and CERN. The new Jefferson Lab data provide coverage of the upper third of the x range, crucial for precision determination of the higher moments. In contrast to previous extractions, these moments have been corrected for nuclear effects in the deuteron using a new global fit to the deuteron and proton data. The obtained experimental moments represent an order of magnitude improvement in precision over previous extractions using high x data. Moreover, recent exciting developments in lattice QCD calculations provide a first ever comparison of these new experimental results with calculations of moments carried out at the physical pion mass, as well as a new approach that first calculates the quark distributions directly before determining moments.

Whole-genome sequencing reveals clinically relevant insights into the aetiology of familial breast cancers

BACKGROUND

Whole-genome sequencing (WGS) is a powerful method for revealing the diversity and complexity of the somatic mutation burden of tumours. Here, we investigated the utility of tumour and matched germline WGS for understanding aetiology and treatment opportunities for high-risk individuals with familial breast cancer.

PATIENTS AND METHODS

We carried out WGS on 78 paired germline and tumour DNA samples from individuals carrying pathogenic variants in BRCA1 (n = 26) or BRCA2 (n = 22) or from non-carriers (non-BRCA1/2; n = 30).

RESULTS

Matched germline/tumour WGS and somatic mutational signature analysis revealed patients with unreported, dual pathogenic germline variants in cancer risk genes (BRCA1/BRCA2; BRCA1/MUTYH). The strategy identified that 100% of tumours from BRCA1 carriers and 91% of tumours from BRCA2 carriers exhibited biallelic inactivation of the respective gene, together with somatic mutational signatures suggestive of a functional deficiency in homologous recombination. A set of non-BRCA1/2 tumours also had somatic signatures indicative of BRCA-deficiency, including tumours with BRCA1 promoter methylation, and tumours from carriers of a PALB2 pathogenic germline variant and a BRCA2 variant of uncertain significance. A subset of 13 non-BRCA1/2 tumours from early onset cases were BRCA-proficient, yet displayed complex clustered structural rearrangements associated with the amplification of oncogenes and pathogenic germline variants in TP53, ATM and CHEK2.

CONCLUSIONS

Our study highlights the role that WGS of matched germline/tumour DNA and the somatic mutational signatures can play in the discovery of pathogenic germline variants and for providing supporting evidence for variant pathogenicity. WGS-derived signatures were more robust than germline status and other genomic predictors of homologous recombination deficiency, thus impacting the selection of platinum-based or PARP inhibitor therapy. In this first examination of non-BRCA1/2 tumours by WGS, we illustrate the considerable heterogeneity of these tumour genomes and highlight that complex genomic rearrangements may drive tumourigenesis in a subset of cases.

Quantitative bias analysis of the association of type 2 diabetes mellitus with 2,2',4,4',5,5'-hexachlorobiphenyl (PCB-153)

An association between serum concentrations of persistent organic pollutants (POPs), such as 2,2',4,4',5,5'-hexachlorobiphenyl (PCB-153), and risk of type 2 diabetes mellitus (T2DM) has been reported. Conditional on body mass index (BMI) and waist circumference (WC), a higher serum PCB-153 concentration may be a marker of T2DM risk because it reflects other aspects of obesity that are related to T2DM risk and to PCB-153 clearance. To estimate the amount of residual confounding by other aspects of obesity, we performed a quantitative bias analysis on the results of a specific study. A physiologically-based pharmacokinetic (PBPK) model was developed to predict serum levels of PCB-153 for a simulated population. T2DM status was assigned to simulated subjects based on age, sex, BMI, WC, and visceral adipose tissue mass. The distributions of age, BMI, WC, and T2DM prevalence of the simulated population were tailored to closely match the target population. Analysis of the simulated data showed that a small part of the observed association appeared to be due to residual confounding. For example, the predicted odds ratio of T2DM that would have been obtained had the results been adjusted for visceral adipose tissue mass, for the ≥90th percentile of PCB-153 serum concentration, was 6.60 (95% CI 2.46-17.74), compared with an observed odds ratio of 7.13 (95% CI 2.65-19.13). Our results predict that the association between PCB-153 and risk of type 2 diabetes mellitus would not be substantially changed by additional adjustment for visceral adipose tissue mass in epidemiologic analyses. Confirmation of these predictions with longitudinal data would be reassuring.