Unveiling Disparities: Exploring Differential Attainment in Postgraduate Training Within Clinical Oncology

AIMS

Differential attainment (DA) in post graduate medical training is a recognised challenge and refers to unexplained variation across groups when split by several protected characteristics. The Royal College of Radiology is committed to fostering diversity, inclusivity, and equality with the goal of narrowing existing gaps and improving training outcomes.

MATERIALS AND METHODS

This was a mixed methods study aiming to understand the causes of DA with view to helping the RCR develop strategies to address this. A cross-sectional survey was completed by 140 clinical oncology trainees in September 2022. Trainees and trainers (17 and 6 respectively) from across England, Scotland, Wales and Northern Ireland, took part in focus group and interviews from August to December 2022. Quantitative and qualitative data merged and interpreted.

RESULT

Results showed international medical graduates and trainees from ethnic minority backgrounds were more likely to encounter challenges. The qualitative findings were used to identify three themes through which these problems could be framed. The trainee as a "space invader," the hidden curriculum of clinical oncology training and the process of navigating and tacking the training journey.

CONCLUSION

Differential attainment is the product of a complex interplay between the trainee, trainer, and the training environment. Therefore, interventions must be tailored to different people and contexts. At a national level, the RCR can adopt general policies to promote this such as mentorship programmes, protected time for supervision and cultural competency training. Efficacy of proposed interventions for trial and their impact on DA should be evaluated to drive evidence-based changes.

Validating a Four-gene Set for H-ARS Severity Prediction in Peripheral Blood Samples of Irradiated Rhesus Macaques

Increased radiological and nuclear threats require preparedness. Our earlier work identified a set of four genes (DDB2, FDXR, POU2AF1 and WNT3), which predicts severity of the hematological acute radiation syndrome (H-ARS) within the first three days postirradiation In this study of 41 Rhesus macaques (Macaca mulatta, 27 males, 14 females) irradiated with 5.8-7.2 Gy (LD29-50/60), including some treated with gamma-tocotrienol (GT3, a radiation countermeasure) we independently validated these genes as predictors in both sexes and examined them after three days. At the Armed Forces Radiobiology Research Institute/Uniformed Services University of the Health Sciences, peripheral whole blood (1 ml) of Rhesus macaques was collected into PAXgene® Blood RNA tubes pre-irradiation after 1, 2, 3, 35 and 60 days postirradiation, stored at -80°C for internal experimental analyses. Leftover tubes from these already ongoing studies were kindly provided to Bundeswehr Institute of Radiobiology. RNA was isolated (QIAsymphony), converted into cDNA, and for further gene expression (GE) studies quantitative RT-PCR was performed. Differential gene expression (DGE) was measured relative to the pre-irradiation Rhesus macaques samples. Within the first three days postirradiation, we found similar results to human data: 1. FDXR and DDB2 were up-regulated, FDXR up to 3.5-fold, and DDB2 up to 13.5-fold in the median; 2. POU2AF1 appeared down regulated around tenfold in nearly all Rhesus macaques; 3. Contrary to human data, DDB2 was more up-regulated than FDXR, and the difference of the fold change (FC) ranged between 2.4 and 10, while the median fold changes of WNT3, except days 1 and 35, were close to 1. Nevertheless, 46% of the Rhesus macaques showed down-regulated WNT3 on day one postirradiation, which decreased to 12.2% on day 3 postirradiation. Considering the extended phase, there was a trend towards decreased fold changes at day 35, with median-fold changes ranging from 0.7 for DDB2 to 0.1 for POU2AF1, and on day 60 postirradiation, DGE in surviving animals was close to pre-exposure values for all four genes. In conclusion, the diagnostic significance for radiation-induced H-ARS severity prediction of FDXR, DDB2, and POU2AF1 was confirmed in this Rhesus macaques model. However, DDB2 showed higher GE values than FDXR. As shown in previous studies, the diagnostic significance of WNT3 could not be reproduced in Rhesus macaques; this could be due to the choice of animal model and methodological challenges.

Validating Radiosensitivity with Pre-Exposure Differential Gene Expression in Peripheral Blood Predicting Survival and Non-Survival in a Second Irradiated Rhesus Macaque Cohort

Radiosensitivity differs in humans and possibly in closely related nonhuman primates. The reasons for variation in radiosensitivity are not well known. In an earlier study, we examined gene expression (GE) pre-radiation in peripheral blood among male (n = 62) and female (n = 60) rhesus macaques (n = 122), which did or did not survive (up to 60 days) after whole-body exposure of 7.0 Gy (LD66/60). Eight genes (CHD5, CHI3L1, DYSF, EPX, IGF2BP1, LCN2, MBOAT4, SLC22A4) revealed significant associations with survival. Access to a second rhesus macaque cohort (males = 40, females = 23, total n = 63) irradiated with 5.8-7.2 Gy (LD29-50/60) and some treated with gamma-tocotrienol (GT3, a radiation countermeasure) allowed us to validate these gene expression changes independently. Total RNA was isolated from whole blood samples and examined by quantitative RT-PCR on a 96-well format. cycle threshold (Ct)-values normalized to 18S rRNA were analyzed for their association with survival. Regardless of the species-specific TaqMan assay, similar results were obtained. Two genes (CHD5 and CHI3L1) out of eight revealed a significant association with survival in the second cohort, while only CHD5 (involved in DNA damage response and proliferation control) showed mean gene expression changes in the same direction for both cohorts. No expected association of CHD5 GE with dose, treatment, or sex could be established. Instead, we observed significant associations for those comparisons comprising pre-exposure samples with CHD5 Ct values ≤ 11 (total n = 17). CHD5 Ct values ≤ 11 in these comparisons were mainly associated with increased frequencies (61-100%) of non-survivors, a trend which depending on the sample numbers, reached significance (P = 0.03) in males and, accordingly, in females. This was also reflected by a logistic regression model including all available samples from both cohorts comprising CHD5 measurements (n = 104, odds ratio 1.38, 95% CI 1.07-1.79, P = 0.01). However, this association was driven by males (odds ratio 1.62, 95% CI 1.10-2.38, P = 0.01) and CHD5 Ct values ≤ 11 since removing low CHD5 Ct values from this model, converted to insignificance (P = 0.19). A second male subcohort comprising high CHD5 Ct values ≥ 14.4 in both cohorts (n = 5) appeared associated with survival. Removing these high CHD5 Ct values converted the model borderline significant (P = 0.051). Based on the probability function of the receiver operating characteristics (ROC) curves, 8 (12.3%) and 5 (7.7%) from 65 pre-exposure RNA measurements in males, death and survival could be predicted with a negative and positive predictive value ranging between 85-100%. An associated odds ratio reflected a 62% elevated risk for dying or surviving per unit change (Ct-value) in gene expression, considering the before-mentioned CHD5 thresholds in RNA copy numbers. In conclusion, we identified two subsets of male animals characterized by increased (Ct values ≤ 11) and decreased (Ct values ≥ 14.4) CHD5 GE copy numbers before radiation exposure, which independently of the cohort, radiation exposure or treatment appeared to predict the death or survival in males.

Development of a Point-of-Care Microfluidic RNA Extraction Slide for Gene Expression Diagnosis after Irradiation

In times of war, radiological/nuclear emergency scenarios have become a reemphasized threat. However, there are challenges in transferring whole-blood samples to laboratories for specialized diagnostics using RNA. This project aims to miniaturize the process of unwieldy conventional RNA extraction with its stationed technical equipment using a microfluidic-based slide (MBS) for point-of-care diagnostics. The MBS is thought to be a preliminary step toward the development of a so-called lab-on-a-chip microfluidic device. A MBS would enable early and fast field care combined with gene expression (GE) analysis for the prediction of hematologic acute radiation syndrome (HARS) severity or identification of RNA microbes. Whole blood samples from ten healthy donors were irradiated with 0, 0.5 and 4 Gy, simulating different ARS severity degrees. RNA quality and quantity of a preliminary MBS was compared with a conventional column-based (CB) RNA extraction method. GE of four HARS severity-predicting radiation-induced genes (FDXR, DDB2, POU2AF1 and WNT3) was examined employing qRT-PCR. Compared to the CB method, twice as much total RNA from whole blood could be extracted using the MBS (6.6 ± 3.2 µg vs. 12.0 ± 5.8 µg) in half of the extraction time, and all MBS RNA extracts appeared DNA-free in contrast to the CB method (30% were contaminated with DNA). Using MBS, RNA quality [RNA integrity number equivalent (RINe)] values decreased about threefold (3.3 ± 0.8 vs. 9.0 ± 0.4), indicating severe RNA degradation, while expected high-quality RINe ≥ 8 were found using column-based method. However, normalized cycle threshold (Ct) values, as well as radiation-induced GE fold-changes appeared comparable for all genes utilizing both methods, indicating that no RNA degradation took place. In summary, the preliminary MBS showed promising features such as: 1. halving the RNA extraction time without the burden of heavy technical equipment (e.g., a centrifuge); 2. absence of DNA contamination in contrast to CB RNA extraction; 3. reduction in blood required, because of twice the biological output of RNA; and 4. equal GE performance compared to CB, thus, increasing its appeal for later semi-automatic parallel field applications.

Applicability of Gene Expression in Saliva as an Alternative to Blood for Biodosimetry and Prediction of Radiation-induced Health Effects

As the great majority of gene expression (GE) biodosimetry studies have been performed using blood as the preferred source of tissue, searching for simple and less-invasive sampling methods is important when considering biodosimetry approaches. Knowing that whole saliva contains an ultrafiltrate of blood and white blood cells, it is expected that the findings in blood can also be found in saliva. This human in vivo study aims to examine radiation-induced GE changes in saliva for biodosimetry purposes and to predict radiation-induced disease, which is yet poorly characterized. Furthermore, we examined whether transcriptional biomarkers in blood can also be found equivalently in saliva. Saliva and blood samples were collected in parallel from radiotherapy (RT) treated patients who suffered from head and neck cancer (n = 8) undergoing fractioned partial-body irradiations (1.8 Gy/fraction and 50-70 Gy total dose). Samples were taken 12-24 h before first irradiation and ideally 24 and 48 h, as well as 5 weeks after radiotherapy onset. Due to the low quality and quantity of isolated RNA samples from one patient, they had to be excluded from further analysis, leaving a total of 24 saliva and 24 blood samples from 7 patients eligible for analysis. Using qRT-PCR, 18S rRNA and 16S rRNA (the ratio being a surrogate for the relative human RNA/bacterial burden), four housekeeping genes and nine mRNAs previously identified as radiation responsive in blood-based studies were detected. Significant GE associations with absorbed dose were found for five genes and after the 2nd radiotherapy fraction, shown by, e.g., the increase of CDKN1A (2.0 fold, P = 0.017) and FDXR (1.9 fold increased, P = 0.002). After the 25th radiotherapy fraction, however, all four genes (FDXR, DDB2, POU2AF1, WNT3) predicting ARS (acute radiation syndrome) severity, as well as further genes (including CCNG1 [median-fold change (FC) = 0.3, P = 0.013], and GADD45A (median-FC = 0.3, P = 0.031)) appeared significantly downregulated (FC = 0.3, P = 0.01-0.03). A significant association of CCNG1, POU2AF1, HPRT1, and WNT3 (P = 0.006-0.04) with acute or late radiotoxicity could be shown before the onset of these clinical outcomes. In an established set of four genes predicting acute health effects in blood, the response in saliva samples was similar to the expected up- (FDXR, DDB2) or downregulation (POU2AF1, WNT3) in blood for up to 71% of the measurements. Comparing GE responses (PHPT1, CCNG1, CDKN1A, GADD45A, SESN1) in saliva and blood samples, there was a significant linear association between saliva and blood response of CDKN1A (R2 = 0.60, P = 0.0004). However, the GE pattern of other genes differed between saliva and blood. In summary, the current human in vivo study, (I) reveals significant radiation-induced GE associations of five transcriptional biomarkers in salivary samples, (II) suggests genes predicting diverse clinical outcomes such as acute and late radiotoxicity as well as ARS severity, and (III) supports the view that blood-based GE response can be reflected in saliva samples, indicating that saliva is a "mirror of the body" for certain but not all genes and, thus, studies for each gene of interest in blood are required for saliva.

PUM1 and PGK1 are Favorable Housekeeping Genes over Established Biodosimetry-related Housekeeping Genes such as HPRT1, ITFG1, DPM1, MRPS5, 18S rRNA and Others after Radiation Exposure

In gene expression (GE) studies, housekeeping genes (HKGs) are required for normalization purposes. In large-scale inter-laboratory comparison studies, significant differences in dose estimates are reported and divergent HKGs are employed by the teams. Among them, the 18S rRNA HKG is known for its robustness. However, the high abundance of 18S rRNA copy numbers requires dilution, which is time-consuming and a possible source of errors. This study was conducted to identify the most promising HKGs showing the least radiation-induced GE variance after radiation exposure. In the screening stage of this study, 35 HKGs were analyzed. This included selected HKGs (ITFG1, MRPS5, and DPM1) used in large-scale biodosimetry studies which were not covered on an additionally employed pre-designed 96-well platform comprising another 32 HKGs used for different exposures. Altogether 41 samples were examined, including 27 ex vivo X-ray irradiated blood samples (0, 0.5, 4 Gy), six X-irradiated samples (0, 0.5, 5 Gy) from two cell lines (U118, A549), as well as eight non-irradiated tissue samples to encompass multiple biological entities. In the independent validation stage, the most suitable candidate genes were examined from another 257 blood samples, taking advantage of already stored material originating from three studies. These comprise 100 blood samples from ex vivo X-ray irradiated (0-4 Gy) healthy donors, 68 blood samples from 5.8 Gy irradiated (cobalt-60) Rhesus macaques (RM) (LD29/60) collected 0-60 days postirradiation, and 89 blood samples from chemotherapy-(CTx) treated breast tumor patients. CTx and radiation-induced GE changes in previous studies appeared comparable. RNA was isolated, converted into cDNA, and GE was quantified employing TaqMan assays and quantitative RT-PCR. We calculated the standard deviation (SD) and the interquartile range (IQR) as measures of GE variance using raw cycle threshold (Ct) values and ranked the HKGs accordingly. Dose, time, age, and sex-dependent GE changes were examined employing the parametrical t-test and non-parametrical Kruskal Wallis test, as well as linear regression analysis. Generally, similar ranking results evolved using either SD or IQR GE measures of variance, indicating a tight distribution of GE values. PUM1 and PGK1 showed the lowest variance among the first ten most suitable genes in the screening phase. MRPL19 revealed low variance among the first ten most suitable genes in the screening phase only for blood and cells, but certain comparisons indicated a weak association of MRPL19 with dose (P = 0.02-0.09). In the validation phase, these results could be confirmed. Here, IQR Ct values from, e.g., X-irradiated blood samples were 0.6 raw Ct values for PUM1 and PGK1, which is considered to represent GE differences as expected due to methodological variance. Overall, when compared, the GE variance of both genes was either comparable or lower compared to 18S rRNA. Compared with the IQR GE values of PUM1 and PGKI, twofold-fivefold increased values were calculated for the biodosimetry HKG HPRT1, and comparable values were calculated for biodosimetry HKGs ITFG1, MRPS5, and DPM1. Significant dose-dependent associations were found for ITFG1 and MRPS5 (P = 0.001-0.07) and widely absent or weak (P = 0.02-0.07) for HPRT1 and DPM1. In summary, PUM1 and PGK1 appeared most promising for radiation exposure studies among the 35 HKGs examined, considering GE variance and adverse associations of GE with dose.

An updated systematic review and meta-analysis of randomised controlled trials on the effects of urate-lowering therapy initiation during a gout flare

BACKGROUND

There is uncertainty about the optimal time to start urate-lowering therapy (ULT) in the setting of a gout flare. The aim was to perform a systematic review and meta-analysis of randomised controlled trials (RCTs) assessing the effects of ULT initiation during a gout flare.

METHODS

This systematic review was conducted in accordance with PRISMA methodology. MEDLINE, EMBASE and The Cochrane Library were searched for studies published between database inception to 1 March 2023. RCTs published in English that examined ULT initiation during a gout flare in adults ≥18 years were included. The quality of included studies was assessed using the revised Cochrane Risk of Bias tool 2.0. Data were extracted for the following outcomes: patient-rated pain score, duration of gout flare, recurrent gout flares, time to achieve target serum urate, adherence to ULT, patient satisfaction with treatment and adverse events. Meta-analyses were performed using Review Manager v5.4. This study is registered on PROSPERO, number CRD42023404680.

RESULTS

A total of 972 studies were identified and of these, six RCTs met the criteria for inclusion in the analysis. Three studies were assessed as having high risk of bias, one study as having some concerns, and two studies as having low risk of bias. In total, there were 445 pooled participants; 226 participants randomised to early initiation of ULT and 219 to placebo or delayed initiation of ULT. Allopurinol was used in three studies, febuxostat in two studies and probenecid in one study. Few participants (n = 62, 13.9 %) had tophaceous gout. Participants with renal impairment were excluded from most studies. There were no differences in patient-rated pain scores at baseline, days 3-4, days 7-8, day 10 or days 14-15 (p ≥ 0.42). Additionally, there was no significant difference in time to resolution of gout flare (standardised mean difference 0.77 days; 95 % CI -0.26 to 1.79; p = 0.14) or the risk of recurrent gout flare in the subsequent 28 to 30 days (RR 1.06; 95 % CI 0.59 to 1.92; p = 0.84). Adverse events were similar between groups. The included studies did not report time to achieve target serum urate, long-term adherence to ULT, or patient satisfaction with treatment.

CONCLUSION

There appears to be no evidence for harm or for benefit to initiating ULT during a gout flare. These findings have limited applicability to patients with tophaceous gout, or those with renal impairment.

Virtual Reality for Pain Management During High-Resolution Manometry: A Randomized Clinical Trial

OBJECTIVE

High-resolution esophageal manometry (HRM) is the gold standard for the diagnosis of esophageal motility disorders. HRM is typically performed in the office with local anesthesia only, and many patients find it unpleasant and painful. The aim of this study was to examine the effects of the use of a virtual reality (VR) headset on pain and anxiety outcomes in patients with dysphagia undergoing HRM.

METHODS

Patients with dysphagia were prospectively recruited and randomized to undergo HRM with and without VR distraction. Data collected included the State-Trait Anxiety Inventory-6 (STAI-6), the Short-Form McGill Pain Questionnaire, heart rate, and galvanic skin response (GSR) tracings.

RESULTS

Forty subjects completed the study, including 20 subjects in the intervention arm and 20 in the control arm. There was evidence of a significant positive effect of VR on calmness (p = 0.0095) STAI-6 rating, as well as on physiologic measures of pain with significantly decreased GSR rise time (p = 0.0137) and average rate of change of conductance change (p = 0.0035).

CONCLUSION

The use of VR during HRM catheter insertion increased calmness compared to control. Change of skin conductance was also reduced in the VR group, suggesting decreased physiologic pain. This study supports the consideration of the use of VR as a distraction tool to improve patient comfort during HRM.

LEVEL OF EVIDENCE

2 Laryngoscope, 134:1118-1126, 2024.

Do Dynamic Plantar Pressures Differ Based on Sonographic Evidence of Metatarsophalangeal Joint Synovitis in People With Rheumatoid Arthritis?

OBJECTIVE

The metatarsophalangeal joints (MTPJs) are the most common location for synovitis in people with rheumatoid arthritis (RA), yet their association with plantar foot pressures has received very little attention. This study aimed to determine whether plantar pressures differed based on sonographic evidence of MTPJ synovitis in people with RA.

METHOD

Ultrasound was used to assess synovitis (grey scale synovial hypertrophy and power Doppler signal) in MTPJs 1 to 5 using the combined EULAR/Outcome Measures in Rheumatology scoring system. Peak pressure (PP) and pressure time integrals (PTIs) were assessed during barefoot walking for seven plantar foot regions (heel, midfoot, first metatarsal, second metatarsal, third to fifth metatarsals, hallux, lesser toes). Mixed-effects linear regression was used to determine the difference in PP and PTI between MTPJs with none/minimal synovitis and MTPJs with moderate/severe synovitis.

RESULTS

Thirty-five participants with RA were included. Mean age was 66.3 years and mean disease duration was 22.2 years. Participants with sonographic evidence of moderate/severe synovitis at the first MTPJ had reduced PTI at the hallux compared with those with none/minimal synovitis at this joint (P = 0.039). Participants with moderate/severe synovitis at the second MTPJ and fourth MTPJ had reduced PP and reduced PTI at lesser toes compared with those with none/minimal synovitis in these joints (all P ≤ 0.048). No significant differences were observed for synovitis in other joints.

CONCLUSION

These findings may be suggestive of an inverse relationship between plantar pressure and soft tissue pathology, which is consistent with an offloading strategy and reduced use of the toes during propulsion.

Improving the capacity of researchers and bereaved parents to co-design and translate stillbirth research together

BACKGROUND

Working with bereaved parents in co-designed stillbirth research, policy and practice is essential to improving care and outcomes.

PROBLEM

Effective parent engagement is often lacking. This may be due to bereaved parents not feeling adequately and appropriately supported to be involved.

AIM

To consult bereaved parents with the aim to understand their experiences, attitudes, and needs around involvement in stillbirth research and gain feedback about the usefulness and appropriateness of a proposed co-designed guide to support their involvement, including content and design aspects of this resource.

METHODS

An online co-designed survey was disseminated via Australian parent support organisations social media in August 2022.

FINDINGS

All 90 respondents were bereaved parents, 94% (n = 85) were female. Two-thirds (67%, n = 60) had never participated in stillbirth research, 80% (n = 72) agreed involvement of bereaved parents in research was important or extremely important and 81% (n = 73) were interested in future research involvement. Common motivations for involvement were wanting to leave a legacy for their baby and knowing research outcomes. Common barriers included not having been asked to participate or not knowing how. Most (89%, n = 80) agreed the proposed guide would be useful. Highly valued topics were the importance of bereaved parents' voices in stillbirth research and how they can make a difference.

CONCLUSION

The majority of bereaved parents we surveyed want to be involved in stillbirth research and would value a resource to support this. The proposed concept and content for a co-designed guide to aid engagement was well supported.

Time-Series Analysis of First-Time Pediatric Speech Delays From 2018 to 2022

This cohort study evaluates changes in pediatric speech delay diagnoses before and after the COVID-19 pandemic.

Vesiclepedia 2024: an extracellular vesicles and extracellular particles repository

Vesiclepedia (http://www.microvesicles.org) is a free web-based compendium of DNA, RNA, proteins, lipids and metabolites that are detected or associated with extracellular vesicles (EVs) and extracellular particles (EPs). EVs are membranous vesicles that are secreted ubiquitously by cells from all domains of life from archaea to eukaryotes. In addition to EVs, it was reported recently that EPs like exomeres and supermeres are secreted by some mammalian cells. Both EVs and EPs contain proteins, nucleic acids, lipids and metabolites and has been proposed to be implicated in several key biological functions. Vesiclepedia catalogues proteins, DNA, RNA, lipids and metabolites from both published and unpublished studies. Currently, Vesiclepedia contains data obtained from 3533 EV studies, 50 550 RNA entries, 566 911 protein entries, 3839 lipid entries, 192 metabolite and 167 DNA entries. Quantitative data for 62 822 entries from 47 EV studies is available in Vesiclepedia. The datasets available in Vesiclepedia can be downloaded as tab-delimited files or accessible through the FunRich-based Vesiclepedia plugin.

Prognostic factors and outcome in cats with thymic epithelial tumours: 64 cases (1999-2021)

OBJECTIVES

To describe the clinical presentation, treatment and outcomes of cats diagnosed with thymic epithelial tumours and to determine prognostic factors for survival and recurrence.

MATERIALS AND METHODS

Clinical records of cats diagnosed with a thymic epithelial tumour between 1999 and 2021 at three referral institutions were retrospectively reviewed.

RESULTS

Sixty-four cats were included. Paraneoplastic syndromes were present in nine cats and metastatic disease was seen in two cats, one at diagnosis and one at the time of recurrence. Median tumour diameter was 6 cm (range, 2 to 15) and a cystic appearance was described on imaging in 25 cats. Surgical excision was attempted in 54 cats with a perioperative mortality rate of 11%. Median survival time for cats surviving to hospital discharge was 897 days (range, 21 to 3322). The 1-, 2- and 5-year survival rates for surgically treated thymic epithelial tumour were 86%, 70% and 66%, respectively. Survival was longer for cats with Masaoka-Koga stage I and II tumours compared to stages III and IV (1366 days versus 454 days; P=0.002). Masaoka-Koga stage was the only significant prognostic factor detected on multi-variable analysis, with stage III and IV tumours associated with increased risk of death (hazard ratio: 5.67, 95% confidence interval: 1.29 to 24.91, P=.021). Tumour recurrence occurred in 11 cats at a median of 564 days (range, 93 to 1095); no significant prognostic factors for recurrence were identified.

CLINICAL SIGNIFICANCE

Cats with thymic epithelial tumours had a good long-term prognosis following surgery. Tumour recurrence can occur late in the disease course and ongoing monitoring should therefore be considered. Masaoka-Koga stage may influence survival time and could be used to predict outcome.

The statistical challenge of analysing changes in dual energy computed tomography (DECT) urate volumes in people with gout

BACKGROUND

Dual energy computed tomography (DECT) allows direct visualization of monosodium urate crystal deposition in gout. However, DECT urate volume data are often highly skewed (mostly small volumes with the remainder considerably larger), making statistical analyses challenging in longitudinal research. The aim of this study was to explore the ability of various analysis methods to normalise DECT urate volume data and determine change in DECT urate volumes over time.

METHODS

Simulated datasets containing baseline and year 1 DECT urate volumes for 100 people with gout were created from two randomised controlled trials. Five methods were used to transform the DECT urate volume data prior to analysis: log-transformation, Box-Cox transformation, log(X-(min(X)-1)) transformation; inverse hyperbolic sine transformation, and rank order. Linear regression analyses were undertaken to determine the change in DECT urate volume between baseline and year 1. Cohen's d were calculated as a measure of effect size for each data treatment method. These analyses were then tested in a validation clinical trial dataset containing baseline and year 1 DECT urate volumes from 91 people with gout.

RESULTS

No data treatment method successfully normalised the distribution of DECT urate volumes. For both simulated and validation data sets, significant reductions in DECT urate volumes were observed between baseline and Year 1 across all data treatment methods and there were no significant differences in Cohen's d effect sizes.

CONCLUSIONS

Normalising highly skewed DECT urate volume data is challenging. Adopting commonly used transformation techniques may not significantly improve the ability to determine differences in measures of central tendency when comparing the change in DECT urate volumes over time.

Major Fusarium species and mycotoxins associated with freshly harvested maize grain in Uruguay

Fusarium species are common fungal pathogens of maize. Fusarium graminearum and Fusarium verticillioides, among others, can cause maize ear rot, and they are also mycotoxin producers. The aims of this work were to determine the frequency and diversity of Fusarium species in Uruguayan maize kernels, evaluate the toxigenic potential of the isolates, determine toxin contamination levels on freshly harvested grain, and assess the sensitivity of main Fusarium species against fungicides. Fusarium verticillioides was the most frequent species isolated, followed by Fusarium graminearum sensu stricto. Of F. verticillioides isolates studied for fumonisin production, 72% produced fumonisin B1 and 32% fumonisin B2. Considering in vitro toxin production by F. graminearum sensu stricto isolates, deoxynivalenol was the main toxin produced, followed by zearalenone and nivalenol. Fumonisins were the most frequently found toxins on freshly harvested maize samples (98% in 2018 and 86% in 2019), and also, fumonisin B1 was the toxin with highest concentration in both years studied (4860 µg/kg in 2018 and 1453 µg/kg in 2019). Deoxynivalenol and zearalenone were also found as contaminants. Metconazole and epoxiconazole were the most effective fungicides tested on F. verticillioides isolates. Fusarium graminearum sensu stricto isolates also were more sensitive to metconazole compared to other fungicides; nevertheless, epoxiconazole was less efficient in controlling this species. This is the first study that reports Fusarium species and mycotoxin contamination levels associated with maize grain in Uruguay. Its detection is the main step to develop management strategies in order to minimize fungal infection in maize crops.

Evaluating the effect of child home safety training upon three family support practitioner groups: a mixed-methods study

AIMS

Unintentional injuries in the home contribute substantially to preschool child morbidity and mortality. Practitioners such as health visitors, family mentors and children's centre staff are well-positioned to facilitate child injury prevention by providing home safety advice to families, and training may enhance their ability to do so. We aimed to assess the impact of child home safety training for these practitioners.

METHODS

An explanatory mixed-methods design was used. Practitioners completed questionnaires before, and up to 7 months after, receiving child home safety training and took part in interviews. Seventy-eight health visitors, 72 family mentors and 11 children's centre staff members completed questionnaires. Items were used to calculate scores on home safety knowledge, confidence to provide home safety advice and belief that child home safety promotion is important. Thematic analysis of interviews with seven health visitors and nine family mentors, open-ended responses to the questionnaires and an additional evaluation form was conducted to explore attendees' perceptions of the training and its impact. In addition, seven health visitors and six children's centre staff who had received no training were interviewed.

RESULTS

Knowledge was greater post-training than pre-training across all participants (p < .001). When practitioner groups were analysed separately, there were significant increases in family mentors' knowledge (p < .001) and belief (p = .016), and health visitors' confidence (p = .0036). Qualitative findings indicated that most training session attendees valued the training, believed their practice relating to child home safety had improved as a result, and felt further similar training sessions would be beneficial. Those who had not attended the sessions described a need for more child home safety training.

CONCLUSIONS

Delivering training to practitioners providing child home safety promotion to families with preschool children can enhance injury prevention knowledge, beliefs and confidence and positively impact on home safety promotion by practitioners.

The Patient Experience of Gout Remission: A Qualitative Study

OBJECTIVE

Preliminary remission criteria for gout have been developed. However, the patient experience of gout remission has not been described. This qualitative study aimed to understand the patient experience of gout remission and views about the preliminary gout remission criteria.

METHODS

Semistructured interviews were conducted. All participants had gout, had not had a gout flare in the preceding 6 months, and were on urate-lowering medication. Participants were asked to discuss their experience of gout remission and views about the preliminary remission criteria. Interviews were audio recorded and transcribed verbatim. Data were analyzed using a reflexive thematic approach.

RESULTS

Twenty participants with gout (17 male participants, median age 63 years) were interviewed. Four key themes of the patient experience of remission were identified: 1) minimal or no gout symptoms (absence of pain due to gout flares, good physical function, smaller or no tophi), 2) freedom from dietary restrictions, 3) gout is "not on the mind", and 4) multifaceted management strategies to maintain remission (regular urate-lowering therapy, exercise, healthy eating). Participants believed that the preliminary remission criteria contained all relevant domains but considered that the pain and patient global assessment domains overlapped with the gout flares domain. Participants regarded 12 months as a more suitable time frame than 6 months to measure remission.

CONCLUSION

Patients experience gout remission as a return to normality with minimal or no gout symptoms, dietary freedom, and absence of mental load. Patients use a range of management strategies to maintain gout remission.

Variability of toe pressures during haemodialysis: comparison of people with and without diabetes; a pilot study

BACKGROUND

Diabetes, end stage renal disease (ESRD), and peripheral arterial disease (PAD) are associated with a higher risk of diabetes-related lower limb amputation. Timely identification of PAD with toe systolic blood pressure (TSBP) and toe-brachial pressure index (TBPI) is critical in order to implement foot protection strategies to prevent foot complications in people with ESRD. There is limited evidence describing the effect of haemodialysis on TSBP and TBPI. This study aimed to determine the variability of TSBP and TBPI during haemodialysis in people with ESRD, and to determine whether any observed variability differed between people with and without diabetes.

METHODS

TSBP and TBPI were taken before dialysis (T1), one hour into dialysis (T2) and in the last 15 min of dialysis (T3) during a single dialysis session. Linear mixed effects models were undertaken to determine the variability in TSBP and TBPI across the three time points and to determine whether this variability differed between people with and without diabetes.

RESULTS

Thirty participants were recruited, including 17 (57%) with diabetes and 13 (43%) with no diabetes. A significant overall reduction in TSBP was observed across all participants (P < 0.001). There was a significant reduction in TSBP between T1 and T2 (P < 0.001) and between T1 and T3 (P < 0.001). There was no significant overall change in TBPI over time (P = 0.62). There was no significant overall difference in TSBP between people with diabetes and people with no diabetes (mean difference [95% CI]: -9.28 [-40.20, 21.64], P = 0.54). There was no significant overall difference in TBPI between people with diabetes and people with no diabetes (mean difference [95% CI]: -0.01 [-0.17, 03.16], P = 0.91).

CONCLUSION

TSBP and TBPI are an essential part of vascular assessment of the lower limb. TBPI remained stable and TSBP significantly reduced during dialysis. Given the frequency and duration of dialysis, clinicians taking toe pressures to screen for PAD should be aware of this reduction and consider how this may have an impact on wound healing capacity and the development of foot related complications.

Microwave therapy for the treatment of plantar warts

BACKGROUND

Plantar warts, or verrucae plantaris, are common lesions causing considerable pain during weightbearing activity. Although current treatment modalities have low success rates, microwave therapy has been introduced as a promising intervention. This study aimed to determine the effectiveness of microwave therapy for the treatment of plantar warts and to determine the clinical factors associated with plantar wart resolution.

METHODS

A retrospective analysis of 150 plantar warts from 45 patients treated with microwave therapy was undertaken. Binomial regression was conducted to explore clinical characteristics (age, gender, immunosuppression, impaired healing, multiple vs single wart, location of lesion, lesion diameter) associated with lesion resolution.

RESULTS

Of the total 150 plantar warts treated with microwave therapy, 125 (83.3%) warts resolved and 25 (17%) warts did not resolve. The mean (SD) total treatment sessions for resolved lesions was 2.8 (1.0). Decreasing age (P = 0.046) was the only clinical characteristic associated with resolution.

CONCLUSIONS

This retrospective study has shown that plantar warts may be resolved with two to three sessions of microwave therapy, which may be more successful in younger populations.

Proteomic analysis of the small extracellular vesicles and soluble secretory proteins from cachexia inducing and non-inducing cancer cells

Cancer cachexia is a wasting syndrome characterised by the loss of fat and/or muscle mass in advanced cancer patients. It has been well-established that cancer cells themselves can induce cachexia via the release of several pro-cachectic and pro-inflammatory factors. However, it is unclear how this process is regulated and the key cachexins that are involved. In this study, we validated C26 and EL4 as cachexic and non-cachexic cell models, respectively. Treatment of adipocytes and myotubes with C26 conditioned medium induced lipolysis and atrophy, respectively. We profiled soluble secreted proteins (secretome) as well as small extracellular vesicles (sEVs) released from cachexia-inducing (C26) and non-inducing (EL4) cancer cells by label-free quantitative proteomics. A total of 1268 and 1022 proteins were identified in the secretome of C26 and EL4, respectively. Furthermore, proteomic analysis of sEVs derived from C26 and EL4 cancer cells revealed a distinct difference in the protein cargo. Functional enrichment analysis using FunRich highlighted the enrichment of proteins that are implicated in biological processes such as muscle atrophy, lipolysis, and inflammation in both the secretome and sEVs derived from C26 cancer cells. Overall, our characterisation of the proteomic profiles of the secretory factors and sEVs from cachexia-inducing and non-inducing cancer cells provides insights into tumour factors that promote weight loss by mediating protein and lipid loss in various organs and tissues. Further investigation of these proteins may assist in highlighting potential therapeutic targets and biomarkers of cancer cachexia.

Gout Remission as a Goal of Urate-Lowering Therapy: A Critical Review

Urate-lowering therapies for the management of gout lead to a reduction in serum urate levels, monosodium urate crystal deposition, and the clinical features of gout, including painful and disabling gout flares, chronic gouty arthritis, and tophi. Thus, disease remission is a potential goal of urate-lowering therapy. In 2016, preliminary gout remission criteria were developed by a large group of rheumatologists and researchers with expertise in gout. The preliminary gout remission criteria were defined as: serum urate < 0.36 mmol/L (6 mg/dL); an absence of gout flares; an absence of tophi; pain due to gout < 2 on a 0-10 scale; and a patient global assessment < 2 on a 0-10 scale over a 12-month period. In this critical review, we describe the development of the preliminary gout remission criteria, the properties of the preliminary gout remission criteria, and clinical studies of gout remission in people taking urate-lowering therapy. We also describe a future research agenda for gout remission.

The assessment and management of sesamoiditis: a focus group study of podiatrists in Aotearoa New Zealand

BACKGROUND

Sesamoiditis is a common inflammatory condition affecting the sesamoid bones at the plantar aspect of the first metatarsophalangeal joint (1MTPJ). However, there are currently no recommendations or clinical guidelines to support podiatrists in their assessment or management of sesamoiditis. The aim of this study was to explore the views of podiatrists in Aotearoa New Zealand on their approaches to the assessment and management of patients with sesamoiditis.

METHODS

This qualitative study included focus group discussions with registered podiatrists. Focus groups took place online via Zoom and were guided by a detailed focus group question schedule. The questions were designed to encourage discussion around assessment approaches used in the diagnosis of sesamoiditis and the treatment tools used to manage patients with sesamoiditis. Focus groups were audio-recorded and transcribed verbatim. Reflexive thematic analysis was used to analyse the data.

RESULTS

A total of 12 registered podiatrists participated in one of three focus groups. Four themes were constructed relating to the assessment of sesamoiditis: (1) obtaining a patient history; (2) recreating patient symptoms; (3) determining contributing biomechanical factors; and (4) ruling out differential diagnoses. Seven themes were constructed relating to the management of sesamoiditis: (1) consideration of patient factors; (2) patient education; (3) cushioning of the sesamoids to allow more comfortable weightbearing of the 1MTPJ; (4) pressure redistribution and offloading of the sesamoids; (5) immobilisation of the 1MTPJ and sesamoids; (6) facilitating efficient sagittal plane motion during gait; (7) referring to other health professionals to find different ways to treat or manage patient symptoms.

CONCLUSION

Podiatrists in Aotearoa New Zealand demonstrate an analytical approach in the assessment and management of patients with sesamoiditis based on their clinical experience and knowledge of lower limb anatomy. A range of assessment and management techniques are selected based on the practitioners personal preferences, as well as the patient's social factors, symptomology, and lower limb biomechanics.

Changes in Minoxidil Prescribing After Media Attention About Oral Use for Hair Loss

This cross-sectional study investigates rates of prescription of low-dose minoxidil after of publication of a newspaper article on this treatment.

Patient-perceived and practitioner-perceived barriers to accessing foot care services for people with diabetes mellitus: a systematic literature review

BACKGROUND

Foot-related complications are common in people with diabetes mellitus, however foot care services are underutilized by this population. This research aimed to systematically review the literature to identify patient and practitioner-perceived barriers to accessing foot care services for people with diabetes.

METHODS

PRISMA guidelines were used to inform the data collection and extraction methods. CINAHL, MEDLINE, and Scopus databases were searched in March 2022 to identify original research articles that reported on barriers to accessing diabetes foot care services from the patient and/or practitioner perspective. Both quantitative and qualitative studies were included. The methodological quality of included studies was assessed using the Critical Appraisal Skills Program (CASP) tool for qualitative/mixed methods studies or the National Heart, Lung & Blood Institute (NHLBI) tool for quantitative studies. Following data extraction, content analysis was used to identify reported barriers. Themes and subthemes were presented separately for patient-perspectives and practitioner-perspectives. A narrative summary was used to synthesize the findings from the included studies.

RESULTS

A total of 20 studies were included. The majority of CASP and NHLBI criteria were met by most studies, indicating good overall methodological quality. Three predominant themes emerged from the patient perspective that represented barriers to accessing foot care services: lack of understanding, socioeconomic factors, and lack of service availability. Four themes emerged from the practitioner perspective: poor interprofessional communication, lack of resources, lack of practitioner knowledge, and perceived patient factors.

CONCLUSIONS

This study has identified a number of barriers to accessing foot care services from both the patient and practitioner perspectives. Although patients focused predominantly on patient-level factors, while practitioners focused on barriers related to the health care system, there was some overlap between them. This emphasizes the importance of recognising both perspectives for the future integration of policy changes and access facilitators that may help to overcome these barriers.

Design study of an edge current density diagnostic using new high-performance single-channel beam emission spectrometers at DIII-D

A novel Motional Stark Effect spectroscopy system has been designed for application at the DIII-D tokamak. The system is optimized for studies of the poloidal and toroidal magnetic field in the plasma pedestal region with frame rates of up to 10 kHz. Light from an existing high-photon-throughput collection lens is analyzed using four single-channel f/2.8 Czerny-Turner spectrometers that use custom-made lens systems instead of mirrors. Each spectrometer has two separate outgoing legs and is operated in a positive grating order, which allows for simultaneous observations of D-alpha and D-beta spectra. Forward modeling using the code FIDASIM shows a radial resolution of the system close to 0.6 cm and sufficiently good spectral resolution when masking the high throughput light collection lens in the horizontal direction to avoid overly strong Doppler broadening of beam emission lines. Moreover, a detailed sensitivity study considering realistic levels of readout and photon noise shows that the poloidal and toroidal magnetic field strengths can be inferred with an uncertainty of less than 1%, which will allow the inference of changes of the plasma current during transient events.

Incident pulmonary hypertension in 13,448 cases investigated with repeat echocardiography: insight from the National Echo Database of Australia (NEDA)

Background

We addressed the paucity of data describing the characteristics and natural history of incident pulmonary hypertension (PHT).

Methods

In this observational clinical cohort study, we examined 85,173 individuals undergoing routine echocardiography for heart disease without evidence of PHT (according to estimated right ventricular systolic pressure, eRVSP &lt;30 mmHg). Subsequent age and sex-specific incidence of PHT were derived from repeat echocardiograms conducted a median of 3.43 (interquartile range, IQR 1.49 to 6.55) years apart in 13,448 adults. Progressive PHT severity with individual data linkage to all-cause mortality were examined per PHT stage: eRVSP 30–39 mmHg (mild PHT), 40–49 mmHg (moderate PHT) and ≥50 mmHg (severe PHT).

Results

A total of 6,169 men (45.9%, mean age 61.4±16.7 years) and 7,279 women (60.8±16.9 years) with no initial evidence of PHT were identified (first echocardiogram). Subsequently, 5,412 (40.2%,) developed PHT (repeat echocardiogram) – comprising 4,125 (30.7%, 65.0±14.3 years), 928 (6.9%, 69.2±13.5 years), and 359 (2.7%, 69.8±12.7 years) cases of mild, moderate, and severe PHT, respectively. The incidence of all stages of PHT was 15.2 cases per million men/annum and 12.5 cases per million women/annum. Overall, median eRVSP increased by +7.4 (IQR +4.6 to +10.1) and +30.7 (IQR +26.0 to +37.3) mmHg; median E:e' ratio increased by +1.0 (IQR −0.4 to +3.2) and +3.6 (IQR +2.0 to +8.2); and median LA volume increased by +5.0 (IQR +0.0 to +12.0) and +19.5 (IQR +9.0 to +31.0) ml/m2, respectively, in mild and severe PHT groups between first and last echocardiograms. During subsequent median 8.1 years follow-up, 2,776/13,448 (20.6%) individuals died from all-cause. Compared to no PHT, the age- and sex-adjusted hazard ratios for all-cause mortality increased to 1.35 (95% confidence interval, CI 1.23–1.47) in mild PHT, 1.94 (95% CI 1.73–2.18) in moderate PHT, and 2.43 (95% CI 2.09–2.83) in severe PHT (all p&lt;0.001).

Conclusions

New onset of PHT is a common finding among individuals with heart disease followed-up with echocardiography. Even milder stage of PHT is associated with higher mortality, reinforcing the need for proactive evaluation for symptoms consistent with PHT.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Johnson & Johnson: Investigator-initiated grant

Impact of time from symptom onset on the diagnostic performance of high-sensitivity cardiac troponin for type 1 myocardial infarction

Background

High-sensitivity cardiac troponin has enabled the rapid rule-out and rule-in of myocardial infarction at presentation. However, increases in cardiac troponin may not be detectable early after symptom onset, and uncertainty remains as to how time of symptom onset influences diagnostic performance.

Purpose

To evaluate the impact of time from symptom onset on the diagnostic performance of high-sensitivity cardiac troponin for type 1 myocardial infarction.

Methods

In a secondary analysis of a prospective multicentre randomised controlled trial of consecutive patients with suspected acute coronary syndrome, we evaluated the diagnostic performance of high-sensitivity cardiac troponin I measurements at presentation stratified by time of symptom onset to blood sampling. Diagnostic performance was evaluated in four groups (≤3 hours, 4–6 hours, 7–12 hours and &gt;12 hours from symptom onset) for recommended thresholds to rule-out (sex-specific 99th centile and optimised threshold [64 ng/L]) type 1 myocardial infarction.

Results

This analysis included 41,104 patients (median 60 [interquartile range 49–74] years, 46% female) of which 12,595 (31%), 10,298 (25%), 7,171 (17%) and 11,040 (27%) presented ≤3 hours, 4–6 hours, 7–12 hours and &gt;12 hours, respectively. Type 1 myocardial infarction was the adjudicated diagnosis in 3,692 (9%) patients. For the rule-out of type 1 myocardial infarction, sensitivity was highest in those tested 7–12 hours from symptom onset and lowest in those tested ≤3 hours. In early presenters, a threshold of &lt;2 ng/L had greater sensitivity and negative predictive value (99.4% [95% CI 98.9 to 99.7%] and 99.7% [95% CI 99.5 to 99.9%]) compared to &lt;5 ng/L (96.7% [95% CI 95.7 to 97.6%] and 99.3% [95% CI 99.1 to 99.5%], respectively). In those tested &gt;3 hrs from symptom onset, the sensitivity and negative predictive value for both thresholds were similar, but a threshold of &lt;5 ng/L correctly ruled out more patients (60% [17,056/28,506] versus 29% [8,316/28,506]). For the rule-in of myocardial infarction, the sensitivity of the 99th centile and 64 ng/L was lowest in patients tested within 3 hours (71.7% [95% CI 69.3 to 74.1%] and 46.5% [95% CI 44.1 to 49.2%], respectively), and increased in those tested later from symptom onset. The specificity and positive predictive value were highest when testing was performed 7–12 hours from symptom onset for the sex-specific 99th centile (92.4% [95% CI 91.8 to 93.0%] and 51.3% [95% CI 48.2–54.5%]) and 64 ng/L (96.2% [95% CI 95.7 to 96.7%] and 61.2% [95% CI 57.3 to 65.2%]).

Conclusions

The diagnostic performance of cardiac troponin for myocardial infarction is strongly influenced by the time from symptom onset to testing. In early presenters the limit of detection may facilitate immediate rule-out of myocardial infarction, but otherwise testing at least 3 hours from symptom onset is needed with the optimal time to rule-in myocardial infarction being 7–12 hours from the onset of symptoms.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): British Heart Foundation (BHF)Medical Research council UK (MRC)

Counting the cost of progressive aortic valve stenosis: an international observational clinical cohort study

Background

We sought, for the first time, to quantify the societal to healthcare burden associated with the entire spectrum of aortic stenosis (AS) - the most common cardiac valve disorder requiring clinical management.

Methods

In this observational clinical cohort study with individual data linkage to all-cause mortality, we examined the distribution of progressive stenosis in the native aortic valves of 98,565 men and 99,357 women aged ≥65 years within a multicentre cohort across 24 sites internationally. Individuals were grouped according to their peak aortic valve velocity on last electrocardiogram investigation: 1.0–1.99 m/s (no AS/reference groups) and then 0.5 m/s increments up to ≥4.0 m/s (severe AS). Sex-specific premature mortality and years of life-lost (YLL) during 5-year follow-up were calculated, along with willingness-to-pay (WTP) to regain quality-adjusted life-years (QALYs) and healthcare costs associated with concurrent heart failure (HF).

Results

Overall, 20,701 men (21.0%; 95% CI 20.8–21.3) and 18,576 women (18.7%; 95% CI 18.5–18.9) had AS at baseline. Five-year mortality in men and women with no AS was 38.6% and 36.8%, respectively. In both sexes, mortality rose from 46.8–49.0% to 59.5–65.7% in the least- to most-severe cases of AS. Premature mortality (53.5–59.1% in the no AS group) declined from 42.4–50.9% to 34.8–35.2% of all deaths. Per 1,000 individuals, AS in men and women was associated with 8 and 13 more premature deaths resulting in 36 and 62 more QALYs (societal cost of $AU1.54 and $AU2.68 million respectively) when compared to no AS. The additional 5-year cost of healthcare utilisation for the 25 and 35 more men and women with concurrent HF and AS was estimated to be $AU1.27 and $AU1.91 million, respectively.

Conclusions

The presence of any degree of aortic valve stenosis is associated with higher levels of premature mortality coupled with excess healthcare costs that impose a heavy societal burden. These findings indicate the need for proactive and cost-effective strategies to promptly detect this common condition.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Edwards LifeSciences: Investigator-initiated grant

The impact of COVID-19 on the clinical experience and training of undergraduate Student radiographers internationally: The clinical tutors' perspective

Introduction

The impact on the clinical training and education of healthcare students by COVID-19 has been documented. However, the thoughts and experiences of clinical tutors (CTs) about radiography students attending for clinical training and education during this now elongated period beyond first recognition of the virus has not been explored. This paper will discuss data collected from CTs in the UK Devolved Nations (UKDN) and the United Arab Emirates (UAE) who were compared because of their similarities in delivery based on individual ‘rules of engagement’ devised by their various health departments.

Aim

The purpose of this study was to examine the clinical tutors' thoughts and experiences of supervising radiography students attending clinical placement during the COVID-19 pandemic.

Methods

The UK Devolved Nations (UKDN) and the United Arab Emirates (UAE) were selected for comparison on an international level as they are geographically distinct with a comparable population and education accredited/acknowledged by the Society and College of Radiographers (SCoR). Data was collected data from CTs across the UKDN and the UAE. The study used an online questionnaire (Google Forms) with closed questions in four themes including: students' experiences, impact on students' clinical placement, attitude of the clinical staff and the potential effects of COVID-19 on future graduates’ skills and competencies. Further data was gathered on the experience of CTs mentoring students during the COVID-19 pandemic.

Results

Data were collected from 59 CTs (81%, n = 48) from UKDN and (19%, n = 11) UAE. Twenty-seven (46%) respondents reported that COVID-19 had a negative impact on clinical practical experience. However, 32 (54%) identified that COVID-19 had no impact on student supervision/feedback or on clinical achievements. Eleven (19%) respondents thought that students should not have been on clinical placement during the pandemic but a further 51% (n = 30) were happy with the students on placement and expressed willingness to delegate work to students. Interestingly, 58% (n = 34) of CTs suggested that future graduates may need a longer preceptorship after they graduate due to receiving decreased clinical experience during the pandemic. Overall, 78% (n = 46) of respondents thought that students improved their clinical confidence by working directly with COVID-19 positive patients.

Conclusion

The current study has identified conflicting opinions across CTs in different clinical departments. Whilst some felt that students should not be in the hospital during the pandemic, others reported that working directly with COVID-19 patients had a positive impact on students as it improved their clinical confidence. Despite the challenges presented by COVID-19, CTs were able to provide direct clinical supervision and feedback to students on clinical placement throughout the pandemic. Nevertheless, future graduates may need a longer preceptorship period due to decreased clinical experience during the pandemic.

Implications for practice

Clinical placements should continue during subsequent COVID-19 waves of infection or future pandemics to ensure development of skills in resilience and adaptability. Underdeveloped skills due to a decreased range of examinations can be rectified when any wave of the infection subsides by providing tailored training based on individual student's needs.

Effect of Commercial Gas Diffusion Layers on Catalyst Durability of Polymer Electrolyte Fuel Cells in Varied Cathode Gas Environment

Gas diffusion layers (GDLs) play a crucial role in heat transfer and water management of cathode catalyst layers in polymer electrolyte fuel cells (PEFCs). Thermal and water gradients can accelerate electrocatalyst degradation and therefore the selection of GDLs can have a major influence on PEFC durability. Currently, the role of GDLs in electrocatalyst degradation is poorly studied. In this study, electrocatalyst accelerated stress test studies are performed on membrane electrode assemblies (MEAs) prepared using three most commonly used GDLs. The effect of GDLs on electrocatalyst degradation is evaluated in both nitrogen (non-reactive) and air (reactive) gas environments at 100% relative humidity. In situ electrochemical characterization and extensive physical characterization is performed to understand the subtle differences in electrocatalyst degradation and correlated to the use of different GDLs. Overall, no difference is observed in the electrocatalyst degradation due to GDLs based on polarization curves at the end of life. But interestingly, MEA with a cracked microporous layer (MPL) in the GDL exhibited a higher electrocatalyst loading loss, which resulted in a lower and more heterogeneous increase in the average electrocatalyst nanoparticle size.

A Multifaceted Evaluation of a COVID-19 Contact Tracing Program in King County, Washington

CONTEXT

Despite the massive scale of COVID-19 case investigation and contact tracing (CI/CT) programs operating worldwide, the evidence supporting the intervention's public health impact is limited.

OBJECTIVE

To evaluate the Public Health-Seattle & King County (PHSKC) CI/CT program, including its reach, timeliness, effect on isolation and quarantine (I&Q) adherence, and potential to mitigate pandemic-related hardships.

DESIGN

This program evaluation used descriptive statistics to analyze surveillance records, case and contact interviews, referral records, and survey data provided by a sample of cases who had recently ended isolation.

SETTING

The PHSKC is one of the largest governmental local health departments in the United States. It serves more than 2.2 million people who reside in Seattle and 38 other municipalities.

PARTICIPANTS

King County residents who were diagnosed with COVID-19 between July 2020 and June 2021.

INTERVENTION

The PHSKC integrated COVID-19 CI/CT with prevention education and service provision.

RESULTS

The PHSKC CI/CT team interviewed 42 900 cases (82% of cases eligible for CI/CT), a mean of 6.1 days after symptom onset and 3.4 days after SARS-CoV-2 testing. Cases disclosed the names and addresses of 10 817 unique worksites (mean = 0.8/interview) and 11 432 other recently visited locations (mean = 0.5/interview) and provided contact information for 62 987 household members (mean = 2.7/interview) and 14 398 nonhousehold contacts (mean = 0.3/interview). The CI/CT team helped arrange COVID-19 testing for 5650 contacts, facilitated grocery delivery for 7253 households, and referred 9127 households for financial assistance. End of I&Q Survey participants (n = 304, 54% of sampled) reported self-notifying an average of 4 nonhousehold contacts and 69% agreed that the information and referrals provided by the CI/CT team helped them stay in isolation.

CONCLUSIONS

In the 12-month evaluation period, CI/CT reached 42 611 households and identified thousands of exposure venues. The timing of CI/CT relative to infectiousness and difficulty eliciting nonhousehold contacts may have attenuated the intervention's effect. Through promotion of I&Q guidance and services, CI/CT can help mitigate pandemic-related hardships.

A delivery service model for genetics: The use of a genetic counselor and nurse practitioner team for diagnosis and care in specific condition populations

Many genetic centers are developing innovative delivery models for services to address the growing need for access to genetics in the setting of a limited genetics-certified workforce. In the literature review, alternative service delivery models-including telehealth and genetic counselor involvement with nongenetics specialty providers-aim to increase efficiency, patient access, and provider satisfaction. This paper outlines a traditional model of pediatric care, with a workflow involving a geneticist and genetic counselor, from preclinic to follow-up. We then present a workflow model of a collaborative team consisting of a genetic counselor and nurse practitioner in condition-specific pediatric clinics. We break down factors influencing the successful implementation of this model, including patient selection, pre-established and adaptive clinic goals, and differentiation of roles of the providers. Potential barriers to generalization and the ongoing success of this clinic model include provider interest in genetics and the necessity for careful triaging by clinicians. Formalized analysis of these clinics has not been performed, though at the presented institution, this clinic model is recognized as an effective way to decrease wait times for patients referred for specific indications and creates an environment that allows providers to specialize, increasing their expertize and confidence in particular genetic areas.

Characteristics and outcomes of hospitalised inpatients with indwelling urinary catheter-a retrospective study from a large regional hospital in queensland

BACKGROUND

Indwelling urinary catheters (IDCs) are a common invasive device in hospitalised patients. Their use is associated with increased risks of developing catheter associated urinary tract infections (CAUTI), and blood stream infections (BSI).

AIMS

To examine the characteristics and outcomes of adult inpatients with an IDC inserted in hospital and identify risk factors for developing CAUTI and BSI.

METHODS

We performed a retrospective observational study of 430 patients with IDC admitted to medical and surgical units of a leading (tertiary) hospital between Nov 2019 till April 2020. Multiple logistic regression analysis was performed to determine independent risk factors for developing urinary tract infection and blood stream infection.

RESULTS

The prevalence of CAUTI in our study was 7.4%. Results of multiple logistic regression indicated that with each day of IDC in situ, the likelihood of UTI development increased by 9% (OR 1.09; 95% CI 1.00 to 1.18; p = 0.03). Age, gender, and catheter reinsertion were not associated with UTI development.

CONCLUSIONS

Longer duration of IDC was associated with elevated risk of developing CAUTI. CAUTI rates were higher than some of those previously published. There was no statistical significance in frequency of CAUTI between medical and surgical patients. No statistically significant variables that contributed to the development of BSI were found. Interventions targeted at reducing catheter days should be used to improve CAUTI rates.

A bibliometric analysis of published research employing musculoskeletal imaging modalities to evaluate foot osteoarthritis

Objectives

Temporal and global changes in research utilising imaging to assess foot osteoarthritis is currently unknown. This study aimed to undertake a bibliometric analysis of published research to: (1) identify the imaging modalities that have been used to evaluate foot osteoarthritis; (2) explore the temporal changes and global differences in the use of these imaging modalities; and (3) to evaluate performance related to publication- and citation-based metrics.

Methods

A literature search was conducted using Scopus to identify studies which had used imaging to assess foot osteoarthritis. Extracted data included publication year, imaging modality, citations, affiliations, and author collaboration networks. Temporal trends in the use of each imaging modality were analysed. Performance analysis and science mapping were used to analyse citations and collaboration networks.

Results

158 studies were identified between 1980 and 2021. Plain radiography was the most widely used modality, followed by computed tomography, magnetic resonance imaging (MRI) and ultrasound imaging (USI), respectively. The number of published studies increased over time for each imaging modality (all P ≥ 0.018). The most productive country was the United States of America (USA), followed by the United Kingdom and Australia. International authorship collaboration was evident in 57 (36.1%) studies. The average citation rate was 23.4 per study, with an average annual citation rate of 2.1.

Conclusions

Published research employing imaging to assess foot osteoarthritis has increased substantially over the past four decades. Although plain radiography remains the gold standard modality, the emergence of MRI and USI in the past two decades continues to advance knowledge and progress research in this field.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13047-022-00549-0.

An evaluation of podiatry service use for people with inflammatory rheumatic diseases: a review of a rheumatology podiatry clinic in Aotearoa New Zealand

Background

Foot problems, including foot pain, structural deformities, skin and nail lesions, and footwear difficulties, are common in people with inflammatory rheumatic diseases. However, dedicated podiatry services are limited, including in Aotearoa New Zealand. This study aimed to evaluate the podiatry service use for people with inflammatory rheumatic diseases who attended a specialist podiatric rheumatology clinic in Aotearoa New Zealand.

Methods

This retrospective review included people with an inflammatory rheumatic disease who attended the Auckland University of Technology Podiatric Rheumatology Clinic between 2010 and 2021. Data were extracted manually from patients’ clinical records, including variables relating to patient characteristics, appointment details, presenting complaint, assessments performed, and treatments provided.

Results

From 2010 to 2021, 157 people with inflammatory rheumatic diseases attended 1570 appointments. The most common presenting concern was foot pain (reported by n = 121, 77.1% patients during at least one appointment), followed by skin/nail lesions (n = 98, 62.4%) and footwear/orthotic needs (n = 90, 57.3%). A range of podiatric interventions were provided to address foot-care needs, in which education (n = 151, 96.2%) and general skin/nail care (n = 107, 68.2%) were the most common treatments provided. The majority of patients also received footwear interventions at some point during their period of service provision (n = 96, 61.1%), followed by orthoses, other padding/offloading devices, wound care, exercise prescription and referrals to other health professionals.

Conclusions

This is the first study to review podiatric service provision for people with inflammatory rheumatic diseases attending a specialist podiatric rheumatology clinic in Aotearoa New Zealand. The results of this study have shown that a podiatry clinic dedicated to people with inflammatory rheumatic diseases addresses the wide range of foot problems through an extensive provision of treatment services.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13047-022-00542-7.

Is repeat serum urate testing superior to a single test to predict incident gout over time?

Elevated serum urate is the most important causal risk factor for developing gout. However, in longitudinal cohort studies, a small proportion of people with normal urate levels develop gout and the majority of those with high urate levels do not. These observations may be due to subsequent variations in serum urate over time. Our analysis examined whether single or repeat testing of serum urate more accurately predicts incident gout over time. Individual participant data from three publicly-available cohorts were included. Data from paired serum urate measures 3-5 years apart, followed by an assessment of gout incidence 5-6 years from the second urate measure were used to calculate the predictive ability of four measures of serum urate on incident gout: the first measure, the second measure, the average of the two measures, and the highest of the two measures. Participants with prevalent gout prior to the second measure were excluded. Receiver operator characteristic (ROC) curves and area under the curve (AUC) statistics were computed to compare the four measures. A total of 16,017 participants were included across the three cohorts, with a mean follow-up from the first serum urate test of 9.3 years (range 8.9-10.1 years). Overall, there was a small increase in the mean serum urate between the first and second measures (322 μmol/L (5.42 mg/dL) vs. 340 μmol/L (5.71 mg/dL), P<0.001) which were a mean of 3.5 years apart, but the first and second measures were highly correlated (r = 0.81, P<0.001). No differences were observed in the predictive ability of incident gout between the four measures of serum urate measurement with ROC curve AUC statistics ranging between 0.81 (95% confidence intervals: 0.78-0.84) and 0.84 (95% confidence intervals: 0.81-0.87). These data show that repeat serum urate testing is not superior to a single measure of serum urate for prediction of incident gout over approximately one decade.

Clinical outcomes, Kadish-INSICA staging and therapeutic targeting of somatostatin receptor 2 in olfactory neuroblastoma

INTRODUCTION

Olfactory neuroblastoma (ONB) is a rare cancer of the sinonasal region. We provide a comprehensive analysis of this malignancy with molecular and clinical trial data on a subset of our cohort to report on the potential efficacy of somatostatin receptor 2 (SSTR2)-targeting imaging and therapy.

METHODS

We conducted a retrospective analysis of 404 primary, locally recurrent, and metastatic olfactory neuroblastoma (ONB) patients from 12 institutions in the United States of America, United Kingdom and Europe. Clinicopathological characteristics and treatment approach were evaluated. SSTR2 expression, SSTR2-targeted imaging and the efficacy of peptide receptor radionuclide therapy [PRRT](177Lu-DOTATATE) were reported in a subset of our cohort (LUTHREE trial; NCT03454763).

RESULTS

Dural infiltration at presentation was a significant predictor of overall survival (OS) and disease-free survival (DFS) in primary cases (n = 278). Kadish-Morita staging and Dulguerov T-stage both had limitations regarding their prognostic value. Multivariable survival analysis demonstrated improved outcomes with lower stage and receipt of adjuvant radiotherapy. Prophylactic neck irradiation significantly reduces the rate of nodal recurrence. 82.4% of the cohort were positive for SSTR2; treatment of three metastatic cases with SSTR2-targeted peptide-radionuclide receptor therapy (PRRT) in the LUTHREE trial was well-tolerated and resulted in stable disease (SD).

CONCLUSIONS

This study presents pertinent clinical data from the largest dataset, to date, on ONB. We identify key prognostic markers and integrate these into an updated staging system, highlight the importance of adjuvant radiotherapy across all disease stages, the utility of prophylactic neck irradiation and the potential efficacy of targeting SSTR2 to manage disease.