Fully Automated Versions of Clinically Validated Nephrometry Scores Demonstrate Superior Predictive Utility versus Human Scores

OBJECTIVE

To automate the generation of three validated nephrometry scoring systems on preoperative computerised tomography (CT) scans by developing artificial intelligence (AI)-based image processing methods. Subsequently, we aimed to evaluate the ability of these scores to predict meaningful pathological and perioperative outcomes.

PATIENTS AND METHODS

A total of 300 patients with preoperative CT with early arterial contrast phase were identified from a cohort of 544 consecutive patients undergoing surgical extirpation for suspected renal cancer. A deep neural network approach was used to automatically segment kidneys and tumours, and then geometric algorithms were used to measure the components of the concordance index (C-Index), Preoperative Aspects and Dimensions Used for an Anatomical classification of renal tumours (PADUA), and tumour contact surface area (CSA) nephrometry scores. Human scores were independently calculated by medical personnel blinded to the AI scores. AI and human score agreement was assessed using linear regression and predictive abilities for meaningful outcomes were assessed using logistic regression and receiver operating characteristic curve analyses.

RESULTS

The median (interquartile range) age was 60 (51-68) years, and 40% were female. The median tumour size was 4.2 cm and 91.3% had malignant tumours. In all, 27% of the tumours were high stage, 37% high grade, and 63% of the patients underwent partial nephrectomy. There was significant agreement between human and AI scores on linear regression analyses (R ranged from 0.574 to 0.828, all P < 0.001). The AI-generated scores were equivalent or superior to human-generated scores for all examined outcomes including high-grade histology, high-stage tumour, indolent tumour, pathological tumour necrosis, and radical nephrectomy (vs partial nephrectomy) surgical approach.

CONCLUSIONS

Fully automated AI-generated C-Index, PADUA, and tumour CSA nephrometry scores are similar to human-generated scores and predict a wide variety of meaningful outcomes. Once validated, our results suggest that AI-generated nephrometry scores could be delivered automatically from a preoperative CT scan to a clinician and patient at the point of care to aid in decision making.

Perceptions of radiographers regarding professional development in clinical practice in KwaZulu-Natal, South Africa

INTRODUCTION

Professional development is a concept inclusive of all learning such as postgraduate qualifications, staff development, and reflective practice, pursued for the betterment of radiographers' professional expertise. Professional development is associated with professional capabilities and quality service delivery to the patient, and this understanding of professional development applies to the radiography profession. The study aimed to explore and describe the perceptions of KwaZulu-Natal (KZN) radiographers regarding the role of professional development in clinical practice.

METHODS

The study followed a qualitative exploratory-descriptive design, whereby the data was collected from 13 radiographers working in rural and urban KZN using one-on-one semi-structured interviews and analysed using Tesch's eight steps of thematic analysis.

RESULTS

Three principal themes emerged from the data analysis. The first theme was the radiographers' views of what constitutes professional development. The second theme highlighted radiographers' views of what promotes professional development among professionals and the final theme concerned the radiographers' views of what hinders professional development.

CONCLUSION

South African radiographers experience a range of challenges regarding professional development participation. There is a need to assist radiography managers to facilitate the professional development of their staff; to develop a culture of professional development among their staff; to recognise and reward radiographers for participating in professional development and to provide relevant and effective professional development opportunities for radiographers.

Long-Term Functional and Oncologic Outcomes Following Robotic Partial and Radical Nephrectomy: A Report from a Single Institution with up to 15 Years of Follow-up

OBJECTIVE

To evaluate the long-term functional and oncological outcomes following robotic partial (RAPN) and radical nephrectomy (RARN).

MATERIALS AND METHODS

A retrospective review was performed on 1816 patients who underwent RAPN and RARN at our institution between January 2006 and January 2018. Patients with long-term follow-ups of at least 5 years were selected. Exclusion criteria included patients with a previous history of partial or radical nephrectomy, known genetic mutations, and whose procedures were performed for benign indications Statistical analysis was performed with results as presented.

RESULTS

A total of 769 and 142 patients who underwent RAPN and RARN met our inclusion criteria. The duration of follow-up was similar after the two procedures with a median of nearly 100 months. The 5- and 10-year chronic kidney disease (CKD) upstaging-free survivals were 74.5% and 65.9% following RAPN and 53% and 46.4% after RARN, respectively. Older age was identified as a potential predictor for CKD progression after RARN, while older age, higher BMI, baseline renal function, and ischemia time were shown to predict CKD progression following RAPN. RCC-related mortality rates for RAPN and RARN were equally 1.1%. No statistically significant differences were identified in the local recurrence, metastatic, and disease-specific survival between the two procedures.

CONCLUSION

Compared to RARN, RAPN conferred a better CKD progression-free survival. Several factors were identified as potential predictors for clinically significant CKD progression both in the early and late postoperative phase. Long-term oncological outcomes between the two procedures remained similarly favorable.

The Concept of Child-Centred Care in Healthcare: A Scoping Review

Although child-centred care is increasingly referred to within the nursing literature, a clear definition of child-centred care and clarity around the concept is yet to be achieved. The objectives of this review were to examine the following: (1) What constitutes the concept of child-centred care in healthcare? (2) How has the concept of child-centred care developed? (3) What is the applicability of child-centred care and what are its limitations? (4) How does the concept of child-centred care benefit and inform children's healthcare? In total, 2984 papers were imported for screening, and, following the removal of duplicates and screening, 21 papers were included in the scoping review. The findings suggest that child-centred care is an emerging, ambiguous poorly defined concept; no clear consensus exists about what constitutes child-centred care. Although it seems antithetical to argue against child-centred care, little robust evidence was identified that demonstrates the impact and benefit of child-centred care. If child-centred care is to be a sustainable, convincing model to guide practice and compete with other models of care, it needs to establish robust evidence of its effectiveness, the impact on children and their families, as well as the wider impacts on the healthcare system.

Extinction risk modeling predicts range-wide differences of climate change impact on Karner blue butterfly (Lycaeides melissa samuelis)

The Karner blue butterfly (Lycaeides melissa samuelis, or Kbb), a federally endangered species under the U.S. Endangered Species Act in decline due to habitat loss, can be further threatened by climate change. Evaluating how climate shapes the population trend of the Kbb can help in the development of adaptive management plans. Current demographic models for the Kbb incorporate in either a density-dependent or density-independent manner. We instead created mixed density-dependent and -independent (hereafter "endo-exogenous") models for Kbbs based on long-term count data of five isolated populations in the upper Midwest, United States during two flight periods (May to June and July to August) to understand how the growth rates were related to previous population densities and abiotic environmental conditions, including various macro- and micro-climatic variables. Our endo-exogenous extinction risk models showed that both density-dependent and -independent components were vital drivers of the historical population trends. However, climate change impacts were not always detrimental to Kbbs. Despite the decrease of population growth rate with higher overwinter temperatures and spring precipitations in the first generation, the growth rate increased with higher summer temperatures and precipitations in the second generation. We concluded that finer spatiotemporally scaled models could be more rewarding in guiding the decision-making process of Kbb restoration under climate change.

Developing rights-based standards for children having tests, treatments, examinations and interventions: using a collaborative, multi-phased, multi-method and multi-stakeholder approach to build consensus

Children continue to experience harm when undergoing clinical procedures despite increased evidence of the need to improve the provision of child-centred care. The international ISupport collaboration aimed to develop standards to outline and explain good procedural practice and the rights of children within the context of a clinical procedure. The rights-based standards for children undergoing tests, treatments, investigations, examinations and interventions were developed using an iterative, multi-phased, multi-method and multi-stakeholder consensus building approach. This consensus approach used a range of online and face to face methods across three phases to ensure ongoing engagement with multiple stakeholders. The views and perspectives of 203 children and young people, 78 parents and 418 multi-disciplinary professionals gathered over a two year period (2020-2022) informed the development of international rights-based standards for the care of children having tests, treatments, examinations and interventions. The standards are the first to reach international multi-stakeholder consensus on definitions of supportive and restraining holds.    Conclusion: This is the first study of its kind which outlines international rights-based procedural care standards from multi-stakeholder perspectives. The standards offer health professionals and educators clear evidence-based tools to support discussions and practice changes to challenge prevailing assumptions about holding or restraining children and instead encourage a focus on the interests and rights of the child. What is Known: • Children continue to experience short and long-term harm when undergoing clinical procedures despite increased evidence of the need to improve the provision of child-centred care. • Professionals report uncertainty and tensions in applying evidence-based practice to children's procedural care. What is New: • This is the first study of its kind which has developed international rights-based procedural care standards from multi-stakeholder perspectives. • The standards are the first to reach international multi-stakeholder consensus on definitions of supportive and restraining holds.

AI-generated R.E.N.A.L.+ Score Surpasses Human-generated Score in Predicting Renal Oncologic Outcomes

OBJECTIVE

To determine whether we can surpass the traditional R.E.N.A.L. nephrometry score (H-score) prediction ability of pathologic outcomes by creating artificial intelligence (AI)-generated R.E.N.A.L.+ score (AI+ score) with continuous rather than ordinal components. We also assessed the AI+ score components' relative importance with respect to outcome odds.

METHODS

This is a retrospective study of 300 consecutive patients with preoperative computed tomography scans showing suspected renal cancer at a single institution from 2010 to 2018. H-score was tabulated by three trained medical personnel. Deep neural network approach automatically generated kidney segmentation masks of parenchyma and tumor. Geometric algorithms were used to automatically estimate score components as ordinal and continuous variables. Multivariate logistic regression of continuous R.E.N.A.L. components was used to generate AI+ score. Predictive utility was compared between AI+, AI, and H-scores for variables of interest, and AI+ score components' relative importance was assessed.

RESULTS

Median age was 60years (interquartile range 51-68), and 40% were female. Median tumor size was 4.2 cm (2.6-6.12), and 92% were malignant, including 27%, 37%, and 23% with high-stage, high-grade, and necrosis, respectively. AI+ score demonstrated superior predictive ability over AI and H-scores for predicting malignancy (area under the curve [AUC] 0.69 vs 0.67 vs 0.64, respectively), high stage (AUC 0.82 vs 0.65 vs 0.71, respectively), high grade (AUC 0.78 vs 0.65 vs 0.65, respectively), pathologic tumor necrosis (AUC 0.81 vs 0.72 vs 0.74, respectively), and partial nephrectomy approach (AUC 0.88 vs 0.74 vs 0.79, respectively). Of AI+ score components, the maximal tumor diameter ("R") was the most important outcomes predictor.

CONCLUSION

AI+ score was superior to AI-score and H-score in predicting oncologic outcomes. Time-efficient AI+ score can be used at the point of care, surpassing validated clinical scoring systems.

Management of encounters related to subfertility and infertility in Australian general practice: a focus on Aboriginal and Torres Strait Islander females

OBJECTIVE

To investigate the management of subfertility and infertility among Aboriginal and Torres Strait Islander females attending Australian general practice.

METHODS

Cross-sectional study of 1,258,581 women (18-49 years) attending general practice between January 2011 and June 2019, utilising data from NPS MedicineWise MedicineInsight, a national general practice database in Australia.

RESULTS

The prevalence of subfertility/infertility encounters was lower for Aboriginal and Torres Strait Islander females (12.37 per 1,000) than for non-Indigenous females (16.62 per 1,000). Aboriginal and Torres Strait Islander females with a subfertility/infertility encounter were younger and more likely to live outside Major cities and in areas of socioeconomic disadvantage than non-Indigenous females. Rates of prescribed infertility medications were not different between groups, however Aboriginal and Torres Strait Islander females were more likely to receive a pelvic ultrasound (24.30% vs. 19.90%); tests for luteinizing hormone (31.89% vs. 25.65%); testosterone (14.93% vs. 9.96%) and; glycated haemoglobin (HbA1c) (6.32% vs. 3.41%),but less likely to receive an anti-müllerian hormone test (2.78% vs. 7.04%).

CONCLUSIONS

Lower encounter rates for infertility/subfertility among Aboriginal and Torres Strait Islander peoples may indicate access issues, preferred use of Aboriginal community-controlled health centres or younger average age at first birth and thus less age-related infertility.

IMPLICATIONS FOR PUBLIC HEALTH

Future efforts should focus on maximising the inclusiveness of infertility surveillance. There is also a need for further research into the experiences of and preferences for infertility care and associated barriers among Aboriginal and Torres Strait Islander people.

Measurement of Direct-Photon Cross Section and Double-Helicity Asymmetry at sqrt[s]=510 GeV in p[over →]+p[over →] Collisions

We present measurements of the cross section and double-helicity asymmetry A_{LL} of direct-photon production in p[over →]+p[over →] collisions at sqrt[s]=510  GeV. The measurements have been performed at midrapidity (|η|<0.25) with the PHENIX detector at the Relativistic Heavy Ion Collider. At relativistic energies, direct photons are dominantly produced from the initial quark-gluon hard scattering and do not interact via the strong force at leading order. Therefore, at sqrt[s]=510  GeV, where leading-order-effects dominate, these measurements provide clean and direct access to the gluon helicity in the polarized proton in the gluon-momentum-fraction range 0.02<x<0.08, with direct sensitivity to the sign of the gluon contribution.

Temporal Validation of The Australian Estimated Post-Transplant Survival Score

AIMS

The Australian estimated post-transplant survival (EPTS-AU) prediction score was developed by re-fitting the United States of America EPTS, without diabetes, to the Australian and New Zealand kidney transplant population over 2002-2013. The EPTS-AU score incorporates age, previous transplantation and time on dialysis. Diabetes was excluded from the score, as this was not previously recorded in the Australian allocation system. In May 2021, the EPTS-AU prediction score was incorporated into the Australian kidney allocation algorithm to optimise utility for recipients (maximised benefit). We aimed to temporally validate the EPTS-AU prediction score to ensure it can be used for this purpose.

METHODS

Using the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, we included adult recipients of deceased donor kidney-only transplants between 2014-2021. We constructed Cox models for patient survival. We assessed validation using measures of model fit (Akaike information criterion and misspecification), discrimination (Harrell's C statistic and Kaplan Meier curves), and calibration (observed versus predicted survival).

RESULTS

6402 recipients were included in the analysis. The EPTS-AU had moderate discrimination with a C statistic of 0.69 (95% CI 0.67,0.71), and clear delineation between Kaplan Meier's survival curves of EPTS-AU. The EPTS was well calibrated with the predicted survivals equating with the observed survival outcomes for all prognostic groups.

CONCLUSIONS

The EPTS-AU performs reasonably well in choosing between recipients (discrimination) and to predict a recipient's survival (calibration). Reassuringly, the score is functioning as intended to predict post-transplant survival for recipients as part of the national allocation algorithm. This article is protected by copyright. All rights reserved.

Use of IsoPSA with prostate MRI PIRADS score in biopsy decision making in patients with elevated PSA

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Background: IsoPSA is prospectively validated to be superior to PSA and percent free PSA in predicting prostate cancer (PCa) as well as clinically significant prostate cancer. We sought to evaluate the use of IsoPSA in combination with prostate magnetic resonance imaging (MRI) and the prostate imaging reporting and data systems (PIRADS) on predicting either benign/indolent or csPCA at biopsy. Methods: This was a single center retrospective review of prospectively collected patient data that included all patients who underwent IsoPSA testing, preoperative prostate MRI and prostate biopsy from 2019-2021. Chi Squared analysis was used to assess for associations between a binary classification of low (<6) or elevated (>6) IsoPSA index, in combination with PIRADS scores in predicting either indolent/benign or csPCa at biopsy. Logistic regression was used to explore independent predictors of csPCa. Receiver Operating Curve (ROC) analysis was completed with areas under the curve (AUC) for IsoPSA and PIRADS scores, both alone and in combination. Predictive probabilities were assessed using combinations of IsoPSA thresholds and PIRADS scores. Results: 207 patients met inclusion criteria. Among patients with a negative MRI, low IsoPSA index was associated with a lower chance of csPCa compared to those with elevated IsoPSA (2% vs 15%, p<0.018). For those with a PIRADS 4-5 lesion, elevated IsoPSA index was associated with a higher chance of csPCa at biopsy compared to a low IsoPSA index (49% vs 19%, p=0.05). On multivariate analysis, elevated IsoPSA and PIRADS 4-5 were independent predictors of csPCa (p<0.001). Similarly, low IsoPSA index and negative MRI were independent predictors of benign/indolent disease at biopsy (p<0.001). Using predictive probabilities, the combination of PIRADS 4-5 with elevated IsoPSA was associated with the highest risk of csPCa (48%) and the highest AUC (0.83) for predicting csPCa. This AUC value was superior to either marker alone (0.76, 0.76) and total PSA alone (0.57) (p<0.001). Conclusions: The combination of elevated IsoPSA with adverse PIRADS score (4-5) is associated with a 48% predicted probability of csPCa at biopsy with an AUC of 0.83, which was more accurate than either marker alone. A low IsoPSA in combination with a negative MRI resulted in a 98% chance of benign/indolent disease at biopsy. These findings may prove useful for the practicing Urologist and may help guide discussions regarding the need for biopsy when interpreting various IsoPSA/PIRADS combinations. [Table: see text]

Predictive accuracy of computer-generated padua nephrometry scores based on continuous variables compared with categorical computer-generated scores and human-generated scores in predicting oncologic and perioperative outcomes

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Background: The Preoperative Aspects and Dimensions Used for Anatomical Classification (PADUA) score is a validated predictor of a patient’s perioperative outcomes following partial nephrectomy. The use of a fully automated, unbiased and time sensitive PADUA scoring system is a novel concept that may help circumvent PADUA’s widespread adoptability. We sought to automate the scoring of preoperative computed tomography scans (CT) using a machine-learning-generated PADUA score (P-AI). In doing so, we aimed to compare P-AI’s ability to predict meaningful perioperative and oncologic outcomes as compared to human generated PADUA scores using both categorical (P-H) and continuous variables (P-AI+). Methods: 300 patients with pre-operative CT scans were identified from a cohort of 544 consecutive patients undergoing surgical extirpation for suspected renal cancer at a single institution. A deep neural network approach was used to automatically segment kidneys and tumors and geometric algorithms were developed to estimate each component of PADUA based on the segmented regions (P-AI). Tumors were also manually scored by medical personnel blinded to the P-AI (P-H). The ability of P-AI and P-AI+ to predict meaningful perioperative and oncologic outcomes was compared to P-H using logistic regression and receiver operating characteristics (ROC) curve analyses and areas under the curve (AUC). Results: Median age was 60 years, 40% were female. Median tumor size was 4.2 cm, 91.3% had malignant tumors, including 27% and 37% with high-stage and high-grade, respectively. Both P-AI and P-H were able to predict the need for partial nephrectomy (p < 0.001). From an oncologic standpoint, P-AI and P-H were able to predict meaningful oncologic outcomes including the presence of malignancy, high grade and high stage disease (p < 0.004) although the ROC curves were not different from one another). Interestingly, when each PADUA component was left as a continuous rather than ordinal variables (P-AI+), this automated continuous score was able to predict surgical type (AUC 0.88), presence of malignancy (AUC 0.67), indolent tumors (AUC 0.79) and high grade (AUC 0.77)/high stage disease (AUC 0.82), better than both P-AI and P-H. Conclusions: When viewed along a continuous spectrum, AI generated PADUA scores (P-AI+) yields predictive surgical and oncologic outcomes superior to both categorical AI and human generated PADUA scores. If nephrometry can be calculated automatically, there is no longer a need to simplify the equations and the use of an AI generated PADUA scoring system, provides a reliable estimate of meaningful outcomes in a manner that is time sensitive and superior to human expert evaluation. Further prospective work and reproducibility from other centers is encouraged.

Phase II study of axitinib prior to partial nephrectomy to preserve renal function: An interim analysis of the PADRES clinical trial

683

Background: In renal cell carcinoma (RCC), partial nephrectomy (PN) is indicated for patients with solitary kidney, chronic kidney disease, or bilateral tumors. A subset of these patients, however, may have large and complex renal masses not initially suitable for PN. Neoadjuvant Tyrosine Kinase Inhibitor therapy has shown promising results in cytoreducing renal tumors and may permit PN in circumstances not otherwise feasible. Methods: This was a single arm phase II clinical trial of neoadjuvant axitinib in patients with complex (RENAL nephrometry score 10-12 and cT1b-cT3M0) biopsy-proven clear cell RCC with strong indications for partial nephrectomy (PN), and in whom radical nephrectomy may result in dialysis dependence. Axitinib 5 mg was administered orally twice daily for 8 weeks prior to surgery. Primary outcome was reduction in longest tumor diameter; secondary outcomes included tumor response (RECIST), change in RENAL score, feasibility of PN, change in estimated glomerular filtration rate (DeGFR), and post-surgical complications. Results: 26 patients were enrolled. 19 (73.1%) patients had ≥ clinical T3a staged tumors. Post therapy, 17 (65.4%) patients had ≥T3a staged tumors. Axitinib resulted in reductions in tumor size (7.7 vs. 6.3 cm, p<0.001) and RENAL score (11 vs. 10, p <0.001); 9 (34.6%) had partial response, and 17 (65.4%) stable disease by RECIST criteria. PN was successfully performed in 19 (73.1%); 24 (96.8%) achieved negative margins. Six (23.1%) had Clavien III-IV post-surgical complications. Median percentage DeGFR was 14.7%; one (3.8%) patient who had a radical nephrectomy had long-term dialysis dependence. Conclusions: Neoadjuvant axitnib resulted in significant reductions in tumor size and complexity, enabling PN in a cohort of complex renal masses, and with acceptable safety and functional preservation. Clinical trial information: NCT03438708 . [Table: see text]

Accuracy of fully automated, AI-generated models compared with validated clinical model to predict post-operative glomerular filtration rate after renal surgery

693

Background: The American Urologic Association (AUA) recommends estimation of the postoperative glomerular filtration rate (GFR) in patients with a renal mass to help decide between partial nephrectomy (PN) or radical nephrectomy (RN). If postoperative GFR<45 mL/min/1.73m2, a PN should be prioritized. Most existing methods to predict postoperative GFR are rarely implemented in the clinical setting due to complexity. Previously validated models based on clinical equations or kidney volumes from hand-segmented or semi-automated segmentations are quite accurate but have seen limited uptake in clinical practice. We hypothesize that we could develop an artificial intelligence (AI)-GFR prediction that would be calculated automatically on a preoperative computed tomography (CT) scan and predict a postoperative GFR as accurately as a validated clinical model. Methods: 300 patients undergoing PN or RN for renal tumor from the 2021Kidney and Kidney Tumor Segmentation Challenge(KiTS21) were analyzed. We excluded 7 patients having bilateral tumors. Preoperative GFR was the closest recorded value preoperatively and postoperative GFR≥90 days postoperatively. Split-renal-function (SRF) was determined in a fully automated way from preoperative imaging and our previously developed deep learning segmentation model. We programmed the algorithm to estimate postoperative GFR as 1.24×preoperative GFR×contralateral SRF for RN; and as 89% of the preoperative GFR for PN. We compared AI-predicted GFR to a validated clinical model (GFR=35+preoperative GFR(x0.65)-18(if radical nephrectomy)-age(x0.25)+3(if tumor size >7 cm)-2 (if diabetes)). We compared the AI and clinical model estimations of GFR to the measured postoperative GFR using correlation coefficients (R) and compared the ability of AI models to predict a postoperative GFR<45 using logistic regression and AUCs. Results: In 293 patients, the median age was 60 years ((IQR) 51-68), 40.6% were female, and 62.1% had PN. The median tumor size was 4.2 (2.6-6.1), and 91.8% of the tumors were malignant, of which 35.1% were high-grade, 25.6% were high-stage, and 21.8% had necrosis. The median R.E.N.A.L. nephrometry score was 8 (7-9). When comparing measured postoperative GFR, the correlation coefficients were 0.75 and 0.77 for the AI model and clinical models, respectively. For the prediction of a postoperative GFR< 45 ml/min/1.73m2, the AI and clinical models performed similarly (AUC of 0.89 and 0.9, respectively). Conclusions: Our study demonstrates the feasibility of a fully automated prediction of postoperative GFR based on CT imaging and baseline GFR with comparable predictive accuracy to existing validated clinical prediction models. These AI-generated predictions can be implemented for decision-making, with no clinical details, clinician time, or measurements needed.

Predictive accuracy of computer-generated C-index nephrometry scores compared with human-generated scores in predicting oncologic and perioperative outcomes

623

Background: The Centrality index (C-index) score is a validated nephrometry scoring system that requires precise measurements and mathematical calculations of cross sectional imaging. Like other nephrometry scores, its implementation has been slowed by required time investment and interobserver variability. We sought to automate this score on preoperative computerized tomography scans by developing an artificial intelligence-generated C-index score. We then aimed to evaluate its ability to predict meaningful oncologic and perioperative outcomes as compared to human-generated C-index nephrometry scores. Methods: 300 patients with preoperative computerized tomography with early arterial contrast phase were identified from a cohort of 544 consecutive patients undergoing surgical extirpation for suspected renal cancer. A deep neural network approach was used to automatically segment kidneys and tumors, and then programed to generate the measurements and calculate C-index score. Human C-index scores were independently calculated by medical personnel blinded to AI-scores. AI- and Human score agreement was assessed using bivariate linear regression correlation and their predictive abilities for both oncologic and perioperative outcomes were assessed using logistic regression and compared with receiver operating characteristic (ROC) curve analyses with measurements of areas under the curve (AUC). Results: Median age was 60 years (IQE 51–68), and 40% were female. Median tumor size was 4.2 cm and 91.3% had malignant tumors. 27% were high stage, 37% high grade, and 63% underwent partial nephrectomy. There was significant agreement between Human scores and AI-scores on linear regression analysis (R2 = 0.738, p <0.0001). Both AI- and Human generated C-index scores similarly predicted meaningful oncologic outcomes, with lower levels of either C-index score associated with increased risk of malignant histology (H-score p = 0.018, AI score p =0.014) high-grade disease (both p <0.0001), and high stage disease (both p <0.0001). Lower levels of either AI or human generated C-index scores also predicted a radical nephrectomy rather than partial nephrectomy surgical approach (both p <0.0001). AUC measurements (Table) were similar but consistently superior for AI generated C-index scores. Conclusions: Fully automated AI-generated C-index scores are comparable to human-generated C-index scores and predict a wide variety of meaningful patient-centered outcomes. Once validated in additional populations, our results suggest that our AI generated C-index could be delivered automatically from a preoperative CT scan to a clinician and patient at the point of care to aid in decision making. [Table: see text]

Impact of strengths model training and supervision on the therapeutic practice of Australian mental health clinicians

This study explored the impact of Strengths Model training, supervision and mentorship on the practice of a group of multi-disciplinary mental health clinicians that included mental health nurses, social workers, psychologists, and occupational therapists. A qualitative approach that combined critical realism and grounded theory was used. The findings demonstrated how a substantive category, Getting to Know Clients Better, facilitated participants' progression through a basic social psychological process, Becoming a Strengths-Informed Practitioner. This process consisted of a discernible and sustained change towards more person-centred, hopeful, and recovery-oriented practice. The findings also described an underlying generative mechanism for this, the Client Becomes Visible, which accorded with theoretical models of empathy, based on enhanced cognitive processing. The strength-based approach to practice facilitated the establishment of a collaborative relationship and a stronger therapeutic alliance between the client and clinician. The research demonstrated that Strengths Model is an effective vehicle for improving recovery-orientated mental health services.

The Long-Term Impact of COVID-19 on Presentations to a Specialist Child and Adolescent Eating Disorder Program

Aim Explore the impact of COVID-19 on numbers and clinical profile of Eating Disorder (ED) presentations to a specialist ED program pre- and during COVID-19. Methods Retrospective chart review of referrals pre- COVID-19 (January 2018 - February 2020) and during COVID-19 (March 2020 - August 2021) were compared. Results 128 youth were assessed with significantly higher rates of referrals each month during COVID-19 compared to pre- COVID-19 (3.78 vs. 2.31, p = 0.02). Youth referred during COVID-19 showed a higher rate of % Ideal Body Weight (IBW) loss (4.8% = vs. 2.6%, p = &lt; 0.001) and had a shorter duration of illness pre-referral (4.8 months vs. 7.4 months, p = 0.001). Fewer youth during COVID- 19 (19% vs. 43%, p = 0.011) were prescribed psychotropic medication. Many youth (80%), self-declared COVID-19 as a contributory factor in the development of their ED. Conclusion This study supports the growing consensus of a COVID-19 specific impact on ED services with higher rates of referrals, youth presenting with a faster pace of weight loss and earlier referral to specialist services. Whether this represents a true increase in EDs or an overall increase in CAMHS referrals with a faster transfer to ED services requires further exploration.

Cost-Effective and Readily Replicable Surgical Simulation Model Improves Trainee Performance in Benchtop Robotic Urethrovesical Anastomosis

INTRODUCTION

Our objective was to develop a simple, cost-effective and reusable model for urethrovesical anastomosis for robotic-assisted radical prostatectomy and evaluate its impact on fundamental surgical skills and confidence of urology trainees.

METHODS

A model for the bladder, urethra and bony pelvis was created from materials easily purchased online. Each participant performed several trials of urethrovesical anastomosis using the da Vinci Si® surgical system. Pre-task confidence was assessed prior to each attempt. Two blinded researchers measured the following outcomes: time-to-anastomosis, number of suture throws, perpendicular needle entry and atraumatic needle driving. Integrity of the anastomosis was estimated by gravity filling and measuring pressure at which leakage occurred. These outcomes were translated into an independently validated Prostatectomy Assessment Competency Evaluation score.

RESULTS

The model took 2 hours to create and total cost was 64 U.S. dollars. Twenty-one residents enrolled and demonstrated significant improvement in time-to-anastomosis, perpendicular needle driving, anastomotic pressure and total Prostatectomy Assessment Competency Evaluation score between the first and third trial. Pre-task confidence was measured on a Likert scale (1-5) and improved significantly over the 3 trials (Likert scale of 1.8, 2.8 and 3.3).

CONCLUSIONS

We developed a cost-effective model of urethrovesical anastomosis that does not require the use of a 3D printer. This study demonstrates significant improvement of fundamental surgical skills and validated surgical assessment score for urology trainees over several trials. Our model shows potential for increasing accessibility of robotic training models for urological education. Additional investigation will be required to further assess the utility and validity of this model.

Higher mycophenolate dosage is associated with an increased risk of squamous cell carcinoma in kidney transplant recipients

BACKGROUND

Kidney transplant recipients are at increased risk of keratinocyte cancers, namely squamous cell and basal cell carcinomas (SCCs and BCCs). This is primarily due to the high levels of immunosuppression that are required to prevent allograft rejection. Different immunosuppressive medications confer different risks, and the effect of mycophenolate mofetil on SCC and BCC risk is unclear. We explored the relationship between mycophenolate dose prescribed over the entire transplant period and the risk of SCC and BCC.

METHODS

Kidney transplant recipients from Queensland, Australia, were recruited between 2012 and 2014 and followed until mid-2016. During this time transplant recipients underwent regular skin examinations to diagnose incident SCCs and BCCs. Immunosuppressive medication regimens were obtained from hospital records, and the average mycophenolate dose/day over the entire transplantation period was calculated for each patient. Doses were divided into three ranked groups, and adjusted relative risks (RR_adj) of developing SCC and BCC tumours were calculated using negative binomial regression with the lowest dosage group as reference. Recipients who had used azathioprine previously were excluded; further sub-group analysis was performed for other immunosuppressant medications.

RESULTS

There were 134 kidney transplant recipients included in the study. The average age was 55, 31% were female and 69% were male. At the highest median mycophenolate dose of 1818 mg/day the SCC risk doubled (RR_adj 2.22, 95% CI 1.03-4.77) when compared to the reference group of 1038 mg/day. An increased risk persisted after accounting for ever-use of ciclosporin, ever-use of tacrolimus, and when excluding mammalian target of rapamycin users. This increased risk was mainly carried by kidney transplant recipients immunosuppressed for five or more years (RR_adj = 11.05 95% CI 2.50-48.81). In contrast, there was no significant association between BCC incidence and therapy with the highest compared with the lowest mycophenolate dosage (RR_adj = 1.27 95% CI 0.56-2.87).

CONCLUSION

Higher mycophenolate dosage is associated with increased SCCs in kidney transplant recipients, particularly those immunosuppressed for more than five years. The increased SCC risk persists after accounting for usage of other immunosuppressant medications.

O-297 Does advanced paternal age influence live birth rate independent of woman’s age: analysis of 18, 825 fresh IVF/ICSI cycles from a national (HFEA) database

Study question

Does advanced paternal age (APA) impact live birth rates (LBRs) in IVF/ICSI treatment independent of female partner’s age?

Summary answer

LBRs decline with paternal age ≥40 years, but not when female partner is &lt; 35 or ≥ 40 years.

What is known already

APA, particularly over 40 years, has been shown to be associated with declining sperm parameters, impaired embryo development, aneuploidy, compromised pregnancy outcomes and mental health abnormalities in the offspring in IVF/ICSI cycles.

However, no significant effect of APA on pregnancy outcomes has been noted in donor oocyte cycles, indicating possible positive effect of female age counteracting negative male age-related IVF/ICSI outcomes.

Data on whether female and male age influence each other, or are independently related to LBR, are limited and inconclusive.

Study design, size, duration

Retrospective analysis of 18, 825 autologous IVF or ICSI with fresh single embryo transfer (SET) cycles from the UK’s national anonymised registry, published online by the Human Fertilisation and Embryology Authority (HFEA).

Study period: 2 years starting from 1st January 2017 to 31st December 2018.

Participants/materials, setting, methods

Couples underwent IVF/ ICSI with fresh SET due to unexplained or tubal infertility. Cycles with male factor, donor sperm and preimplantation genetic testing were excluded.

Female age was grouped to &lt; 35 years, 35-39 years and 40-44 years; male age to &lt; 35 years (control group), 35-39 years, 40-44 years, 45-50 years, 51-55 years and &gt;55 years.

Chi-square to compare binominal data; multiple logistic regression to find correlation of male and female age on LBR adjusting confounders.

Main results and the role of chance

Overall, LBR per SET declined from 39.1% in men &lt;35 years (control group) to 25.9% (p &lt; 0.0001), 23.0% (p &lt; 0.0001), 22.9% (p &lt; 0.0001) and 25.4% (p = 0.002) in 40-44, 45-50, 51-55 and &gt;55 years, respectively.

However, in the subgroups of women &lt;35 years, the LBRs were no different whether men were of &lt; 35 (41.3%), 40-45 (40.8%) or &gt; 55 (41.7%) years. Similar trend was observed in women aged 40-44 years: LBRs were 12.3%, 11.9%, and 17.4% in men aged &lt;35, 40-44, and &gt;55 year, respectively. Only in women aged 35-40 years, LBRs dropped from 32.8% in men aged &lt;35 years down to 27.9% (p = 0.004), 28.1% (p = 0.04), 28.7% (p = 0.33) and 25% (p = 0.22) in 40-44, 45-50, 51-55 and &gt;55 years, respectively. The findings remained the same with ICSI only cycles.

Individually, male age, female age, treatment-type (IVF or ICSI) and day of transfer were significantly correlated with LBR. Overall, after adjusting for confounders, both male (p = 0.01) and female’s age (p &lt; 0.0001) remained independently related to LBRs.; male age did not correlate with LBRs in women aged &lt;35 years or 40-44 years.

Limitations, reasons for caution

Information on ovarian reserve and treatment protocols were not available. However, this may have little impact, given large population studied. Exclusion of male infertility might have reduced the ‘effect-size’ but was important to eliminate non-age-related male factors, in order to assess only men’s age on the pregnancy outcome.

Wider implications of the findings

Oocytes in women &lt;35 appear to reduce the negative impact of older sperm on LBR, but not in women 35-39 years of age. This is useful information when counselling couples and in fertility education setting. Further research is needed to clarity the mechanism underlying our findings.

Trial registration number

Does advanced paternal age influence live birth rate independent of woman’s age: analysis of 18, 825 fresh IVF/ICSI cycles from a national (HFEA) database

Prognostic factors and clinical outcomes in patients with upper tract urothelial carcinoma undergoing surgery: The Cleveland Clinic experience

4593

Background: Upper tract urothelial carcinoma (UTUC) is a rare and heterogeneous disease accounting for approximately 5-10% of UC. While tumor grade and stage are known prognostic factors, data on other factors affecting outcomes in UTUC patients (pts) undergoing surgery is scant. We studied effect of various clinical factors and treatment on outcomes in UTUC. Methods: This is a single-institution retrospective study of 607 pts with UTUC undergoing surgery (nephroureterectomy (NU) or ureterectomy (U)) between Jan 2000 and Dec 2020. We studied effect of demographics, clinicopathological features, tumor location, preoperative Neutrophil-to-Lymphocyte ratio (NLR) and Albumin-to-Globulin ratio (AGR) and use of neoadjuvant or adjuvant chemotherapy on overall survival (OS) and recurrence free survival (RFS). Results: Of the 607 pts 401 (66.06%) were males and 355 (58.48%) were > 70 yrs; 232 pts (38.22%) had UTUC of renal pelvis, 242 (39.87%) of ureter and 133 (21.91%) of both. 542 pts (89.29%) underwent radical NU and 65 (10.71%) segmental U; 328 patients (54.04%) were diagnosed with muscle invasive UC (MIUC) ( > / = pT2) and 276 (45.47%) with non-MIUC ( < / = pT2). Only 51 (8.4%) pts had lymph node positive (N+) disease. Lymphovascular invasion (LVI) was identified in 163 (26.85%) and carcinoma- in-situ (CIS) in 163 (26.85%) pts. Surgical margins were positive in 92 pts (15.16%). Median NLR cutoff was 3.25 and AGR cutoff was 1.25 (dichotomized based on literature). 44 pts (7.2%) received Neoadjuvant chemotherapy and 49 pts (8%) received adjuvant chemotherapy. Tumor recurrence occurred in 216 pts (35.58%) of which 65% were at urothelial and 35% at non-urothelial sites. With median follow up of 35.2 mos, median OS was 82.69 mos and 5-yr OS rate was 60%; median RFS was 29.47 mos and 5-yr RFS rate was 40%. High grade, age > / = 70 yrs, high NLR, low AGR, presence of LVI, positive margins, CIS, MIUC, N+ disease were associated with worse outcomes. Pts with only renal pelvis involvement had better OS. Conclusions: In this large, long term follow-up series of UTUC pts, we identified several prognostic factors besides grade and stage that impact outcomes. These findings warrant further validation for use in clinical practice. [Table: see text]

Profile of individuals with low back pain and factors defining chronicity of pain: a population-based study in Ethiopia

Purpose

Low back pain (LBP) is the most prevalent public health problem globally, second only to headaches in the ranking of painful disorders that affect human beings. However, evidence about the profile of LBP patients is lacking in low-income countries for appropriate management approaches. This study examined the profile of individuals with LBP and factors defining chronicity of pain in Ethiopia.

Methods

A population-based cross-sectional study design was used to collect data from 1812 adults (≥ 18 years) with LBP at present. Data were collected by interviewing the study participants using an instrument developed and validated in the same study population. The instrument includes socio-demographic information, health behaviours/lifestyle habits, beliefs about pain, and pain and general health-related characteristics of the participants. Data analysis was performed using R version 3.5.1. Both unconditional and conditional logistic regression models were fitted and Odds Ratio (OR) with 95% confidence intervals (95% CIs) were computed to identify factors significantly associated with chronicity of pain at p ≤ 0.05 significance level.

Results

Negative beliefs about pain, a varying degree of pain interference with daily and social activities, complaining of pain in other anatomical sites other than the low back region, general health status rated as not excellent, depressive symptomology, and sleeping problems/insomnia were common within the profile of individuals with LBP. Age, educational level, residential setting, beliefs about pain, and depressive symptomology were found to have a statistically significant association with chronicity of pain.

Conclusions

This study provides an overview of the profile of individuals with LBP and factors defining chronicity of pain, assisting clinicians to design appropriate management strategies to improve patients' outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11136-022-03148-5.

Biomarkers of systemic inflammation predict survival with first-line immune checkpoint inhibitors in non-small-cell lung cancer

INTRODUCTION

Pembrolizumab is an established first-line option for patients with advanced non-small-cell lung cancer (NSCLC) expressing programmed death-ligand 1 ≥50%. Durable responses are seen in a subset of patients; however, many derive little clinical benefit. Biomarkers of the systemic inflammatory response predict survival in NSCLC. We evaluated their prognostic significance in patients receiving first-line pembrolizumab for advanced NSCLC.

METHODS

Patients treated with first-line pembrolizumab for advanced NSCLC with programmed death-ligand 1 expression ≥50% at two regional Scottish cancer centres were identified. Pretreatment inflammatory biomarkers (white cell count, neutrophil count, neutrophil/lymphocyte ratio, platelet/lymphocyte ratio, albumin, prognostic nutritional index) were recorded. The relationship between these and progression-free survival (PFS) and overall survival (OS) were examined.

RESULTS

Data were available for 219 patients. On multivariate analysis, albumin and neutrophil count were independently associated with PFS (P < 0.001, P = 0.002, respectively) and OS (both P < 0.001). A simple score combining these biomarkers was explored. The Scottish Inflammatory Prognostic Score (SIPS) assigned 1 point each for albumin <35 g/l and neutrophil count >7.5 × 10⁹/l to give a three-tier categorical score. SIPS predicted PFS [hazard ratio 2.06, 95% confidence interval (CI) 1.68-2.52 (P < 0.001)] and OS [hazard ratio 2.33, 95% CI 1.86-2.92 (P < 0.001)]. It stratified PFS from 2.5 (SIPS2), to 8.7 (SIPS1) to 17.9 months (SIPS0) (P < 0.001) and OS from 5.1 (SIPS2), to 12.4 (SIPS1) to 28.7 months (SIPS0) (P < 0.001). The relative risk of death before 6 months was 2.96 (95% CI 1.98-4.42) in patients with SIPS2 compared with those with SIPS0-1 (P < 0.001).

CONCLUSIONS

SIPS, a simple score combining albumin and neutrophil count, predicts survival in patients with NSCLC receiving first-line pembrolizumab. Unlike many proposed prognostic scores, SIPS uses only routinely collected pretreatment test results and provides a categorical score. It stratifies survival across clinically meaningful time periods that may assist clinicians and patients with treatment decisions. We advocate validation of the prognostic utility of SIPS in this and other immune checkpoint inhibitor treatment settings.

Association of hysterectomy and invasive epithelial ovarian and tubal cancer: a cohort study within UKCTOCS

OBJECTIVE

To investigate the association between hysterectomy with conservation of one or both adnexa and ovarian and tubal cancer.

DESIGN

Prospective cohort study.

SETTING

Thirteen NHS Trusts in England, Wales and Northern Ireland.

POPULATION

A total of 202 506 postmenopausal women recruited between 2001 and 2005 to the UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS) and followed up until 31 December 2014.

METHODS

Multiple sources (questionnaires, hospital notes, Hospital Episodes Statistics, national cancer/death registries, ultrasound reports) were used to obtain accurate data on hysterectomy (with conservation of one or both adnexa) and outcomes censored at bilateral oophorectomy, death, ovarian/tubal cancer diagnosis, loss to follow up or 31 December 2014. Cox proportional hazards regression models were used to assess the association.

MAIN OUTCOME MEASURES

Invasive epithelial ovarian and tubal cancer (WHO 2014) on independent outcome review.

RESULTS

Hysterectomy with conservation of one or both adnexa was reported in 41 912 (20.7%; 41 912/202 506) women. Median follow up was 11.1 years (interquartile range 9.96-12.04), totalling >2.17 million woman-years. Among women who had undergone hysterectomy, 0.55% (231/41 912) were diagnosed with ovarian/tubal cancer, compared with 0.59% (945/160 594) of those with intact uterus. Multivariable analysis showed no evidence of an association between hysterectomy and invasive epithelial ovarian/tubal cancer (hazard ratio 0.98, 95% CI 0.85-1.13, P = 0.765).

CONCLUSIONS

This large cohort study provides further independent validation that hysterectomy is not associated with alteration of invasive epithelial ovarian and tubal cancer risk. These data are important both for clinical counselling and for refining risk prediction models.

TWEETABLE ABSTRACT

Hysterectomy does not alter risk of invasive epithelial ovarian and tubal cancer.

Probing Gluon Spin-Momentum Correlations in Transversely Polarized Protons through Midrapidity Isolated Direct Photons in p^{↑}+p Collisions at sqrt[s]=200 GeV

Studying spin-momentum correlations in hadronic collisions offers a glimpse into a three-dimensional picture of proton structure. The transverse single-spin asymmetry for midrapidity isolated direct photons in p^{↑}+p collisions at sqrt[s]=200  GeV is measured with the PHENIX detector at the Relativistic Heavy Ion Collider (RHIC). Because direct photons in particular are produced from the hard scattering and do not interact via the strong force, this measurement is a clean probe of initial-state spin-momentum correlations inside the proton and is in particular sensitive to gluon interference effects within the proton. This is the first time direct photons have been used as a probe of spin-momentum correlations at RHIC. The uncertainties on the results are a 50-fold improvement with respect to those of the one prior measurement for the same observable, from the Fermilab E704 experiment. These results constrain gluon spin-momentum correlations in transversely polarized protons.

What happened to the preserved renal parenchyma after partial nephrectomy?

e16581

Background: Partial nephrectomy (PN) is the standard therapy for small renal mass, despite various degree of ischemia reperfusion injury (IRI) is always inevitable as the renal artery is usually clamped during PN. In mouse IRI model, unilateral renal artery clamped for 21 minutes results to sever kidney fibrosis in one year. However, what happened to the preserved renal parenchyma after several years since PN is still a mystery. The aim of the study is to compare the pathological chronic kidney disease (CKD) score of normal renal parenchyma before and several years after PN, as well as to explore the factors that associated with CKD score increase and GFR decline. Methods: We retrospectively collected the clinicopathologic data of 114 renal cell carcinoma (RCC) patients who underwent PN and subsequent radical nephrectomy (RN) due to tumor recurrence in 19 Chinese centers and Cleveland clinic. Macroscopic normal renal parenchyma was sampled at least 5 mm away from the tumor border in PN specimen and at distal portion of the kidney in RN specimen. Pathological CKD score is a summary of glomerular, tubular, interstitial, and vascular score. MDRD2 equation was used to estimate the glomerular filtration rate (GFR). Predictive factors for CKD score increase were evaluated by logistic regression. Results: A total of 64 patients that have all the required data were included in the analysis. The median duration warm ischemia (n = 41) and hypothermia (n = 23) were both 23 min. In a median interval of 2.44 years, the CKD score arose in 73.4% (47/64) patients, with 45.3% (29/64) cases increased by ≥3. Even so, no kidney fibrosis was observed in this cohort including in those with extend warm ischemia (≥45min). There was no significant difference in the change of CKD score during patients with different ischemia time and type. However, patients with comorbidities such as hypertension, diabetes mellitus or CKD (HTN/DM/CKD) showed higher rate and extent of CKD score increase. In multivariate analysis, HTN/DM/CKD was found to be an independent predictor for the CKD score increase [OR:4.24 (1.23-14.64)]. However, the decline of GFR was mild and analogous between patients with or without CKD score increase (23.03±22.53ml/min/1.73m2 vs. 24.27±21.79ml/min/1.73m2, p = 0.856). Conclusions: In majority, preserved renal parenchyma after PN suffered pathological deterioration. Ischemia time and type seem to have limited impact on the change of CKD score of preserved renal parenchyma during PN. Patients with HTN/DM/CKD have higher risk of CKD score increase in despite of similar mild GFR deterioration.

Numerical estimates of square lattice star vertex exponents

We implement parallel versions of the generalized atmospheric Rosenbluth methods and Wang-Landau algorithms for stars and for acyclic uniform branched networks in the square lattice. These are models of monodispersed branched polymers, and we estimate the star vertex exponents σ_{f} for f stars, and the entropic exponent γ_{G} for networks with comb and brush connectivity in two dimensions. Our results verify the predicted (but not rigorously proven) exact values of the vertex exponents and we test the scaling relation [B. Duplantier, J. Stat. Phys. 54, 581 (1989)JSTPBS0022-471510.1007/BF01019770]γ_{G}-1=[under ∑]f≥1m_{f}σ_{f}for several acyclic branched networks in two dimensions.

Macrophage immunomodulation through new polymers that recapitulate functional effects of itaconate as a power house of innate immunity

Itaconate (ITA) is an emerging powerhouse of innate immunity with therapeutic potential that is limited in its ability to be administered in a soluble form. We developed a library of polyester materials that incorporate ITA into polymer backbones resulting in materials with inherent immunoregulatory behavior. Harnessing hydrolytic degradation release from polyester backbones, ITA polymers resulted in the mechanism specific immunoregulatory properties on macrophage polarization in vitro. In a functional assay, the polymer-released ITA inhibited bacterial growth on acetate. Translation to an in vivo model of biomaterial associated inflammation, intraperitoneal injection of ITA polymers demonstrated a rapid resolution of inflammation in comparison to a control polymer silicone, demonstrating the value of sustained biomimetic presentation of ITA.

Retention of radiographers: A qualitative exploration of factors influencing decisions to leave or remain within the NHS

INTRODUCTION

In many countries a widening imbalance exists between radiographer workforce supply and demand. Improving retention is a rapid method of workforce expansion which is gaining importance with policy makers and providers. To better understand the current leaver profile, this study aimed to identify why radiographers leave the NHS early, and what incentives are important in their decision to stay.

METHODS

A qualitative framework methodology used semi-structured telephone interviews to explore the perspectives of radiography managers, radiographers who have left the NHS, and those considering leaving. Purposive sampling ensured representation across radiography professional groups, geographical and organisational diversity, and stages of career.

RESULTS

Three over-arching themes were identified across all radiographer professional groups (n = 44): 1) Challenging working patterns and the impact on employee health and wellbeing; 2) Lack of flexibility in working terms and conditions; 3) Lack of timely career progression and access to CPD, and the need to feel valued. Radiographers were keen to express how they 'loved being a radiographer'; small concessions and changes to workplace culture might be the incentive to remain in radiography that some were clearly searching for. Manager participants recognised the need to offer greater flexibility in working patterns but this was challenging within financial and service delivery constraints.

CONCLUSIONS

While some influencing factors varied between radiographer professional groups, the three themes were consistent across participants. Failure to address these concerns will exacerbate the loss of experienced and highly trained staff from the NHS at a time when demand for services continues to rise.

IMPACT ON PRACTICE

Recommendations are presented related to three primary themes which will be a catalyst for sharing of best practice between radiology and radiotherapy centres.

Facilitating individuals and families affected by fragile X syndrome to participate in medication trials

BACKGROUND

Recently, there has been an increasing number of trials of medications for fragile X syndrome (FXS). In order to be adequately powered, trials have involved many centres around the world with relatively small numbers of participants recruited at each site. This study aims to understand the barriers to, and how best to facilitate participation in, medication trials in order to improve recruitment and the experience of participants with FXS.

METHODS

A mixed methods design was used to collect both quantitative and qualitative data. Participants were invited to participate through the UK Fragile X Society, a local mailing list and through social media. Those who agreed to participate completed a quantitative questionnaire and indicated whether they would be willing to participate in a follow-up focus group.

RESULTS

The questionnaire was completed by 328 individuals who either had FXS, or were a parent, carer or family member of an individual with FXS. Over two-thirds of participants reported concern about side effects, while over one-third mentioned swallowing tablets, blood tests, financial aspects and travel as barriers to participation. Focus groups with 12 individuals highlighted themes of trial challenges, strategies to overcome these and motivating factors to participate.

CONCLUSIONS

Many of the factors, which potentially negatively influence participation in a clinical trial for FXS, could be mitigated in relatively simple ways. Easily accessible information, particularly about safety issues, the research team and the trial environment should be standard practice. Desensitisation programmes for blood testing, provision of different preparations of medication (e.g. liquid) and use of a combination of local, remote and site visits to reduce travel and time should also be considered.

Serial endometrial thickness and risk of non-endometrial hormone-dependent cancers in postmenopausal women in UK Collaborative Trial of Ovarian Cancer Screening

OBJECTIVE

Estrogen is a well-established risk factor for various cancers. It causes endometrial proliferation, which is assessed routinely as endometrial thickness (ET) using transvaginal ultrasound (TVS). Only one previous study, restricted to endometrial and breast cancer, has considered ET and the risk of non-endometrial cancer. The aim of this study was to explore the association between baseline and serial ET measurements and nine non-endometrial hormone-sensitive cancers, in postmenopausal women, using contemporary statistical methodology that attempts to minimize the biases typical of endogenous serial data.

METHODS

This was a cohort study nested within the UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS). In the ultrasound arm of UKCTOCS, 50639 postmenopausal women, aged 50-74, underwent annual TVS examination, of whom 38 105 had a valid ET measurement, no prior hysterectomy and complete covariate data, and were included in this study. All women were followed up through linkage to national cancer registries. The effect of ET on the risk of six estrogen-dependent cancers (breast, ovarian, colorectal, bladder, lung and pancreatic) was assessed using joint models for longitudinal biomarker and time-to-event data, and Cox models were used to assess the association between baseline ET measurement and these six cancers in addition to liver cancer, gastric cancer and non-Hodgkin's lymphoma (NHL). All models were adjusted for current hormone-replacement therapy (HRT) use, body mass index, age at last menstrual period, parity and oral contraceptive pill use.

RESULTS

The 38 105 included women had a combined total of 267 567 (median, 8; interquartile range, 5-9) valid ET measurements. During a combined total of 407 838 (median, 10.9) years of follow-up, 1398 breast, 351 endometrial, 381 lung, 495 colorectal, 222 ovarian, 94 pancreatic, 79 bladder, 62 gastric, 38 liver cancers and 52 NHLs were registered. Using joint models, a doubling of ET increased significantly the risk of breast (hazard ratio (HR), 1.21; 95% CI, 1.09-1.36; P = 0.001), ovarian (HR, 1.39; 95% CI, 1.06-1.82; P = 0.018) and lung (HR, 1.25; 95% CI, 1.02-1.54; P = 0.036) cancers. There were no statistically significant associations between ET and the remaining six cancers.

CONCLUSION

Postmenopausal women with high/increasing ET on TVS are at increased risk of breast, ovarian and lung cancer. It is important that clinicians are aware of these risks, as TVS is a common investigation. © 2019 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.

Erratum: Evolution of π^{0} Suppression in Au+Au Collisions from sqrt[s_{NN}]=39 to 200 GeV [Phys. Rev. Lett. 109, 152301 (2012)]

This corrects the article DOI: 10.1103/PhysRevLett.109.152301.

A phase Ib trial of neoadjuvant/adjuvant durvalumab +/- tremelimumab in locally advanced renal cell carcinoma (RCC)

5021

Background: Effective neoadjuvant and adjuvant therapies are lacking in locally advanced RCC. Given robust activity of checkpoint inhibitors in mRCC, a phase Ib trial of perioperative Durvalumab (D) +/- Tremelimumab (T) in locally advanced RCC was conducted (NCT02762006). Methods: Pts with radiographic evidence of high risk localized RCC (clinical stage T2b-4 and/or N1, M0 disease), adequate performance status, and adequate laboratory values were eligible. Primary objective was safety and feasibility of neoadjuvant/adjuvant D +/- T. Results: Twenty-nine pts were enrolled. Cohorts, regimens, and immune-related adverse events (irAE) are detailed in the table. In total, 79% male, median age 61 (range, 42-84), 8%/88%/4% clinical T2/T3/T4, 27% positive clinical lymph nodes (LN+), and median time from neoadjuvant dose to surgery was 7 days. On surgical pathology: 5%/14%/77%/5% pathologic T1/T2/T3/T4, and 13% LN+. Median time from treatment to first grade (Gr) >3 irAE or any Gr irAE requiring corticosteroids was 99 days (range, 32-207). There were no treatment-related delays to nephrectomy or surgical complications. Although not meeting the protocol-defined MTD, given higher than expected irAEs, the study was suspended. Conclusions: Perioperative durvalumab in locally advanced RCC appears safe. The addition of tremelimumab is associated with higher rates of toxicity. Updated toxicity will be presented. Clinical trial information: NCT02762006 . [Table: see text]

Determinants of healthcare utilisation for low back pain: A population-based study in Ethiopia

Low back pain (LBP) remains one of the major public health problems worldwide. However, in low-income countries, such as those in Africa, the epidemiological data on healthcare utilisation for LBP are lacking due to more pressing problems such as infectious diseases, to which the majority of health resources are channelled. Therefore, this study aimed at investigating the determinants of healthcare utilisation for LBP in the general population of Ethiopia. A population-based cross-sectional study was conducted in South-West Shewa zone of Ethiopia from June to November 2018. The data were collected by interviewing adults with LBP (n = 1812, randomly selected) using a psychometrically tested and validated instrument, analysed using R version 3.5.1. A log-binomial regression model was used to determine the prevalence ratio with a 95% confidence interval (CI) in identifying factors associated with healthcare utilisation for LBP. Estimates of population parameters were also presented with 95% CIs and p values. For all applications of inferential statistics, a p value of ≤.05 was taken as the significance level. The lifetime prevalence of healthcare utilisation for LBP was 36.1%, 95% CI: 33.9-38.1, while the annual prevalence rate was 30%, 95% CI: 27.9-32.2. Of those with a 1-year history of healthcare utilisation, while 7.4%, 95% CI: 4.9-10.3 rural and 36.6%, 95% CI: 29.5-44 urban populations utilised healthcare from general hospitals, 1.4%, 95% CI: 0.3-2.7 rural and 6.8%, 95% CI: 3.1-10.8 urban populations utilised healthcare from specialised hospitals. Several sociodemographic factors, modifiable health behaviours/lifestyle habits, pain interrelated factors, and specific factors such as beliefs about the pain, depressive symptoms and insomnia were associated with healthcare utilisation for LBP. The implications of this research are that it may be prudent for the Ethiopian healthcare policy makers to develop the necessary strategies to meet the health needs of both urban and rural populations with LBP.