It's not a virus! Reconceptualizing and de-pathologizing music performance anxiety

Music Performance Anxiety (MPA) is one of the most widespread and debilitating challenges facing musicians, affecting significant numbers of performers in terms of both their personal and professional functioning. Although numerous interventions exist to target MPA, its prevalence remains unchanged since the first large-scale studies of the 1980s, indicating that available interventions are having limited impact. This review synthesizes and critiques existing literature in order to investigate possible reasons for the limited efficacy of current approaches to managing MPA. Key concepts discussed include conceptual and methodological challenges surrounding defining MPA, theoretical perspectives on MPA's etiology and manifestation, and the coping strategies and interventions used to manage MPA. MPA has predominantly been investigated pathologically and defined as a negative construct manifesting in unwanted symptoms. Based on this conceptualization, interventions largely seek to manage MPA through ameliorating symptoms. This review discusses possible reasons why this approach has broadly not proved successful, including the issue of relaxation being both unrealistic and counterproductive for peak performance, issues associated with intentionally changing one's state creating resistance thus exacerbating anxiety, and focusing on the presence of, rather than response to, symptoms. Despite 50 years of research, MPA remains an unsolved enigma and continues to adversely impact musicians both on and off the stage. Reconceptualizing MPA as a normal and adaptive response to the pressures of performance may offer a new perspective on it, in terms of its definition, assessment and management, with practical as well as theoretical implications.

Advanced quantitative evaluation of PET systems using the ACR phantom and NiftyPET software

PURPOSE

A novel phantom-imaging platform, a set of software tools, for automated and high-precision imaging of the American College of Radiology (ACR) positron emission tomography (PET) phantom for PET/magnetic resonance (PET/MR) and PET/computed tomography (PET/CT) systems is proposed.

METHODS

The key feature of this platform is the vector graphics design that facilitates the automated measurement of the knife-edge response function and hence image resolution, using composite volume of interest templates in a 0.5 mm resolution grid applied to all inserts of the phantom. Furthermore, the proposed platform enables the generation of an accurate μ $\mu$ -map for PET/MR systems with a robust alignment based on two-stage image registration using specifically designed PET templates. The proposed platform is based on the open-source NiftyPET software package used to generate multiple list-mode data bootstrap realizations and image reconstructions to determine the precision of the two-stage registration and any image-derived statistics. For all the analyses, iterative image reconstruction was employed with and without modeled shift-invariant point spread function and with varying iterations of the ordered subsets expectation maximization (OSEM) algorithm. The impact of the activity outside the field of view (FOV) was assessed using two acquisitions of 30 min each, with and without the activity outside the FOV.

RESULTS

The utility of the platform has been demonstrated by providing a standard and an advanced phantom analysis including the estimation of spatial resolution using all cylindrical inserts. In the imaging planes close to the edge of the axial FOV, we observed deterioration in the quantitative accuracy, reduced resolution (FWHM increased by 1-2 mm), reduced contrast, and background uniformity due to the activity outside the FOV. Although it slows convergence, the PSF reconstruction had a positive impact on resolution and contrast recovery, but the degree of improvement depended on the regions. The uncertainty analysis based on bootstrap resampling of raw PET data indicated high precision of the two-stage registration.

CONCLUSIONS

We demonstrated that phantom imaging using the proposed methodology with the metric of spatial resolution and multiple bootstrap realizations may be helpful in more accurate evaluation of PET systems as well as in facilitating fine tuning for optimal imaging parameters in PET/MR and PET/CT clinical research studies.

Training injury incidence in an amateur women's rugby union team in New Zealand over two consecutive seasons

OBJECTIVES

To describe the training injury incidence in amateur women's rugby union in New Zealand over two consecutive seasons.

DESIGN

A prospective cohort observational study METHODS: A total of 69 amateur women's rugby 15s team playerswere observed. Training exposure and training injury incidence were calculated.

RESULTS

The 38 training injuries resulted in a total injury incidence of 11.4 (8.3-15.6) per 1,000 training-hours. There were 12 injuries that resulted in a time-loss injury incidence of 3.6 (95% CI: 2.0-6.3) per 1,000 training-hours. Forwards recorded more total (RR: 1.8 [95% CI: 0.9-3.5]; p=0.0516) and time-loss (RR: 2.0 [95% CI: 0.6-6.6]; p=0.2482) injuries than Backs. The tackle was the most common injury cause for total (3.0 [95% CI: 1.6-5.6] per 1,000 training-hours.) injuries, but collisions (1.5 [95% CI: 0.6-3.6] per 1,000 training-hours.) with the ground or another person were the most common cause for time-loss injuries.The training injuries occurred most often to the lower limb and during the latter part of training sessions. These injuries were mostly minor in nature resulting in minimal time-loss away from training.

DISCUSSION

The time-loss injury incidence (3.6 per 1,000 training-hours.) for the amateur women's rugby 15s team players was higher than that reported for National (1.2 per 1,000 training-hours.) and Rugby World Cup for women (0.2 to 3.0 per 1,000 training-hours.) competitions.

CONCLUSION

The training injury incidence in amateur women's rugby union in New Zealand was higher than that reported for national and international rugby union injury incidences.

Emotion Regulation Processes Can Benefit Self-Regulated Learning in Classical Musicians

Self-regulated learning (SRL) is the degree to which students are metacognitively, motivationally, and behaviourally active participants in their own learning process. It involves the self-regulation of cognitive, behavioural, and affective processes. SRL holds significant potential for enhancing practise and achievement. Although affect is acknowledged as one of the three fundamental processes in SRL, there is limited research investigating it. However, emotions have been found to influence SRL efficiency while emotion regulation (ER) can impact learning outcomes. Thus, this study sought to investigate how ER processes relate to SRL among professional musicians who perform Western classical music. Four forms of regulation (reappraisal, suppression, rumination, repression) were examined in relation to the SRL three-phase model. Professional musicians (N = 334) of 39 nationalities (age: 18–66; [M = 28]; female = 215; male = 119) completed a survey comprising the Self-Regulated Learning in Music Questionnaire, the Emotion Regulation Questionnaire, and demographic items. A significant positive correlation emerged between SRL and reappraisal, and significant negative correlations emerged between SRL and the other three processes. Further multiple linear regression analysis revealed that reappraisal, practise hours, and expertise accounted for 26% of the variance in SRL. Finally, a factorial (2 × 2 × 2) ANOVA yielded significant group differences on ER as a function of gender, expertise, and occupation. Results suggest that reappraisal can enhance the use of SRL in musicians, thus highlighting the potential utility in considering ER as part of SRL. These results suggest that by including training on emotion regulation strategies within musicians’ educational institutions and workplaces, efficiency and engagement in SRL can be enhanced. This could produce more effective learning strategies and outcomes, together with higher musical achievements.

Thrombus formation on bioprosthetic aortic valves

Background

18F-GP1 is a novel radiotracer with a high affinity for the platelet glycoprotein IIb/IIIa receptor. Subclinical bioprosthetic valve thrombus has been postulated as a trigger for accelerated valve degeneration.

Purpose

To determine the feasibility of 18F-GP1 positron-emission tomography-computed tomography (PET-CT) for the detection of subclinical bioprosthetic aortic valve thrombus.

Methods

(i) Explanted degenerated aortic valve prostheses underwent histology and imaging. (ii) In a prospective observational study, patients with bioprosthetic aortic valve replacement (AVR) underwent echocardiography and 18F-GP1 PET-CT. Valves were assessed for hypoattenuating leaflet thickening (HALT), hypo-attenuation affection leaflet motion (HAM) and GP1 uptake.

Results

(i) GP1 correlated with thrombus on explanted valves (Figure). (ii) The first 6 patients (Table) were asymptomatic and had normally functioning surgical bioprostheses on echocardiography. At a median of 166 (range 122–189) days post-AVR, no patients had HALT or HAM on CT. There was avid focal GP1 uptake on the leaflets of all 6 patients which appeared most prominent along the leaflet edges (Figure). Only one patient had focal uptake in the valve frame, remote from the leaflets. In a separate cohort undergoing 18F-GP1 PET-CT for other conditions, there was no uptake on normal, native aortic valves (n=8).

Conclusion

For the first time, we demonstrate that 18F-GP1 PET-CT is a highly sensitive method of assessing platelet activation on bioprosthetic aortic valves. Despite the absence of CT evidence, early thrombus appeared to be a universal finding on recently implanted valve prostheses. The biological and clinical implications of subclinical bioprosthetic aortic valve thrombus have yet to be established.

GP1 uptake in AVR

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): British Heart Foundation

The clinical and cost effectiveness of surgical interventions for stones in the lower pole of the kidney: the percutaneous nephrolithotomy, flexible ureterorenoscopy and extracorporeal shockwave lithotripsy for lower pole kidney stones randomised controlled trial (PUrE RCT) protocol

INTRODUCTION

Renal stones are common, with a lifetime prevalence of 10% in adults. Global incidence is increasing due to increases in obesity and diabetes, with these patient populations being more likely to suffer renal stone disease. Flank pain from stones (renal colic) is the most common cause of emergency admission to UK urology departments. Stones most commonly develop in the lower pole of the kidney (in ~35% of cases) and here are least likely to pass without intervention. Currently there are three technologies available within the UK National Health Service to remove lower pole kidney stones: extracorporeal shockwave lithotripsy (ESWL), percutaneous nephrolithotomy (PCNL) and flexible ureterorenoscopy (FURS) with laser lithotripsy. Current evidence indicates there is uncertainty regarding the management of lower pole stones, and each treatment has advantages and disadvantages. The aim of this trial is to determine the clinical and cost effectiveness of FURS compared with ESWL or PCNL in the treatment of lower pole kidney stones.

METHODS

The PUrE (PCNL, FURS and ESWL for lower pole kidney stones) trial is a multi-centre, randomised controlled trial (RCT) evaluating FURS versus ESWL or PCNL for lower pole kidney stones. Patients aged ≥16 years with a stone(s) in the lower pole of either kidney confirmed by non-contrast computed tomography of the kidney, ureter and bladder (CTKUB) and requiring treatment for a stone ≤10 mm will be randomised to receive FURS or ESWL (RCT1), and those requiring treatment for a stone >10 mm to ≤25 mm will be randomised to receive FURS or PCNL (RCT2). Participants will undergo follow-up by questionnaires every week up to 12 weeks post-intervention and at 12 months post-randomisation. The primary clinical outcome is health status measured by the area under the curve calculated from multiple measurements of the EuroQol five dimensions five-level version (EQ-5D-5L) questionnaire up to 12 weeks post-intervention. The primary economic outcome is the incremental cost per quality-adjusted life year gained at 12 months post-randomisation.

DISCUSSION

The PUrE trial aims to provide robust evidence on health status, quality of life, clinical outcomes and resource use to directly inform choice and National Health Service provision of the three treatment options.

TRIAL REGISTRATION

ISRCTN: ISRCTN98970319. Registered on 11 November 2015.

Conservatory Musicians' Temporal Organization and Self-Regulation Processes in Preparing for a Music Exam

Performing at the very highest levels requires rigorous preparation before the important performance. Musicians and especially music students encounter many challenges when preparing themselves for an important musical performance. This study sought to identify and analyze the context-specific temporal organization and self-regulation efforts that music students employ during their preparation period. Conservatory musicians were recruited from an Australian University Conservatorium. Thirteen conservatory musicians aged between 19 and 21 years (M = 19.6; SD = 0.76) participated in the study. All musicians, through an elicitation interview, were asked to recall and reconstruct their preparation period, leading up to a performance exam. Elicitation interviews provided access to music students' experiences by describing their general preparation. The results showed that conservatory musicians go through different phases (Phase 1: Choosing a piece; Phase 2: Piece discovery; Phase 3: Piece interpretation; Phase 4: Performance preparation). Self-regulatory efforts to prepare for a music performance exam vary from one musician to another. Organizational and disorganizational competencies, specific self-regulatory skills, seem not to be exploited by conservatory musicians. Also, during their preparation, most music students prefer technical and musical work than challenges such as playing in front of the public. Emotionally, conservatory musicians go through pleasant and unpleasant emotions depending on the phase of their preparation. Our results show that music students could benefit from advice on how to organize their preparation period well before an important performance takes place. Implications for conservatory musicians and teachers are discussed.

Dalton's and Amagat's laws fail in gas mixtures with shock propagation

A shock propagating through a gas mixture leads to pressure, temperature, and density increases across the shock front. Rankine-Hugoniot relations correlating pre- and post-shock quantities describe a calorically perfect gas but deliver a good approximation for real gases, provided the pre-shock conditions are well characterized with a thermodynamic mixing model. Two classic thermodynamic models of gas mixtures are Dalton's law of partial pressures and Amagat's law of partial volumes. We measure post-shock temperature and pressure in experiments with nonreacting binary mixtures of sulfur hexafluoride and helium (two dramatically disparate gases) and show that neither model can accurately predict the observed values, on time scales much longer than that of the shock front passage, due to the models' implicit assumptions about mixture behavior on the molecular level. However, kinetic molecular theory can help account for the discrepancy. Our results provide starting points for future theoretical work, experiments, and code validation.

TECRA® Unique™ Test for Rapid Detection of Salmonella in Food: Collaborative Study

The TECRA® Unique™ Salmonella test uses the principle of immunoenrichment to allow rapid detection of Salmonellae in food. A collaborative study was conducted to compare the TECRA Salmonella Unique test with the reference culture method given in the U.S. Food and Drug Administration's Bacteriological Analytical Manual. Three food types (milk powder, pepper, and soy flour) were analyzed in Australia and 2 food types (milk chocolate and dried egg) were analyzed in the United States. Forty-one collaborators participated in the study. For each of the 5 foods at each of the 3 levels, a comparison showed no significant differences (p ≥ 0.05) in the proportion of positive test samples for Unique and that for the reference method using the Chi-square test for independence with continuity correction.

VIDAS® Enzyme-Linked Immunofluorescent Assay for Detection of Listeria in Foods: Collaborative Study

The VIDAS LIS method and the traditional culture methods for detection of Listeria species in food were evaluated in a multilaboratory comparative study. The 6 foods tested were either naturally contaminated or inoculated with 3 different concentrations of Listeria. Results for each food and each contamination level with the VIDAS LIS method were as good as or better than those obtained with the traditional culture method. Of 1558 samples tested, 935 were positive: 839 by the VIDAS method and 809 by standard culture methods. Overall false negative rates were 10.3 and 13.5% for the VIDAS LIS and culture methods, respectively. The false positive rate for the VIDAS LIS assay was 1.4% based on 9 VIDAS LIS positive assays that did not confirm positive by isolation of Listeria. The agreement between the VIDAS LIS and culture methods for all samples tested was 86%.

Oxidative Stress and Cardiovascular Risk in Type 1 Diabetes Mellitus: Insights From the DCCT/EDIC Study

Background

Hyperglycemia leading to increased oxidative stress is implicated in the increased risk for the development of macrovascular and microvascular complications in patients with type 1 diabetes mellitus.

Methods and Results

A random subcohort of 349 participants was selected from the DCCT / EDIC (Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications) cohort. This included 320 controls and 29 cardiovascular disease cases that were augmented with 98 additional known cases to yield a case cohort of 447 participants (320 controls, 127 cases). Biosamples from DCCT baseline, year 1, and closeout of DCCT , and 1 to 2 years post‐ DCCT ( EDIC years 1 and 2) were measured for markers of oxidative stress, including plasma myeloperoxidase, paraoxonase activity, urinary F 2α isoprostanes, and its metabolite, 2,3 dinor‐8 iso prostaglandin F 2α . Following adjustment for glycated hemoblobin and weighting the observations inversely proportional to the sampling selection probabilities, higher paraoxonase activity, reflective of antioxidant activity, and 2,3 dinor‐8 iso prostaglandin F 2α , an oxidative marker, were significantly associated with lower risk of cardiovascular disease (−4.5% risk for 10% higher paraoxonase, P <0.003; −5.3% risk for 10% higher 2,3 dinor‐8 iso prostaglandin F 2α , P =0.0092). In contrast, the oxidative markers myeloperoxidase and F 2α isoprostanes were not significantly associated with cardiovascular disease after adjustment for glycated hemoblobin. There were no significant differences between DCCT intensive and conventional treatment groups in the change in all biomarkers across time segments.

Conclusions

Heightened antioxidant activity (rather than diminished oxidative stress markers) is associated with lower cardiovascular disease risk in type 1 diabetes mellitus, but these biomarkers did not change over time with intensification of glycemic control.

Clinical Trial Registration

URL : https://www.clinicaltrials.gov . Unique identifiers: NCT 00360815 and NCT 00360893.

A water-soluble, bay-functionalized perylenediimide derivative - correlating aggregation and excited state dynamics

The aggregation and the photophysics of a water soluble perylenediimide (PDI) derivative that features two bromine substituents in the bay positions has been probed. Non-fluorescent aggregates were found to be present at concentrations of 1.0 × 10^-5 M. In situ small-angle X-ray scattering (SAXS) measurements and complementary molecular modeling showed the presence of PDI aggregates. In their singlet excited states, the PDI aggregates are characterized by distinct transient fingerprints and rapid deactivation, as revealed by pump-probe experiments on the femto-, pico-, nano-, and microsecond timescales. The product of this deactivation is a PDI triplet excited state. The efficiency of the triplet formation depends on the concentration, and hence on the degree of aggregation. Notably, for PDI concentrations in the range of the critical micelle concentration, the efficiency of intersystem crossing is close to zero. In short, we have demonstrated, for the first time, aggregation-induced formation of triplet excited states for PDI derivatives.

Perceived Enablers and Barriers to Optimal Health among Music Students: A Qualitative Study in the Music Conservatoire Setting

Student health and wellbeing within higher education has been documented as poor in relation to the general population. This is a particular problem among students at music conservatoires, who are studying within a unique educational context that is known to generate both physical and psychological challenges. This article examines how conservatoire students experience health and wellbeing within their institutional context, using a framework from health promotion to focus attention on perceived enablers and barriers to optimal health in relation to three levels: lifestyle, support services, and conservatoire environment. In order to respond to the individuality of students’ experiences, a qualitative approach was taken based on semi-structured interviews with 20 current or recent conservatoire students in the United Kingdom. Thematic analysis revealed a complex set of enablers and barriers: (i) lifestyle enablers included value placed on the importance of optimal health and wellbeing for musicians and daily practices to enable this; lifestyle barriers included struggling to maintain healthy lifestyles within the context of musical practice and learning; (ii) support enablers included accessible support sources within and beyond the conservatoire; support barriers included a perceived lack of availability or awareness of appropriate support; (iii) environmental enablers included positive and enjoyable experiences of performance as well as strong relationships and communities; environmental barriers included experiences of comparison and competition, pressure and stress, challenges with negative performance feedback, psychological distress, and perceived overwork. The findings reveal a need for health promotion to focus not only on individuals but also on the daily practices and routines of conservatoires. Additionally, they suggest that continued work is required to embed health and wellbeing support as an integral component of conservatoire education, raising awareness so that all students are fully informed of where, and how, to seek the information or help that they may need. Finally, they indicate a need for more radical scrutiny of the cultures of conservatoires and an assessment of how these can be modified to best optimize students’ health and wellbeing.

Impact of major vascular resection on short- and long-term outcomes in patients with intrahepatic cholangiocarcinoma

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Background: Major vascular (IVC or portal vein) resection for Intrahepatic Cholangiocarcinoma (ICC) has traditionally been considered a relative contraindication to resection. We sought to define perioperative outcomes and survival of ICC patients undergoing liver surgery with major vascular resection using a multi-institutional database. Methods: 1,087 ICC patients who underwent liver resection between 1990-2016 were identified from 13 participating institutions. Multivariable logistic and cox regressions were used to determine the impact of major vascular resection on perioperative outcomes and long-term overall survival. Results: Of 1,087 patients who underwent resection, 128(11.8%) also underwent major vascular resection [21(16.4%)IVC resections, 98(76.6%)PV resections, 9(7.0%)combined resections]. One hundred eighty-seven(17.2%) patients received neoadjuvant therapy. Most patients underwent a major hepatectomy involving ≥ 3 liver segments(n = 664,61.1%). On final pathology, the majority of patients had T1(40.4%) or T2(35.5%) tumors; 194(17.8%) had lymph node metastasis. Patients undergoing major vascular resection had more advanced T3/T4 tumors [44(34.4%) vs. 137(14.3%) without resection;P < 0.001]. Of note, major vascular resection was not associated with the risk of any complication (OR .680,95%CI 0.32-1.45) or major complication (OR 0.69,95%CI 0.35-1.33); post-operative mortality was also comparable between groups (OR 1.06, 95%CI 0.32-3.48). In addition, median recurrence-free (14.0 months vs.14.7 months, HR.737,95%CI .49-1.10) and overall (33.4 months vs.40.2 months, HR .709,95%CI.36-1.40) survival were similar among patients who did and did not undergo major vascular resection, respectively(both P > 0.05). Conclusions: Among patients with ICC, major vascular resection was not associated with increased peri-operative morbidity or mortality at major centers. Long-term outcomes following resection of ICC requiring vascular resection were also comparable to outcomes following resection of tumors without vascular involvement. Concurrent major vascular resection should be considered in appropriately selected ICC patients.

The Influence of Head Impact Threshold for Reporting Data in Contact and Collision Sports: Systematic Review and Original Data Analysis

BACKGROUND

Head impacts and resulting head accelerations cause concussive injuries. There is no standard for reporting head impact data in sports to enable comparison between studies.

OBJECTIVE

The aim was to outline methods for reporting head impact acceleration data in sport and the effect of the acceleration thresholds on the number of impacts reported.

METHODS

A systematic review of accelerometer systems utilised to report head impact data in sport was conducted. The effect of using different thresholds on a set of impact data from 38 amateur senior rugby players in New Zealand over a competition season was calculated.

RESULTS

Of the 52 studies identified, 42% reported impacts using a >10-g threshold, where g is the acceleration of gravity. Studies reported descriptive statistics as mean ± standard deviation, median, 25th to 75th interquartile range, and 95th percentile. Application of the varied impact thresholds to the New Zealand data set resulted in 20,687 impacts of >10 g, 11,459 (45% less) impacts of >15 g, and 4024 (81% less) impacts of >30 g.

DISCUSSION

Linear and angular raw data were most frequently reported. Metrics combining raw data may be more useful; however, validity of the metrics has not been adequately addressed for sport. Differing data collection methods and descriptive statistics for reporting head impacts in sports limit inter-study comparisons. Consensus on data analysis methods for sports impact assessment is needed, including thresholds. Based on the available data, the 10-g threshold is the most commonly reported impact threshold and should be reported as the median with 25th and 75th interquartile ranges as the data are non-normally distributed. Validation studies are required to determine the best threshold and metrics for impact acceleration data collection in sport.

CONCLUSION

Until in-field validation studies are completed, it is recommended that head impact data should be reported as median and interquartile ranges using the 10-g impact threshold.

Using carbon nanodots as inexpensive and environmentally friendly sensitizers in mesoscopic solar cells

We discuss the use of carbon nanodots (CNDs) as sensitizers in mesoscopic solar cells. The CNDs are synthesized using a one-step, bottom-up microwave approach with citric acid, urea, and formic acid as precursors in aqueous media. Their light-harvesting capabilities can be tuned by adjusting the synthetic parameters. Comprehensive spectroscopic and theoretical studies allow us to rationalize the nature of their absorption features. Promising power conversion efficiencies (η) of 0.24% can be achieved from these cheap and eco-friendly sensitizers by optimizing the solar-cell assembly process. Interestingly, we found that extending the light absorption towards longer wavelengths does not necessarily improve the performance of the solar cells, since the longer-wavelength absorption features hardly contribute to the cells' photo-action spectra, so that the overall power conversion efficiency is actually worse. The origin of the lower performance is corroborated in transient absorption spectroscopy and photovoltage decay measurements. Our work points, on one hand, to the limits of as-synthesized CNDs as photosensitizers and, on the other hand, to possible improvements.

Use of drug therapy in the management of symptomatic ureteric stones in hospitalised adults: a multicentre, placebo-controlled, randomised controlled trial and cost-effectiveness analysis of a calcium channel blocker (nifedipine) and an alpha-blocker (tamsulosin) (the SUSPEND trial)

BACKGROUND

Ureteric colic, the term used to describe the pain felt when a stone passes down the ureter from the kidney to the bladder, is a frequent reason for people to seek emergency health care. Treatment with the muscle-relaxant drugs tamsulosin hydrochloride (Petyme, TEVA UK Ltd) and nifedipine (Coracten(®), UCB Pharma Ltd) as medical expulsive therapy (MET) is increasingly being used to improve the likelihood of spontaneous stone passage and lessen the need for interventional procedures. However, there remains considerable uncertainty around the effectiveness of these drugs for routine use.

OBJECTIVES

To determine whether or not treatment with either tamsulosin 400 µg or nifedipine 30 mg for up to 4 weeks increases the rate of spontaneous stone passage for people with ureteric colic compared with placebo, and whether or not it is cost-effective for the UK NHS.

DESIGN

A pragmatic, randomised controlled trial comparing two active drugs, tamsulosin and nifedipine, against placebo. Participants, clinicians and trial staff were blinded to treatment allocation. A cost-utility analysis was performed using data gathered during trial participation.

SETTING

Urology departments in 24 UK NHS hospitals.

PARTICIPANTS

Adults aged between 18 and 65 years admitted as an emergency with a single ureteric stone measuring ≤ 10 mm, localised by computerised tomography, who were able to take trial medications and complete trial procedures.

INTERVENTIONS

Eligible participants were randomised 1 : 1 : 1 to take tamsulosin 400 µg, nifedipine 30 mg or placebo once daily for up to 4 weeks to make the following comparisons: tamsulosin or nifedipine (MET) versus placebo and tamsulosin versus nifedipine.

MAIN OUTCOME MEASURES

The primary effectiveness outcome was the proportion of participants who spontaneously passed their stone. This was defined as the lack of need for active intervention for ureteric stones at up to 4 weeks after randomisation. This was determined from 4- and 12-week case-report forms completed by research staff, and from the 4-week participant self-reported questionnaire. The primary economic outcome was the incremental cost per quality-adjusted life-year (QALY) gained over 12 weeks. We estimated costs from NHS sources and calculated QALYs from participant completion of the European Quality of Life-5 Dimensions health status questionnaire 3-level response (EQ-5D-3L™) at baseline, 4 weeks and 12 weeks.

RESULTS

Primary outcome analysis included 97% of the 1167 participants randomised (378/391 tamsulosin, 379/387 nifedipine and 379/399 placebo participants). The proportion of participants who spontaneously passed their stone did not differ between MET and placebo [odds ratio (OR) 1.04, 95% confidence interval (CI) 0.77 to 1.43; absolute difference 0.8%, 95% CI -4.1% to 5.7%] or between tamsulosin and nifedipine [OR 1.06, 95% CI 0.74 to 1.53; absolute difference 1%, 95% CI -4.6% to 6.6%]. There was no evidence of a difference in QALYs gained or in cost between the trial groups, which means that the use of MET would be very unlikely to be considered cost-effective. These findings were unchanged by extensive sensitivity analyses around predictors of stone passage, including sex, stone size and stone location.

CONCLUSIONS

Tamsulosin and nifedipine did not increase the likelihood of stone passage over 4 weeks for people with ureteric colic, and use of these drugs is very unlikely to be cost-effective for the NHS. Further work is required to investigate the phenomenon of large, high-quality trials showing smaller effect size than meta-analysis of several small, lower-quality studies.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN69423238. European Clinical Trials Database (EudraCT) number 2010-019469-26.

FUNDING

This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 63. See the NIHR Journals Library website for further project information.

Abstract PD6-08: IMAGE: Individualized molecular analyses guide efforts in breast cancer with comprehensive genomic profiling of tissue and plasma tumor DNA

Background: Standard treatment options for patients with metastatic triple negative breast cancer (TNBC) are limited to chemotherapy. Molecular profiling of tumors may allow for novel treatment recommendations.

Methods: We initiated a prospective study designated IMAGE. Women with newly progressing metastatic TNBC who received at least one line of prior chemotherapy were eligible. New metastatic biopsies were obtained for molecular profiling at study entry. Archived metastatic biopsy specimens were allowed if patients had not commenced new systemic therapy. The specimens were reviewed by the study pathologist and stained for ER, PR, HER2, and androgen receptor (AR) by immunohistochemistry. Specimens underwent hybrid-capture based comprehensive genomic profiling (CGP) (Foundation Medicine Inc., Cambridge, MA). Clinical data and genomic profiling reports were reviewed by the GAITWAY (Genomic Alterations in Tumors with Actionable Yields) Molecular Profile Tumor Board. Recommendations were communicated to the treating oncologist and patients were followed for treatment decision and clinical outcomes. Peripheral blood was also analyzed by an investigational assay for circulating plasma tumor DNA (ptDNA) (Foundation Medicine Inc.) at study entry, and when obtainable, from serial blood draws at time of progression. The primary objective was to assess feasibility of completing the process from consent to GAITWAY recommendations within 28 days for at least 80% of patients.

Results: From September 2013 to April 2015, we enrolled 26 eligible women. Median age was 55 (range 25-67); patients identified as white 12 (46%), black 11 (42%), or other 3 (12%); median number of prior lines of treatment was 3; and 65.4% of patients had visceral disease. Twenty (77%) eligible patients received CGP of a metastatic site biopsy. Six patients did not undergo CGP due to either absence of a metastatic site amenable for biopsy or inadequate tissue for CGP. The study met the predefined statistical endpoint for futility and was closed after 20 patients had undergone CGP. Twelve (60%) evaluable patients received treatment recommendations within 28 days of study consent. Failure to meet this time frame was due to difficulties in accessing archival tumor tissue (N=5) and need for additional tissue for molecular analysis (N=3). Preliminary results demonstrate high concordance between mutations in metastatic biopsies and ptDNA in 15/17 patients.

Enrolled in IMAGE26Successful NGS20Potentially actionable mutation identified15GAITWAY recommended targeted therapy as possible next treatment13Received targeted therapy4

Conclusions: CGP of patients with metastatic TNBC can provide additional information that may help direct treatment. However, difficulties in obtaining adequate tumor tissue may hinder this approach. Use of a well-validated ptDNA profiling assay could be an alternative to overcome these limitations.

Citation Format: Parsons HA, Beaver JA, Cimino-Mathews A, Zorzi J, Slater S, Clark T, Lipson D, Ali SM, Kennedy M, Otto GA, Young LE, Jeter S, VanDenBerg DA, Rosner GL, Park BH, Stearns V. IMAGE: Individualized molecular analyses guide efforts in breast cancer with comprehensive genomic profiling of tissue and plasma tumor DNA. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr PD6-08.

Management of cardiac arrest survivors in UK intensive care units: a survey of practice

BACKGROUND

Cardiac arrest is a common presentation to intensive care units. There is evidence that management protocols between hospitals differ and that this variation is mirrored in patient outcomes between institutions, with standardised treatment protocols improving outcomes within individual units. It has been postulated that regionalisation of services may improve outcomes as has been shown in trauma, burns and stroke patients, however a national protocol has not been a focus for research. The objective of our study was to ascertain current management strategies for comatose post cardiac arrest survivors in intensive care in the United Kingdom.

METHOD

A telephone survey was carried out to establish the management of comatose post cardiac arrest survivors in UK intensive care units. All 235 UK intensive care units were contacted and 208 responses (89%) were received.

RESULTS

A treatment protocol is used in 172 units (82.7%). Emergency cardiology services were available 24 hours a day, 7 days a week in 54 (26%) hospitals; most units (123, 55.8%) transfer patients out for urgent coronary angiography. A ventilator care bundle is used in 197 units (94.7%) and 189 units (90.9%) have a policy for temperature management. Target temperature, duration and method of temperature control and rate of rewarming differ between units. Access to neurophysiology investigations was poor with 91 units (43.8%) reporting no availability.

CONCLUSIONS

Our results show that treatments available vary considerably between different UK institutions with only 28 units (13.5%) able to offer all aspects of care. This suggests the need for 'cardiac arrest care bundles' and regional centres to ensure cardiac arrests survivors have access to appropriate care.

The interface of inflammation and subclinical atherosclerosis in granulomatosis with polyangiitis (Wegener's): a preliminary study

The objective of this study is to assess the relationship between inflammatory disease in granulomatosis with polyangiitis (GPA, Wegener's) and the development of subclinical atherosclerosis. A total of 46 adult patients with GPA were enrolled. Disease status was measured by Birmingham vasculitis assessment scores as modified for GPA, vasculitis damage index, disease duration, and number of relapses. Classic atherosclerotic risk factors, platelet aggregation responses, and circulating microparticle (MP) levels were recorded. All patients underwent carotid artery intima-media thickness (IMT) measurement as outcome for subclinical atherosclerosis. In univariate analyses, systolic and diastolic blood pressure, creatinine, and age were significantly associated with higher IMT (ρ values 0.37, 0.38, 0.35, and 0.054, respectively [P < 0.02 for all]). In a multiple regression model, greater number of relapses, older age at the onset of disease, and higher diastolic blood pressure were found to be associated with higher IMT (P values 0.003, <0.001, and 0.031, respectively). MP counts and platelet reactivity correlated well with disease activity in GPA. Furthermore, MPs were found to activate vascular endothelial cells and platelets in vitro. The cumulative burden of systemic inflammation in GPA correlated with the development of subclinical atherosclerosis. The correlation with subclinical atherosclerosis could be because of glucocorticoid use and not the inflammatory process in GPA, giving the inherent bias that exits with the use of glucocorticoid with each relapse. The findings of increased levels of circulating leukocyte-derived MPs and enhanced platelet reactivity during relapse suggest possible roles for MPs and platelets in disease pathogenesis and support a growing literature that links inflammation, atherosclerosis, and platelet activation. This hypothesis is further substantiated by our demonstration that MPs isolated from plasma of GPA patients can activate platelets and vascular endothelial cells.

Medical expulsive therapy in adults with ureteric colic: a multicentre, randomised, placebo-controlled trial

BACKGROUND

Meta-analyses of previous randomised controlled trials concluded that the smooth muscle relaxant drugs tamsulosin and nifedipine assisted stone passage for people managed expectantly for ureteric colic, but emphasised the need for high-quality trials with wide inclusion criteria. We aimed to fulfil this need by testing effectiveness of these drugs in a standard clinical care setting.

METHODS

For this multicentre, randomised, placebo-controlled trial, we recruited adults (aged 18-65 years) undergoing expectant management for a single ureteric stone identified by CT at 24 UK hospitals. Participants were randomly assigned by a remote randomisation system to tamsulosin 400 μg, nifedipine 30 mg, or placebo taken daily for up to 4 weeks, using an algorithm with centre, stone size (≤5 mm or >5 mm), and stone location (upper, mid, or lower ureter) as minimisation covariates. Participants, clinicians, and trial personnel were masked to treatment assignment. The primary outcome was the proportion of participants who did not need further intervention for stone clearance within 4 weeks of randomisation, analysed in a modified intention-to-treat population defined as all eligible patients for whom we had primary outcome data. This trial is registered with the European Clinical Trials Database, EudraCT number 2010-019469-26, and as an International Standard Randomised Controlled Trial, number 69423238.

FINDINGS

Between Jan 11, 2011, and Dec 20, 2013, we randomly assigned 1167 participants, 1136 (97%) of whom were included in the primary analysis (17 were excluded because of ineligibility and 14 participants were lost to follow-up). 303 (80%) of 379 participants in the placebo group did not need further intervention by 4 weeks, compared with 307 (81%) of 378 in the tamsulosin group (adjusted risk difference 1·3% [95% CI -5·7 to 8·3]; p=0·73) and 304 (80%) of 379 in the nifedipine group (0·5% [-5·6 to 6·5]; p=0·88). No difference was noted between active treatment and placebo (p=0·78), or between tamsulosin and nifedipine (p=0·77). Serious adverse events were reported in three participants in the nifedipine group (one had right loin pain, diarrhoea, and vomiting; one had malaise, headache, and chest pain; and one had severe chest pain, difficulty breathing, and left arm pain) and in one participant in the placebo group (headache, dizziness, lightheadedness, and chronic abdominal pain).

INTERPRETATION

Tamsulosin 400 μg and nifedipine 30 mg are not effective at decreasing the need for further treatment to achieve stone clearance in 4 weeks for patients with expectantly managed ureteric colic.

FUNDING

UK National Institute for Health Research Health Technology Assessment Programme.

Use of the King-Devick test for sideline concussion screening in junior rugby league

AIM

To determine whether the King-Devick (K-D) test used as a sideline test in junior rugby league players over 12 matches in a domestic competition season could identify witnessed and incidentally identified episodes of concussion.

METHODS

A prospective observational cohort study of a club level junior rugby league team (n=19) during the 2014 New Zealand competition season involved every player completing two pre-competition season baseline trials of the K-D test. Players removed from match participation, or who reported any signs or symptoms of concussion were assessed on the sideline with the K-D test and referred for further medical assessment. Players with a pre- to post-match K-D test difference >3s were referred for physician evaluation.

RESULTS

The baseline test-retest reliability of the K-D test was high (rs=0.86; p<0.0001). Seven concussions were medically identified in six players who recorded pre- to post-match K-D test times greater than 3s (mean change of 7.4s). Post-season testing of players demonstrated improvement of K-D time scores consistent with learning effects of using the K-D test (67.7s vs. 62.2s).

DISCUSSION

Although no witnessed concussions occurred during rugby play, six players recorded pre- to post-match changes with a mean delay of 4s resulting in seven concussions being subsequently confirmed post-match by health practitioners. All players were medically managed for a return to sports participation.

CONCLUSION

The K-D test was quickly and easily administered making it a practical sideline tool as part of the continuum of concussion assessment tools for junior rugby league players.

Correction: Influences on and patterns in total gaseous mercury (TGM) at Harwell, England

Correction for ‘Influences on and patterns in total gaseous mercury (TGM) at Harwell, England’ by J. Kentisbeer et al., Environ. Sci.: Processes Impacts, 2015, DOI: 10.1039/c4em00652f.

Influences on and patterns in total gaseous mercury (TGM) at Harwell, England

Total gaseous mercury (TGM) was monitored during 2013 at the rural monitoring site, Harwell, England using the Tekran 2537A monitoring system. Average TGM for the year was 1.45 ± 0.24 ng m(-3). This is comparable to other northern hemisphere studies, but on average 0.5 ng m(-3) higher than at its sister monitoring station at Auchencorth Moss, Scotland, but 14% lower than that found in a similar study at the same location of 1.68 ng m(-3) in 1995/6. Using wind sector analysis we show the important influence of local emissions, with our data showing that the largest influence on TGM observed is that of the adjacent Science & Innovation campus, making the site more a 'suburban background'. By using co-located measurements of black carbon and sulphur dioxide as tracers, we present an initial investigation into the impact of the closure of Didcot A coal fired power station, which ceased operating in March 2013. Further analysis using air mass back trajectories shows the long-range contribution to TGM from continental Europe, and that the lowest levels are associated with marine air masses from the west.