An HLA-E-targeted TCR bispecific molecule redirects T cell immunity against Mycobacterium tuberculosis

Peptides presented by HLA-E, a molecule with very limited polymorphism, represent attractive targets for T cell receptor (TCR)-based immunotherapies to circumvent the limitations imposed by the high polymorphism of classical HLA genes in the human population. Here, we describe a TCR-based bispecific molecule that potently and selectively binds HLA-E in complex with a peptide encoded by the inhA gene of Mycobacterium tuberculosis (Mtb), the causative agent of tuberculosis in humans. We reveal the biophysical and structural bases underpinning the potency and specificity of this molecule and demonstrate its ability to redirect polyclonal T cells to target HLA-E-expressing cells transduced with mycobacterial inhA as well as primary cells infected with virulent Mtb. Additionally, we demonstrate elimination of Mtb-infected cells and reduction of intracellular Mtb growth. Our study suggests an approach to enhance host T cell immunity against Mtb and provides proof of principle for an innovative TCR-based therapeutic strategy overcoming HLA polymorphism and therefore applicable to a broader patient population.

Brain Function and Pain Interference after Pediatric Intensive Interdisciplinary Pain Treatment

BACKGROUND AND OBJECTIVES

Intensive interdisciplinary pain treatments (IIPTs) are programs that aim to improve functioning in youth with severe chronic pain. Little is known about how the brain changes following IIPT, however, decreased brain responses to emotional stimuli have been identified previously in pediatric chronic pain relative to healthy controls. We examined whether IIPT increased brain responses to emotional stimuli, and whether this change was associated with a reduction in pain interference.

METHODS

Twenty youth with chronic pain aged 14-18 years were scanned using fMRI, pre- and post-IIPT. During the fMRI, patients were presented with emotional stimuli (i.e., faces expressing happiness/fear), neutral expressions, and control (i.e., scrambled) images. Patients completed a measure of pain interference pre- and post-IIPT. Paired t-tests were used to examine differences in brain activation in response to emotional versus neutral stimuli, pre- to post-IIPT. Data from significant brain clusters were entered into linear mixed models to examine the relationships between brain activation and impairment pre- and post-IIPT.

RESULTS

Patients demonstrated a decrease in middle frontal gyrus (MFG) activation in response to emotional stimuli (happy + fear) relative to scrambled images, between pre- and post-IIPT (P<0.05). Lower MFG activation was associated with lower pain interference, pre- and-post IIPT (P<0.05).

CONCLUSION

Contrary to our hypothesis, IIPT was associated with a reduction in MFG activation to emotional stimuli, and this change was associated with reduced pain interference. The MFG is a highly interconnected brain area involved in both pain chronification and antinociception. With further validation of these results, the MFG may represent an important biomarker for evaluating patient treatment response and target for future pain interventions.

Sleep disturbances, altered brain microstructure and chronic headache in youth

Chronic headache (persistent or recurrent headache for 3-months or longer) is highly prevalent among youth. While sleep disturbances have been associated with headache, their inter-relationship with brain connectivity remains unknown. This observational study examined whether self-report and actigraphy measures of sleep were associated with alterations to white matter tracts (i.e., uncinate fasciculus and cingulum) in youth with chronic headache versus healthy controls. Thirty youth aged 10-18 years with chronic headache and thirty controls underwent an MRI. Diffusion tensor images were obtained and mean fractional anisotropy values of the cingulum and uncinate were extracted. One-week prior to their MRI, youth wore an actigraph to obtain sleep duration, wake after sleep onset and sleep efficiency measures. Moreover, they completed questionnaires regarding their sleep quality and pain symptomatology. Linear regression was applied to examine the relationships between sleep (self-report and actigraphy), fractional anisotropy, and number of headache days per month. Self-report and actigraphy measures of sleep did not differ between patients and controls. However, poorer self-reported sleep quality was associated with lower fractional anisotropy values in the left uncinate (P = 0.05). Lower left uncinate fractional anisotropy was related to increased headache frequency (P = 0.002) in youth with chronic headache. Therefore, alterations to connectivity may be associated with the relationship between altered perceptions of sleep and headache chronicity.

Trajectories of pain intensity, pain catastrophizing, and pain interference in the perinatal and postpartum period

Introduction

Chronic pain (pain >3 months) is a growing epidemic. Normal pregnancy may give rise to recurrent and sometimes constant pain for women. Women with worse pain symptoms are more likely to report symptoms of anxiety, depression, and/or insomnia during the perinatal period, which may impact labor and delivery outcomes. We examined the relationship between demographic and psychological predictors of pain throughout pregnancy and into the postpartum.

Objectives

To examine trajectories of pain intensity, pain catastrophizing, and pain interference during pregnancy and the early postpartum, and associated sociodemographic predictors of trajectory membership.

Methods

One hundred forty-two pregnant women were assessed at 4 time points for measures of pain intensity, pain catastrophizing, pain interference, and symptoms of insomnia, depression, and generalized anxiety. Women completed the first survey before 20 weeks' gestation and were reassessed every 10 weeks. Surveys were completed on average at 15 weeks', 25 weeks', and 35 weeks' gestation, and at 6-week postpartum. Using latent class mixed models, trajectory analysis was used to determine trajectories of pain intensity, pain catastrophizing, and pain interference.

Results

A 1-class pain intensity model, 2-class pain catastrophizing model, and 3-class pain interference model were identified. Adaptive lasso and imputation demonstrated model robustness. Individual associations with trajectories included baseline symptoms of anxiety, depression, and insomnia, and pain symptomology.

Conclusion

These findings may help to identify women who are at high risk for experiencing pain symptoms during pregnancy and could aid in developing targeted management strategies to prevent mothers from developing chronic pain during their pregnancy and into the postpartum period.

Association of epidural analgesia in labor with neurodevelopmental outcomes in premature infants born at <29 weeks of gestational age

OBJECTIVE

To explore associations between epidural administration to mothers in labor with neurodevelopmental outcomes at 3 years corrected age in preterm infants born <29 weeks gestational age.

STUDY DESIGN

Infants born <29 weeks gestational age between 2006 and 2012 were included. Our primary outcome was a composite of death or neurodevelopmental impairment at 3 years corrected age. Infants were divided into those whose mothers did or did not receive epidural analgesia in labor. Univariable and multivariable regression was used for analysis.

RESULTS

There were 548 infants in the no epidural analgesia group and 121 in the epidural analgesia group. The adjusted odds ratio (95%CI) of neurodevelopmental impairment or death in the epidural group was 1.25 (0.82-1.93). Propensity score-matched results were 1.32 (0.79-2.22).

CONCLUSION

Preterm infants born <29 weeks gestational age to mothers who received epidural analgesia during labor were not associated with poor neurodevelopmental outcomes at 3 years corrected age.

Alcohol to-go sales policies at on-premise drinking establishments near large public US universities during the COVID-19 pandemic

AIMS

Sweeping policy changes during the COVID-19 pandemic increased alcohol availability through permitted to-go sales, potentially posing unique risks to college students. While to-go sales may make binge drinking more convenient, little remains known about these practices. Therefore, this study aimed to assess whether drinking establishments' to-go sales practices are associated with their other operational practices and state policy.

METHOD

This cross-sectional analysis included 221 randomly selected bars, nightclubs, and restaurants within two miles of a large public university. Telephone interviews assessed establishment practices, and the Alcohol Policy Information System provided state alcohol to-go laws. Regression models tested whether establishment to-go sales practices were associated with their business practices (logistic regression) and state policy (generalized estimating equations).

RESULTS

Nearly one-half (44.8%) of drinking establishments sold alcohol to-go. Establishments with higher vodka prices had nearly 30% higher odds of selling spirits to-go (aOR = 1.29) and establishments offering happy hours specials had more than twice the odds of selling beer (aOR = 2.22), wine (aOR = 2.53), and spirits to-go (aOR = 2.60). Additionally, establishments that implemented physical distance requirements had higher odds of selling wine to-go (aOR = 3.00). State to-go laws were associated with higher odds of selling wine (aOR = 3.99) and spirits to-go (aOR = 5.43) in the full sample and beer to-go (aOR = 4.92) in urban counties.

CONCLUSIONS

Establishments that sell alcohol to-go tend to engage in other practices designed to drive sales. Evaluations of alcohol to-go sales laws on risky consumption among priority populations, including college students, are urgently needed to inform decisions about how to appropriately regulate sales.

Parent Anxiety, Depression, Protective Responses, and Parenting Stress in the Context of Parent and Child Chronic Pain: A Daily Diary Study of Parent Variability

Parents with (vs without) chronic pain report poorer psychosocial functioning (eg, worse mental health, parenting difficulties), which has been linked to poorer child outcomes (eg, child pain). However, emerging research suggests that individuals vary in their functioning from day-to-day, particularly those with chronic pain. This study used daily diaries to compare parents with (versus without) chronic pain on variability in their anxiety, mood, protective responses, and parenting stress. We also examined parent chronic pain status as a moderator of the associations between parent variability and youth daily pain and interference. Participants were 76 youth with chronic pain (Mage = 14.26; 71.1% female) and one of their parents (89.5% mothers; n = 38 or 50.0% endorsing chronic pain). Parents and youth completed self-report questionnaires and 7 days of diaries. Parent variability was calculated to reflect the frequency and size of day-to-day changes. Multilevel models revealed that parents with (vs without) chronic pain were significantly more variable in their parenting stress, but not in their anxiety, mood, or protective responses. Contrary to hypotheses, parent variability was not significantly related to youth daily pain intensity or interference and parent chronic pain did not moderate any associations. Instead, mean levels of parent anxiety, protective responses, and parenting stress across the week significantly predicted youth daily pain interference. Findings suggest that while variability was observed among parents (with and without chronic pain) of youth with chronic pain, it did not significantly predict youth's daily pain-related functioning. Further research is needed to confirm these initial findings. PERSPECTIVE: Parents with chronic pain have expressed concerns that the variable nature of their pain negatively impacts their children. Our results found that parents (with and without chronic pain) were variable in their anxiety, mood, protective responses, and parenting stress, but this variability did not significantly predict youth's chronic pain-related functioning.

Instability of the HLA-E peptidome of HIV presents a major barrier to therapeutic targeting

Naturally occurring T cells that recognize microbial peptides via HLA-E, a nonpolymorphic HLA class Ib molecule, could provide the foundation for new universal immunotherapeutics. However, confidence in the biological relevance of putative ligands is crucial, given that the mechanisms by which pathogen-derived peptides can access the HLA-E presentation pathway are poorly understood. We systematically interrogated the HIV proteome using immunopeptidomic and bioinformatic approaches, coupled with biochemical and cellular assays. No HIV HLA-E peptides were identified by tandem mass spectrometry analysis of HIV-infected cells. In addition, all bioinformatically predicted HIV peptide ligands (>80) were characterized by poor complex stability. Furthermore, infected cell elimination assays using an affinity-enhanced T cell receptor bispecific targeted to a previously reported HIV Gag HLA-E epitope demonstrated inconsistent presentation of the peptide, despite normal HLA-E expression on HIV-infected cells. This work highlights the instability of the HIV HLA-E peptidome as a major challenge for drug development.

Allopurinol and cardiovascular outcomes in patients with ischaemic heart disease: the ALL-HEART RCT and economic evaluation

Background

Allopurinol is a xanthine oxidase inhibitor that lowers serum uric acid and is used to prevent acute gout flares in patients with gout. Observational and small interventional studies have suggested beneficial cardiovascular effects of allopurinol.

Objective

To determine whether allopurinol improves major cardiovascular outcomes in patients with ischaemic heart disease.

Design

Prospective, randomised, open-label, blinded endpoint multicentre clinical trial.

Setting

Four hundred and twenty-four UK primary care practices.

Participants

Aged 60 years and over with ischaemic heart disease but no gout.

Interventions

Participants were randomised (1 : 1) using a central web-based randomisation system to receive allopurinol up to 600 mg daily that was added to usual care or to continue usual care.

Main outcome measures

The primary outcome was the composite of non-fatal myocardial infarction, non-fatal stroke or cardiovascular death. Secondary outcomes were non-fatal myocardial infarction, non-fatal stroke, cardiovascular death, all-cause mortality, hospitalisation for heart failure, hospitalisation for acute coronary syndrome, coronary revascularisation, hospitalisation for acute coronary syndrome or coronary revascularisation, all cardiovascular hospitalisations, quality of life and cost-effectiveness. The hazard ratio (allopurinol vs. usual care) in a Cox proportional hazards model was assessed for superiority in a modified intention-to-treat analysis.

Results

From 7 February 2014 to 2 October 2017, 5937 participants were enrolled and randomised to the allopurinol arm (n = 2979) or the usual care arm (n = 2958). A total of 5721 randomised participants (2853 allopurinol; 2868 usual care) were included in the modified intention-to-treat analysis population (mean age 72.0 years; 75.5% male). There was no difference between the allopurinol and usual care arms in the primary endpoint, 314 (11.0%) participants in the allopurinol arm (2.47 events per 100 patient-years) and 325 (11.3%) in the usual care arm (2.37 events per 100 patient-years), hazard ratio 1.04 (95% confidence interval 0.89 to 1.21); p = 0.65. Two hundred and eighty-eight (10.1%) participants in the allopurinol arm and 303 (10.6%) participants in the usual care arm died, hazard ratio 1.02 (95% confidence interval 0.87 to 1.20); p = 0.77. The pre-specified health economic analysis plan was to perform a 'within trial' cost-utility analysis if there was no statistically significant difference in the primary endpoint, so NHS costs and quality-adjusted life-years were estimated over a 5-year period. The difference in costs between treatment arms was +£115 higher for allopurinol (95% confidence interval £17 to £210) with no difference in quality-adjusted life-years (95% confidence interval -0.061 to +0.060). We conclude that there is no evidence that allopurinol used in line with the study protocol is cost-effective.

Limitations

The results may not be generalisable to younger populations, other ethnic groups or patients with more acute ischaemic heart disease. One thousand six hundred and thirty-seven participants (57.4%) in the allopurinol arm withdrew from randomised treatment, but an on-treatment analysis gave similar results to the main analysis.

Conclusions

The ALL-HEART study showed that treatment with allopurinol 600 mg daily did not improve cardiovascular outcomes compared to usual care in patients with ischaemic heart disease. We conclude that allopurinol should not be recommended for the secondary prevention of cardiovascular events in patients with ischaemic heart disease but no gout.

Future work

The effects of allopurinol on cardiovascular outcomes in patients with ischaemic heart disease and co-existing hyperuricaemia or clinical gout could be explored in future studies.

Trial registration

This trial is registered as EU Clinical Trials Register (EudraCT 2013-003559-39) and ISRCTN (ISRCTN 32017426).

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 11/36/41) and is published in full in Health Technology Assessment; Vol. 28, No. 18. See the NIHR Funding and Awards website for further award information.

Remote monitoring of patients with rheumatoid arthritis: a mixed methods evaluation across six hospitals in London, UK

OBJECTIVES

This study evaluated the scale-up of a remote monitoring (RM) service, capturing monthly Rheumatoid Arthritis Impact of Disease scores and patient-generated text messages, for patients with rheumatoid arthritis (RA; in remission or with low disease activity) attending routine outpatient clinics across six hospitals. We explored patients and staff experiences and implementation outcomes.

METHODS

A pragmatic, mixed methods approach was used, with active patient involvement throughout. We undertook a rapid review, analysed service-level data, and conducted a patient survey and patient and staff interviews, informed by the Capability, Opportunity, Motivation, Behaviour (COM-B) and Exploration, Preparation, Implementation, Sustainment (EPIS) theoretical frameworks.

RESULTS

The review included 37 articles, covering themes of patient and clinician acceptability, engagement, feasibility and clinical impact. Service-level data (n = 202) showed high levels of patient engagement with the service. The patient survey (n = 155) showed patients felt the service was easy to use, had confidence in it and felt it improved access to care. Patient interview (n = 22) findings mirrored those of the survey. Motivating factors included increased responsiveness and ease of contact with clinical teams. Views from staff interviews (n = 16) were more mixed. Some implementation barriers were specific to roll-out sites. Prioritisation of staff needs was emphasised.

CONCLUSION

Patients were positive about the service and engagement was high. Staff views and engagement were more mixed. Results suggest that equal levels of patient and staff engagement are required for sustainability. These findings further our understanding of the implementation challenges to scaling RM interventions for patients with RA in routine care settings.

Delta-8 THC Retail Availability, Price, and Minimum Purchase Age

Background: Retail sales of Delta-8 tetrahydrocannabinol (THC) products have increased in the U.S. market since the passing of the 2018 Farm Bill, and there is currently little regulation of marketing/sales and limited related safety standards in many states. After thousands of calls to poison control centers (40% for individuals under 18 years old and 70% requiring health care facility evaluation), the Food and Drug Administration issued warnings on Delta-8 THC products, stating their psychoactive effects and that some manufacturers may synthesize Delta-8 using unsafe household chemicals. The current study describes the Delta-8 THC retail sales environment in Fort Worth, Texas. Given its relatively inexpensive manufacturing and that low prices are a major determinant of cannabis use, the price of Delta-8 THC products was examined. This study also examined whether retail outlets in areas with greater socioeconomic deprivation had higher odds of selling Delta-8 THC products. This is important because if Delta-8 THC retailers are disproportionately located in more socioeconomically deprived communities, residents of these communities can more easily access these products and may have higher risk of adverse consequences. Methods: Potential Delta-8 THC retailers were selected by identifying lists of current retail locations with alcohol, cannabidiol, and/or tobacco licenses in Fort Worth. Trained research assistants called outlets in September and October 2021 to query about sales of products containing Delta-8 THC. The response rate was 69% (n=1,223). Outlets' 9-digit zip codes were merged with Area Deprivation Index scores. Products and purported minimum age were described. Chi-squared and Student's t-tests were used. Results: Eleven percent of outlets (n=133) reported selling Delta-8 THC. Ninety-six percent sold vapes and/or "flower" (i.e., hemp leaves coated with Delta-8 THC distillate) and 76% sold edibles. Among the least expensive products available, edibles cost, on average, $8.58 less than flower/vapes (p<0.001). Outlets that sold Delta-8 THC were located in areas with greater deprivation (p=0.02). Most reported a minimum purchase age of 21; however, 4% reported 18 years or no minimum age. Conclusions: Delta-8 THC retail outlets were disproportionately located in areas with more socioeconomic deprivation. Legal intervention such as zoning, minimum age, and tax laws may help reduce Delta-8 THC-related disparities.

The analgesic effect of transversalis fascia plane block after caesarean section under spinal anaesthesia with intrathecal morphine: a randomised controlled trial

We aimed to test whether bilateral injection of bupivacaine 0.25% in the transversalis fascia plane reduced 24 h opioid dose after singleton caesarean section, under spinal anaesthesia with intrathecal morphine, compared with saline 0.9% injectate. We allocated randomly 52 women to bilateral injection of 20 ml saline 0.9% on arrival in the post-anaesthesia care unit and 54 women to bilateral injection of 20 ml bupivacaine 0.25% (with adrenaline 2.5 μg.ml-1 ). Mean (SD) cumulative morphine equivalent opioid dose 24 h after saline injection was 32.3 (28.3) mg and 18.7 (20.2) mg after bupivacaine injection, a mean (95%CI) difference of 13.7 (4.1-23.2) mg (p = 0.006). Median (IQR [range]) time to first postoperative opioid dose was 3.0 (1.5-10.3 [0.0-57.4]) h after saline 0.9% and 8.2 (2.7-29.6 [0.2-55.4]) h after bupivacaine 0.25% (p = 0.054). Transversalis fascia plane with bupivacaine 0.25% with adrenaline reduced postoperative pain at rest during 48 h (0-10-point scale) by a mean (95%CI) of 0.9 (0.2-1.6) points (p = 0.013) and on movement by 1.2 (0.4-2.1) points (p = 0.004). We conclude that transversalis fascia plane bupivacaine 0.25% with adrenaline reduces pain and opioid dose after caesarean section compared with saline 0.9%.

Randomised controlled trial of analgesia for the management of acute severe pain from traumatic injury: study protocol for the paramedic analgesia comparing ketamine and morphine in trauma (PACKMaN)

BACKGROUND

Prehospital analgesia is often required after traumatic injury, currently morphine is the strongest parenteral analgesia routinely available for use by paramedics in the United Kingdom (UK) when treating patients with severe pain. This protocol describes a multi-centre, randomised, double blinded trial comparing the clinical and cost-effectiveness of ketamine and morphine for severe pain following acute traumatic injury.

METHODS

A two arm pragmatic, phase III trial working with two large NHS ambulance services, with an internal pilot. Participants will be randomised in equal numbers to either (1) morphine or (2) ketamine by IV/IO injection. We aim to recruit 446 participants over the age of 16 years old, with a self-reported pain score of 7 or above out of 10. Randomised participants will receive a maximum of 20 mg of morphine, or a maximum of 30 mg of ketamine, to manage their pain. The primary outcome will be the sum of pain intensity difference. Secondary outcomes measure the effectiveness of pain relief and overall patient experience from randomisation to arrival at hospital as well as monitoring the adverse events, resource use and cost-effectiveness outcomes.

DISCUSSION

The PACKMAN study is the first UK clinical trial addressing the clinical and cost-effectiveness of ketamine and morphine in treating acute severe pain from traumatic injury treated by NHS paramedics. The findings will inform future clinical practice and provide insights into the effectiveness of ketamine as a prehospital analgesia.

TRIAL REGISTRATION

ISRCTN, ISRCTN14124474. Registered 22 October 2020, https://www.isrctn.com/ISRCTN14124474.

Epidemiological and strain characteristics of invasive meningococcal disease prior to, during and after COVID-19 pandemic restrictions in England

OBJECTIVES

In 2020, COVID-19 pandemic restrictions led to a major suppression of meningococcal disease in England. Here we describe the epidemiology of invasive meningococcal disease in the three years prior to the COVID-19 pandemic, and the three years immediately after the introduction of restrictions.

METHODS

The UK Health Security Agency conducts national meningococcal disease surveillance in England consisting of laboratory-based case confirmation with strain characterisation by culture and/or molecular detection, as well as clinical follow-up of all cases.

RESULTS

In the pre-pandemic period, 554-742 IMD cases were laboratory-confirmed per year. MenB caused 57.2% of cases, followed by MenW (22.7%), MenY (10.6%) and MenC (7.7%). The introduction of restrictions in late March 2020 led to a 73% reduction in IMD. After the removal of restrictions in 2021, a resurgence in MenB was observed, primarily in teenagers and young adults. During the following winter period (2022/23), MenB disease increased to the highest level since 2012 with cases rising across multiple age groups, however, cases in young children eligible for MenB vaccination remained lower than prior to the pandemic. MenACWY cases remained very low throughout the pandemic period.

CONCLUSIONS

Once pandemic restrictions in England were removed, MenB quickly rebounded- initially driven by a resurgence in teenagers/young adults, but later among other age groups. MenACWY cases remain very low due to the protection afforded by the adolescent MenACWY conjugate vaccine programme.

Rotator cuff outcomes and mental health indices: Correlation or causation?

Background

Psychological factors such as catastrophizing, anxiety, and depression influence clinical outcomes in many conditions. Our purpose was to examine trends and associations between these and outcomes of rotator cuff surgery.

Methods

148 patients (76 W:72 M, 55.1 ± 8.2 years) with unilateral symptomatic rotator cuff syndrome were followed for 1 year after surgery. The Western Ontario Rotator Cuff Score (WORC), the Pain Catastrophizing Score (PCS), and the Hospital Anxiety and Depression Score (HADS) were administered. Evolution and associations of WORC, HADS and PCS scores were examined using uni- and multivariate analyzes.

Results

At 1 year, PCS, HADS-A, and HADS-D scores negatively correlated with WORC score (R = -0.6, -0.61, -0.69). The strength of correlation was lower between baseline PCS, HADS-A, and HADS-D scores and 1-year WORC score (R = -0.38, -0.43, -0.42). Prior anxiety diagnosis was associated with higher HADS-A scores at 2- and 6- weeks post-op (p = 0.013, 0.011). 106 participants experienced an improving HADS-D over the year of follow-up. Worse pre-op pain, WORC, PCS, HADS-A, HADS-D, cardiovascular disease and current smoking were associated with non-improving HADS-D.

Discussion

Patient-reported outcomes of rotator cuff surgery are associated with patient-reported anxiety, depression, and pain catastrophizing. In many, all outcome scores improved over time suggesting a two-way association between shoulder condition and psychological parameters.

Level of evidence

II.

Adolescent Advertising Exposure to Cannabis Products in Rural Oklahoma via Medical Dispensaries

OBJECTIVE

We assess cannabis advertising exposure among adolescents in rural Oklahoma from medical dispensaries.

METHOD

Our mixed-methods study identified medical dispensaries within a 15-minute drive time of rural Oklahoma high schools. Study staff completed observational data collection forms and took photographs of each dispensary. Quantitative data from the forms and qualitative coding of photographs were used to describe dispensary characteristics and likely advertising exposure for adolescents.

RESULTS

Ninety-two dispensaries were identified across 20 rural communities. The majority presented as retail spaces (n = 71). Product (n = 22) and price promotions (n = 27) were common. Coding of dispensary photographs found that product promotions advertised cannabis use modalities, with cannabis flower being the most common (n = 15), followed by edibles (n = 9) and concentrates (n = 9). Among dispensaries with price promotions, discounts (n = 19) and prices under $10 (n = 14) were common.

CONCLUSIONS

Sampled rural medical dispensaries present as retail spaces and are a likely source of adolescent cannabis advertising exposure.

"It Becomes a Family I'm a Part of…We Get to Carry Each Other": Themes from Qualitative Interview of Patients Enrolled in an Inpatient Palliative Care Support Program for Adolescents and Young Adults

Background: The pediatric palliative care literature provides little evidence regarding the lived experiences of adolescents and young adults (AYAs). Objectives: We sought to evaluate the aspects of a palliative care peer support program, which were most helpful to patients, and identify areas for improvement to better address their psychosocial needs. Design: This was a retrospective, cross-sectional study, which described self-reported Streetlight program evaluation using thematic analysis of interviews with AYAs. A total of 10 interviews was completed. Setting/Subjects: Thirty-three current and former Streetlight participants (13-30), enrolled in the Streetlight program for at least six months, were recruited during hospital admissions and clinic visits at UF Health Shands Hospital in the United States. Of the 33, 2 participants died before interviews could be conducted. A total of 10 interviews were conducted. Results: Thematic analysis of the 10 individuals identified 5 themes. They were (1) normalization of life in hospital, (2) mental health and instillation of hope, (3) companionship and connection, (4) diversity of volunteers, and (5) gratitude. Conclusions: Results suggest that AYAs who participated in a peer support, palliative care program benefitted from their exposure to volunteer social support. Addressing the need for continued study of this population provides opportunities to expand peer support, pediatric palliative care programs to other hospitals and care facilities.

The Impact of Temporary Assistance for Needy Families Benefit Requirements and Sanctions on Maternal Material Hardship, Mental Health, and Parental Aggravation

INTRODUCTION

Temporary Assistance for Needy Families requirements can be stress-inducing, difficult for families to complete, and may be detrimental during early life. We assessed the impact of TANF requirements on primary caregiving mothers' experiences of material hardship, anxiety, depression, and parental aggravation in the first year of a child's life.

METHODS

Survey responses were selected from mothers in the Future of Families and Childhood Wellbeing Study, who received TANF in the first year of their child's life (N = 1085).

RESULTS

Survey-weighted regression models showed associations between: presence of any requirements and increased material hardship, work requirements and increased material hardship, requirement to name the father of their child and increased depression, benefit cuts and increased parental aggravation, and benefit cuts and increased material hardship.

DISCUSSION

Federal and state policies should revise requirement programs to increase program accessibility and support the mental health and financial stability of mothers applying for TANF to facilitate sustainable movement into employment.

The Use and Efficacy of FFR-CT: Real-World Multicenter Audit of Clinical Data With Cost Analysis

BACKGROUND

Fractional flow reserve-computed tomography (FFR-CT) is endorsed by UK and U.S. chest pain guidelines, but its clinical effectiveness and cost benefit in real-world practice are unknown.

OBJECTIVES

The purpose of this study was to audit the use of FFR-CT in clinical practice against England's National Institute for Health and Care Excellence guidance and assess its diagnostic accuracy and cost.

METHODS

A multicenter audit was undertaken covering the 3 years when FFR-CT was centrally funded in England. For coronary computed tomographic angiograms (CCTAs) submitted for FFR-CT analysis, centers provided data on symptoms, CCTA and FFR-CT findings, and subsequent management. Audit standards included using FFR-CT only in patients with stable chest pain and equivocal stenosis (50%-69%). Diagnostic accuracy was evaluated against invasive FFR, when performed. Follow-up for nonfatal myocardial infarction and all-cause mortality was undertaken. The cost of an FFR-CT strategy was compared to alternative stress imaging pathways using cost analysis modeling.

RESULTS

A total of 2,298 CCTAs from 12 centers underwent FFR-CT analysis. Stable chest pain was the main symptom in 77%, and 40% had equivocal stenosis. Positive and negative predictive values of FFR-CT were 49% and 76%, respectively. A total of 46 events (2%) occurred over a mean follow-up period of 17 months; FFR-CT (cutoff: 0.80) was not predictive. The FFR-CT strategy costs £2,102 per patient compared with an average of £1,411 for stress imaging.

CONCLUSIONS

In clinical practice, the National Institute for Health and Care Excellence criteria for using FFR-CT were met in three-fourths of patients for symptoms and 40% for stenosis. FFR-CT had a low positive predictive value, making its use potentially more expensive than conventional stress imaging strategies.

Healthcare use attributable to COVID-19: a propensity-matched national electronic health records cohort study of 249,390 people in Wales, UK

BACKGROUND

To determine the extent and nature of changes associated with COVID-19 infection in terms of healthcare utilisation, this study observed healthcare contact 1 to 4 and 5 to 24 weeks following a COVID-19 diagnosis compared to propensity-matched controls.

METHODS

Two hundred forty nine thousand three hundred ninety Welsh individuals with a positive reverse transcription-polymerase chain reaction (RT-PCR) test were identified from data from national PCR test results. After elimination criteria, 98,600 positive individuals were matched to test negative and never tested controls using propensity matching. Cohorts were split on test location. Tests could be taken in either the hospital or community. Controls were those who had tested negative in their respective environments. Survival analysis was utilised for first clinical outcomes which are grouped into primary and secondary. Primary outcomes include post-viral-illness and fatigue as an indication of long-COVID. Secondary outcomes include clinical terminology concepts for embolism, respiratory conditions, mental health conditions, fit notes, or hospital attendance. Increased instantaneous risk for positive individuals was quantified using hazard ratios (HR) from Cox regression, while absolute risk (AR) and relative risk were quantified using life table analysis.

RESULTS

Analysis was conducted using all individuals and stratified by test location. Cases are compared to controls from the same test location. Fatigue (HR: 1.77, 95% CI: 1.34-2.25, p =  < 0.001) and embolism (HR: 1.50, 95% CI: 1.15-1.97, p = 0.003) were more likely to occur in all positive individuals in the first 4 weeks; however, anxiety and depression (HR: 0.83, 95% CI: 0.73-0.95, p = 0.007) were less likely. Positive individuals continued to be more at risk of fatigue (HR: 1.47, 95% CI: 1.24-1.75, p =  < 0.001) and embolism (HR: 1.51, 95% CI: 1.13-2.02, p = 0.005) after 4 weeks. All positive individuals are also at greater risk of post-viral illness (HR: 4.57, 95% CI: 1.77-11.80, p = 0.002). Despite statistical association between testing positive and several conditions, life table analysis shows that only a small minority of the study population were affected.

CONCLUSIONS

Community COVID-19 disease is associated with increased risks of post-viral-illness, fatigue, embolism, and respiratory conditions. Despite elevated risks, the absolute healthcare burden is low. Subsequently, either very small proportions of people experience adverse outcomes following COVID-19 or they are not presenting to healthcare.

Baseline Factors Associated with Pain Intensity, Pain Catastrophizing, and Pain Interference in Intensive Interdisciplinary Pain Treatment for Youth

Background: More could be known about baseline factors related to desirable Intensive Interdisciplinary Pain Treatment (IIPT) outcomes. This study examined how baseline characteristics (age, gender, child pain catastrophizing (PCS-C), pain interference, pain intensity, anxiety, depression, paediatric health-related quality of life (PedsQLTM), and parent catastrophizing (PCS-P)) were associated with discharge and 3-month follow-up scores of PCS-C, pain intensity, and pain interference. Methods: PCS-C, pain intensity, and pain interference T-scores were acquired in 45 IIPT patients aged 12-18 at intake (baseline), discharge, and 3-month follow-up. Using available and imputed data, linear mixed models were developed to explore associations between PCS-C, pain intensity, and pain interference aggregated scores at discharge and follow-up with baseline demographics and a priori selected baseline measures of pain, depression, anxiety, and PCS-C/P. Results: PCS-C and pain interference scores decreased over time compared to baseline. Pain intensity did not change significantly. Baseline PCS-C, pain interference, anxiety, depression, and PedsQLTM were associated with discharge/follow-up PCS-C (available and imputed data) and pain interference scores (available data). Only baseline pain intensity was significantly associated with itself at discharge/follow-up. Conclusions: Participants who completed the IIPT program presented with reduced PCS-C and pain interference over time. Interventions that target pre-treatment anxiety and depression may optimize IIPT outcomes.

The Impact of Increased Minimum Wage on Child Neglect Varies by Developmental Age of Child

Children in poverty are at significantly greater risk of experiencing child maltreatment. Family economic security policies, such as minimum wage laws, offer a promising prevention strategy to support low-income families. This study utilized data from the Fragile Families and Child Wellbeing Study, a longitudinal birth cohort study, to examine the effect of changes in state-specific minimum wage laws on maternal self-reported child maltreatment and material hardship as it varies by developmental age of the child. A series of fixed effects models with an interaction between the minimum wage and the age of the focal child were used to estimate if there was variation by developmental period of the impact of minimum wage laws on the following outcome variables: all domains of child maltreatment, maternal work-related stress, reported material hardship, aggravation in parenting, and maternal depression. Results revealed significant effects of increased minimum wage on maternal self-reported child neglect and material hardship when children are 3 years of age, and this relationship became non-significant as children aged. No effect was observed by age for other forms of child maltreatment nor any other outcome variables. Study findings suggest minimum wage laws may have differential effects on child neglect depending on the developmental period in which they are received.

Global funding for cancer research between 2016 and 2020: a content analysis of public and philanthropic investments

BACKGROUND

Cancer is a leading cause of disease burden globally, with more than 19·3 million cases and 10 million deaths recorded in 2020. Research is crucial to understanding the determinants of cancer and the effects of interventions, and to improving outcomes. We aimed to analyse global patterns of public and philanthropic investment in cancer research.

METHODS

In this content analysis, we searched the UberResearch Dimensions database and Cancer Research UK data for human cancer research funding awards from public and philanthropic funders between Jan 1, 2016, and Dec 31, 2020. Included award types were project and programme grants, fellowships, pump priming, and pilot projects. Awards focused on operational delivery of cancer care were excluded. Awards were categorised by cancer type, cross-cutting research theme, and research phase. Funding amount was compared with global burden of specific cancers, measured by disability-adjusted life-years, years lived with disability, and mortality using data from the Global Burden of Disease study.

FINDINGS

We identified 66 388 awards with total investment of about US$24·5 billion in 2016-20. Investment decreased year-on-year, with the largest drop observed between 2019 and 2020. Pre-clinical research received 73·5% of the funding across the 5 years ($18 billion), phase 1-4 clinical trials received 7·4% ($1·8 billion), public health research received 9·4% ($2·3 billion), and cross-disciplinary research received 5·0% ($1·2 billion). General cancer research received the largest investment ($7·1 billion, 29·2% of the total funding). The most highly funded cancer types were breast cancer ($2·7 billion [11·2%]), haematological cancer ($2·3 billion [9·4%]), and brain cancer ($1·3 billion [5·5%]). Analysis by cross-cutting theme revealed that 41·2% of investment ($9·6 billion) went to cancer biology research, 19·6% ($4·6 billion) to drug treatment research, and 12·1% ($2·8 billion) to immuno-oncology. 1·4% of the total funding ($0·3 billion) was spent on surgery research, 2·8% ($0·7 billion) was spent on radiotherapy research, and 0·5% ($0·1 billion) was spent on global health studies.

INTERPRETATION

Cancer research funding must be aligned with the global burden of cancer with more equitable funding for cancer research in low-income and middle-income countries (which account for 80% of cancer burden), both to support research relevant to these settings, and build research capacity within these countries. There is an urgent need to prioritise investment in surgery and radiotherapy research given their primacy in the treatment of many solid tumours.

FUNDING

None.

Multigenic resistance to Xylella fastidiosa in wild grapes (Vitis sps.) and its implications within a changing climate

Xylella fastidiosa is a bacterium that infects crops like grapevines, coffee, almonds, citrus and olives. There is little understanding of the genes that contribute to plant resistance, the genomic architecture of resistance, and the potential role of climate in shaping resistance, in part because major crops like grapevines (Vitis vinifera) are not resistant to the bacterium. Here we study a wild grapevine species, V. arizonica, that segregates for resistance. Using genome-wide association, we identify candidate resistance genes. Resistance-associated kmers are shared with a sister species of V. arizonica but not with more distant species, suggesting that resistance evolved more than once. Finally, resistance is climate dependent, because individuals from low ( < 10 °C) temperature locations in the wettest quarter were typically susceptible to infection, likely reflecting a lack of pathogen pressure in colder climates. In fact, climate is as effective a predictor of resistance phenotypes as some genetic markers. We extend our climate observations to additional crops, predicting that increased pathogen pressure is more likely for grapevines and almonds than some other susceptible crops.

Carriage of Neisseria meningitidis among travelers attending the Hajj pilgrimage, circulating serogroups, sequence types and antimicrobial susceptibility: A multinational longitudinal cohort study

BACKGROUND

Travel to international mass gatherings such as the Hajj pilgrimage increases the risk of Neisseria meningitidis transmission and meningococcal disease. We investigated carriage and acquisition of N. meningitidis among travelers to Hajj and determined circulating serogroups, sequence types and antibiotic susceptibility among isolates.

METHOD

We conducted a multinational longitudinal cohort study among 3921 traveling pilgrims in two phases: Pre-Hajj and Post-Hajj. For each participant, a questionnaire was administered and an oropharyngeal swab was obtained. N. meningitidis was isolated, serogrouped, and subjected to whole genome sequence analysis and antibiotic susceptibility testing.

RESULTS

Overall carriage and acquisition rates of N. meningitidis were 0.74% (95%CI: 0.55-0.93) and 1.10% (95%CI: 0.77-1.42) respectively. Carriage was significantly higher Post-Hajj (0.38% vs 1.10%, p = 0.0004). All isolates were nongroupable, and most belonged to the ST-175 complex and were resistant to ciprofloxacin with reduced susceptibility to penicillins. Three potentially invasive isolates (all genogroup B) were identified in the Pre-Hajj samples. No factors were associated with Pre-Hajj carriage. Suffering influenza like illness symptoms and sharing a room with >15 people were associated with lower carriage Post-Hajj (adjOR = 0.23; p = 0.008 and adjOR = 0.27; p = 0.003, respectively).

CONCLUSION

Carriage of N. meningitidis among traveler to attending Hajj was low. However, most isolates were resistant to ciprofloxacin used for chemoprophylaxis. A review of the current meningococcal disease preventive measures for Hajj is warranted.

How Are Retailers Describing Delta-8 THC?A Mixed-Methods Study in Fort Worth, Texas

OBJECTIVE

Delta-8 tetrahydrocannabinol (THC) is a largely unregulated psychoactive substance rising in popularity in the United States. This study aimed to understand how retailers explained Delta-8 THC to potential customers and if these descriptions were associated with socioeconomic deprivation surrounding the retail location.

METHOD

In Fort Worth, Texas, stores with retail alcohol, cannabidiol (CBD), or tobacco licenses were called. Among the 133 stores that sold Delta-8 THC, 125 retailers (94%) answered the question "What is Delta-8?" Qualitative methods were used to identify related themes; logistic regression models tested associations between themes and area deprivation index (ADI) scores, a measure of socioeconomic deprivation (1-10; 10 = most deprived areas).

RESULTS

Retailers often compared Delta-8 THC to other substances (49%). Although most often described as a type of cannabis (34%), several retailers likened Delta-8 to CBD (19%) or hemp (7%), which are nonpsychoactive. Retailers also described potential effects from use (35%). Some retailers reported that they were unsure of what Delta-8 was (21%), told surveyors to look it up themselves (6%), or withheld information (9%). Higher ADI scores were associated with higher odds of retailers communicating limited information (odds ratio = 1.21, 95% CI [1.04, 1.40], p = .011).

CONCLUSIONS

Study findings may inform the development of marketing regulations, as well as informational campaigns for both retailers and consumers.

Evaluation of federated learning variations for COVID-19 diagnosis using chest radiographs from 42 US and European hospitals

OBJECTIVE

Federated learning (FL) allows multiple distributed data holders to collaboratively learn a shared model without data sharing. However, individual health system data are heterogeneous. "Personalized" FL variations have been developed to counter data heterogeneity, but few have been evaluated using real-world healthcare data. The purpose of this study is to investigate the performance of a single-site versus a 3-client federated model using a previously described Coronavirus Disease 19 (COVID-19) diagnostic model. Additionally, to investigate the effect of system heterogeneity, we evaluate the performance of 4 FL variations.

MATERIALS AND METHODS

We leverage a FL healthcare collaborative including data from 5 international healthcare systems (US and Europe) encompassing 42 hospitals. We implemented a COVID-19 computer vision diagnosis system using the Federated Averaging (FedAvg) algorithm implemented on Clara Train SDK 4.0. To study the effect of data heterogeneity, training data was pooled from 3 systems locally and federation was simulated. We compared a centralized/pooled model, versus FedAvg, and 3 personalized FL variations (FedProx, FedBN, and FedAMP).

RESULTS

We observed comparable model performance with respect to internal validation (local model: AUROC 0.94 vs FedAvg: 0.95, P = .5) and improved model generalizability with the FedAvg model (P < .05). When investigating the effects of model heterogeneity, we observed poor performance with FedAvg on internal validation as compared to personalized FL algorithms. FedAvg did have improved generalizability compared to personalized FL algorithms. On average, FedBN had the best rank performance on internal and external validation.

CONCLUSION

FedAvg can significantly improve the generalization of the model compared to other personalization FL algorithms; however, at the cost of poor internal validity. Personalized FL may offer an opportunity to develop both internal and externally validated algorithms.

Mixed-methods implementation study of a virtual culturally tailored diabetes self-management programme for African and Caribbean communities (HEAL-D) in south London and its scaling up across NHS regions in England: study protocol

INTRODUCTION

The National Health Service Insight Prioritisation Programme was established to accelerate the implementation and evaluation of innovation that supports post-pandemic working. Supporting this, the Academic Health Science Network and National Institute for Health and Care Research Applied Research Collaboration in South London are testing and evaluating the implementation and scale-up of a type 2 diabetes (T2D) intervention.T2D is estimated to be three times more prevalent in UK African and Caribbean communities than in white Europeans. To tackle ethnic inequities in T2D healthcare access, an evidence-based, culturally tailored self-management and education programme for African and Caribbean adults (Healthy Eating &amp; Active Lifestyles for Diabetes, HEAL-D) has been codeveloped with people with lived experience. Initially a face-to-face programme, HEAL-D pivoted to virtual delivery in response to COVID-19.The purpose of this study is to explore the (1) feasibility and acceptability of a virtual delivery model for HEAL-D in south London and (2) factors affecting its scale-up across other areas in England.

METHODS AND ANALYSIS

The study will have two strands: (1) mixed-methods prospective evaluation of HEAL-D virtual delivery in south London using routinely collected service-level data, service delivery staff and service user interviews and observations; and (2) prospective qualitative study of the scale-up of this virtual delivery comprising interviews and focus groups with members of the public, and diabetes services commissioners and providers across England. Qualitative data will be analysed using thematic analysis. Quantitative analysis will use descriptive statistics and reporting summary tables and figures. The study will be grounded in well-established implementation frameworks and service user involvement.

ETHICS AND DISSEMINATION

'Minimal Risk Registration' ethical clearance was granted by King's College London's Research Ethics Office (ref: MRA-21/22-28498). Results will be published in a peer-reviewed journal and summaries provided to the study funders and participants.

Cost-Effectiveness of Triple Therapy with Budesonide/Glycopyrronium/Formoterol Fumarate Dihydrate versus Dual Therapies in Moderate-to-Very Severe Chronic Obstructive Pulmonary Disease: United Kingdom Analysis Using the ETHOS Study

Background

In the 52-week ETHOS study (NCT02465567), fixed-dose triple therapy with budesonide/glycopyrronium/formoterol fumarate dihydrate (BGF) reduced moderate or severe chronic obstructive pulmonary disease (COPD) exacerbations versus fixed-dose long-acting muscarinic antagonist (LAMA)/long-acting β₂-agonist (LABA) or inhaled corticosteroid (ICS)/LABA dual therapies. Here, ETHOS data were used to estimate the long-term cost-effectiveness of BGF versus LAMA/LABA and ICS/LABA dual therapies in the United Kingdom.

Methods

Costs, exacerbations, quality-adjusted life-years (QALYs), and LYs were extrapolated using a Markov model that considered disease severity progression, risk of moderate and severe exacerbations, adverse events, and treatment discontinuation in patients with moderate-to-very severe COPD receiving BGF 320/14.4/10 µg, the LAMA/LABA glycopyrronium/formoterol fumarate dihydrate 14.4/10 µg (GFF), or the ICS/LABA budesonide/formoterol fumarate dihydrate 320/10 µg (BFF). Utilities for COPD severity states were estimated using EuroQol 5-dimension 5-level data from ETHOS. Exacerbation disutilities were sourced from published literature. Healthcare resource utilization was based on ETHOS data, published literature, key external experts’ input, and informed assumptions. Unit costs came from the UK National Health Service Schedule of Reference Costs, Unit Costs of Health and Social Care from the Personal Social Services Research Unit, and published literature. A lifetime horizon was considered, with costs, QALYs, and LYs discounted at 3.5% per annum.

Results

The incremental cost–utility ratio (ICUR; per QALY gained) was £9901 for BGF versus GFF and £2164 for BGF versus BFF. The probability of treatments being cost-effective at the conventional UK-adopted willingness-to-pay threshold of ICUR <£20,000 was 85.1% for BGF, 14.3% for GFF, and 0.6% for BFF.

Conclusion

Based on ETHOS data, BGF was demonstrated to be cost-effective versus LAMA/LABA and ICS/LABA dual therapies at the conventional UK-adopted willingness-to-pay threshold (ICUR <£20,000). The main cost-effectiveness driver for BGF versus LAMA/LABA and ICS/LABA therapies was reduction in rate of exacerbations, which reduced costs and preserved quality of life.

A national assessment of on-premise drinking establishments near public universities: Drink prices, drink specials, indoor tobacco use, and state-level alcohol laws

BACKGROUND

Inexpensive drinks and price promotions increase alcohol consumption and have been observed at on-premise drinking establishments near large colleges. Some bars may sell tobacco products and allow indoor tobacco use to encourage patrons to stay and drink more. This study examined drink prices/specials and associated practices of on-premise drinking establishments including tobacco sales and policies regarding tobacco use.

METHODS

In 2018, telephone calls about prices/practices were made to 403 randomly selected bars/nightclubs within 2 miles of large residential universities in each U.S. state. The Alcohol Policy Information System provided data on state-level alcohol laws. Multivariable linear and logistic regression models examined associations between alcohol prices/specials, state laws, and establishment practices.

RESULTS

The average price for the least expensive draft beer and a vodka shot at each location were $3.62 (SD = $1.15) and $4.77 (SD = $1.16), respectively. Most establishments (65%) had happy hour specials, 6% had 2-for-1 specials, 91% sold food, 9% sold cigarettes, 8% allowed smoking indoors, and 18% permitted electronic cigarette (e-cigarette) use indoors. Allowing e-cigarette use indoors (b = -0.54) and selling cigarettes (b = -0.79) were associated with lower vodka prices; allowing cigarette smoking indoors (b = -0.46) was associated with lower beer prices. Lower beer prices (OR = 1.38), selling food (OR = 2.97), and no state law banning happy hour specials altogether (OR = 4.24) or with full-day price reduction exemptions (OR = 12.74) were associated with higher odds of having happy hour specials. Allowing e-cigarette use indoors was associated with having 2-for-1 specials (OR = 6.38).

CONCLUSION

In bars near large public universities, beers and shots were often available for less than $5 and drink specials were prevalent. Further, some establishments allowed tobacco use indoors and/or sold cigarettes. Laws that increase alcohol taxes, set minimum drink prices, and ban the sale and indoor use of tobacco products at on-premise drinking locations are important harm reduction tools.

Allopurinol versus usual care in UK patients with ischaemic heart disease (ALL-HEART): a multicentre, prospective, randomised, open-label, blinded-endpoint trial

BACKGROUND

Allopurinol is a urate-lowering therapy used to treat patients with gout. Previous studies have shown that allopurinol has positive effects on several cardiovascular parameters. The ALL-HEART study aimed to determine whether allopurinol therapy improves major cardiovascular outcomes in patients with ischaemic heart disease.

METHODS

ALL-HEART was a multicentre, prospective, randomised, open-label, blinded-endpoint trial done in 18 regional centres in England and Scotland, with patients recruited from 424 primary care practices. Eligible patients were aged 60 years or older, with ischaemic heart disease but no history of gout. Participants were randomly assigned (1:1), using a central web-based randomisation system accessed via a web-based application or an interactive voice response system, to receive oral allopurinol up-titrated to a dose of 600 mg daily (300 mg daily in participants with moderate renal impairment at baseline) or to continue usual care. The primary outcome was the composite cardiovascular endpoint of non-fatal myocardial infarction, non-fatal stroke, or cardiovascular death. The hazard ratio (allopurinol vs usual care) in a Cox proportional hazards model was assessed for superiority in a modified intention-to-treat analysis (excluding randomly assigned patients later found to have met one of the exclusion criteria). The safety analysis population included all patients in the modified intention-to-treat usual care group and those who took at least one dose of randomised medication in the allopurinol group. This study is registered with the EU Clinical Trials Register, EudraCT 2013-003559-39, and ISRCTN, ISRCTN32017426.

FINDINGS

Between Feb 7, 2014, and Oct 2, 2017, 5937 participants were enrolled and then randomly assigned to receive allopurinol or usual care. After exclusion of 216 patients after randomisation, 5721 participants (mean age 72·0 years [SD 6·8], 4321 [75·5%] males, and 5676 [99·2%] white) were included in the modified intention-to-treat population, with 2853 in the allopurinol group and 2868 in the usual care group. Mean follow-up time in the study was 4·8 years (1·5). There was no evidence of a difference between the randomised treatment groups in the rates of the primary endpoint. 314 (11·0%) participants in the allopurinol group (2·47 events per 100 patient-years) and 325 (11·3%) in the usual care group (2·37 events per 100 patient-years) had a primary endpoint (hazard ratio [HR] 1·04 [95% CI 0·89-1·21], p=0·65). 288 (10·1%) participants in the allopurinol group and 303 (10·6%) participants in the usual care group died from any cause (HR 1·02 [95% CI 0·87-1·20], p=0·77).

INTERPRETATION

In this large, randomised clinical trial in patients aged 60 years or older with ischaemic heart disease but no history of gout, there was no difference in the primary outcome of non-fatal myocardial infarction, non-fatal stroke, or cardiovascular death between participants randomised to allopurinol therapy and those randomised to usual care.

FUNDING

UK National Institute for Health and Care Research.

An analysis of Neisseria meningitidis strains causing meningococcal septic arthritis in England, and Wales: 2010-2020

OBJECTIVES

To analyse clinical meningococcal strains associated with meningococcal septic arthritis cases in England and Wales, and to identify associations between patient age, the synovial joint affected and strain characteristics.

METHODS

IMD cases confirmed by the Meningococcal Reference Unit (UK Health Security Agency) between January 2010 and December 2020 were included in the analysis. Septic arthritis cases were defined as those featuring detection and/or isolation of N. meningitidis from an articular site. Capsular grouping was performed by serology on clinical isolates and/or real-time PCR on clinical samples.

RESULTS

We identified 162 cases of meningococcal septic arthritis, representing 2% of all invasive meningococcal disease cases during the study period. The knee and the hip were the most commonly affected joints, with the former significantly more frequent in adults and the latter seen more commonly in children and adolescents. Group B strains were between 2 and 6 times less likely to cause septic arthritis in relation to groups W, C and Y strains.

CONCLUSIONS

Meningococcal septic arthritis remains a rare manifestation of invasive meningococcal disease. Strain and age associations identified in this study remain unexplained. Future analyses including clinical case information may help to explain these interesting findings.

Unencapsulated penicillin-resistant Neisseria meningitidis ST-53 clonal complex strain causing symptomatic proctitis in an HIV-negative man who has sex with men: A case report

We report a case of Neisseria meningitidis symptomatic proctitis in an HIV-negative man who has sex with men attending the genitourinary clinic in Malta. The proctitis was caused by a rare clinical unencapsulated penicillin-resistant N. meningitidis strain of the ST-53 clonal complex.

Histamine-2(H2 ) Antagonists can be safely removed from standard Paclitaxel Pre-medication regimens

Aims

The aim of this study is to investigate the rates of hypersensitivity reactions (HSRs) in patients receiving paclitaxel chemotherapy, with and without a histamine‐2 (H₂) antagonists.

Method

This prospective, multi‐centre, cohort study compared patients receiving paclitaxel treated with premedication regimens containing chlorphenamine, dexamethasone and an H₂ antagonist vs patients treated without an H₂ antagonist. Rates of HSRs were described and logistic multivariable regression was used to investigate any associations with H₂ antagonist treatment, adjusting for confounding variables.

Results

A total of 1043 individuals were included in the study; of these, 638 (61%) patients received an H₂ antagonist and 405 (49%) were not given an H₂ antagonist. Incidence of HSR in the cohort treated with H₂ antagonists was 11.31% (n = 70) vs 9.86% (n = 41) in the cohort without. There was no statistically significant difference between the rates of HSR observed in those receiving and not receiving an H₂ antagonist (odds ratio 1.04, 95% CI 0.65, 1.66, P = .9).

Conclusions

Results presented within the study are consistent with other recently published evidence to suggest that H₂ antagonists do not confer any advantage as part of premedication regimens in reducing the incidence of HSR in patients treated with paclitaxel.

Treatment of periodontitis for glycaemic control in people with diabetes mellitus

BACKGROUND

Glycaemic control is a key component in diabetes mellitus (diabetes) management. Periodontitis is the inflammation and destruction of the underlying supporting tissues of the teeth. Some studies have suggested a bidirectional relationship between glycaemic control and periodontitis.  Treatment for periodontitis involves subgingival instrumentation, which is the professional removal of plaque, calculus, and debris from below the gumline using hand or ultrasonic instruments. This is known variously as scaling and root planing, mechanical debridement, or non-surgical periodontal treatment. Subgingival instrumentation is sometimes accompanied by local or systemic antimicrobials, and occasionally by surgical intervention to cut away gum tissue when periodontitis is severe. This review is part one of an update of a review published in 2010 and first updated in 2015, and evaluates periodontal treatment versus no intervention or usual care.  OBJECTIVES: To investigate the effects of periodontal treatment on glycaemic control in people with diabetes mellitus and periodontitis.

SEARCH METHODS

An information specialist searched six bibliographic databases up to 7 September 2021 and additional search methods were used to identify published, unpublished, and ongoing studies.  SELECTION CRITERIA: We searched for randomised controlled trials (RCTs) of people with type 1 or type 2 diabetes mellitus and a diagnosis of periodontitis that compared subgingival instrumentation (sometimes with surgical treatment or adjunctive antimicrobial therapy or both) to no active intervention or 'usual care' (oral hygiene instruction, education or support interventions, and/or supragingival scaling (also known as PMPR, professional mechanical plaque removal)). To be included, the RCTs had to have lasted at least 3 months and have measured HbA1c (glycated haemoglobin).

DATA COLLECTION AND ANALYSIS

At least two review authors independently examined the titles and abstracts retrieved by the search, selected the included trials, extracted data from included trials, and assessed included trials for risk of bias. Where necessary and possible, we attempted to contact study authors. Our primary outcome was blood glucose levels measured as glycated (glycosylated) haemoglobin assay (HbA1c), which can be reported as a percentage of total haemoglobin or as millimoles per mole (mmol/mol). Our secondary outcomes included adverse effects, periodontal indices (bleeding on probing, clinical attachment level, gingival index, plaque index, and probing pocket depth), quality of life, cost implications, and diabetic complications.

MAIN RESULTS

We included 35 studies, which randomised 3249 participants to periodontal treatment or control. All studies used a parallel-RCT design and followed up participants for between 3 and 12 months. The studies focused on people with type 2 diabetes, other than one study that included participants with type 1 or type 2 diabetes. Most studies were mixed in terms of whether metabolic control of participants at baseline was good, fair, or poor. Most studies were carried out in secondary care.  We assessed two studies as being at low risk of bias, 14 studies at high risk of bias, and the risk of bias in 19 studies was unclear. We undertook a sensitivity analysis for our primary outcome based on studies at low risk of bias and this supported the main findings. Moderate-certainty evidence from 30 studies (2443 analysed participants) showed an absolute reduction in HbA1c of 0.43% (4.7 mmol/mol) 3 to 4 months after treatment of periodontitis (95% confidence interval (CI) -0.59% to -0.28%; -6.4 mmol/mol to -3.0 mmol/mol). Similarly, after 6 months, we found an absolute reduction in HbA1c of 0.30% (3.3 mmol/mol) (95% CI -0.52% to -0.08%; -5.7 mmol/mol to -0.9 mmol/mol; 12 studies, 1457 participants), and after 12 months, an absolute reduction of 0.50% (5.4 mmol/mol) (95% CI -0.55% to -0.45%; -6.0 mmol/mol to -4.9 mmol/mol; 1 study, 264 participants). Studies that measured adverse effects generally reported that no or only mild harms occurred, and any serious adverse events were similar in intervention and control arms. However, adverse effects of periodontal treatments were not evaluated in most studies.

AUTHORS' CONCLUSIONS

Our 2022 update of this review has doubled the number of included studies and participants, which has led to a change in our conclusions about the primary outcome of glycaemic control and in our level of certainty in this conclusion. We now have moderate-certainty evidence that periodontal treatment using subgingival instrumentation improves glycaemic control in people with both periodontitis and diabetes by a clinically significant amount when compared to no treatment or usual care. Further trials evaluating periodontal treatment versus no treatment/usual care are unlikely to change the overall conclusion reached in this review.

Disseminated protothecosis with central nervous system involvement in a dog in New Zealand

CASE HISTORY

A 1-year-old Border Terrier presented with acute onset of neurological signs and neck pain.

CLINICAL FINDINGS

Severe generalised ataxia, muscle tremors and cranial nerve deficits were noted. Multifocal brain lesions were suspected based on neurological examination. Computed tomography revealed an abdominal mass and cerebellar herniation through the foramen magnum.

LABORATORY AND PATHOLOGICAL FINDINGS

Cytological and histopathological analysis of the abdominal mass revealed necrotising and granulomatous lymphadenitis with intralesional algal elements most consistent with Prototheca spp.. Culture of a sample from the mesenteric lymph node confirmed the presence of Prototheca spp. which was identified as P. bovis based on sequencing of a DNA fragment amplified by PCR. Following inadequate response to symptomatic therapy and poor prognosis, the dog was subjected to euthanasia. Histopathological evaluation of the central nervous system lesions, identified granulomatous meningitis and ventriculitis with the presence of intralesional algae.

DIAGNOSIS

Disseminated protothecosis with granulomatous meningitis and ventriculitis caused by Prototheca bovis (formerly P. zopfii gen. 2).

CLINICAL RELEVANCE

This is the first case report of disseminated protothecosis with central nervous system involvement in a dog in New Zealand.

International society of oncology pharmacy practitioners (ISOPP) position statement: The role of oncology pharmacy practitioners in immunotherapy treatment with immune checkpoint inhibitors for malignant conditions

Oncology pharmacists, pharmacy technicians and assistants are key members of the multidisciplinary health care team (MHT) caring for patients receiving immunotherapy with immune checkpoint inhibitors. The International Society of Oncology Pharmacy Practitioners (ISOPP) developed this position statement to provide guidance on the role of oncology pharmacy practitioners in caring for patients receiving immune checkpoint inhibitors.Four key recommendations were identified: 1) participation as an integrated, collaborative member of the MHT;2) provision of education and training for patients, students, residents, fellows and other members of the MHT;3) involvement in clinical governance to optimise the use of immune checkpoint inhibitors and4) involvement in research and development in the field of immunotherapy.In summary, oncology pharmacy practitioners play essential roles within the MHT in caring for patients receiving immune checkpoint inhibitors.

Oral cancer awareness and education within the pharmacy profession

The incidence of oral cancers are rising in the UK, with early detection a significant positive prognostic factor. The Covid-19 pandemic has negatively impacted patients access to dental services, reducing a potential avenue to diagnosis. Community pharmacists are well positioned to play an expanded role in supporting earlier detection. This study seeks to identify levels of awareness and knowledge of oral cancer amongst community pharmacists, to inform development of educational resources.A cross-sectional digital survey was distributed via social media between August and September 2021. Data were collected on participant's demographics, oral cancer awareness and educational resources relevant to oral cancer. The results obtained were analysed using descriptive statistics in IBM SPSS software.61 pharmacists completed the survey. The majority were female (n = 40; 65.6%) aged 18-30 (n = 33; 54.1%). Less than half of respondents reported feeling confident in recognising risk factors (37.7%; n = 23). A substantial minority (n = 8; 13.1%) incorrectly selected fluoride toothpaste use as a risk factor for oral cancer. Most respondents correctly suggested signposting patients with signs or symptoms of oral cancer to a General Medical or General Dental Practitioner (GDP) (n = 35; 57.3%, n = 46; 75.4%). 91.8% of respondents (n = 56) would welcome an educational resource to support professional development.This study demonstrates a need for further educational resources regarding oral cancer, specifically aimed at community pharmacists. Community Pharmacists have a crucial role in efforts to improve rates of early detection of oral cancers. Work should be completed to explore the establishment of direct referral pathways from community pharmacy to secondary care.

Incidence, morbidity, and associated factors for sepsis in women hospitalized for delivery: a nationwide retrospective observational population-based study in Canada

PURPOSE

The objective of this research was to examine the epidemiology of maternal sepsis in Canada.

METHODS

We conducted a population-based retrospective cohort study of women (≥ 20 weeks gestation) hospitalized for delivery in all Canadian hospitals (excluding Quebec) between 1 April 2004 and 31 March 2017. Data were obtained from the national Canadian Institute for Health Information database and sepsis cases were identified via International Classification of Diseases, Tenth Revision, Canada (ICD-10-CA) codes. Our primary outcome was the number of hospitalizations for delivery associated with maternal sepsis. We further explored associations between patient characteristics, obstetric procedures/conditions, medical conditions, and maternal sepsis. Associations were presented using odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

There were 4,183 cases of sepsis in 3,653,783 hospitalizations for delivery during the study period, with an incidence of 114 (95% CI, 111 to 118) per 100,000 hospitalizations and a mortality rate of 0.5%. Annual sepsis rates per 100,000 hospitalizations ranged from a high of 160 (95% CI, 146 to 177) in 2004 to 94 (95% CI, 83 to 106) in 2011. Highest regional rates were observed in the Territories (224 per 100,000). Severe sepsis was seen in 14% (n = 568) of all patients with sepsis, which was one or more of septic shock (15%; n = 85), organ failure (61%; n = 345), intensive care unit admission (78%; n = 443), or mortality (3%; n = 19). Multivariable models showed that postpartum hemorrhage (OR, 2.9; 95% CI, 2.7 to 3.2), Cesarean delivery (OR, 3.2; 95% CI, 3.0 to 3.5), anemia (OR, 3.9; 95% CI, 3.5 to 4.3), hysterectomy (OR, 4.9; 95% CI, 3.6 to 6.6), chorioamnionitis (OR, 7.6; 95% CI, 6.9 to 8.3), as well as cardiorespiratory, renal and liver conditions were associated with maternal sepsis.

CONCLUSION

Maternal sepsis rates have been decreasing in Canada but remain higher than those in the UK and USA. Our study explored associations with maternal sepsis and shows that one in seven women with sepsis develop severe sepsis-related morbidity, which warrants risk stratification and health policy changes.

Allergic rhinitis: diagnosis and management

Allergic rhinitis affects 20% of the population of the UK. It confers a significant health burden upon the individual as it affects the patient's quality of life and is associated with serious comorbidities including asthma, sinusitis and conjunctivitis. Owing to its prevalence, it has a significant economic impact through its effects on education, productivity and use of healthcare resources. This review focuses on the management of allergic rhinitis and potential future treatments, because of the lack of clear national guidelines and because this illness is often misdiagnosed and mismanaged. The article provides a comprehensive overview of allergic rhinitis and illustrates the assessment criteria for various subcategories.