Why do Chinese Youth Seek Cancer Risk Information Online? Evidence from Four Cities

This study, inspired by the Risk Information Seeking and Processing (RISP) model, examines the mechanisms by which perceived hazard characteristics and the informational subjective norms of Chinese youth, aged from 14 to 44 years old, become associated with their intentions to seek cancer risk information online. A sample of 684 Chinese youths was collected from four cities in Mainland China with results revealing that perceived hazard characteristics and informational subjective norms motivate their online cancer risk information seeking intentions. Specifically, perceived probability, perceived severity, and institutional trust are positively related to negative affect, however the relationship between personal control and negative affect is not significant. Institutional trust and personal control are positively related to positive affect while perceived probability and perceived severity have no significant effect on positive affect. Negative affect and informational subjective norms are positively related to perceived information insufficiency, while the relationship between positive affect and perceived information insufficiency is not significant. Negative affect, positive affect, informational subjective norms, and perceived information insufficiency are all positively related to the online cancer risk information seeking intentions of Chinese youth.

Assessing an innovative method to promote learning from patient narratives: Findings from a field experiment in ambulatory care

OBJECTIVE

To assess whether an online interactive report designed to facilitate interpretation of patients' narrative feedback produces change in ambulatory staff learning, behavior at the individual staff and practice level, and patient experience survey scores.

DATA SOURCES AND SETTING

We studied 22 ambulatory practice sites within an academic medical center using three primary data sources: 333 staff surveys; 20 in-depth interviews with practice leaders and staff; and 9551 modified CG-CAHPS patient experience surveys augmented by open-ended narrative elicitation questions.

STUDY DESIGN

We conducted a cluster quasi-experimental study, comparing 12 intervention and 10 control sites. At control sites, narratives were delivered free-form to site administrators via email; at intervention sites, narratives were delivered online with interactive tools for interpretation, accompanied by user training. We assessed control-versus-intervention site differences in learning, behavior, and patient experience scores.

DATA COLLECTION

Staff surveys and interviews were completed at intervention and control sites, 9 months after intervention launch. Patient surveys were collected beginning 4 months pre-launch through 9 months post-launch. We used control-versus-intervention and difference-in-difference analyses for survey data and thematic analysis for interview data.

PRINCIPAL FINDINGS

Interviews suggested that the interface facilitated narrative interpretation and use for improvement. Staff survey analyses indicated enhanced learning from narratives at intervention sites (29% over control sites' mean of 3.19 out of 5 across eight domains, p < 0.001) and greater behavior change at staff and practice levels (31% and 21% over control sites' means of 3.35 and 3.39, p < 0.001, respectively). Patient experience scores for interactions with office staff and wait time information increased significantly at intervention sites, compared to control sites (3.7% and 8.2%, respectively); however, provider listening scores declined 3.3%.

CONCLUSIONS

Patient narratives presented through structured feedback reporting methods can catalyze positive changes in staff learning, promote behavior change, and increase patient experience scores in domains of non-clinical interaction.

Impact of maintaining serum potassium concentration ≥ 3.6mEq/L versus ≥ 4.5mEq/L for 120 hours after isolated coronary artery bypass graft surgery on incidence of new onset atrial fibrillation: Protocol for a randomized non-inferiority trial

BACKGROUND

Atrial Fibrillation After Cardiac Surgery (AFACS) occurs in about one in three patients following Coronary Artery Bypass Grafting (CABG). It is associated with increased short- and long-term morbidity, mortality and costs. To reduce AFACS incidence, efforts are often made to maintain serum potassium in the high-normal range (≥ 4.5mEq/L). However, there is no evidence that this strategy is efficacious. Furthermore, the approach is costly, often unpleasant for patients, and risks causing harm. We describe the protocol of a planned randomized non-inferiority trial to investigate the impact of intervening to maintain serum potassium ≥ 3.6 mEq/L vs ≥ 4.5 mEq/L on incidence of new-onset AFACS after isolated elective CABG.

METHODS

Patients undergoing isolated CABG at sites in the UK and Germany will be recruited, randomized 1:1 and stratified by site to protocols maintaining serum potassium at either ≥ 3.6 mEq/L or ≥ 4.5 mEq/L. Participants will not be blind to treatment allocation. The primary endpoint is AFACS, defined as an episode of atrial fibrillation, flutter or tachycardia lasting ≥ 30 seconds until hour 120 after surgery, which is both clinically detected and electrocardiographically confirmed. Assuming a 35% incidence of AFACS in the 'tight control group', and allowing for a 10% loss to follow-up, 1684 participants are required to provide 90% certainty that the upper limit of a one-sided 97.5% confidence interval (CI) will exclude a > 10% difference in favour of tight potassium control. Secondary endpoints include mortality, use of hospital resources and incidence of dysrhythmias not meeting the primary endpoint (detected using continuous heart rhythm monitoring).

DISCUSSION

The Tight K Trial will assess whether a protocol to maintain serum potassium ≥ 3.6 mEq/L is non inferior to maintaining serum potassium ≥ 4.5 mEq/L in preventing new-onset AFACS after isolated CABG.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04053816. Registered on 13 August 2019. Last update 7 January 2021.

Percutaneous Left Ventricular Unloading During High-Risk Coronary Intervention: Rationale and Design of the CHIP-BCIS3 Randomized Controlled Trial

INTRODUCTION

Percutaneous coronary intervention for complex coronary disease is associated with a high risk of cardiogenic shock. This can cause harm and limit the quality of revascularization achieved, especially when left ventricular function is impaired at the outset. Elective percutaneous left ventricular unloading is increasingly used to mitigate adverse events in patients undergoing high-risk percutaneous coronary intervention, but this strategy has fiscal and clinical costs and is not supported by robust evidence.

METHODS

CHIP-BCIS3 (Controlled Trial of High-Risk Coronary Intervention With Percutaneous Left Ventricular Unloading) is a prospective, multicenter, open-label randomized controlled trial that aims to determine whether a strategy of elective percutaneous left ventricular unloading is superior to standard care (no planned mechanical circulatory support) in patients undergoing nonemergent high-risk percutaneous coronary intervention. Patients are eligible for recruitment if they have severe left ventricular systolic dysfunction, extensive coronary artery disease, and are due to undergo complex percutaneous coronary intervention (to the left main stem with calcium modification or to a chronic total occlusion with a retrograde approach). Cardiogenic shock and acute ST-segment-elevation myocardial infarction are exclusions. The primary outcome is a hierarchical composite of all-cause death, stroke, spontaneous myocardial infarction, cardiovascular hospitalization, and periprocedural myocardial infarction, analyzed using the win ratio. Secondary outcomes include completeness of revascularization, major bleeding, vascular complications, health economic analyses, and health-related quality of life. A sample size of 250 patients will have in excess of 80% power to detect a hazard ratio of 0.62 at a minimum of 12 months, assuming 150 patients experience an event across all follow-up.

CONCLUSIONS

To date, 169 patients have been recruited from 21 National Health Service hospitals in the United Kingdom, with recruitment expected to complete in 2024.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT05003817.

Sustainability in healthcare: patient and public perspectives

The sustainable healthcare agenda has become increasingly prominent in recent years. But what does this mean for patients? In this article, we draw on our personal views and experiences as patients, carers and patient advocates, and consider the effects that efforts to improve the sustainability of healthcare may have on care quality and patient experience. We also review the small amount of existing research and policy in this area, with particular focus on documents from the National Institute for Health and Care Excellence and the Health Foundation. Based on synthesising these resources with our own experiences, we make recommendations on how to: share information with patients about how they can contribute to healthcare sustainability; offer more sustainable alternatives without pressure; account for diverse patient views on the relevance of sustainable healthcare; provide information about the impact of healthcare on the environment; involve patients and the public in leading positive change; and avoid broadening health inequalities. There is a clear need for more research and engagement to help advance our understanding and weigh up the benefits to individual patients vs. the environmental impacts on the wider population.

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

BACKGROUND

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Operational data for the risk management of victim operated explosive devices in humanitarian mine action: A Practitioner's perspective

Since Mine Action's inception at the end of the 1980s, operators have collected limited data on the Victim Operated Explosive Devices (VOEDs) they clear. This includes not only data on the explosive ordnance itself but data on how they were found, where they were found and how they were processed and ultimately destroyed. In a context where detection of mines, boobytraps and certain Victim Operated Improvised Explosive Devices (VOIEDs) is an ongoing humanitarian and military challenge, significantly expanded operational data collection provides an achievable way to facilitate enhanced operational risk management. Risk decisions inherent in the clearance of VOEDs are better if made on the basis of extensive operational data. In the absence of a technological solution to detect and positively discriminate VOEDs from false positive indications, the collection of operational data offers the best prospect for "managing" if not "solving" the problem.

An in vitro toxicological assessment of two electronic cigarettes: E-liquid to aerosolisation

Interest in the toxicological assessment of iterations of e-cigarette devices, e-liquid formulations and flavour use is increasing. Here, we describe a multiple test matrix and in vitro approach to assess the biological impact of differing e-cigarette activation mechanism (button vs. puff-activated) and heating technology (cotton vs. ceramic wick). The e-liquids selected for each device contained the same nicotine concentration and flavourings. We tested both e-liquid and aqueous extract of e-liquid aerosol using a high throughput cytotoxicity and genotoxicity screen. We also conducted whole aerosol assessment both in a reconstituted human airway lung tissue (MucilAir) with associated endpoint assessment (cytotoxicity, TEER, cilia beat frequency and active area) and an Ames whole aerosol assay with up to 900 consecutive undiluted puffs. Following this testing it is shown that the biological impact of these devices is similar, taking into consideration the limitations and capturing efficiencies of the different testing matrices. We have contextualised these responses against previous published reference cigarette data to establish the comparative reduction in response consistent with reduced risk potential of the e-cigarette products tested in this study as compared to conventional cigarettes.

Quantification of putative ovarian cancer serum protein biomarkers using a multiplexed targeted mass spectrometry assay

BACKGROUND

Ovarian cancer is the most lethal gynecologic malignancy in women, and high-grade serous ovarian cancer (HGSOC) is the most common subtype. Currently, no clinical test has been approved by the FDA to screen the general population for ovarian cancer. This underscores the critical need for the development of a robust methodology combined with novel technology to detect diagnostic biomarkers for HGSOC in the sera of women. Targeted mass spectrometry (MS) can be used to identify and quantify specific peptides/proteins in complex biological samples with high accuracy, sensitivity, and reproducibility. In this study, we sought to develop and conduct analytical validation of a multiplexed Tier 2 targeted MS parallel reaction monitoring (PRM) assay for the relative quantification of 23 putative ovarian cancer protein biomarkers in sera.

METHODS

To develop a PRM method for our target peptides in sera, we followed nationally recognized consensus guidelines for validating fit-for-purpose Tier 2 targeted MS assays. The endogenous target peptide concentrations were calculated using the calibration curves in serum for each target peptide. Receiver operating characteristic (ROC) curves were analyzed to evaluate the diagnostic performance of the biomarker candidates.

RESULTS

We describe an effort to develop and analytically validate a multiplexed Tier 2 targeted PRM MS assay to quantify candidate ovarian cancer protein biomarkers in sera. Among the 64 peptides corresponding to 23 proteins in our PRM assay, 24 peptides corresponding to 16 proteins passed the assay validation acceptability criteria. A total of 6 of these peptides from insulin-like growth factor-binding protein 2 (IBP2), sex hormone-binding globulin (SHBG), and TIMP metalloproteinase inhibitor 1 (TIMP1) were quantified in sera from a cohort of 69 patients with early-stage HGSOC, late-stage HGSOC, benign ovarian conditions, and healthy (non-cancer) controls. Confirming the results from previously published studies using orthogonal analytical approaches, IBP2 was identified as a diagnostic biomarker candidate based on its significantly increased abundance in the late-stage HGSOC patient sera compared to the healthy controls and patients with benign ovarian conditions.

CONCLUSIONS

A multiplexed targeted PRM MS assay was applied to detect candidate diagnostic biomarkers in HGSOC sera. To evaluate the clinical utility of the IBP2 PRM assay for HGSOC detection, further studies need to be performed using a larger patient cohort.

Predictive Modeling for Hospital Readmissions for Patients with Heart Disease: An updated review from 2012-2023

Hospital readmissions are a major concern for healthcare leaders, policy makers, and patients, resulting in adverse health outcomes and imposing an increased burden on hospital resources. This review aims to synthesize existing literature on predictive models focused on patients diagnosed with heart disease, which is known for its high readmission rates. Seven databases (i.e., Web of Science, Scopus, PubMed, ProQuest, Ovid, Cochrane Library and EBSCO) were consulted resulting in the inclusion of 56 eligible studies. Among these, 44 focused on model development, 7 on model validation, 4 on model improvement, and 1 on model implementation. Data were extracted on readmission types, data sources, modeling methods, and predictors, while assessments were conducted to analyze the quality of the studies. Findings showed that readmission types were significantly influenced by policy decisions, data predominantly originated from hospitals, and the prevalent modeling methods used were regression and single-layer machine learning techniques. The most important clinical predictors were related to comorbidities and complications, while the key demographic predictors were age and race. The study found that, despite advancements during the last decade, several limitations exist in current research, particularly in addressing attrition bias and handling missing data. Future research should, therefore, focus on optimizing readmission types, enhancing model generalization, using interpretable models, and emphasizing model implementation.

Percutaneous Revascularization for Ischemic Left Ventricular Dysfunction: Cost-Effectiveness Analysis of the REVIVED-BCIS2 Trial

BACKGROUND

Percutaneous coronary intervention (PCI) is frequently undertaken in patients with ischemic left ventricular systolic dysfunction. The REVIVED (Revascularization for Ischemic Ventricular Dysfunction)-BCIS2 (British Cardiovascular Society-2) trial concluded that PCI did not reduce the incidence of all-cause death or heart failure hospitalization; however, patients assigned to PCI reported better initial health-related quality of life than those assigned to optimal medical therapy (OMT) alone. The aim of this study was to assess the cost-effectiveness of PCI+OMT compared with OMT alone.

METHODS

REVIVED-BCIS2 was a prospective, multicenter UK trial, which randomized patients with severe ischemic left ventricular systolic dysfunction to either PCI+OMT or OMT alone. Health care resource use (including planned and unplanned revascularizations, medication, device implantation, and heart failure hospitalizations) and health outcomes data (EuroQol 5-dimension 5-level questionnaire) on each patient were collected at baseline and up to 8 years post-randomization. Resource use was costed using publicly available national unit costs. Within the trial, mean total costs and quality-adjusted life-years (QALYs) were estimated from the perspective of the UK health system. Cost-effectiveness was evaluated using estimated mean costs and QALYs in both groups. Regression analysis was used to adjust for clinically relevant predictors.

RESULTS

Between 2013 and 2020, 700 patients were recruited (mean age: PCI+OMT=70 years, OMT=68 years; male (%): PCI+OMT=87, OMT=88); median follow-up was 3.4 years. Over all follow-ups, patients undergoing PCI yielded similar health benefits at higher costs compared with OMT alone (PCI+OMT: 4.14 QALYs, £22 352; OMT alone: 4.16 QALYs, £15 569; difference: -0.015, £6782). For both groups, most health resource consumption occurred in the first 2 years post-randomization. Probabilistic results showed that the probability of PCI being cost-effective was 0.

CONCLUSIONS

A minimal difference in total QALYs was identified between arms, and PCI+OMT was not cost-effective compared with OMT, given its additional cost. A strategy of routine PCI to treat ischemic left ventricular systolic dysfunction does not seem to be a justifiable use of health care resources in the United Kingdom.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT01920048.

Frequency and characteristics of chemotherapy-associated thrombotic microangiopathy: Analysis from a large pharmacovigilance database

We used the information component (IC), a disproportionate Bayesian analysis comparing the number of observed versus expected adverse drug reactions, to determine the potential association between anti-neoplastic agents and thrombotic microangiopathy (TMA). The IC025 indicates the lower end of 95% of IC, in which a value >0 suggests a disproportionality signal between the drug of interest and the adverse drug reaction. Carfilzomib had the highest IC025 for TMA among all studied chemotherapies followed by gemcitabine, mitomycin, bevacizumab, and bortezomib.

Delayed Surgical Intervention After Chemoradiotherapy in Esophageal Cancer: (DICE) Study

OBJECTIVE

To determine the impact of delayed surgical intervention following chemoradiotherapy (CRT) on survival from esophageal cancer.

BACKGROUND

CRT is a core component of multimodality treatment for locally advanced esophageal cancer. The timing of surgery following CRT may influence the probability of performing an oncological resection and the associated operative morbidity.

METHODS

This was an international, multicenter, cohort study, including patients from 17 centers who received CRT followed by surgery between 2010 and 2020. In the main analysis, patients were divided into 4 groups based upon the interval between CRT and surgery (0-50, 51-100, 101-200, and >200 days) to assess the impact upon 90-day mortality and 5-year overall survival. Multivariable logistic and Cox regression provided hazard ratios (HRs) with 95% CIs adjusted for relevant patient, oncological, and pathologic confounding factors.

RESULTS

A total of 2867 patients who underwent esophagectomy after CRT were included. After adjustment for relevant confounders, prolonged interval following CRT was associated with an increased 90-day mortality compared with 0 to 50 days (reference): 51 to 100 days (HR=1.54, 95% CI: 1.04-2.29), 101 to 200 days (HR=2.14, 95% CI: 1.37-3.35), and >200 days (HR=3.06, 95% CI: 1.64-5.69). Similarly, a poorer 5-year overall survival was also observed with prolonged interval following CRT compared with 0 to 50 days (reference): 101 to 200 days (HR=1.41, 95% CI: 1.17-1.70), and >200 days (HR=1.64, 95% CI: 1.24-2.17).

CONCLUSIONS

Prolonged interval following CRT before esophagectomy is associated with increased 90-day mortality and poorer long-term survival. Further investigation is needed to understand the mechanism that underpins these adverse outcomes observed with a prolonged interval to surgery.

Multiorgan MRI findings after hospitalisation with COVID-19 in the UK (C-MORE): a prospective, multicentre, observational cohort study

INTRODUCTION

The multiorgan impact of moderate to severe coronavirus infections in the post-acute phase is still poorly understood. We aimed to evaluate the excess burden of multiorgan abnormalities after hospitalisation with COVID-19, evaluate their determinants, and explore associations with patient-related outcome measures.

METHODS

In a prospective, UK-wide, multicentre MRI follow-up study (C-MORE), adults (aged ≥18 years) discharged from hospital following COVID-19 who were included in Tier 2 of the Post-hospitalisation COVID-19 study (PHOSP-COVID) and contemporary controls with no evidence of previous COVID-19 (SARS-CoV-2 nucleocapsid antibody negative) underwent multiorgan MRI (lungs, heart, brain, liver, and kidneys) with quantitative and qualitative assessment of images and clinical adjudication when relevant. Individuals with end-stage renal failure or contraindications to MRI were excluded. Participants also underwent detailed recording of symptoms, and physiological and biochemical tests. The primary outcome was the excess burden of multiorgan abnormalities (two or more organs) relative to controls, with further adjustments for potential confounders. The C-MORE study is ongoing and is registered with ClinicalTrials.gov, NCT04510025.

FINDINGS

Of 2710 participants in Tier 2 of PHOSP-COVID, 531 were recruited across 13 UK-wide C-MORE sites. After exclusions, 259 C-MORE patients (mean age 57 years [SD 12]; 158 [61%] male and 101 [39%] female) who were discharged from hospital with PCR-confirmed or clinically diagnosed COVID-19 between March 1, 2020, and Nov 1, 2021, and 52 non-COVID-19 controls from the community (mean age 49 years [SD 14]; 30 [58%] male and 22 [42%] female) were included in the analysis. Patients were assessed at a median of 5·0 months (IQR 4·2-6·3) after hospital discharge. Compared with non-COVID-19 controls, patients were older, living with more obesity, and had more comorbidities. Multiorgan abnormalities on MRI were more frequent in patients than in controls (157 [61%] of 259 vs 14 [27%] of 52; p<0·0001) and independently associated with COVID-19 status (odds ratio [OR] 2·9 [95% CI 1·5-5·8]; padjusted=0·0023) after adjusting for relevant confounders. Compared with controls, patients were more likely to have MRI evidence of lung abnormalities (p=0·0001; parenchymal abnormalities), brain abnormalities (p<0·0001; more white matter hyperintensities and regional brain volume reduction), and kidney abnormalities (p=0·014; lower medullary T1 and loss of corticomedullary differentiation), whereas cardiac and liver MRI abnormalities were similar between patients and controls. Patients with multiorgan abnormalities were older (difference in mean age 7 years [95% CI 4-10]; mean age of 59·8 years [SD 11·7] with multiorgan abnormalities vs mean age of 52·8 years [11·9] without multiorgan abnormalities; p<0·0001), more likely to have three or more comorbidities (OR 2·47 [1·32-4·82]; padjusted=0·0059), and more likely to have a more severe acute infection (acute CRP >5mg/L, OR 3·55 [1·23-11·88]; padjusted=0·025) than those without multiorgan abnormalities. Presence of lung MRI abnormalities was associated with a two-fold higher risk of chest tightness, and multiorgan MRI abnormalities were associated with severe and very severe persistent physical and mental health impairment (PHOSP-COVID symptom clusters) after hospitalisation.

INTERPRETATION

After hospitalisation for COVID-19, people are at risk of multiorgan abnormalities in the medium term. Our findings emphasise the need for proactive multidisciplinary care pathways, with the potential for imaging to guide surveillance frequency and therapeutic stratification.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Gender differences in PTSD severity and pain outcomes: baseline results from the LAMP trial

Background

Post-traumatic stress disorder (PTSD) and chronic pain are highly prevalent comorbid conditions. Veterans dually burdened by PTSD and chronic pain experience more severe outcomes compared to either disorder alone. Few studies have enrolled enough women Veterans to test gender differences in pain outcomes [catastrophizing, intensity, interference] by the severity of PTSD.

Aim

Examine gender differences in the association between PTSD symptoms and pain outcomes among Veterans enrolled in a chronic pain clinical trial.

Methods

Participants were 421 men and 386 women Veterans with chronic pain who provided complete data on PTSD symptoms and pain outcomes. We used hierarchical linear regression models to examine gender differences in pain outcomes by PTSD symptoms.

Results

Adjusted multivariable models indicated that PTSD symptoms were associated with higher levels of pain catastrophizing (0.57, 95% CI [0.51, 0.63]), pain intensity (0.30, 95% CI [0.24, 0.37]), and pain interference (0.46, 95% CI [0.39, 0.52]). No evidence suggesting differences in this association were found in either the crude or adjusted models (all interaction p-values<0.05).

Conclusion

These findings may reflect the underlying mutual maintenance of these conditions whereby the sensation of pain could trigger PTSD symptoms, particularly if the trauma and pain are associated with the same event. Clinical implications and opportunities testing relevant treatments that may benefit both chronic pain and PTSD are discussed.

Expedited transfer to a cardiac arrest centre for non-ST-elevation out-of-hospital cardiac arrest (ARREST): a UK prospective, multicentre, parallel, randomised clinical trial

BACKGROUND

The International Liaison Committee on Resuscitation has called for a randomised trial of delivery to a cardiac arrest centre. We aimed to assess whether expedited delivery to a cardiac arrest centre compared with current standard of care following resuscitated cardiac arrest reduces deaths.

METHODS

ARREST is a prospective, parallel, multicentre, open-label, randomised superiority trial. Patients (aged ≥18 years) with return of spontaneous circulation following out-of-hospital cardiac arrest without ST elevation were randomly assigned (1:1) at the scene of their cardiac arrest by London Ambulance Service staff using a secure online randomisation system to expedited delivery to the cardiac catheter laboratory at one of seven cardiac arrest centres or standard of care with delivery to the geographically closest emergency department at one of 32 hospitals in London, UK. Masking of the ambulance staff who delivered the interventions and those reporting treatment outcomes in hospital was not possible. The primary outcome was all-cause mortality at 30 days, analysed in the intention-to-treat (ITT) population excluding those with unknown mortality status. Safety outcomes were analysed in the ITT population. The trial was prospectively registered with the International Standard Randomised Controlled Trials Registry, 96585404.

FINDINGS

Between Jan 15, 2018, and Dec 1, 2022, 862 patients were enrolled, of whom 431 (50%) were randomly assigned to a cardiac arrest centre and 431 (50%) to standard care. 20 participants withdrew from the cardiac arrest centre group and 19 from the standard care group, due to lack of consent or unknown mortality status, leaving 411 participants in the cardiac arrest centre group and 412 in the standard care group for the primary analysis. Of 822 participants for whom data were available, 560 (68%) were male and 262 (32%) were female. The primary endpoint of 30-day mortality occurred in 258 (63%) of 411 participants in the cardiac arrest centre group and in 258 (63%) of 412 in the standard care group (unadjusted risk ratio for survival 1·00, 95% CI 0·90-1·11; p=0·96). Eight (2%) of 414 patients in the cardiac arrest centre group and three (1%) of 413 in the standard care group had serious adverse events, none of which were deemed related to the trial intervention.

INTERPRETATION

In adult patients without ST elevation, transfer to a cardiac arrest centre following resuscitated cardiac arrest in the community did not reduce deaths.

FUNDING

British Heart Foundation.

Arrhythmia and Death Following Percutaneous Revascularization in Ischemic Left Ventricular Dysfunction: Prespecified Analyses From the REVIVED-BCIS2 Trial

BACKGROUND

Ventricular arrhythmia is an important cause of mortality in patients with ischemic left ventricular dysfunction. Revascularization with coronary artery bypass graft or percutaneous coronary intervention is often recommended for these patients before implantation of a cardiac defibrillator because it is assumed that this may reduce the incidence of fatal and potentially fatal ventricular arrhythmias, although this premise has not been evaluated in a randomized trial to date.

METHODS

Patients with severe left ventricular dysfunction, extensive coronary disease, and viable myocardium were randomly assigned to receive either percutaneous coronary intervention (PCI) plus optimal medical and device therapy (OMT) or OMT alone. The composite primary outcome was all-cause death or aborted sudden death (defined as an appropriate implantable cardioverter defibrillator therapy or a resuscitated cardiac arrest) at a minimum of 24 months, analyzed as time to first event on an intention-to-treat basis. Secondary outcomes included cardiovascular death or aborted sudden death, appropriate implantable cardioverter defibrillator (ICD) therapy or sustained ventricular arrhythmia, and number of appropriate ICD therapies.

RESULTS

Between August 28, 2013, and March 19, 2020, 700 patients were enrolled across 40 centers in the United Kingdom. A total of 347 patients were assigned to the PCI+OMT group and 353 to the OMT alone group. The mean age of participants was 69 years; 88% were male; 56% had hypertension; 41% had diabetes; and 53% had a clinical history of myocardial infarction. The median left ventricular ejection fraction was 28%; 53.1% had an implantable defibrillator inserted before randomization or during follow-up. All-cause death or aborted sudden death occurred in 144 patients (41.6%) in the PCI group and 142 patients (40.2%) in the OMT group (hazard ratio, 1.03 [95% CI, 0.82-1.30]; P=0.80). There was no between-group difference in the occurrence of any of the secondary outcomes.

CONCLUSIONS

PCI was not associated with a reduction in all-cause mortality or aborted sudden death. In patients with ischemic cardiomyopathy, PCI is not beneficial solely for the purpose of reducing potentially fatal ventricular arrhythmias.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT01920048.

Knowledge transfer between physicians from different geographical regions in China's online health communities

Online Health Communities (OHCs) are a type of self-organizing platform that provide users with access to social support, information, and knowledge transfer opportunities. The medical expertise of registered physicians in OHCs plays a crucial role in maintaining the quality of online medical services. However, few studies have examined the effectiveness of OHCs in transferring knowledge between physicians and most do not distinguish between the explicit and tacit knowledge transferred between physicians. This study aims to demonstrate the cross-regional transfer characteristics of medical knowledge, especially tacit and explicit knowledge. Based on data collected from 4716 registered physicians on Lilac Garden (DXY.cn), a leading Chinese OHC, Exponential Random Graph Models are used to (1) examine the overall network and two subnets of tacit and explicit knowledge (i.e., clinical skills and medical information), and (2) identify patterns in the knowledge transferred between physicians, based on regional variations. Analysis of the network shows that physicians located in economically developed regions or regions with sufficient workforces are more likely to transfer medical knowledge to those from poorer regions. Analysis of the subnets demonstrate that only Gross Domestic Product (GDP) flows are supported in the clinical skill network since discussions around tacit knowledge are a direct manifestation of physicians' professional abilities. These findings extend current understanding about social value creation in OHCs by examining the medical knowledge flows generated by physicians between regions with different health resources. Moreover, this study demonstrates the cross-regional transfer characteristics of explicit and tacit knowledge to complement the literature on the effectiveness of OHCs to transfer different types of knowledge.

Evaluation of the accuracy and intra- and interobserver reliability of three manual laxity tests for canine cranial cruciate ligament rupture-An ex vivo kinetic and kinematic study

OBJECTIVES

To investigate the accuracy and intra- and interobserver reliability of the cranial drawer test (CD), tibial compression test (TCT), and the new tibial pivot compression test (TPCT) in an experimental setting resembling acute cranial cruciate ligament rupture (CCLR) and to elucidate the ability to subjectively estimate cranial tibial translation (CTT) during testing.

STUDY DESIGN

Experimental ex vivo study.

SAMPLE POPULATION

Ten cadaveric hindlimbs of large dogs.

METHODS

Kinetic and 3D-kinematic data was collected while three observers performed the tests on each specimen with intact (INTACT) and transected cranial cruciate ligament (CCLD) and compared using three-way repeated-measures ANOVA. Subjectively estimated CTT (SCTT), obtained during a separate round of testing, was compared to kinematic data by Pearson correlation.

RESULTS

CTT was significantly higher for CCLD than for INTACT for all tests, resulting in 100% sensitivity and specificity. TPCT induced the highest CTT and internal rotation. Intra- and interobserver agreement of translation was excellent. For rotation and kinetics, agreement was more variable. SCTT strongly correlated with the objectively measured values.

CONCLUSION

The CD, TCT and the new TPCT were all accurate and reliable. The high translations and rotations during TPCT are promising, encouraging further development of this test. SCTT was reliable in our experimental setting.

CLINICAL SIGNIFICANCE

Veterinary manual laxity tests are accurate and reliable in acute CCLR. The TPCT might have potential for the assessment of subtle and rotational canine stifle instabilities. The high reliability of SCTT implies that grading schemes for stifle laxity, similar to human medicine, could be developed.

Practice variation in anastomotic leak after esophagectomy: Unravelling differences in failure to rescue

INTRODUCTION

Failure to rescue (FTR) is an important outcome measure after esophagectomy and reflects mortality after postoperative complications. Differences in FTR have been associated with hospital resection volume. However, insight into how centers manage complications and achieve their outcomes is lacking. Anastomotic leak (AL) is a main contributor to FTR. This study aimed to assess differences in FTR after AL between centers, and to identify factors that explain these differences.

METHODS

TENTACLE - Esophagus is a multicenter, retrospective cohort study, which included 1509 patients with AL after esophagectomy. Differences in FTR were assessed between low-volume (<20 resections), middle-volume (20-60 resections) and high-volume centers (≥60 resections). Mediation analysis was performed using logistic regression, including possible mediators for FTR: case-mix, hospital resources, leak severity and treatment.

RESULTS

FTR after AL was 11.7%. After adjustment for confounders, FTR was lower in high-volume vs. low-volume (OR 0.44, 95%CI 0.2-0.8), but not versus middle-volume centers (OR 0.67, 95%CI 0.5-1.0). After mediation analysis, differences in FTR were found to be explained by lower leak severity, lower secondary ICU readmission rate and higher availability of therapeutic modalities in high-volume centers. No statistically significant direct effect of hospital volume was found: high-volume vs. low-volume 0.86 (95%CI 0.4-1.7), high-volume vs. middle-volume OR 0.86 (95%CI 0.5-1.4).

CONCLUSION

Lower FTR in high-volume compared with low-volume centers was explained by lower leak severity, less secondary ICU readmissions and higher availability of therapeutic modalities. To reduce FTR after AL, future studies should investigate effective strategies to reduce leak severity and prevent secondary ICU readmission.

Routine cerebral embolic protection in transcatheter aortic valve implantation: rationale and design of the randomised British Heart Foundation PROTECT-TAVI trial

Transcatheter aortic valve implantation (TAVI) is an established treatment for aortic stenosis. Cerebral embolic protection (CEP) devices may impact periprocedural stroke by capturing debris destined for the brain. However, there is a lack of high-quality randomised trial evidence supporting the use of CEP during TAVI. The British Heart Foundation (BHF) PROTECT-TAVI trial will address whether the routine use of CEP reduces the incidence of stroke in patients undergoing TAVI. BHF PROTECT-TAVI is a prospective, open-label, outcome-adjudicated, multicentre randomised controlled trial. The trial is open to all adult patients scheduled for TAVI at participating specialist cardiac centres across the United Kingdom who are able to receive the CEP device. The trial will recruit 7,730 participants. Participants will be randomised in a 1:1 ratio to undergo TAVI with CEP or TAVI without CEP (standard of care). The primary outcome is the incidence of stroke at 72 hours post-TAVI. Key secondary outcomes include the incidence of stroke and all-cause mortality up to 12 months post-TAVI, disability and cognitive outcomes, stroke severity, access site complications and a health economics analysis. The sample size of 7,730 participants has 80% power to detect a 33% relative risk reduction from a 3% incidence of the primary outcome in the controls. Trial recruitment commenced in October 2020. As of October 2022, 3,068 patients have been enrolled. BHF PROTECT-TAVI is designed to provide definitive evidence on the clinical efficacy and cost-effectiveness of using routine CEP with the SENTINEL device to reduce stroke in TAVI.

Comparative kinetic and kinematic evaluation of TPLO and TPLO combined with extra-articular lateral augmentation: A biomechanical study

OBJECTIVES

To investigate stifle kinematics and kinetics following TPLO and TPLO combined with an extra-articular lateral augmentation (TPLO-IB) during the tibial compression test (TCT) and the tibial pivot compression test (TPT), applied with an external (eTPT) and an internal moment (iTPT).

STUDY DESIGN

Experimental ex vivo study.

SAMPLE POPULATION

Ten cadaveric hindlimbs of dogs weighing 23-40 kg.

METHODS

3D-kinematic and kinetic data were collected while performing TCT, eTPT, and iTPT and compared under the conditions (1) normal, (2) CCL deficient, (3) TPLO, and (4) TPLO-IB. Two-way repeated-measures ANOVA was used to examine the effect of test and treatment on kinetic and kinematic data.

RESULTS

Mean ± SD preoperative TPA was 24.7° ± 1.7°, postoperative TPA was 5.9° ± 0.7°. During TCT, there was no difference in cranial tibial translation between the intact stifle and after TPLO (p = .17). In contrast, cranial tibial translation was six times larger in TPLO compared to intact when performing eTPT and iTPT (p < .001). Cranial tibial translation with TCT, eTPT and iTPT was not different between intact stifle and TPLO-IB. Intraclass correlation coefficient for eTPT and iTPT after TPLO and TPLO-IB was excellent being 0.93 (0.70-0.99) and 0.91 (0.73-0.99), respectively.

CONCLUSION

Whereas TCT is negative after TPLO, instability persists when a rotational moment is combined using eTPT and iTPT. TPLO-IB neutralizes craniocaudal and rotational instability when performing TCT, eTPT, and iTPT.

Ursodeoxycholic acid in the management of symptomatic gallstone disease: systematic review and clinician survey

BACKGROUND

Symptomatic gallstones are common. Ursodeoxycholic acid (UDCA) is a bile acid that dissolves gallstones. There is increasing interest in UDCA for symptomatic gallstones, particularly in those unfit for surgery.

METHOD

A UK clinician survey of use and opinions about UDCA in symptomatic gallstones was performed, assessing clinicians' beliefs and perceptions of UDCA effectiveness. A systematic review was performed in accordance with the PRISMA guidelines. PubMed, MEDLINE, and Embase databases were searched for studies of UDCA for symptomatic gallstones (key terms included 'ursodeoxycholic acid'; 'UDCA'; 'biliary pain'; and 'biliary colic'). Information was assessed by two authors, including bias assessment, with independent review of conflicts.

RESULTS

Overall, 102 clinicians completed the survey, and 42 per cent had previous experience of using UDCA. Survey responses demonstrated clinical equipoise surrounding the benefit of UDCA for the management of symptomatic gallstones, with no clear consensus for benefit or non-benefit; however, 95 per cent would start using UDCA if there was a randomized clinical trial (RCT) demonstrating a benefit. Eight studies were included in the review: four RCTs, three prospective studies, and one retrospective study. Seven of eight studies were favourable of UDCA for biliary pain. Outcomes and follow-up times were heterogenous, as well as comparator type, with only four of eight studies comparing with placebo.

CONCLUSION

Evidence for UDCA in symptomatic gallstones is scarce and heterogenous. Clinicians currently managing symptomatic gallstone disease are largely unaware of the benefit of UDCA, and there is clinical equipoise surrounding the benefit of UDCA. Level 1 evidence is required by clinicians to support UDCA use in the future.

Violence on the front line: a qualitative comparative analysis of the causes of patient violence towards medical staff in China during the COVID-19 pandemic

COVID-19, reduced funding and a shortage of healthcare workers has led to growing international concern about patient violence towards medical staff in medical settings. As the number of reported physical and verbal assaults increases, many medical staff are considering leaving their positions due to the resulting impact on their mental and physical wellbeing, creating a critical need to understand the causes for violence towards medical staff working on the front line. This study aims to examine the causes for patient violence towards medical staff in China during the COVID-19 pandemic. A case library was created containing twenty reported incidents of patient violence towards medical staff during the pandemic in China. Based on the Triadic Reciprocal Determinism (TRD) theory, we identify the personal, environmental, and behavioral factors, that cause incidents of violence towards medical staff. The outcome was set as 'Medical Staff Casualties', referring to whether, due to the violence experienced, the medical staff member was injured or died, or only experienced threatening or insulting behavior. Data was analyzed using Qualitative Comparative Analysis (QCA) to clarify the relationship between the different conditions and their relationship with the outcome. The study's results reveal that Relationship Closeness is a necessary condition for patient violence in the presence of outcome. Secondly, four distinct types of causes for patient violence towards medical staff were identified: Strong Relationship Oriented Violence, Healthcare Resources and Services Mismatched Violence, Violence caused by Ineffective Patient-Physician Communication, and Ineffective Communication Superimposed Low Patient Compliance Violence. Scientific guidance is provided for the creation of measures to prevent future violence towards medical staff from occurring. Strict precautions should be taken for preventing violence to protect a healthy society and harmonious medical environment, emphasizing the need for joint governance of multiple participants.

The association between iron deficiency and outcomes: a secondary analysis of the intravenous iron therapy to treat iron deficiency anaemia in patients undergoing major abdominal surgery (PREVENTT) trial

In the intravenous iron therapy to treat iron deficiency anaemia in patients undergoing major abdominal surgery (PREVENTT) trial, the use of intravenous iron did not reduce the need for blood transfusion or reduce patient complications or length of hospital stay. As part of the trial protocol, serum was collected at randomisation and on the day of surgery. These samples were analysed in a central laboratory for markers of iron deficiency. We performed a secondary analysis to explore the potential interactions between pre-operative markers of iron deficiency and intervention status on the trial outcome measures. Absolute iron deficiency was defined as ferritin <30 μg.l^-1 ; functional iron deficiency as ferritin 30-100 μg.l^-1 or transferrin saturation < 20%; and the remainder as non-iron deficient. Interactions were estimated using generalised linear models that included different subgroup indicators of baseline iron status. Co-primary endpoints were blood transfusion or death and number of blood transfusions, from randomisation to 30 days postoperatively. Secondary endpoints included peri-operative change in haemoglobin, postoperative complications and length of hospital stay. Most patients had iron deficiency (369/452 [82%]) at randomisation; one-third had absolute iron deficiency (144/452 [32%]) and half had functional iron deficiency (225/452 [50%]). The change in pre-operative haemoglobin with intravenous iron compared with placebo was greatest in patients with absolute iron deficiency, mean difference 8.9 g.l^-1 , 95%CI 5.3-12.5; moderate in functional iron deficiency, mean difference 2.8 g.l^-1 , 95%CI -0.1 to 5.7; and with little change seen in those patients who were non-iron deficient. Subgroup analyses did not suggest that intravenous iron compared with placebo reduced the likelihood of death or blood transfusion at 30 days differentially across subgroups according to baseline ferritin (p = 0.33 for interaction), transferrin saturation (p = 0.13) or in combination (p = 0.45), or for the number of blood transfusions (p = 0.06, 0.29, and 0.39, respectively). There was no beneficial effect of the use of intravenous iron compared with placebo, regardless of the metrics to diagnose iron deficiency, on postoperative complications or length of hospital stay.

Predicting COVID-19 vaccination intentions: the roles of threat appraisal, coping appraisal, subjective norms, and negative affect

BACKGROUND

As a new disease, communities possess little natural immunity to COVID-19 and vaccines are considered critical to preventing and reducing the incidence of severe illness. This study, inspired by Protection Motivation Theory (PMT), examines the relationship between citizens' threat appraisal, coping appraisal, subjective norms, negative affect, and their COVID-19 vaccination intentions.

METHODS

A sample of 340 citizens from two main cities in Mainland China, Xi'an and Wuxi, was used for data analysis. Structural Equation Modeling (SEM) was employed with latent and observed variables to test hypotheses. Data were analyzed using AMOS 24.0.

RESULTS

Several findings extend current understanding. Firstly, our proposed model explains 73% of the variance in vaccination intentions. Secondly, perceived severity only indirectly shapes COVID-19 vaccination intentions through negative affect. Thirdly, negative affect and response costs are negatively related to COVID-19 vaccination intentions. Finally, Perceived probability, subjective norms, response efficacy and self-efficacy are positively related to COVID-19 vaccination intentions; among them, self-efficacy contributes the most, followed by response efficacy and subjective norms, and lastly perceived probability.

CONCLUSION

Theoretically, this study increases current understanding about subjective norms and affective responses. We provoke a certain amount of thought about the role of affect response in relation to threat appraisal and vaccination intentions. Specifically, governments must be vigilant that citizens' negative affect, such as fear, may cause vaccine hesitation.

Safety and efficacy of tenecteplase in patients with wake-up stroke assessed by non-contrast CT (TWIST): a multicentre, open-label, randomised controlled trial

BACKGROUND

Current evidence supports the use of intravenous thrombolysis with alteplase in patients with wake-up stroke selected with MRI or perfusion imaging and is recommended in clinical guidelines. However, access to advanced imaging techniques is often scarce. We aimed to determine whether thrombolytic treatment with intravenous tenecteplase given within 4·5 h of awakening improves functional outcome in patients with ischaemic wake-up stroke selected using non-contrast CT.

METHODS

TWIST was an investigator-initiated, multicentre, open-label, randomised controlled trial with blinded endpoint assessment, conducted at 77 hospitals in ten countries. We included patients aged 18 years or older with acute ischaemic stroke symptoms upon awakening, limb weakness, a National Institutes of Health Stroke Scale (NIHSS) score of 3 or higher or aphasia, a non-contrast CT examination of the head, and the ability to receive tenecteplase within 4·5 h of awakening. Patients were randomly assigned (1:1) to either a single intravenous bolus of tenecteplase 0·25 mg per kg of bodyweight (maximum 25 mg) or control (no thrombolysis) using a central, web-based, computer-generated randomisation schedule. Trained research personnel, who conducted telephone interviews at 90 days (follow-up), were masked to treatment allocation. Clinical assessments were performed on day 1 (at baseline) and day 7 of hospital admission (or at discharge, whichever occurred first). The primary outcome was functional outcome assessed by the modified Rankin Scale (mRS) at 90 days and analysed using ordinal logistic regression in the intention-to-treat population. This trial is registered with EudraCT (2014-000096-80), ClinicalTrials.gov (NCT03181360), and ISRCTN (10601890).

FINDINGS

From June 12, 2017, to Sept 30, 2021, 578 of the required 600 patients were enrolled (288 randomly assigned to the tenecteplase group and 290 to the control group [intention-to-treat population]). The median age of participants was 73·7 years (IQR 65·9-81·1). 332 (57%) of 578 participants were male and 246 (43%) were female. Treatment with tenecteplase was not associated with better functional outcome, according to mRS score at 90 days (adjusted OR 1·18, 95% CI 0·88-1·58; p=0·27). Mortality at 90 days did not significantly differ between treatment groups (28 [10%] patients in the tenecteplase group and 23 [8%] in the control group; adjusted HR 1·29, 95% CI 0·74-2·26; p=0·37). Symptomatic intracranial haemorrhage occurred in six (2%) patients in the tenecteplase group versus three (1%) in the control group (adjusted OR 2·17, 95% CI 0·53-8·87; p=0·28), whereas any intracranial haemorrhage occurred in 33 (11%) versus 30 (10%) patients (adjusted OR 1·14, 0·67-1·94; p=0·64).

INTERPRETATION

In patients with wake-up stroke selected with non-contrast CT, treatment with tenecteplase was not associated with better functional outcome at 90 days. The number of symptomatic haemorrhages and any intracranial haemorrhages in both treatment groups was similar to findings from previous trials of wake-up stroke patients selected using advanced imaging. Current evidence does not support treatment with tenecteplase in patients selected with non-contrast CT.

FUNDING

Norwegian Clinical Research Therapy in the Specialist Health Services Programme, the Swiss Heart Foundation, the British Heart Foundation, and the Norwegian National Association for Public Health.

The effects of information framing on self-protective behavior: Evidence from the COVID-19 vaccine uptake

Objectives

The Healthy China 2030 strategy outlines the government's plans for healthcare reform, emphasizing the need for increased awareness about infectious diseases to prevent and fight future infections. Information campaigns can be used as a medium to raise awareness and encourage citizens' willingness to protect themselves against diseases, such as COVID-19. Extant studies have found that individual health behavior decision-making can be changed under different information frames. However, limited evidence is available about emerging infectious diseases. Based on the Prospect Theory and Theory of Planned Behavior, the impact of information frames on self-protective behavior-vaccination against COVID-19 is investigated in this study.

Methods

A 2(gain/loss frame)*2(factual/emotional frame) intergroup experimental design was designed to explore the effects of different information frames. 228 valid participants in China were recruited and the experiment was performed online.

Results

First, the gain frame was more effective in promoting public self-protection behavior than the loss frame under information frame intervention. Compared with the factual frame, the emotional frame is more effective in reducing individual risk perception. Second, perceptual behavior control has masking effects on self-protection behavior under the influence of the gain/loss frame. Third, age, subjective norms, attitudes, and the gain frame, have predictive effects on self-protection behavior.

Conclusions

This study provides empirical evidence on the impact of information framing interventions on public self-protection behavior during the COVID-19 pandemic and provides important practical implications for public administrators and media practitioners.

Carpal Tunnel Syndrome as a Test Case for Value Assessment During the Presurgical Period: The Impact of Structure and Processes of Care

BACKGROUND

Few performance measures assess presurgical value (quality and utilization).

OBJECTIVES

Using carpal tunnel syndrome (CTS) as a case study: (1) develop a model to evaluate presurgical quality and utilization and (2) identify opportunities for value improvement.

RESEARCH DESIGN

A retrospective cohort study utilizing Veterans Affairs (VA) national administrative data.

SUBJECTS

Patients who were evaluated in a VA primary care clinic on at least 1 occasion for CTS and received carpal tunnel release over a 7-year period.

MEASURES

We modeled facility-level performance on 2 outcomes: surgical delay (marker of quality) and number of presurgical encounters (utilization) for CTS, and examined association between patient, facility, and care process variables and performance.

RESULTS

Among 41,912 Veterans undergoing carpal tunnel release at 127 VA medical centers, the median facility-level predicted probability of surgical delay was 48%, with 16 (13%) facilities having significantly less delay than the median and 13 (10%) facilities having greater delay. The median facility-level predicted number of presurgical encounters was 8.8 visits, with 22 (17%) facilities having significantly fewer encounters and 22 (17%) facilities having more. Care processes had a stronger association with both outcomes than structural variables included in the models. Processes associated with the greatest deviations in predicted delay and utilization included receipt of repeat electrodiagnostic testing, use of 2 or more nonoperative treatments, and community referral outside of VA.

CONCLUSIONS

Using CTS as a test case, this study demonstrates the potential to assess presurgical value and identify modifiable care processes associated with presurgical delay and utilization performance.

OGBN O04 Upper Gastrointestinal Training in the UK & Ireland – a Roux Group Study

Background

Surgical training programmes in the United Kingdom and Ireland (UK&I) are in a transition period evidenced by new surgical curricula. This study is the first to collate the opinions of UK&I trainee and consultant surgeons regarding the current Upper Gastrointestinal (UGI) training model.

Methods

A questionnaire was developed and distributed via national UGI societies and the social media platform, Twitter. A total of 241 responses were received with all UK&I regions represented.

Results

The median time to Certificate of Completion of Training (CCT) of 13 years was considered reasonable (50.2%), however the majority (67.2%) found training to be unfocused. The suggested targets for publications, presentations and audits were 3–5 (trainee vs consultant &lt;3 vs 3–5, p&lt;0.001), &lt;3 (&lt;3 vs 3–5, p=0.002) and 3–5 (&lt;3 vs 3–5, p&lt;0.001) respectively. The majority (61.9%) considered a higher academic degree advantageous but felt it should not be compulsory. Interestingly, most respondents (63.5%) had or planned to undertake one. Crucially, there were geographical discrepancies in access to training, particularly in bariatrics, robotic surgery, and endoscopy. Proficiency in diagnostic endoscopy was deemed essential for CCT and consultant practice (81.7% and 67.6% respectively). The current index UGI operative requirements were felt to be achievable (87.6%) but inadequate for day one consultant practice (74.7%), an opinion shared by both the trainee and consultant groups (p=0.662). Reassuringly, most respondents (76.3%) deemed there to be a role for on-the-job operative training following consultant appointment. Post-CCT fellowships were not considered necessary for consultant appointment, however the majority (73.6%) again recognised its advantage.

Conclusions

While variations were seen in the opinions of trainee and consultant surgeons, the current CCT requirements as outlined by the Joint Committee on Surgical Training are consistent with the overall perspective of the UGI community. Areas for improvement include flexibility in geographical working and provisions for endoscopy training, to ensure equal access.

OGC O02 The prognostic effect of pathological lymph node regression after neoadjuvant chemotherapy for oesophageal adenocarcinoma – a multicentre study

Background

The prognostic benefits of primary tumour and lymph node (LN) downstaging after neoadjuvant chemotherapy for oesophageal adenocarcinoma are well described. Pathological primary tumour regression grading (TRG) is widely used in the assessment of response to chemotherapy and has been shown to have prognostic value in this patient group. However, there is a lack of robust evidence regarding the prognostic effect of pathological response in LN despite emerging evidence of a discrepancy, up to 25% of patients in some studies, between TRG in the primary tumour and response in regional LNs. Although primary tumour regression is routinely documented as part of the standard pathological reporting of oesophagectomy specimens, LN regression is generally overlooked despite it's potential prognostic value. The aim of this study was to investigate the relationship between pathological response in LN, tumour recurrence and survival.

Methods

Multicentre cohort study including 763 patients with oesophageal adenocarcinoma treated with neoadjuvant chemotherapy followed by surgery at Guy's and St Thomas’ NHS Foundation Trust (NHS-FT), The Royal Marsden NHS-FT, University Hospitals Birmingham NHS-FT, University Hospital Southampton NHS-FT and Belfast Health and Social Care Trust. Tumour regression was assessed in the primary tumour (as described by Mandard) and, retrospectively, in LNs retrieved from oesophagectomy specimens. LN were graded according to the proportion of fibrosis and residual tumour providing a LN regression score (LNRS). LNRS 1, complete response; LNRS 2, &lt; 10% remaining tumour; LNRS 3, 10–50% remaining tumour; LNRS 4, &gt; 50% viable tumour; LNRS 5, no evidence of response. Regression was defined as a LNRS of 1–3. Patients were classified as LN negative (no evidence of tumour or regression in any LN), complete LN-responders (evidence of regression ≥1 LN, no residual tumour in any LN), partial LN-responders (evidence of regression ≥1 LN with residual tumour ≥1 LN) and LN non-responders (no or minimal regression in any LN). Survival analysis was performed using multivariable Cox regression providing hazard ratios (HR) with 95% confidence intervals (CI) adjusting for age, gender, chemotherapy regimen, clinical stage, tumour grade, lympho-vascular invasion and primary tumour response.

Results

Mean age was 63 years with the majority male (86.2%). In total, 17,930 LN from 763 patients were analysed for evidence of response to chemotherapy. Overall, 243 (31.8%) patients were classified as LN negative, 62 (8.1%) as complete LN-responders, 155 (20.3%) as partial LN-responders and 303 (39.7%) as LN non-responders. Less than half (322/763, 42.2%) of patients demonstrated a pathological response in the primary tumour (Mandard score 1–3). Some patients had a LN response in the absence of a response in the primary tumour (97/431, 22.5%). Multivariable Cox regression survival analysis demonstrated improved overall survival in complete LN-responders (HR 0.37 95% CI 0.24–0.58), partial LN-responders (HR 0.70 95% CI 0.55–0.89) and LN negative patients (HR 0.34 95% CI 0.26–0.44) compared to LN non-responders. Similar results were observed for disease-free survival (complete LN-responders, HR 0.34 95% CI 0.22–0.53; partial LN-responders, HR 0.74 95% CI 0.58–0.93; LN negative, HR 0.33 95% CI 0.25–0.42). Rates of tumour recurrence were lower in patients who demonstrated a LN response or had negative LN (LN negative 23.0% vs complete LN-responders 19.4% vs partial LN-responders 50.3% vs LN non-responders 66.7%, p&lt;0.001).

Conclusions

In this cohort of patients with oeosphageal adenocarcinoma treated with neoadjuvant chemotherapy prior to surgical resection, LN regression was a strong predictive factor for better survival. This relationship was independent of primary tumour response, which was discordant in a significant number of patients. Complete LN-responders had equivalent survival to those with negative LN. Complete and partial LN-responders had better survival than LN non-responders. Evaluation and documentation of LN regression should be considered during the standard pathological reporting of oesophagectomy specimens.

OGC O04 A Preoperative Scoring Model to Estimate the Risk of Conduit Necrosis in Oesophagectomy Patients - Results From the Oesophago-Gastric Anastomosis Audit

Background

Both conduit necrosis (CN) and anastomotic leak (AL) after oesophagectomy is associated with high morbidity and mortality and therefore identification of preoperative, modifiable risk factors are desirable. Once identified, risk factors can be used to create a risk scoring model which can be used to aid preoperative counselling and guide postoperative management. The aim of this study was to use the prospectively collected, multicentre data from the Oesophago-Gastric Anastomosis Audit (OGAA) to generate a risk scoring model for conduit necrosis and anastomotic leak after oesophagectomy.

Methods

This prospective multicentre cohort study included patients undergoing oesophagectomy for oesophageal cancer between April 2018 and December 2018 (with 90 days of follow-up). Definitions for AL and CN were those set out by the Esophageal Complications Consensus Group. Univariate and multivariate analyses were performed to identify risk factors for both AL and CN. The cohort was then randomly split into a derivation an validation set. A risk score was then produced for both AL and CN using the derivation set, then internally validated using the validation set.

Results

This study included 2247 oesophagectomies across 137 hospitals in 41 countries. The AL rate was 14.2% (n = 319) and CN rate was 2.7% (n = 60). Preoperative factors that were independent predictors of CN were: body mass index (BMI), Eastern Cooperative Oncology Group (ECOG) performance status, previous myocardial infarction (MI) and smoking history. These were converted into a risk-scoring model and internally validated using the validation set with an area under the receiver operating characteristic curve (AUROC) of 0.775. Preoperative factors that were independent predictors of AL were cardiovascular comorbidity (previous MI, peripheral vascular disease, previous stroke) and chronic obstructive pulmonary disease (COPD). This was converted to a risk scoring model but when internally validated the AUROC showed insufficient predictive ability (0.618).

Conclusions

The present risk scoring model provides an internally validated tool to estimate a patient's risk of CN preoperatively. This could be used to inform preoperative counselling and guide postoperative management. External validation is required to further assess the predictive ability of this score. Despite a large dataset, AL proves difficult to predict using preoperative factors.

Facility-level program components leading to population impact: a coincidence analysis of obesity treatment options within the Veterans Health Administration

Obesity is a well-established risk factor for increased morbidity and mortality. Comprehensive lifestyle interventions, pharmacotherapy, and bariatric surgery are three effective treatment approaches for obesity. The Veterans Health Administration (VHA) offers all three domains but in different configurations across medical facilities. Study aim was to explore the relationship between configurations of three types of obesity treatments, context, and population impact across VHA using coincidence analysis. This was a cross-sectional analysis of survey data describing weight management treatment components linked with administrative data to compute population impact for each facility. Coincidence analysis was used to identify combinations of treatment components that led to higher population impact. Facilities with higher impact were in the top two quintiles for (1) reach to eligible patients and (2) weight outcomes. Sixty-nine facilities were included in the analyses. The final model explained 88% (29/33) of the higher-impact facilities with 91% consistency (29/32) and was comprised of five distinct pathways. Each of the five pathways depended on facility complexity-level plus factors from one or more of the three domains of weight management: comprehensive lifestyle interventions, pharmacotherapy, and/or bariatric surgery. Three pathways include components from multiple treatment domains. Combinations of conditions formed "recipes" that lead to higher population impact. Our coincidence analyses highlighted both the importance of local context and how combinations of specific conditions consistently and uniquely distinguished higher impact facilities from lower impact facilities for weight management.

Cyberbullying definitions and measurements in children and adolescents: Summarizing 20 years of global efforts

Despite numerous instruments existing to assist in the measurement of specific cyberbullying behaviors or cyberbullying in general, it is still unclear their purpose, corresponding scenarios, and their effectiveness. This study, therefore, aims to provide a comprehensive review of academic efforts on cyberbullying definitions, measurements, and their effectiveness in children and adolescents in the past two decades. A systematic review was performed using ASReview, an open source machine learning systematic review system. Three bibliographic citation databases, including Web of Science core collection, PubMed, and EBSCO were adopted for all relevant literature published from January 2001 to August 2021. In total, twenty-five studies, mentioning seventeen cyberbullying measurement scales, met the study collection criteria. The results found that most failed to provide a clear definition of cyberbullying, often providing unclear and inconsistent descriptions for the youth. Similarly, studies found it difficult to clearly reflect the three key elements of bullying, namely: harmfulness, repetitiveness, and the power imbalance between bullies and victims. With regard to cyberbullying types, most presented two or three categories, including victimization, perpetration, and bystanding, while some suggested four types based on the nature of the cyberbullying behavior, including written or verbal, visual or sexual, character impersonation, and exclusion. If characteristics are considered, cyberbullying becomes more specific with multiple categories being proposed, including flaming (or roasting), harassment, denigration, defamation, outing, jokes, online sexual harassment, and cyberstalking. With regard to measurements, many scales have been proposed and frequently refined to capture specific cyberbullying experience of the youth. This study emphasizes the value and importance of providing clear cyberbullying definitions and helps scholars in youth cyberbullying choose appropriate measurement scales.

The Impact of County Medical Community Reform on the Medical Service Efficiency of County-Level Public General Hospitals in China: A Case Study of Shanxi Province

China introduced the county medical community (CMC) reform, aimed to provide high-quality medical resources to rural citizens, in 2017. This study examines the impact of the reform on the medical service efficiency of county-level public general hospitals in Shanxi Province, China. In total, 92 county-level public general hospitals from Shanxi Province were taken as the research objective, and the super-efficiency SBM-DEA model was applied to measure medical service efficiency. Further, a two-way fixed-effect model was used to evaluate the impact of CMC reform on the medical service efficiency of county-level public general hospitals by using health statistics data from 2014 to 2018. The study reveals that the CMC reform improved the medical service efficiency of county-level public general hospitals by 15.6%. Moreover, the CMC reform had regional heterogeneity in its impact on the medical service efficiency of county-level public general hospitals. The CMC reform improved the medical service efficiency of hospitals in the southern region more than in the northern region of the province. The medical service efficiency of hospitals in the central region was also improved by CMC reform, but the causal relationship was not found significant. Further, hospital-level factors (e.g., fixed assets, hospital stay, and regional health center) and environmental factors (e.g., GDP, population, urbanization rate, and government subsidies) affected the medical service efficiency of county-level public hospitals during the process of promoting the CMC reform.

Promoting public engagement with household waste separation through government social media: A case study of Shanghai

Government agencies around the world are increasingly using social media to promote public engagement with government-initiated activities, such as Household Waste Separation (HWS). However, existing studies fail to examine how governments can use their official social media accounts to promote public engagement with HWS. This pioneering study investigates the effects of dialogic loop, media richness, content theme, and emotional valence on public engagement with HWS through Government Social Media (GSM). Moreover, the influencing mechanisms are explored by examining the moderating role of social media capital. In total, 1795 posts were scraped from the official Sina Weibo accounts of seventeen Shanghai governments and later analyzed. Results reveal that dialogic loop positively predicts public engagement with HWS through GSM, but media richness negatively affects public engagement. Content themes have significantly different impacts on the level of public engagement with HWS through GSM. Unexpectedly, the effect of emotional valence is not significant. This study is the first of its kind to demonstrate the moderating role of social media capital which is seen to weaken the positive effect of dialogic loop on public engagement with HWS through GSM and mitigate the negative effect of media richness.

Percutaneous Revascularization for Ischemic Left Ventricular Dysfunction

BACKGROUND

Whether revascularization by percutaneous coronary intervention (PCI) can improve event-free survival and left ventricular function in patients with severe ischemic left ventricular systolic dysfunction, as compared with optimal medical therapy (i.e., individually adjusted pharmacologic and device therapy for heart failure) alone, is unknown.

METHODS

We randomly assigned patients with a left ventricular ejection fraction of 35% or less, extensive coronary artery disease amenable to PCI, and demonstrable myocardial viability to a strategy of either PCI plus optimal medical therapy (PCI group) or optimal medical therapy alone (optimal-medical-therapy group). The primary composite outcome was death from any cause or hospitalization for heart failure. Major secondary outcomes were left ventricular ejection fraction at 6 and 12 months and quality-of-life scores.

RESULTS

A total of 700 patients underwent randomization - 347 were assigned to the PCI group and 353 to the optimal-medical-therapy group. Over a median of 41 months, a primary-outcome event occurred in 129 patients (37.2%) in the PCI group and in 134 patients (38.0%) in the optimal-medical-therapy group (hazard ratio, 0.99; 95% confidence interval [CI], 0.78 to 1.27; P = 0.96). The left ventricular ejection fraction was similar in the two groups at 6 months (mean difference, -1.6 percentage points; 95% CI, -3.7 to 0.5) and at 12 months (mean difference, 0.9 percentage points; 95% CI, -1.7 to 3.4). Quality-of-life scores at 6 and 12 months appeared to favor the PCI group, but the difference had diminished at 24 months.

CONCLUSIONS

Among patients with severe ischemic left ventricular systolic dysfunction who received optimal medical therapy, revascularization by PCI did not result in a lower incidence of death from any cause or hospitalization for heart failure. (Funded by the National Institute for Health and Care Research Health Technology Assessment Program; REVIVED-BCIS2 ClinicalTrials.gov number, NCT01920048.).

Understanding HCP views about delivering a rehabilitation programme for people living with atrial fibrillation

Background

People living with Atrial Fibrillation (AF) can experience symptoms such as palpitation, dyspnea, fatigue and dizziness which lead to reduced physical activity levels and quality of life [1,2]. Current management of AF mainly focus on pharmacological treatments and invasive procedures, while no routine prescription of exercise or rehabilitation programme is offered.

Purpose

To assess the views and opinions of healthcare professionals about delivering a tailored exercise/cardiac rehabilitation programme to people living with AF, and to explore the barriers in referral to this programme.

Methods

A cross-sectional survey was conducted online between April and September 2021 for healthcare professionals who are involved in the care for adults with AF in UK. A range of professions were targeted, including general practitioners, cardiac physicians, physiotherapists and nurses. The survey comprised twelve questions designed to explore healthcare professional views about rehabilitation programmes for adults with AF, factors influencing their decision to recommend rehabilitation and barriers to the referral process.

Results

Overall, n=209 participants responded from a wide range of disciplines (57% female, 43% specialist arrhythmia nurses). The majority of participants agreed that a rehabilitation programme would be beneficial to support patients to perform daily activities (127, 61%), with n=123, 58% agreeing that rehabilitation programme would be beneficial in reducing breathlessness and would reduce other symptoms such as palpitation (108, 52%).

Nearly all the healthcare professional (n=206/99%) suggested that a tailored programme should include information about AF (206, 99%), weight management and symptom management (n=197, 94%) aside from exercise. The factors that strongly influence their decision to refer to a rehabilitation programme included patients with low physical activity levels (n=166, 80%) and low exercise tolerance (n=157, 76%). The main barrier in referring to the programme was transportation problems (n=128, 62%) (Figure 1). The majority reported that home based programme would be the best way to deliver the programme (166, 79%) (Figure 2).

Conclusions

The responses indicate the enthusiasm for a programme targeting people with AF, poor activity levels was the main reason for referral.

Funding Acknowledgement

Type of funding sources: None.