Online Resources for Robin Sequence; an Analysis of Readability

The objective was to evaluate the readability of easily accessible parent-directed information concerning Robin Sequence (RS) online, compared to the American Medical Association (AMA)-recommended sixth grade (age 11-12) readability level.

A Google search of the term "Pierre Robin Sequence information" was performed. The first ten websites were evaluated using six commonly used readability formulas. Sample texts from three websites were 'translated' by the authors, with the aim of achieving a sixth grade readability level.

The following outcomes were used: Automated Readability Index (ARI), Coleman Liau Index (CLI), Gunning Fog Score, Simple Measure of Gobbledygook (SMOG), Flesch Kincaid Grade Level (FKGL), and Flesch Reading Ease (FRE) score.

The mean pooled grade level of the top 10 included websites was 12.1 (age 17-18). The overall FRE Index was 45.8, which is equivalent to a College-grade reading level. The mean grade level by each test used was: Flesch-Kincaid Grade Level 11.6 (age 16-17), Gunning Fog Score 13.3 (age 18+), SMOG 10.0 (age 14-15), Coleman-Liau Index 13.8 (age 18+), and ARI 12.0 (age 17-18). The author-translated resources achieved pooled mean grade levels of 6.3-6.5.

Parent-directed online materials concerning RS have a readability in excess of the AMA-recommended sixth grade reading level. Even though the condition is complex, more readable resources are achievable. Coproduction of parent-directed resources in association with public an patient involvement (PPI) contributors is encouraged.

'They're Going to Die at Some Point, but We're all Going to Die' - A Qualitative Exploration of Bereavement in Later Life

This article reports on a qualitative study to investigate what bereavement means to older people. Drawing upon 80 in-depth interviews collected from eight British and Australian retirement communities, our study revealed that facing bereavement while ageing includes experiences of losing both others and the wholeness of the self. Core themes identified how the experience of losing others can be compounded by ageing-related challenges, undermining older people's defence from bereavement and frustrating their fundamental meaning and being. The older people's dynamic responses were also captured, highlighting the importance of supporting their agency to deal with the deeper pain of loss. By extending the concept of bereavement in later life, we also called for a more grief literate culture to mitigate the multifaceted and often deeper distresses of bereavement that older people may face alongside ageing.

Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

A gradual separation from the world: commentary on a qualitative exploration of existential loneliness in old age

AIMS AND METHODS

Loneliness is a prevalent and significant issue. It has been identified as a particularly important physical and mental health risk for older people. This article critically explores and discusses a recent study that sought to qualitatively explore the lived experiences of existential loneliness in a large sample of older people living in retirement community contexts.

FINDINGS

The data pointed to complex, multilayered challenges, often brought about by ageing, that give rise to unique experiences of existential loneliness for many older people.

CONCLUSIONS

For clinical practitioners, understanding how older people experience existential loneliness is essential if we are to develop support mechanisms that compassionately and empathically respond to them.

Central Slip Repair using Trans-articular K-wires: A Comparative Study

Central slip disruption may lead to PIP joint dysfunction causing significant morbidity. Existing evidence for any specific surgical management of these injuries is limited but does favor early mobilization of the PIP joint. Aim: To assess the functional outcome in a cohort of patients undergoing central slip repair with internal K-wire proximal interphalangeal joint splinting and complete immobilization against those with external splinting only. Methods: A single center retrospective analysis of all patients that underwent operative central slip repair in our institution over a 5-year period. Data were collected via the HIPE database and clinical notes. Data relating to demographics as well as range of motion, total active motion {(TAM) (TAM%)} score, and hand therapy rehabilitation type were analyzed. Results: The study population was n = 44 patients. N = 33 patients were treated without a K-wire and n = 11 treated with a K-wire. There was a male predominance, 81.8% (n = 36). Mean age was 40.4 years. There was no significant difference in the mean TAM achieved at final measurement between the "no K-wire" and the "K-wire" treatment groups [no K-wire 202.1° (standard deviations (SD) 40.0) vs. K-wire 187.4° (SD 28.2), p = 0.208]. The "no K-wire group" achieved a mean TAM % of 78.0 (SD 11.4) and the "K-wire group" achieved a mean TAM % of 72.1 (SD 10.8); no statistically significant difference in mean scores was observed between groups. Conclusion: Our study has shown comparable functional outcomes between those having complete joint immobilization with internal K-wire splinting and those that are externally splinted only following central slip repair.

"They want you to know who they really are inside of the old visage"-biographical storytelling as a methodological tool to explore emotional challenges in old age

BACKGROUND

Growing older is often associated with resilience, contentedness and inner growth. Older people however are also at risk of confronting unique emotional challenges as a result of varied ageing-related experiences. By employing a biographical lens, we aim to introduce storytelling as a methodological tool to more holistically explore older people's emotional challenges and to improve their wellbeing.

METHODS

Building upon theoretical understandings about the narrative construction of identity across the life span, we draw upon a qualitative study about older people's loneliness as an example to showcase the methodological value and feasibility of biographical storytelling. We aim to better understand the nuanced and sometimes painful emotional experiences that can be encountered alongside ageing.

RESULTS

Findings from the qualitative study we showcase, highlight that unique emotional pains and the (in)ability to deal with such in old age could be deeply rooted in older people's earlier lives. These findings contextualise people's emotional challenges and needs within their identity, as a narrative thread that links their past, present and expected future. As such, our example study shows that emotional challenges in old age are not only ageing-related, but can be more fundamentally connected to disruptions to the ongoing flow of narrative identity construction.

CONCLUSION

The highly retrospective and reflexive nature of these findings illustrates the methodological merit of biographical storytelling. We argue that the impact of biographical storytelling can go further than both conventional semi-structured narrative interviews and existing interventional tools. Instead, it is a particularly useful research methodology to explore human experiences and needs in the unique context of ageing. This methodological development thus provides an insightful analytical lens to explore how older people's earlier life experiences may be carried forward and confronted to shape their emotional stability in the present and future stages of their ageing lives. Beyond the methodological significance, we further demonstrate the benefits of empowering older people to reconstruct their ageing lives in the context of their biography.

Tracing the international arrivals of SARS-CoV-2 Omicron variants after Aotearoa New Zealand reopened its border

In the second quarter of 2022, there was a global surge of emergent SARS-CoV-2 lineages that had a distinct growth advantage over then-dominant Omicron BA.1 and BA.2 lineages. By generating 10,403 Omicron genomes, we show that Aotearoa New Zealand observed an influx of these immune-evasive variants (BA.2.12.1, BA.4, and BA.5) through the border. This is explained by the return to significant levels of international travel following the border's reopening in March 2022. We estimate one Omicron transmission event from the border to the community for every ~5,000 passenger arrivals at the current levels of travel and restriction. Although most of these introductions did not instigate any detected onward transmission, a small minority triggered large outbreaks. Genomic surveillance at the border provides a lens on the rate at which new variants might gain a foothold and trigger new waves of infection.

Acellular dermal substitute use in the reconstruction of axillary hidradenitis suppurativa

Hidradenitis suppurativa (HS) is a chronic recurrent debilitating condition that affects the skin near to the follicular glands. The disease manifests with the formation of abscesses that can be complicated by rupture, sinus tracts, and scarring leading to pain, chronic discharge, malodor, and scar contractures. The management of HS is multidisciplinary, involving general lifestyle modification, medical treatment, and surgery. A wide range of surgical interventions has been described for HS disease control and management. However, surgical management strategies are highly variable. We describe the case of a 33-year-old female with refractory HS which was reconstructed with Matriderm® and an immediate split-thickness skin graft. Acellular dermal skin substitutes may be an alternative to conventional means of HS reconstruction, producing subtle, pliable, and durable skin.

247 Axillary Hidradenitis Suppurativa: A One-Stage Reconstruction Approach Using Acellular Dermal Substitute

Hidradenitis suppurativa (HS) is a chronic recurrent debilitating condition. It is characterized by abscesses, and can be complicated by rupture, scarring sinuses. The management of HS is multidisciplinary, involving general lifestyle modification, medical treatment, and surgery. A wide range of surgical interventions have been described for HS disease control and management. However, surgical management strategies are highly variable. We present a case of a 33-year-old female with extensive HS in both axillae resulting in extreme pain, restriction of shoulders movement with severe impact on quality of life. After failure of non-operative management, she underwent a wide excision of all pathological axillary disease. One week later, she had a single-stage reconstruction with Matriderm®. and a meshed split thickness skin graft. Acellular dermal skin substitutes may be an alternative to conventional means of hidradenitis suppurativa reconstruction, producing subtle, pliable, and durable skin.

"We are good neighbours, but we are not carers!": Lived experiences of conflicting (in)dependence needs in retirement villages across the United Kingdom and Australia

BACKGROUND AND OBJECTIVES

This study sought to qualitatively explore the lived experiences of 80 older people living in retirement villages across the UK and Australia. We focused on residents' narratives around the themes of independence/dependence.

RESEARCH DESIGN AND METHODS

Qualitative semi-structured interviews permitted in-depth exploration of how older people understood and experienced issues related to independence/dependence in the context of retirement living.

RESULTS

Core themes identified strikingly different and often competing needs and narratives around independence/dependence. Of note was the fact that narratives and needs around independence/dependence frequently collided and conflicted, creating a sense of 'us' and 'them' in the retirement community. The primary source of such conflict was reflected by the fact that residents seeking a 'prolonged midlife' often felt that frailer and more dependent residents were a burden on them and were not suited to an 'independent living community.'

DISCUSSION AND IMPLICATIONS

Our findings are discussed in relation to the challenges such competing narratives create for retirement villages as living environments for a group of people that are far from homogenous.

Atypical facial presentation of subcutaneous fat necrosis of the newborn

Subcutaneous fat necrosis of the newborn (SCFN) is a rare self-limiting panniculitis. It is thought to be associated with perinatal hypoxia and therapeutic hypothermia. It is characterised by firm subcutaneous nodules on the back, shoulder and arms. We present a rare facial presentation of SCFN in a 4-week-old infant with no history of therapeutic cooling. She presented with a discrete right cheek mass with no overlying skin changes. We present the diagnostic challenge and undertake a review of the literature. SCFN is an important differential diagnosis in a neonate with subcutaneous facial lesions. SCFN can be complicated by metabolic derangements including hypercalcaemia.

Camptodactyly and DiGeorge syndrome: A rare hand anomaly

The most common deletion syndrome is 22q11.2 and it effects an estimated 1 in 3000 live births. Major features of this multisystem condition include congenital abnormalities, developmental delay, learning difficulties, immunodeficiency, endocrine anomalies and an array of psychiatric disorders. However, variability in phenotype and severity may cause the diagnosis to be overlooked. Early clinical recognition and treatment of DiGeorge syndrome has been shown to increase early life survival, decrease complications and enhance overall quality of life.

Skeletal anomalies are infrequently described in 22q11.2 but a subset of patients exhibit upper and lower limb deformities. We present the case of a 5 year-old girl with bilateral fifth digit camptodactyly caused by a fibrous band, and the surgical management of this condition. The current report adds to the body of evidence that camptodactyly is a rare clinical feature of 22q11.2 deletion syndrome, and may serve as a diagnostic aid in these patients.

Is Parental Attachment Security Contextual? Exploring Context-Specific Child-Parent Attachment Patterns and Psychological Well-Being in Taiwanese Youths

Scant research to date has explored the possibility of context-specific variation in attachment security within a given relationship. In this paper, two cross-sectional studies were designed (1) to develop and validate context-specific attachment scales in Traditional-Chinese and (2) to explore variations in attachment security within a given parental relationship but between the contexts of sport and academics, relating them to global attachment patterns and indicators of psychological well-being. Results indicated that Taiwanese youth can and do perceive contextual variation within a given parental relationship. However, the relationship between such contextual variation and psychological outcomes was complex. Contextual variation may be a meaningful and useful way to explore and think about within-parent attachment fluctuation.

CSACI guidelines for the ethical, evidence-based and patient-oriented clinical practice of oral immunotherapy in IgE-mediated food allergy

Background

Oral immunotherapy (OIT) is an emerging approach to the treatment of patients with IgE-mediated food allergy and is in the process of transitioning to clinical practice.

Objective

To develop patient-oriented clinical practice guidelines on oral immunotherapy based on evidence and ethical imperatives for the provision of safe and efficient food allergy management.

Materials and methods

Recommendations were developed using a reflective patient-centered multicriteria approach including 22 criteria organized in five dimensions (clinical, populational, economic, organizational and sociopolitical). Data was obtained from: (1) a review of scientific and ethic literature; (2) consultations of allergists, other healthcare professionals (pediatricians, family physicians, nurses, registered dieticians, psychologists, peer supporters), patients and caregivers; and patient associations through structured consultative panels, interviews and on-line questionnaire; and (3) organizational and economic data from the milieu of care. All data was synthesized by criteria in a multicriteria deliberative guide that served as a platform for structured discussion and development of recommendations for each dimension, based on evidence, ethical imperatives and other considerations.

Results

The deliberative grid included 162 articles from the literature and media reviews and data from consultations involving 85 individuals. Thirty-eight (38) recommendations were made for the practice of oral immunotherapy for the treatment of IgE mediated food allergy, based on evidence and a diversity of ethical imperatives. All recommendations were aimed at fostering a context conducive to achieving objectives identified by patients and caregivers with food allergy. Notably, specific recommendations were developed to promote a culture of shared responsibility between patients and healthcare system, equity in access, patient empowerment, shared decision making and personalization of OIT protocols to reflect patients' needs. It also provides recommendations to optimize organization of care to generate capacity to meet demand according to patient choice, e.g. OIT or avoidance. These recommendations were made acknowledging the necessity of ensuring sustainability of the clinical offer in light of various economic considerations.

Conclusions

This innovative CPG methodology was guided by patients' perspectives, clinical evidence as well as ethical and other rationales. This allowed for the creation of a broad set of recommendations that chart optimal clinical practice and define the conditions required to bring about changes to food allergy care that will be sustainable, equitable and conducive to the well-being of all patients in need.

Abstract TS1-2: Proteogenomic Landscape of Prospectively Collected Breast Cancer

A persistent central deficiency in our knowledge of cancer concerns how genomic changes drive the proteome and phosphoproteome to execute phenotypic characteristics. Furthermore increasing evidence implicating epigenetic and post-translational changes in cancer biology reinforce the notion that molecular profiles based on nucleic acids are incomplete and are critically complemented by analyses of proteins and their post-translational modifications. We present the first integrated proteogenomic study on a prospectively collected breast cancer cohort, and provide new insights including on taxonomy, metabolic dependencies, and immune milieu. 122 invasive ductal breast cancer samples were collected under the auspices of the National Cancer Institute’s Clinical Proteomics Tumor Analysis Consortium using rigorous protocols to minimize ischemic time and other pre-analytical variability. Samples underwent comprehensive genomic and proteomic characterization, providing whole exome, whole genome, copy number, RNAseq, global proteome, phosphoproteome, and acetylome data. Multi-omics clustering by nonnegative matrix factorization revealed basal-, luminal A-, and HER2-enriched clusters, as well as a combined luminal A/B cluster. Luminal A and A/B clusters were distinguished by differential expression of cytoskeletal signatures possibly driven by YAP1 overexpression and hyper-phosphorylation in the luminal A subset. Kinase outlier analysis revealed luminal A enrichment of PEAK1, an atypical kinase that regulates YAP1 expression. PTPN2, recently shown to synergize with anti-PD1 therapy, was an outlier in basal tumors, suggesting therapeutic opportunities in that difficult-to-treat subtype. Acetylation plays a dominant role in mitochondrial metabolism, and downregulation of deacetylase SIRT3 in basal and HER2-enriched samples was associated with upregulation of TCA cycle- and amino acid metabolism-related proteins suggesting metabolic dependencies that could be exploited. Immunological subtyping of the breast cohort identified immune-cold, immune-hot, immune-excluded and interferon-independent clusters associated with distinct patterns of tumor-infiltrating lymphocytes. Basal tumors generally overexpressed PDL1 relative to other subtypes, whereas the newly described immuno-oncology target SIGLEC15 was overexpressed in luminal tumors. While these and other analyses are intended to provide new insights into breast cancer biology and facilitate testable therapeutic hypotheses, the larger purpose of the program is to provide a resource to the breast cancer and broader scientific communities. To facilitate this, these and previously published data will be integrated to provide a sample set of 199 proteogenomically characterized breast cancers for further exploration.

Citation Format: M Gillette, K Krug, S Satpathy, E Jaehnig, A Karpova, K Clauser, L Tang, L Blumenberg, R Kothadia, K Ruggles, B Zhang, L Ding, P Mertins, DR Mani, M Ellis, S Carr. Proteogenomic Landscape of Prospectively Collected Breast Cancer [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr TS1-2.

Unpaid carer inequalities: a public health concern

Key messages

unpaid (family)carers are at risk of being exposed to a range of health inequalities which can have individual and societal consequences. Interventions that acknowledge the relationship and draw on social dimensions may off coping may offer effective ways forward.

Referral of patients to plastic surgeons following self-harm: Opportunities for suicide prevention

Self-harm is a common source of referral to plastic and hand surgery services. Appropriate management of these patients is complex and includes the need for close liaison with mental health services. Self-harm is the single biggest risk factor for completed suicide, thereby increasing the risk by a factor of 66.¹ This study aimed to analyse the clinical pathway and demographics of patients referred to plastic surgeons following self-harm. This 6-year retrospective series included patients referred to plastic surgeons following self-harm within the Galway University Hospital group. Patients were identified through the Hospital inpatient enquiry system, cross-referenced with data from the National Suicide Research Foundation. Data collected included demographics, psychiatric history, details of self-harm injury, admission pathway and operative intervention. Forty-nine patients were referred to plastic surgery services during the study period, accounting for 61 individual presentations. The male-to-female ratio was 26 (53%) to 23 (47%). Mean age was 40 years (range 21-95 years). Alcohol or illicit substance use was recorded in 17 of 61 (28%) presentations. Mortality from suicide occurred in 4 patients (8%). Mental health assessment was not carried out in 9 presentations (15%). Documentation of need for close or one-to-one observation was made in 11 cases (20%) and was not referred to in 43 cases (83%) following mental health assessment. This study demonstrates significant diversity in the management of this vulnerable patient group and may inform development of referral pathways to improve the safety of transfer, surgical admission and discharge of patients following self-harm, in consultation with mental health services.

Prospective Validation of the NCI Breast Cancer Risk Assessment Tool and the Autodensity Mammographic Density Tool on 40,000 Australian Screening Program Participants

Background: In Australia and elsewhere, there is a growing interest in delivering more personalised, risk-based breast cancer screening protocols. This requires reliable, feasible and accurate estimates of risk. The US National Cancer Institute Breast Cancer Risk Assessment Tool (BCRAT) and the AutoDensity fully automated mammographic density measurement tool have each been shown to stratify women into groups according to their risk of breast cancer; the AutoDensity tool also provides information on the likely sensitivity and specificity of mammographic screening tests. The Australian 'lifepool' cohort of over 53,000 women recruited predominantly through BreastScreen Australia screening program offers an opportunity to validate these tools and examine how they can be combined to estimate various risks. Aim: To validate BCRAT and AutoDensity on a large Australian population, and examine how the tools can be combined to provide information on breast cancer risk and the accuracy of the screening test. Methods: We use lifepool cohort questionnaire data and linked screening records and mammograms, cancer registrations and death records to describe the association between BCRAT and AutoDensity scores assessed at the time of screening and future breast cancer diagnosis. We use hazards models to account for censoring and describe outcomes according to mode of detection (screen-detected, interval cancers or other). Our primary analysis is restricted to women in the historical screening target age range of 50-69 with no prevalent breast cancer diagnosis on entry to the lifepool cohort. Results: The primary analysis included approximately 40,000 women with a median follow-up period of 4.5 years (1.1-6.5 years). The BCRAT tool generated a median 5-year breast cancer risk score of 1.5% (range 0.6%-22.0%). Compared with women in the lowest quintile of this score, women in the highest quintile had a 2.3-fold risk (95% CI 1.7-3.0, P < 0.001) of incident invasive breast cancer. For the approximately 35,000 women with digital screening mammograms on enrolment, women in the highest quintile of AutoDensity values had a 1.5-fold risk (95% CI 1.1-2.0 P = 0.011) of incident invasive breast cancer and a 2.6-fold risk (95% CI 1.1-6.2, P = 0.034) of an interval cancer compared with women in the lowest quintile. With BRCAT and AutoDensity measurements weakly correlated (r2= 0.003, P = 0.05), we demonstrate various approaches to combining this information to stratify women according to breast cancer risk and risk of an interval cancer. Conclusion: The US National Cancer Institute Breast Cancer Risk Assessment Tool and the AutoDensity mammographic density tool can be used to stratify breast cancer screening participants into risk groups according to their future breast cancer risk and the risk of an interval cancer. This is likely to be of interest to screening program managers and policy-makers, and women considering screening participation.

Radiological "Teddy Bear" Sign on CT Imaging to Aid Internal Carotid Artery Localization in Transsphenoidal Pituitary and Anterior Skull Base Surgery

Objectives  Internal carotid artery (ICA) injury remains a rare but potentially fatal complication of transsphenoidal pituitary or anterior skull base surgery. Preoperative imaging must be scrutinized to minimize risk. On axial computed tomography (CT), the protrusions of the ICAs into the sphenoid resemble a "teddy bear." This article aims to describe the sign, its grading system (0-2) and quantify its presence. Design  Retrospective review of preoperative CT imaging. Setting  Tertiary referral center in the United Kingdom. Participants  One hundred patients who underwent endoscopic transsphenoidal surgery for pituitary disease were enrolled. Main Outcome Measure  The presence and grading of the "teddy bear" sign were assessed on preoperative CT imaging. Results  A grade 2 (strongly positive) "teddy bear" sign was identified in 40% at the level of the superior pituitary fossa, 78% at the inferior pituitary fossa, and 59% at the clivus. A grade 1 (intermediate) sign was seen in 23.5, 7.5, and 10% of cases, respectively. In 5% of cases, the sign was grade 0 at all levels-indicating poor intraoperative localization of the ICA. Conclusion  The "teddy bear" sign is a useful preoperative tool for identification of anatomy predisposing patients to a higher risk of ICA injury. Those patients who have an absent or grade 0 "teddy bear" sign require extra care to ensure intraoperative localization of the ICAs which may include the use of neuronavigation or a Doppler probe. A grade 2 sign predicts good intraoperative localization of the ICA intraoperatively to inform the safe lateral limit of sellar bone resection.

Changing operating lists on the day of surgery: a service evaluation

This study aims to explore how often the operating list is changed on the day of surgery and the reasons why this may occur. The purpose was to analyse the wider potential impact that changing the list on the day of surgery may have on patient safety, patient satisfaction and theatre efficiency. Survey data was collected across a multi-specialty elective operating department. The findings demonstrated that a significant change in operating lists occurred in 37.3% of sessions, for a variety of potentially avoidable reasons. We concluded that improved organisation and communication before the planned session could reduce the occurrence of changes, thereby increasing patient safety, theatre efficiency and potentially reducing incidents.

Fostering secure attachment: experiences of animal companions in the foster home

This study sought to use attachment theory as a lens through which to explore children's relationships with animal companions in the context of long-term foster care. Inductive and deductive thematic analyses of longitudinal case study data from eight children and their foster families suggested (a) that children's relationships with animal companions satisfied attachment-related functions in their own right and (b) that animal companions also helped to soften perceptions of foster caregivers, facilitating opportunities for the development of closeness. Animals in the foster home may therefore play an important part in helping children to find and develop secure, warm, and loving relationships.

The physiological response to cold-water immersion following a mixed martial arts training session

Combative sport is one of the most physically intense forms of exercise, yet the effect of recovery interventions has been largely unexplored. We investigated the effect of cold-water immersion on structural, inflammatory, and physiological stress biomarkers following a mixed martial arts (MMA) contest preparation training session in comparison with passive recovery. Semiprofessional MMA competitors (n = 15) were randomly assigned to a cold-water immersion (15 min at 10 °C) or passive recovery protocol (ambient air) completed immediately following a contest preparation training session. Markers of muscle damage (urinary myoglobin), inflammation/oxidative stress (urinary neopterin + total neopterin (neopterin + 7,8-dihydroneopterin)), and hypothalamic-pituitary axis (HPA) activation (saliva cortisol) were determined before, immediately after, and 1, 2, and 24 h postsession. Ratings of perceived soreness and fatigue, counter movement jump, and gastrointestinal temperature were also measured. Concentrations of all biomarkers increased significantly (p < 0.05) postsession. Cold water immersion attenuated increases in urinary neopterin (p < 0.05, d = 0.58), total neopterin (p < 0.05, d = 0.89), and saliva cortisol after 2 h (p < 0.05, d = 0.68) and urinary neopterin again at 24 h (p < 0.01, d = 0.57) in comparison with passive recovery. Perceived soreness, fatigue, and gastrointestinal temperatures were also lower for the cold-water immersion group at several time points postsession whilst counter movement jump did not differ. Combative sport athletes who are subjected to impact-induced stress may benefit from immediate cold-water immersion as a simple recovery intervention that reduces delayed onset muscle soreness as well as macrophage and HPA activation whilst not impairing functional performance.