The association between living alone, loneliness and suicide mortality and effect modification by age: A case:control study

BACKGROUND

Social isolation is a potentially reversible risk factor for suicide.

METHODS

A matched case control study design was used. The study population was from England and identified from an electronic primary case database with linkage to a secondary care database and Office for National Statistics mortality data. Cases were individuals who had been recorded as dying by suicide. Controls were randomly selected, matched by primary care centre and date of suicide mortality.

RESULTS

Data were available from 14,515 cases who died from suicide and 580,159 controls. After adjustment for age and sex, the risk of suicide in individuals who had previously been reported to be either living alone or suffering loneliness was increased (Odds ratio OR 4.9; 95 % confidence intervals CI: 4.4 to 5.5). Age affected the level of this risk, with individuals aged 15 to 34 years who were lonely or lived alone having a much higher risk of suicide (OR 16.4; 95 % CI: 8.7 to 31.1).

LIMITATIONS

We can demonstrate an association between loneliness and living alone, but this may not be a causal effect. The conclusions may not be generalisable to societies outside the UK.

CONCLUSIONS

Loneliness and social isolation are associated with an approximately five-fold increase in risk of mortality from suicide, which was substantially higher in younger adults. These represent potentially reversible risk factors for suicide mortality and may also help identify individuals who are at a higher risk of suicide.

Safety of e-cigarettes and nicotine patches as stop-smoking aids in pregnancy: Secondary analysis of the Pregnancy Trial of E-cigarettes and Patches (PREP) randomized controlled trial

AIMS

The aim of this study was to examine the safety of e-cigarettes (EC) and nicotine patches (NRT) when used to help pregnant smokers quit.

DESIGN

A recent trial of EC versus NRT reported safety outcomes in the randomized arms. We conducted a further analysis based on product use.

SETTING

Twenty-three hospitals in England and a stop-smoking service in Scotland took part.

PARTICIPANTS

The participants comprised 1140 pregnant smokers.

INTERVENTIONS

We compared women using and not using EC and NRT regularly during pregnancy.

MEASUREMENTS

Measurements included nicotine intake compared with baseline, birth weight, other pregnancy outcomes, adverse events, maternal respiratory symptoms and relapse in early abstainers.

FINDINGS

Use of EC was more common than use of NRT (47.3% vs 21.6%, P < 0.001). Women who stopped smoking (abstainers) and used EC at the end-of-pregnancy (EOP) reduced their salivary cotinine by 45% [49.3 ng/ml, 95% confidence interval (CI) = -79.8 to -10]. Only one abstainer used NRT at EOP. In dual users, cotinine increased by 19% (24 ng/ml, 95% CI = 3.5-68). In women reporting a reduction of at least 50% in cigarette consumption, cotinine levels increased by 10% in those using nicotine products and by 9% in those who did not. Birth weights in dual users and exclusive smokers were the same (3.1 kg). Birth weight in abstainers using either nicotine product was higher than in smokers [3.3 kg, standard deviation (SD) = 0.7] versus 3.1 kg, SD = 0.6; difference = 0.15 kg, 95% CI = 0.05-0.25) and not different from abstainers not using nicotine products (3.1 kg, SD = 0.8). Abstainers and smokers using nicotine products had no worse pregnancy outcomes or more adverse events than abstainers and smokers not using them. EC users reported more improvements than non-users in cough [adjusted relative risk (aRR) = 0.59, 95% CI = 0.37-0.93] and phlegm (aRR = 0.53, 95% CI = 0.31-0.92), controlling for smoking status. EC or NRT use had no association with relapse.

CONCLUSIONS

Regular use of e-cigarettes or nicotine patches by pregnant smokers does not appear to be associated with any adverse outcomes.

Effect of 3 months and 12 months of financial incentives on 12-month postpartum smoking cessation maintenance: A randomized controlled trial

BACKGROUND AND AIMS

Offering financial incentives is effective for smoking cessation during pregnancy. We tested the effectiveness of financial incentives for maintaining postpartum cessation, comparing 12-month and 3-month incentives with each other and with usual care (UC).

DESIGN, SETTING AND PARTICIPANTS

This study was a pragmatic, multi-centre, three-arm randomized controlled trial involving four English, National Health Service, stop smoking services. A total of 462 postpartum women (aged ≥ 16 years) took part, who stopped smoking during pregnancy with financial incentives, validated as abstinent from smoking at end of pregnancy or early postpartum.

INTERVENTIONS

Interventions comprised (i) UC; (ii) UC plus up to £60 of financial voucher incentives offered to participants and £60 offered to an optional significant-other supporter, over 3 months postpartum, contingent upon validated abstinence ('3-month incentives'); or (iii) UC plus '3-month incentives' plus £180 of vouchers offered to participants over 9 months postpartum, contingent upon abstinence ('12-month incentives').

MEASUREMENTS

Primary outcome: biochemically validated abstinence at 1 year postpartum. To adjust for testing all comparisons between groups with equal precision, P < 0.017 was necessary for significance.

SECONDARY OUTCOMES

self-reported and validated abstinence at 3 months postpartum; self-reported abstinence at 1 year postpartum.

FINDINGS

Primary outcome ascertainment: abstinence was 39.6% (63/159) 12 months incentives, 21.4% (33/154) 3 months incentives and 28.2% (42/149) UC. Adjusted odds ratios [95% confidence interval (CI)] = 12-month versus 3-month incentives OR = 2.41 (95% CI = 1.46-3.96), P = 0.001; 12 months versus UC 1.67 (1.04-2.70), P = 0.035; 3 months versus UC 0.69 (0.41-1.17), P = 0.174. Bayes factors indicated that for 12-month versus 3-month incentives and 12 months versus UC there was good evidence for the alternative hypothesis, and for 3 months versus UC there was good evidence for the null hypothesis.

CONCLUSIONS

This randomized controlled trial provides weak evidence that up to £300 of voucher incentives over 12 months is effective for maintaining smoking abstinence postpartum compared with usual care. There was good evidence that 12-month incentives are superior to those over only 3 months, for which there was no evidence of effectiveness relative to usual care.

Is prone positioning a valid intervention for ARDS in the deployed intensive care unit?

Prone positioning is an intervention used for patients with acute respiratory distress syndrome (ARDS) whose hypoxia is worsening despite conventional treatment. Previously used infrequently, it became an important treatment escalation strategy for hypoxia during the COVID-19 pandemic. Current evidence for prone positioning suggests increased survivability in intubated patients with moderate to severe ARDS who are prone for >12 hours a day. As a relatively low-cost, low-tech intervention with a growing evidence base, the viability of prone positioning in the deployed land environment is considered in this article. The practical technique of prone positioning is easy to teach to healthcare staff experienced in manual handling. However, it requires significant resources, in particular staff numbers, and time to execute and maintain, and necessitates a pressure-minimising mattress. Additionally, staff are placed at increased risk of musculoskeletal injuries and potential exposure to aerosolised microbes if there is a disconnection of the breathing system. We conclude that in the deployed 2/1/2/12 facility (or larger), with access to higher staff numbers and high-specification mattresses, prone positioning is a valid escalation technique for intubated hypoxic patients with ARDS. However, in smaller facilities where resources are constrained, its implementation is unlikely to be achievable.

Uptake and 4-week quit rates from an opt-out co-located smoking cessation service delivered alongside community-based low-dose computed tomography screening within the Yorkshire Lung Screening Trial

BACKGROUND

Up to 50% of those attending for low-dose computed tomography screening for lung cancer continue to smoke and co-delivery of smoking cessation services alongside screening may maximise clinical benefit. Here we present data from an opt-out co-located smoking cessation service delivered alongside the Yorkshire Lung Screening Trial (YLST).

METHODS

Eligible YLST participants were offered an immediate consultation with a smoking cessation practitioner (SCP) at their screening visit with ongoing smoking cessation support over subsequent weeks.

RESULTS

Of 2150 eligible participants, 1905 (89%) accepted the offer of an SCP consultation during their initial visit, with 1609 (75%) receiving ongoing smoking cessation support over subsequent weeks. Uptake of ongoing support was not associated with age, ethnicity, deprivation or educational level in multivariable analyses, although men were less likely to engage (adjusted OR (ORadj) 0.71, 95% CI 0.56-0.89). Uptake was higher in those with higher nicotine dependency, motivation to stop smoking and self-efficacy for quitting. Overall, 323 participants self-reported quitting at 4 weeks (15.0% of the eligible population); 266 were validated by exhaled carbon monoxide (12.4%). Multivariable analyses of eligible smokers suggested 4-week quitting was more likely in men (ORadj 1.43, 95% CI 1.11-1.84), those with higher motivation to quit and previous quit attempts, while those with a stronger smoking habit in terms of cigarettes per day were less likely to quit.

CONCLUSIONS

There was high uptake for co-located opt-out smoking cessation support across a wide range of participant demographics. Protected funding for integrated smoking cessation services should be considered to maximise programme equity and benefit.

Implementation of a diagnostic stewardship intervention to improve blood-culture utilization in 2 surgical ICUs: Time for a blood-culture change

OBJECTIVE

We compared the number of blood-culture events before and after the introduction of a blood-culture algorithm and provider feedback. Secondary objectives were the comparison of blood-culture positivity and negative safety signals before and after the intervention.

DESIGN

Prospective cohort design.

SETTING

Two surgical intensive care units (ICUs): general and trauma surgery and cardiothoracic surgery.

PATIENTS

Patients aged ≥18 years and admitted to the ICU at the time of the blood-culture event.

METHODS

We used an interrupted time series to compare rates of blood-culture events (ie, blood-culture events per 1,000 patient days) before and after the algorithm implementation with weekly provider feedback.

RESULTS

The blood-culture event rate decreased from 100 to 55 blood-culture events per 1,000 patient days in the general surgery and trauma ICU (72% reduction; incidence rate ratio [IRR], 0.38; 95% confidence interval [CI], 0.32-0.46; P < .01) and from 102 to 77 blood-culture events per 1,000 patient days in the cardiothoracic surgery ICU (55% reduction; IRR, 0.45; 95% CI, 0.39-0.52; P < .01). We did not observe any differences in average monthly antibiotic days of therapy, mortality, or readmissions between the pre- and postintervention periods.

CONCLUSIONS

We implemented a blood-culture algorithm with data feedback in 2 surgical ICUs, and we observed significant decreases in the rates of blood-culture events without an increase in negative safety signals, including ICU length of stay, mortality, antibiotic use, or readmissions.

Comparative epidemiology of hospital-onset bloodstream infections (HOBSIs) and central line-associated bloodstream infections (CLABSIs) across a three-hospital health system

OBJECTIVE

To evaluate the comparative epidemiology of hospital-onset bloodstream infection (HOBSI) and central line-associated bloodstream infection (CLABSI).

DESIGN AND SETTING

Retrospective observational study of HOBSI and CLABSI across a three-hospital healthcare system from 01/01/2017 to 12/31/2021.

METHODS

HOBSIs were identified as any non-commensal positive blood culture event on or after hospital day 3. CLABSIs were identified based on National Healthcare Safety Network (NHSN) criteria. We performed a time-series analysis to assess comparative temporal trends among HOBSI and CLABSI incidence. Using univariable and multivariable regression analyses, we compared demographics, risk factors, and outcomes between non-CLABSI HOBSI and CLABSI, as HOBSI and CLABSI are not exclusive entities.

RESULTS

HOBSI incidence increased over the study period (IRR 1.006 HOBSI/1,000 patient days; 95% CI 1.001-1.012; P = .03), while no change in CLABSI incidence was observed (IRR .997 CLABSIs/1,000 central line days, 95% CI .992-1.002, P = .22). Differing demographic, microbiologic, and risk factor profiles were observed between CLABSIs and non-CLABSI HOBSIs. Multivariable analysis found lower odds of mortality among patients with CLABSIs when adjusted for covariates that approximate severity of illness (OR .27; 95% CI .11-.64; P < .01).

CONCLUSIONS

HOBSI incidence increased over the study period without a concurrent increase in CLABSI in our study population. Furthermore, risk factor and outcome profiles varied between CLABSI and non-CLABSI HOBSI, which suggest that these metrics differ in important ways worth considering if HOBSI is adopted as a quality metric.

Use of plasmapheresis to lower anti-AAV antibodies in nonhuman primates with pre-existing immunity to AAVrh74

Patients with pre-existing immunity to adeno-associated virus (AAV) are currently unable to receive systemic gene transfer therapies. In this nonhuman primate study, we investigated the impact of immunosuppression strategies on gene transfer therapy safety and efficacy and analyzed plasmapheresis as a potential pretreatment for circumvention of pre-existing immunity or redosing. In part 1, animals received delandistrogene moxeparvovec (SRP-9001), an AAVrh74-based gene transfer therapy for Duchenne muscular dystrophy. Cohort 1 (control, n = 2) received no immunosuppression; cohorts 2-4 (n = 3 per cohort) received prednisone at different time points; and cohort 5 (n = 3) received rituximab, sirolimus, and prednisone before and after dosing. In part 2, cohorts 2-4 underwent plasmapheresis before redosing; cohort 5 was redosed without plasmapheresis. We analyzed safety, immune response (humoral and cell-mediated responses and complement activation), and vector genome distribution. After 2 or 3 plasmapheresis exchanges, circulating anti-AAVrh74 antibodies were reduced, and animals were redosed. Plasmapheresis was well tolerated, with no abnormal clinical or immunological observations. Cohort 5 (redosed with high anti-AAVrh74 antibody titers) had hypersensitivity reactions, which were controlled with treatment. These findings suggest that plasmapheresis is a safe and effective method to reduce anti-AAV antibody levels in nonhuman primates prior to gene transfer therapy. The results may inform human studies involving redosing or circumvention of pre-existing immunity.

A dynamical measure of the black hole mass in a quasar 11 billion years ago

Tight relationships exist in the local Universe between the central stellar properties of galaxies and the mass of their supermassive black hole (SMBH)1-3. These suggest that galaxies and black holes co-evolve, with the main regulation mechanism being energetic feedback from accretion onto the black hole during its quasar phase4-6. A crucial question is how the relationship between black holes and galaxies evolves with time; a key epoch to examine this relationship is at the peaks of star formation and black hole growth 8-12 billion years ago (redshifts 1-3)7. Here we report a dynamical measurement of the mass of the black hole in a luminous quasar at a redshift of 2, with a look back in time of 11 billion years, by spatially resolving the broad-line region (BLR). We detect a 40-μas (0.31-pc) spatial offset between the red and blue photocentres of the Hα line that traces the velocity gradient of a rotating BLR. The flux and differential phase spectra are well reproduced by a thick, moderately inclined disk of gas clouds within the sphere of influence of a central black hole with a mass of 3.2 × 108 solar masses. Molecular gas data reveal a dynamical mass for the host galaxy of 6 × 1011 solar masses, which indicates an undermassive black hole accreting at a super-Eddington rate. This suggests a host galaxy that grew faster than the SMBH, indicating a delay between galaxy and black hole formation for some systems.

Primary care consultation patterns prior to suicide: a nationally representative case-control study

BACKGROUND

Consultation with primary health care may provide an opportunity to identify patients at higher suicide risk.

AIMS

To explore primary care consultation patterns in the 5 years before suicide to identify suicide high-risk groups and common reasons for consulting.

DESIGN

A case-control study in England from 2001 to 2019 using electronic health records.

METHOD

Analysis of 14515 patients aged ≥15 who died by suicide and up to 40 matched live controls per case (N=594674).

RESULTS

Frequent consultations (>once per month in the final year) were associated with increased suicide risk (age and sex adjusted odds ratio (OR) 5.88; 95% CI: 5.47-6.32). The associated rise in suicide risk was seen across all sociodemographic groups as well as in those with and without psychiatric comorbidities. However, specific groups were more influenced by the effect of high-frequency consultation (>once per month in the final year) demonstrating higher suicide risk compared to their counterparts who consulted once: females (adjusted OR 9.50; 95% CI: 7.82-11.54); patients aged 15 to 45 (adjusted OR 8.08; 95% CI: 7.29-8.96); patients experiencing less socioeconomic deprivation (adjusted OR 6.56; 95% CI: 5.77-7.46); and those with psychiatric conditions (adjusted OR 4.57;95% CI: 4.12 to 5.06). Medication review, depression and pain were the commonest reasons for which suicide decedents consulted in the year before death.

CONCLUSION

Escalating, or more than monthly consultations are associated with increased suicide risk regardless of patients' sociodemographic characteristics and regardless of the presence (or absence) of known psychiatric illnesses.

Functional Magnetic Resonance Imaging of the Amygdala and Subregions at 3 Tesla: A Scoping Review

The amygdalae are a pair of small brain structures, each of which is composed of three main subregions and whose function is implicated in neuropsychiatric conditions. Functional Magnetic Resonance Imaging (fMRI) has been utilized extensively in investigation of amygdala activation and functional connectivity (FC) with most clinical research sites now utilizing 3 Tesla (3T) MR systems. However, accurate imaging and analysis remains challenging not just due to the small size of the amygdala, but also its location deep in the temporal lobe. Selection of imaging parameters can significantly impact data quality with implications for the accuracy of study results and validity of conclusions. Wide variation exists in acquisition protocols with spatial resolution of some protocols suboptimal for accurate assessment of the amygdala as a whole, and for measuring activation and FC of the three main subregions, each of which contains multiple nuclei with specialized roles. The primary objective of this scoping review is to provide a broad overview of 3T fMRI protocols in use to image the activation and FC of the amygdala with particular reference to spatial resolution. The secondary objective is to provide context for a discussion culminating in recommendations for a standardized protocol for imaging activation of the amygdala and its subregions. As the advantages of big data and protocol harmonization in imaging become more apparent so, too, do the disadvantages of data heterogeneity. EVIDENCE LEVEL: 3 TECHNICAL EFFICACY: Stage 2.

Improved motif-scaffolding with SE(3) flow matching

Protein design often begins with knowledge of a desired function from a motif which motif-scaffolding aims to construct a functional protein around. Recently, generative models have achieved breakthrough success in designing scaffolds for a diverse range of motifs. However, the generated scaffolds tend to lack structural diversity, which can hinder success in wet-lab validation. In this work, we extend FrameFlow, an SE(3) flow matching model for protein backbone generation, to perform motif-scaffolding with two complementary approaches. The first is motif amortization, in which FrameFlow is trained with the motif as input using a data augmentation strategy. The second is motif guidance, which performs scaffolding using an estimate of the conditional score from FrameFlow, and requires no additional training. Both approaches achieve an equivalent or higher success rate than previous state-of-the-art methods, with 2.5 times more structurally diverse scaffolds. Code: https://github.com/microsoft/frame-flow.

Long-term safety and functional outcomes of delandistrogene moxeparvovec gene therapy in patients with Duchenne muscular dystrophy: A phase 1/2a nonrandomized trial

INTRODUCTION/AIMS

Delandistrogene moxeparvovec is indicated in the United States for the treatment of ambulatory pediatric patients aged 4 through 5 years with Duchenne muscular dystrophy (DMD) with a confirmed mutation in the DMD gene. Long-term delandistrogene moxeparvovec microdystrophin protein (a shortened dystrophin that retains key functional domains of the wild-type protein) expression may positively alter disease progression in patients with DMD. We evaluated long-term safety and functional outcomes of delandistrogene moxeparvovec in patients with DMD.

METHODS

An open-label, phase 1/2a, nonrandomized controlled trial (Study 101; NCT03375164) enrolled ambulatory males, ≥4 to <8 years old, with DMD. Patients received a single intravenous infusion (2.0 × 1014 vg/kg by supercoiled quantitative polymerase chain reaction) of delandistrogene moxeparvovec and prednisone (1 mg/kg/day) 1 day before to 30 days after treatment. The primary endpoint was safety. Functional outcomes were change from baseline in North Star Ambulatory Assessment (NSAA) and timed function tests.

RESULTS

Four patients (mean age, 5.1 years) were enrolled. There were 18 treatment-related adverse events; all occurred within 70 days posttreatment and resolved. Mean NSAA total score increased from 20.5 to 27.5, baseline to year 4, with a mean (standard deviation) change of +7.0 (2.9). Post hoc analysis demonstrated a statistically significant and clinically meaningful 9-point difference in NSAA score, relative to a propensity-score-weighted external control cohort (least-squares mean [standard error] = 9.4 [3.4]; P = .0125).

DISCUSSION

Gene transfer therapy with delandistrogene moxeparvovec treatment is well tolerated, with a favorable safety profile. Functional improvements are sustained through 4 years, suggesting delandistrogene moxeparvovec may positively alter disease progression.

Infection prevention and control in CT Part 1: An Australian study of roles, responsibilities and practices

INTRODUCTION

The computed tomography (CT) suite presents Infection Prevention and Control (IPC) risks for staff and patients. This is the first of a two-part series on IPC in the CT setting and reports on Australian baseline data related to intravenous contrast media administration and the use of power injectors in the CT suite, including knowledge sources related to the delivery of contrast media. The second part provides insights into CT staff's perceptions of high-risk scenarios for non-adherence to standard or transmission-based precautions.

METHODS

The study employed an online survey design, directed at radiographers and radiology nurses working in Australia. The survey included questions relating to CT workplace staffing and equipment, contrast media use and occupational roles, and knowledge sources used for infection control and contrast injectors.

RESULTS

Overall, 160 study participants completed the survey (radiographers: n = 138, 86.3%; nurses: n = 22, 13.7%). Differences were identified between public and private practice. Public hospitals completed more contrast-enhanced scans, and with dual injecting systems, operated and cleaned by radiographers and nurses. Private clinics generally used single-system, power injectors. Radiographers and nurses relied heavily on their colleagues and product guidelines for IPC information. IPC teams were uncommon in private clinics, very common in public departments and 50% of respondents had undertaken IPC training in the last 12 months.

CONCLUSION

Insights into use and duties of professionals delivering intravenous contrast media administration using power injectors in the CT suite will help to inform decision-making processes on IPC education strategies and map risk.

IMPLICATION FOR PRACTICE

Future research should focus on how radiology workers in CT perceive IPC risk and/or might vary from best practice, which has direct clinical implications for safety if contamination, or incorrect information is routinely applied.

Infection prevention and control in CT Part 2: Radiographers' and radiology nurses' perceptions of high-risk scenarios contributing to non-adherence to IPC protocols

INTRODUCTION

Adherence to standard and transmission-based precautions in the computed tomography (CT) setting is central to effective infection prevention and control (IPC), yet there is limited evidence about medical imaging (MI) professionals' self-reported predictors of IPC breaches. This is the second of a two-part series on IPC in the CT setting. Part 1 reported on Australian baseline data relating to intravenous contrast media administration and power injectors. Part 2 presents Australian radiographers' and radiology nurses' perceptions of clinical situations that reduce adherence to standard and transmission-based precautions in CT.

METHODS

A self-administered survey was distributed to Australian radiographers and radiology nurses working in CT. Responses to an open-ended question "If I was to not adhere to the standard and transmission-based precautions in the CT department, it is most likely when …" was analysed using inductive coding for themes, followed by deductive analysis mapped to the Systems Engineering Initiative for Patient Safety (SEIPS) model.

RESULTS

Study participants (n = 136) were radiographers (n = 119; 87.5%) and nurses (n = 17; 12.5%). 'Four themes were derived from the inductive analysis: (1) high-risk working conditions, (2) compliance with good practice, (3) attitudes and practice, and (4) quality of communication. Deductive analysis, using the SEIPS domains revealed that predominant issues related to 'Tasks' (43.7%) and 'Organisation' (30.6%) followed by issues related to 'Person' (16.9%), 'Tools and technology' (6.9%) and 'Environment' (1.9%).

CONCLUSION

Multi-faceted pressures on radiology staff may compromise adherence to standard and transmission-based precautions in CT. Task difficulty, time pressures whilst undertaking tasks, and reduced staffing could lead to lower adherence to standard and transmission-based precautions.

IMPLICATIONS FOR PRACTICE

Future studies that focus on evaluation of 'Tasks' and 'Organisation' domains of the SEIPS model may provide further insights to non-adherence behaviours in MI.

Gene therapy with bidridistrogene xeboparvovec for limb-girdle muscular dystrophy type 2E/R4: phase 1/2 trial results

Limb-girdle muscular dystrophy 2E/R4 is caused by mutations in the β-sarcoglycan (SGCB) gene, leading to SGCB deficiency and consequent muscle loss. We developed a gene therapy approach based on functional replacement of the deficient SCB protein. Here we report interim results from a first-in-human, open-label, nonrandomized, phase 1/2 trial evaluating the safety and efficacy of bidridistrogene xeboparvovec, an adeno-associated virus-based gene therapy containing a codon-optimized, full-length human SGCB transgene. Patients aged 4-15 years with confirmed SGCB mutations at both alleles received one intravenous infusion of either 1.85 × 1013 vector genome copies kg-1 (Cohort 1, n = 3) or 7.41 × 1013 vector gene copies kg-1 (Cohort 2, n = 3). Primary endpoint was safety, and secondary endpoint was change in SGCB expression in skeletal muscle from baseline to Day 60. We report interim Year 2 results (trial ongoing). The most frequent treatment-related adverse events were vomiting (four of six patients) and gamma-glutamyl transferase increase (three of six patients). Serious adverse events resolved with standard therapies. Robust SGCB expression was observed: Day 60 mean (s.d.) percentage of normal expression 36.2% (2.7%) in Cohort 1 and 62.1% (8.7%) in Cohort 2. Post hoc exploratory analysis showed preliminary motor improvements using the North Star Assessment for Limb-girdle Type Muscular Dystrophies maintained through Year 2. The 2-year safety and efficacy of bidridistrogene xeboparvovec support clinical development advancement. Further studies are necessary to confirm the long-term safety and efficacy of this gene therapy. ClinicalTrials.gov registration: NCT03652259 .

Modifiable risk factors for diphtheria: A systematic review and meta-analysis

Objective

To identify modifiable risk factors for diphtheria and assess their strengths of association with the disease.

Methods

This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. Electronic databases and grey literature were searched from inception until January 2023. Studies had to report on diphtheria cases and estimates of association for at least one potential risk factor or sufficient data to calculate these. The quality of non-ecological studies was assessed using the Newcastle-Ottawa Scale (NOS), while the quality of evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria.

Results

The search yielded 37,705 papers, of which 29 were ultimately included. All the non-ecological studies were of moderate to high quality. Meta-analysis of 20 studies identified three factors increasing the risk of diphtheria: incomplete vaccination (<3 doses) (pooled odds ratio (POR) = 2.2, 95% confidence interval (CI) = 1.4-3.4); contact with a person with skin lesions (POR = 4.8, 95% CI = 2.1-10.9); and low knowledge of diphtheria (POR = 2.4, 95% CI = 1.2-4.7). Contact with a case of diphtheria; sharing a bed or bedroom; sharing utensils, cups, and glasses; infrequent bathing; and low parental education were associated with diphtheria in multiple studies. Evidence for other factors was inconclusive. The quality of evidence was low or very low for all the risk factors.

Conclusions

Findings from the review suggest that countries seeking to control diphtheria need to strengthen surveillance, improve vaccination coverage, and increase people's knowledge of the disease. Future research should focus on understudied or inconclusive risk factors.

Perceived psychological control relates to coping-related drinking motives via social anxiety among adolescents: A cross-sectional mediation analysis

Accumulating evidence suggests that particular parenting behaviors (e.g., elevated psychological control) may increase risk for both problematic social anxiety and alcohol use among youth; however, no work has yet examined these factors together in a single model. Building developmentally sensitive models of problematic alcohol use trajectories is key to developing effective prevention and intervention strategies. The present study includes 94 adolescents (ages 14-17 years; 53.3% girls; 89.2% White) entering a treatment facility for a variety of internalizing and externalizing forms of psychological distress. Levels of perceived parental psychological control, social anxiety, and coping-related drinking motives were assessed. Higher levels of perceived psychological control were associated with a greater endorsement of coping-related drinking motives; however, a significant proportion of that association was accounted for by elevated social anxiety symptoms. These data extend the existing literature and lay groundwork for more sophisticated experimental and longitudinal designs to corroborate the findings. Moreover, personality-targeted drinking interventions for adolescents may benefit from identifying elevated perceived psychological control as a developmentally relevant risk factor for social anxiety and problematic drinking motives and administering relevant interventions (e.g., personality-targeted coping skills training, parent-involved care) before drinking patterns are established.

Delandistrogene Moxeparvovec Gene Therapy in Ambulatory Patients (Aged ≥4 to <8 Years) with Duchenne Muscular Dystrophy: 1-Year Interim Results from Study SRP-9001-103 (ENDEAVOR)

OBJECTIVE

Delandistrogene moxeparvovec is approved in the USA for the treatment of ambulatory patients (4-5 years) with Duchenne muscular dystrophy. ENDEAVOR (SRP-9001-103; NCT04626674) is a single-arm, open-label study to evaluate delandistrogene moxeparvovec micro-dystrophin expression, safety, and functional outcomes following administration of commercial process delandistrogene moxeparvovec.

METHODS

In cohort 1 of ENDEAVOR (N = 20), eligible ambulatory males, aged ≥4 to <8 years, received a single intravenous infusion of delandistrogene moxeparvovec (1.33 × 1014  vg/kg). The primary endpoint was change from baseline (CFBL) to week 12 in delandistrogene moxeparvovec micro-dystrophin by western blot. Additional endpoints evaluated included: safety; vector genome copies; CFBL to week 12 in muscle fiber-localized micro-dystrophin by immunofluorescence; and functional assessments, including North Star Ambulatory Assessment, with comparison with a propensity score-weighted external natural history control.

RESULTS

The 1-year safety profile of commercial process delandistrogene moxeparvovec in ENDEAVOR was consistent with safety data reported in other delandistrogene moxeparvovec trials (NCT03375164 and NCT03769116). Delandistrogene moxeparvovec micro-dystrophin expression was robust, with sarcolemmal localization at week 12; mean (SD) CFBL in western blot, 54.2% (42.6); p < 0.0001. At 1 year, patients demonstrated stabilized or improved North Star Ambulatory Assessment total scores; mean (SD) CFBL, +4.0 (3.5). Treatment versus a propensity score-weighted external natural history control demonstrated a statistically significant difference in least squares mean (standard error) CFBL in North Star Ambulatory Assessment, +3.2 (0.6) points; p < 0.0001.

INTERPRETATION

Results confirm efficient transduction of muscle by delandistrogene moxeparvovec. One-year post-treatment, delandistrogene moxeparvovec was well tolerated, and demonstrated stabilized or improved motor function, suggesting a clinical benefit for patients with Duchenne muscular dystrophy. ANN NEUROL 2023;94:955-968.

Does the availability of prior mammograms improve radiologists' observer performance?-a scoping review

Objective

The objective of this review was to examine the impact of previous mammogram availability on radiologists' performance from screening populations and experimental studies.

Materials and Methods

A search of the literature was conducted using five databases: MEDLINE, PubMed, Web of Science, ScienceDirect, and CINAHL as well as Google and reference lists of articles. Keywords were combined with "AND" or "OR" or "WITH" and included "prior mammograms, diagnostic performance, initial images, diagnostic efficacy, subsequent images, previous imaging, and radiologist's performance". Studies that assessed the impact of previous mammogram availability on radiologists' performance were reviewed. The Standard for Reporting Diagnostic Accuracy guidelines was used to critically appraise individual sources of evidence.

Results

A total of 15 articles were reviewed. The sample of mammogram cases used across these studies varied from 36 to 1,208,051. Prior mammograms did not affect sensitivity [with priors: 62-86% (mean = 73.3%); without priors: 69.4-87.4% (mean = 75.8%)] and cancer detection rate, but increased specificity [with priors: 72-96% (mean = 87.5%); without priors: 63-87% (mean = 80.5%)] and reduced false-positive rates [with priors: 3.7 to 36% (mean = 19.9%); without priors 13.3-49% (mean = 31.4%)], recall rates [with priors: 3.8-57% (mean = 26.6%); without priors: [4.9%-67.5% (mean = 37.9%)], and abnormal interpretation rate decreased by 4% with priors. Evidence for the associations between the availability of prior mammograms and positive-predictive value, area under the curve (AUC) from the receiver operating characteristic curve (ROC) and localisation ROC AUC, and positive-predictive value of recall is limited and unclear.

Conclusion

Availability of prior mammograms reduces recall rates, false-positive rates, abnormal interpretation rates, and increases specificity without affecting sensitivity and cancer detection rate.

Propagation-based phase-contrast imaging of the breast: image quality and the effect of X-ray energy and radiation dose

OBJECTIVES

Propagation-based phase-contrast computed tomography (PB-CT) is a new imaging technique that exploits refractive and absorption properties of X-rays to enhance soft tissue contrast and improve image quality. This study compares image quality of PB-CT and absorption-based CT (AB-CT) for breast imaging while exploring X-ray energy and radiation dose.

METHODS

Thirty-nine mastectomy samples were scanned at energy levels of 28-34keV using a flat panel detector at radiation dose levels of 4mGy and 2mGy. Image quality was assessed using signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), spatial resolution (res) and visibility (vis). Statistical analysis was performed to compare PB-CT images against their corresponding AB-CT images scanned at 32keV and 4mGy.

RESULTS

The PB-CT images at 4mGy, across nearly all energy levels, demonstrated superior image quality than AB-CT images at the same dose. At some energy levels, the 2mGy PB-CT images also showed better image quality in terms of CNR/Res and vis compared to the 4mGy AB-CT images. At both investigated doses, SNR and SNR/res were found to have a statistically significant difference across all energy levels. The difference in vis was statistically significant at some energy levels.

CONCLUSION

This study demonstrates superior image quality of PB-CT over AB-CT, with X-ray energy playing a crucial role in determining image quality parameters.

ADVANCES IN KNOWLEDGE

Our findings reveal that standard dose PB-CT outperforms standard dose AB-CT across all image quality metrics. Additionally, we demonstrate that low dose PB-CT can produce superior images compared to standard dose AB-CT in terms of CNR/Res and vis.

The Blunt Liver and Spleen Trauma (BLAST) audit: national survey and prospective audit of children with blunt liver and spleen trauma in major trauma centres

PURPOSE

To compare the reported and observed management of UK children with blunt liver or spleen injury (BLSI) to the American Pediatric Surgical Association (APSA) 2019 BLSI guidance.

METHODS

UK Paediatric Major Trauma Centres (pMTCs) undertook 1 year of prospective data collection on children admitted to or discussed with those centres with BLSI and an online questionnaire was distributed to all consultants who care for children with BLSI in those centres.

RESULTS

All 21/21 (100%) pMTCs participated; 131 patients were included and 100/152 (65%) consultants responded to the survey. ICU care was reported and observed to be primarily determined using haemodynamic status or concomitant injuries rather than injury grade, in accordance with APSA guidance. Bed rest was reported to be determined by grade of injury by 63% of survey respondents and observed in a similar proportion of patients. Contrary to APSA guidance, follow-up radiological assessment of the injured spleen or liver was undertaken in 44% of patients before discharge and 32% after discharge, the majority of whom were asymptomatic.

CONCLUSIONS

UK management of BLSI differs from many aspects of APSA guidance. A shift towards using clinical features to determine ICU admission and readiness for discharge is demonstrated, in line with a strong evidence base. However, routine bed rest and re-imaging after BLSI is common, contrary to APSA guidance. This disparity may exist due to concern that evidence around the incidence, presentation and natural history of complications after conservatively managed BLSI, particularly bleeding from pseudoaneurysms, is weak.

Radiographers' organisational commitment and occupational stress: First Covid-19 wave

INTRODUCTION

Radiographers, like many health professionals, are in a high-risk group for succumbing to workplace demands beyond their ability to cope, particularly in the context of the COVID-19 pandemic resulting in occupational stress. Occupational stress has been linked to poor organisational commitment. Therefore, the purpose of this research was to evaluate radiographers' organisational commitment and occupational stress after the first wave of the COVID-19 pandemic.

METHODS

A mixed method approach entailed data collected from purposively sampled Australian radiographers working during the first COVID-19 wave. The quantitative phase used an online commitment questionnaire, and 21 semi-structured individual virtual interviews were conducted in the qualitative phase. Data interpretation and analysis used statistical and thematic approaches.

RESULTS

The quantitative data revealed a higher level of continuance than affective and normative commitment. Whereas the qualitative findings showed participants high levels of affective commitment to their occupation and, together with leadership support, working collectively towards a positive outcome.

CONCLUSION

Despite the variety of occupational stressors that arose during the COVID-19 crisis, Australian radiographers enjoy a high level of occupational and organisational commitment.

IMPLICATIONS FOR PRACTICE

Radiographers' organisational commitment represents their emotional and psychological attachment to their workplace, and radiographers experiencing occupational stress represent high levels of psychosomatic distress and burnout. Therefore, considering radiographers' organisational commitment and occupational stress is essential in the delivery of services, quality of patient care and radiographers well-being.

Evaluation of common prescription analgesics and adjuvant analgesics as markers of suicide risk: a longitudinal population-based study in England

Background

Analgesics prescriptions may provide a marker for identifying individuals at higher risk of suicide. In particular, awareness of which analgesics are implicated may help clinicians assess and modify risk.

Method

A case-control study in England using the Clinical Practice Research Datalink (for primary care records) linked with hospital and national mortality electronic registries. We included patients aged ≥15 who died by suicide between 2001 and 2019 (N = 14,515), to whom we individually matched 580,159 controls by suicide date and general practice (N = 594,674). Odds ratios (ORs) for suicide, controlled for age and sex, were assessed using conditional logistic regression.

Findings

Suicide risks were highest in those prescribed adjuvant analgesics (pregabalin, gabapentin and carbamazepine) (adjusted OR 4.07; 95% confidence intervals CI: 3.62-4.57), followed by those prescribed opioids (adjusted OR 2.01; 95% CI: 1.88-2.15) and those prescribed non-opioid analgesics (adjusted OR 1.48; 95% CI: 1.39-1.58) compared to those not prescribed these medications. By individual analgesic, the highest suicide risks were seen in patients prescribed oxycodone (adjusted OR 6.70; 95% CI: 4.49-9.37); pregabalin (adjusted OR 6.50; 95% CI: 5.41-7.81); morphine (adjusted OR 4.54; 95% CI: 3.73-5.52); and gabapentin (adjusted OR 3.12; 95% CI: 2.59-3.75). Suicide risk increased linearly with the number of analgesic prescriptions in the final year (p < 0.01 based on the likelihood ratio test), and the more different analgesics categories were prescribed in the final year (p < 0.01 based on the likelihood ratio test).

Interpretation

Analgesic prescribing was associated with higher suicide risk. This is a particular issue with regard to adjuvant non-opiate analgesics.

Funding

There was no funding for this study.

PREFER: A New Predictive Modeling Framework for Molecular Discovery

Machine-learning and deep-learning models have been extensively used in cheminformatics to predict molecular properties, to reduce the need for direct measurements, and to accelerate compound prioritization. However, different setups and frameworks and the large number of molecular representations make it difficult to properly evaluate, reproduce, and compare them. Here we present a new PREdictive modeling FramEwoRk for molecular discovery (PREFER), written in Python (version 3.7.7) and based on AutoSklearn (version 0.14.7), that allows comparison between different molecular representations and common machine-learning models. We provide an overview of the design of our framework and show exemplary use cases and results of several representation-model combinations on diverse data sets, both public and in-house. Finally, we discuss the use of PREFER on small data sets. The code of the framework is freely available on GitHub.

Colon surgical-site infections and the impact of "present at the time of surgery (PATOS)" in a large network of community hospitals

OBJECTIVES

To describe the epidemiology of complex colon surgical procedures (COLO), stratified by present at time of surgery (PATOS) surgical-site infections (SSIs) and non-PATOS SSIs and their impact on the epidemiology of colon-surgery SSIs.

DESIGN

Retrospective cohort study.

METHODS

SSI data were prospectively collected from patients undergoing colon surgical procedures (COLOs) as defined by the National Healthcare Safety Network (NHSN) at 34 community hospitals in the southeastern United States from January 2015 to June 2019. Logistic regression models identified specific characteristics of complex COLO SSIs, complex non-PATOS COLO SSIs, and complex PATOS COLO SSIs.

RESULTS

Over the 4.5-year study period, we identified 720 complex COLO SSIs following 28,188 COLO surgeries (prevalence rate, 2.55 per 100 procedures). Overall, 544 complex COLO SSIs (76%) were complex non-PATOS COLO SSIs (prevalence rate [PR], 1.93 per 100 procedures) and 176 (24%) complex PATOS COLO SSIs (PR, 0.62 per 100 procedures). Age >75 years and operation duration in the >75th percentile were independently associated with non-PATOS SSIs but not PATOS SSIs. Conversely, emergency surgery and hospital volume for COLO procedures were independently associated with PATOS SSIs but not non-PATOS SSIs. The proportion of polymicrobial SSIs was significantly higher for non-PATOS SSIs compared with PATOS SSIs.

CONCLUSIONS

Complex PATOS COLO SSIs have distinct features from complex non-PATOS COLO SSIs. Removal of PATOS COLO SSIs from public reporting allows more accurate comparisons among hospitals that perform different case mixes of colon surgeries.

Genetic predisposition to metabolically unfavourable adiposity and prostate cancer risk: A Mendelian randomization analysis

BACKGROUND

The associations of adiposity with aggressive prostate cancer risk are unclear. Using two-sample Mendelian randomization, we assessed the association of metabolically unfavourable adiposity (UFA), favourable adiposity (FA) and for comparison body mass index (BMI), with prostate cancer, including aggressive prostate cancer.

METHODS

We examined the association of these genetically predicted adiposity-related traits with risk of prostate cancer overall, aggressive and early onset disease using outcome summary statistics from the PRACTICAL consortium (including 15,167 aggressive cases).

RESULTS

In inverse-variance weighted models, there was little evidence that genetically predicted one standard deviation higher UFA, FA and BMI were associated with aggressive prostate cancer [OR: 0.85 (95% CI:0.61-1.19), 0.80 (0.53-1.23) and 0.97 (0.88-1.08), respectively]; these associations were largely consistent in sensitivity analyses accounting for horizontal pleiotropy. There was no strong evidence that genetically determined UFA, FA or BMI were associated with overall prostate cancer or early age of onset prostate cancer.

CONCLUSIONS

We did not find differences in the associations of UFA and FA with prostate cancer risk, which suggest that adiposity is unlikely to influence prostate cancer via the metabolic factors assessed; however, these did not cover some aspects related to metabolic health that may link obesity with aggressive prostate cancer, which should be explored in future studies.

Disinfection efficacy of Oxivir TB wipe residue on severe acute respiratory coronavirus virus 2 (SARS-CoV-2)

We assessed Oxivir Tb wipe disinfectant residue in a controlled laboratory setting to evaluate low environmental contamination of SARS-CoV-2. Frequency of viral RNA detection was not statistically different between intervention and control arms on day 3 (P=0.14). Environmental contamination viability is low; residual disinfectant did not significantly contribute to low contamination.

Expression of SRP-9001 dystrophin and stabilization of motor function up to 2 years post-treatment with delandistrogene moxeparvovec gene therapy in individuals with Duchenne muscular dystrophy

Introduction: Delandistrogene moxeparvovec (SRP-9001) is an investigational gene transfer therapy designed for targeted expression of SRP-9001 dystrophin protein, a shortened dystrophin retaining key functional domains of the wild-type protein. Methods: This Phase 2, double-blind, two-part (48 weeks per part) crossover study (SRP-9001-102 [Study 102]; NCT03769116) evaluated delandistrogene moxeparvovec in patients, aged ≥4 to <8 years with Duchenne muscular dystrophy. Primary endpoints (Part 1) were change from baseline (CFBL) in SRP-9001 dystrophin expression (Week 12), by Western blot, and in North Star Ambulatory Assessment (NSAA) score (Week 48). Safety assessments included treatment-related adverse events (TRAEs). Patients were randomized and stratified by age to placebo (n = 21) or delandistrogene moxeparvovec (n = 20) and crossed over for Part 2. Results: SRP-9001 dystrophin expression was achieved in all patients: mean CFBL to Week 12 was 23.82% and 39.64% normal in Parts 1 and 2, respectively. In Part 1, CFBL to Week 48 in NSAA score (least-squares mean, LSM [standard error]) was +1.7 (0.6) with treatment versus +0.9 (0.6) for placebo; p = 0.37. Disparity in baseline motor function between groups likely confounded these results. In 4- to 5-year-olds with matched baseline motor function, CFBL to Week 48 in NSAA scores was significantly different (+2.5 points; p = 0.0172), but not significantly different in 6-to-7-year-olds with imbalanced baseline motor function (-0.7 points; p = 0.5384). For patients treated with delandistrogene moxeparvovec in Part 2, CFBL to Week 48 in NSAA score was +1.3 (2.7), whereas for those treated in Part 1, NSAA scores were maintained. As all patients in Part 2 were exposed to treatment, results were compared with a propensity-score-weighted external control (EC) cohort. The LSM difference in NSAA score between the Part 2 treated group and EC cohort was statistically significant (+2.0 points; p = 0.0009). The most common TRAEs were vomiting, decreased appetite, and nausea. Most occurred within the first 90 days and all resolved. Discussion: Results indicate robust expression of SRP-9001 dystrophin and overall stabilization in NSAA up to 2 years post-treatment. Differences in NSAA between groups in Part 1 were not significant for the overall population, likely because cohorts were stratified only by age, and other critical prognostic factors were not well matched at baseline.

Knowledge, attitudes and practice of infection prevention and control in the CT suite

BACKGROUND

Infection, prevention, and control (IPC) practices are essential to protect patients and staff within healthcare facilities. Radiology departments cater to both inpatients and outpatients, and breaches of IPC practice have led to outbreaks of disease within healthcare facilities. This study aims to examine the knowledge, attitudes and practice (KAP) of computed tomography (CT) radiographers and nurses in their infection, prevention, and control (IPC) practice. The KAP components focuses on the CT environment, contrast injector use, and workplace factors that impact IPC practice.

METHODS

A cross-sectional KAP survey was distributed online to Australian CT radiographers and radiology nurses across different institutions. The survey covered demographics, each KAP component, and workplace culture. Spearman's correlation was used to compare KAP scores. Kruskal-Wallis test was used to compare the KAP scores between demographic categories, and Chi Square was used to compare demographic data with workplace culture.

RESULTS

There were 147 respondents, 127 of which were radiographers and 20 were nurses. There was a moderate positive correlation between knowledge and attitude for radiographers (rho = 0.394, p < 0.001). Radiographers also had a moderate positive relationship between attitudes and practice (rho = 0.466, p < 0.001). Both radiographers and nurses scored high in the knowledge section of the survey, but nurses had statistically significant higher practice scores than radiographers (p = 0.014). CT radiographers who had an IPC team in their workplace or worked in public hospitals, had statistically significant higher attitudes and practice scores. Age, education, and years of experience did not impact on KAP scores.

CONCLUSION

The study found that radiographers and nurses had a good baseline knowledge of standard precautions. IPC teams and continued training is important to positively influence knowledge and attitudes of health professionals towards IPC practice. The KAP survey was a useful tool to assess the knowledge, attitudes, and practice on IPC of CT radiographers and nurses and identified areas for education, interventions, and leadership.

Helping pregnant smokers quit: a multi-centre randomised controlled trial of electronic cigarettes versus nicotine replacement therapy

Background

Some pregnant smokers try e-cigarettes, but effectiveness and safety of such use are unknown.

Objectives

To compare effectiveness and safety of nicotine patches and e-cigarettes in pregnancy.

Design

A pragmatic multi-centre randomised controlled trial.

Setting

Twenty-three hospitals across England, and a Stop Smoking Service in Scotland.

Participants

One thousand one hundred and forty pregnant daily smokers (12-24 weeks' gestation) motivated to stop smoking, with no strong preference for using nicotine patches or e-cigarettes.

Interventions

Participants in the e-cigarette arm were posted a refillable e-cigarette device with two 10 ml bottles of tobacco-flavoured e-liquid (18 mg nicotine). Participants in the nicotine patches arm were posted a 2-week supply of 15 mg/16-hour nicotine patches. Supplies were provided for up to 8 weeks. Participants sourced further supplies themselves as needed. Participants in both arms received support calls prior to their target quit date, on the quit date, and weekly for the next 4 weeks.

Outcome measures

The primary outcome was validated prolonged abstinence at the end of pregnancy. Participants lost to follow-up or not providing biochemical validation were included as non-abstainers. Secondary outcomes included self-reported abstinence at different time points, treatment adherence and safety outcomes.

Results

Only 55% of self-reported abstainers mailed back useable saliva samples. Due to this, validated sustained abstinence rates were low (6.8% vs. 4.4% in the e-cigarettes and nicotine patches arms, respectively, risk ratio = 1.55, 95% confidence interval 0.95 to 2.53; Bayes factor = 2.7). In a pre-specified sensitivity analysis that excluded abstainers using non-allocated products, the difference became significant (6.8% vs. 3.6%, risk ratio = 1.93, 95% confidence interval 1.14 to 3.26; Bayes factor = 10). Almost a third of the sample did not set a target quit date and the uptake of support calls was low, as was the initial product use. At end of pregnancy, 33.8% versus 5.6% of participants were using their allocated product in the e-cigarettes versus nicotine patches arm (risk ratio = 6.01, 95% confidence interval 4.21 to 8.58). Regular use of e-cigarettes in the nicotine patches arm was more common than use of nicotine replacement products in the e-cigarette arm (17.8% vs. 2.8%). Rates of adverse events and adverse birth outcomes were similar in the two study arms, apart from participants in the e-cigarette arm having fewer infants with low birthweight (<2500 g) (9.6% vs. 14.8%, risk ratio = 0.65, 95% confidence interval 0.47 to 0.90; Bayes factor = 10.3).

Limitations

Low rates of validation reduced the study power. A substantial proportion of participants did not use the support on offer sufficiently to test its benefits. Sample size may have been too small to detect differences in less frequent adverse effects.

Conclusions

E-cigarettes were not significantly more effective than nicotine patches in the primary analysis, but when e-cigarettes use in the nicotine patches arm was accounted for, e-cigarettes were almost twice as effective as patches in all abstinence outcomes. In pregnant smokers seeking help, compared to nicotine patches, e-cigarettes are probably more effective, do not pose more risks to birth outcomes assessed in this study and may reduce the incidence of low birthweight.

Future work

Routine monitoring of smoking cessation and birth outcomes in pregnant women using nicotine patches and e-cigarettes and further studies are needed to confirm these results.

Trial registration

This trial is registered as ISRCTN62025374 and Eudract 2017-001237-65.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 27, No. 13. See the NIHR Journals Library website for further project information.

Responsible AI practice and AI education are central to AI implementation: a rapid review for all medical imaging professionals in Europe

Artificial intelligence (AI) has transitioned from the lab to the bedside, and it is increasingly being used in healthcare. Radiology and Radiography are on the frontline of AI implementation, because of the use of big data for medical imaging and diagnosis for different patient groups. Safe and effective AI implementation requires that responsible and ethical practices are upheld by all key stakeholders, that there is harmonious collaboration between different professional groups, and customised educational provisions for all involved. This paper outlines key principles of ethical and responsible AI, highlights recent educational initiatives for clinical practitioners and discusses the synergies between all medical imaging professionals as they prepare for the digital future in Europe. Responsible and ethical AI is vital to enhance a culture of safety and trust for healthcare professionals and patients alike. Educational and training provisions for medical imaging professionals on AI is central to the understanding of basic AI principles and applications and there are many offerings currently in Europe. Education can facilitate the transparency of AI tools, but more formalised, university-led training is needed to ensure the academic scrutiny, appropriate pedagogy, multidisciplinarity and customisation to the learners' unique needs are being adhered to. As radiographers and radiologists work together and with other professionals to understand and harness the benefits of AI in medical imaging, it becomes clear that they are faced with the same challenges and that they have the same needs. The digital future belongs to multidisciplinary teams that work seamlessly together, learn together, manage risk collectively and collaborate for the benefit of the patients they serve.

Towards virtual histology with X-ray grating interferometry

Breast cancer is the most common type of cancer worldwide. Diagnosing breast cancer relies on clinical examination, imaging and biopsy. A core-needle biopsy enables a morphological and biochemical characterization of the cancer and is considered the gold standard for breast cancer diagnosis. A histopathological examination uses high-resolution microscopes with outstanding contrast in the 2D plane, but the spatial resolution in the third, Z-direction, is reduced. In the present paper, we propose two high-resolution table-top systems for phase-contrast X-ray tomography of soft-tissue samples. The first system implements a classical Talbot-Lau interferometer and allows to perform ex-vivo imaging of human breast samples with a voxel size of 5.57 μm. The second system with a comparable voxel size relies on a Sigray MAAST X-ray source with structured anode. For the first time, we demonstrate the applicability of the latter to perform X-ray imaging of human breast specimens with ductal carcinoma in-situ. We assessed image quality of both setups and compared it to histology. We showed that both setups made it possible to target internal features of breast specimens with better resolution and contrast than previously achieved, demonstrating that grating-based phase-contrast X-ray CT could be a complementary tool for clinical histopathology.

Rehabilitation post-COVID-19: cross-sectional observations using the Stanford Hall remote assessment tool

INTRODUCTION

The multisystem COVID-19 can cause prolonged symptoms requiring rehabilitation. This study describes the creation of a remote COVID-19 rehabilitation assessment tool to allow timely triage, assessment and management. It hypotheses those with post-COVID-19 syndrome, potentially without laboratory confirmation and irrespective of initial disease severity, will have significant rehabilitation needs.

METHODS

Cross-sectional study of consecutive patients referred by general practitioners (April-November 2020). Primary outcomes were presence/absence of anticipated sequelae. Binary logistic regression was used to test association between acute presentation and post-COVID-19 symptomatology.

RESULTS

155 patients (n=127 men, n=28 women, median age 39 years, median 13 weeks post-illness) were assessed using the tool. Acute symptoms were most commonly shortness of breath (SOB) (74.2%), fever (73.5%), fatigue (70.3%) and cough (64.5%); and post-acutely, SOB (76.7%), fatigue (70.3%), cough (57.4%) and anxiety/mood disturbance (39.4%). Individuals with a confirmed diagnosis of COVID-19 were 69% and 63% less likely to have anxiety/mood disturbance and pain, respectively, at 3 months.

CONCLUSIONS

Rehabilitation assessment should be offered to all patients suffering post-COVID-19 symptoms, not only those with laboratory confirmation and considered independently from acute illness severity. This tool offers a structure for a remote assessment. Post-COVID-19 programmes should include SOB, fatigue and mood disturbance management.

Promoting Recovery Following Birth Brachial Plexus Palsy

Neonatal brachial plexus palsies (NBPP) occur in 1.74 per 1000 live births with 20% to 30% having persistent deficits. Dysfunction can range from mild to severe and is correlated with the number of nerves involved and the degree of injury. In addition, there are several comorbidities and musculoskeletal sequelae that directly impact the overall functional development. This review addresses the nonsurgical and surgical management options and provides guidance for pediatricians on monitoring and when to refer for specialty care.

A mainstreaming oncogenomics model: improving the identification of Lynch syndrome

Introduction

"Mainstreaming" is a proposed strategy to integrate genomic testing into oncology. The aim of this paper is to develop a mainstreaming oncogenomics model by identifying health system interventions and implementation strategies for mainstreaming Lynch syndrome genomic testing.

Methods

A rigorous theoretical approach inclusive of conducting a systematic review and qualitative and quantitative studies was undertaken using the Consolidated Framework for Implementation Research. Theory-informed implementation data were mapped to the Genomic Medicine Integrative Research framework to generate potential strategies.

Results

The systematic review identified a lack of theory-guided health system interventions and evaluation for Lynch syndrome and other mainstreaming programs. The qualitative study phase included 22 participants from 12 health organizations. The quantitative Lynch syndrome survey included 198 responses: 26% and 66% from genetic and oncology health professionals, respectively. Studies identified the relative advantage and clinical utility of mainstreaming to improve genetic test access and to streamline care, and adaptation of current processes was recognized for results delivery and follow-up. Barriers identified included funding, infrastructure and resources, and the need for process and role delineation. The interventions to overcome barriers were as follows: embedded mainstream genetic counselors, electronic medical record genetic test ordering, results tracking, and mainstreaming education resources. Implementation evidence was connected through the Genomic Medicine Integrative Research framework resulting in a mainstreaming oncogenomics model.

Discussion

The proposed mainstreaming oncogenomics model acts as a complex intervention. It features an adaptable suite of implementation strategies to inform Lynch syndrome and other hereditary cancer service delivery. Implementation and evaluation of the model are required in future research.

Delivering yoga to people with hypertension in the UK: A qualitative study to explore yoga providers' knowledge, experiences, and attitudes

Background and Aims

Yoga has become increasingly popular in the world and the UK for improving health and well-being. A growing body of research suggests that yoga could be used to improve the management of hypertension in addition to current management strategies. Previous cross-sectional studies have also reported that hypertension is one of the most commonly disclosed health conditions in yoga sessions in the United Kingdom. Therefore, semi-structured qualitative interviews were conducted with yoga providers in the United Kingdom (n = 19) to explore their knowledge, experiences, and attitudes toward delivering yoga to people with hypertension.

Methods

Interviews were audio-recorded, transcribed verbatim, and analyzed thematically.

Results

Eight themes were identified. Yoga providers were generally aware of the health conditions of their attendees, and they had a reasonable knowledge of the causes, signs and symptoms, and management of hypertension. While most had received some information about hypertension as part of their initial yoga teaching training, this was generally felt to be limited. They mentioned the biopsychosocial benefits of yoga on hypertension but also expressed their concerns about the lack of regulation, the wide disparity in what is being delivered under the label of yoga, and the competency of some yoga providers.

Conclusion

The findings suggest that yoga provision in the United Kingdom should be regulated with a better link with health service providers. A manual and training for yoga providers in the United Kingdom for managing hypertension using yoga would be helpful to address the training needs of yoga providers. However, there is a need for more robust studies before recommending the implementation of yoga in the management of hypertension in the United Kingdom.

Australian student radiographers' experiences and perspectives in general paediatric medical imaging examinations

INTRODUCTION

Paediatric patients differ from adult patients with respect to anatomy, examination factors, behaviour, and intellectual development, requiring dedicated specialised knowledge and expertise. In the absence of a formal dedicated paediatric medical imaging subspecialty, this study undertook to understand student radiographers' experiences and perspectives on paediatric medical imaging.

METHODS

The study entailed a descriptive cross-sectional survey design entailed a 51-item closed and open-ended response questionnaire using a total sampling method. Data were collected from both under- and postgraduate student radiographers who undertook clinical placement. Data interpretation and analysis involved statistical analysis of close-ended questions and thematic analysis of open-ended questions.

RESULTS

The overall response rate was 70%. Most participants acknowledged the importance of dedicated paediatric content as well as the theory content covered. The shortcoming in pre-placement practical component was overcome through varied approaches like observations and attempting through supervision whilst experiencing uncertainty, anxiety and felt unfair to risk the patient. As reported in literature like their qualified counterparts expressed similar challenges in technique adaptation, styles of interactions in gaining cooperation from both the children and parents. They also felt paediatric content and the practicals should be embedded throughout the course offering to not compromise the day-to-day service delivery.

CONCLUSIONS

The study findings iterate the importance paediatric imaging in the service delivery context. The importance of undertaking these examinations reliant on experiential learning is insufficient to bridge the gap of preparation prior to placement.

IMPLICATIONS FOR PRACTICE

Collaborative academic and clinical radiography education will ensure that radiography students' dedicated specialised paediatric imaging knowledge and experience are enhanced.

Do Reader Characteristics Affect Diagnostic Efficacy in Screening Mammography? A Systematic Review

To examine reader characteristics associated with diagnostic efficacy in the interpretation of screening mammograms. A systematic search of the literature was conducted using databases such as Cochrane, Scopus, Medline, Embase, Web of Science, and PubMed. Search terms were combined with "AND" or "OR" and included: "Radiologist's characteristics AND performance"; "radiologist experience AND screening mammography"; "annual volume read AND diagnostic efficacy"; "screening mammography performance OR diagnostic efficacy". Studies were included if they assessed reader performance in screening mammography interpretation, breast readers, used a reference standard to assess the performance, and were published in the English language. Twenty-eight studies were reviewed. Increasing reader's age was associated with lower false positive rates. No association was found between gender and performance. Half of the studies showed no association between years of reading mammograms and performance. Most studies showed that high reading volume was more likely to be associated with increased sensitivity, cancer detection rates (CDR), lower recall rate, and lower false positive rates. Inconsistent associations were found between fellowship training in breast imaging and reader performance. Specialization in breast imaging was associated with better CDR, sensitivity, and specificity. Limited studies were available to establish the association between performance and factors such as time spent in breast imaging (n = 2), screening focus (n = 1), formal rotation in mammography (n = 1), owner of practice (n = 1), and practice type (n = 1). No individual characteristics is associated with versatility in diagnostic efficacy, albeit reading volume and specialization in breast imaging appear to be associated with with increased sensitivity and CDR without significantly affecting other performance metrics.

Assessing the implementation of COVID-19 structured reporting templates for chest radiography: a scoping review

Objective

One of the common modalities used in imaging COVID-19 positive patients is chest radiography (CXR), and serves as a valuable imaging method to diagnose and monitor a patients' condition. Structured reporting templates are regularly used for the assessment of COVID-19 CXRs and are supported by international radiological societies. This review has investigated the use of structured templates for reporting COVID-19 CXRs.

Methods

A scoping review was conducted on literature published between 2020 and 2022 using Medline, Embase, Scopus, Web of Science, and manual searches. An essential criterion for the inclusion of the articles was the use of reporting methods employing either a structured quantitative or qualitative reporting method. Thematic analyses of both reporting designs were then undertaken to evaluate utility and implementation.

Results

Fifty articles were found with the quantitative reporting method used in 47 articles whilst 3 articles were found employing a qualitative design. Two quantitative reporting tools (Brixia and RALE) were used in 33 studies, with other studies using variations of these methods. Brixia and RALE both use a posteroanterior or supine CXR divided into sections, Brixia with six and RALE with four sections. Each section is scaled numerically depending on the level of infection. The qualitative templates relied on selecting the best descriptor of the presence of COVID-19 radiological appearances. Grey literature from 10 international professional radiology societies were also included in this review. The majority of the radiology societies recommend a qualitative template for reporting COVID-19 CXRs.

Conclusion

Most studies employed quantitative reporting methods which contrasted with the structured qualitative reporting template advocated by most radiological societies. The reasons for this are not entirely clear. There is also a lack of research literature on both the implementation of the templates or comparing both template types, indicating that the use of structured radiology reporting types may be an underdeveloped clinical strategy and research methodology.

Advances in knowledge

This scoping review is unique in that it has undertaken an examination of the utility of the quantitative and qualitative structured reporting templates for COVID-19 CXRs. Moreover, through this review, the material examined has allowed a comparison of both instruments, clearly showing the favoured style of structured reporting by clinicians. At the time of the database interrogation, there were no studies found had undertaken such examinations of both reporting instruments. Moreover, due to the enduring influence of COVID-19 on global health, this scoping review is timely in examining the most innovative structured reporting tools that could be used in the reporting of COVID-19 CXRs. This report could assist clinicians in decision-making regarding templated COVID-19 reports.

How do stroke early supported discharge services achieve intensive and responsive service provision? Findings from a realist evaluation study (WISE)

BACKGROUND

Stroke Early Supported Discharge (ESD) involves provision of responsive and intensive rehabilitation to stroke survivors at home and it is recommended as part of the stroke care pathway. Core components have been identified to guide the delivery of evidence-based ESD, however, service provision in England is of variable quality. The study sought to understand how and in what conditions the adoption of these components drives the delivery of responsive and intensive ESD services in real world settings.

METHODS

This qualitative study was part of a wider multimethod realist evaluation project (WISE) conducted to inform large-scale ESD implementation. Overarching programme theories and related context-mechanism-outcome configurations were used as a framework to guide data collection and analysis. Six case study sites were purposively selected; interviews and focus groups with ESD staff members were conducted and analysed iteratively.

RESULTS

We interviewed 117 ESD staff members including clinicians and service managers. Staff highlighted the role of certain core components including eligibility criteria, capacity, team composition and multidisciplinary team (MDT) coordination in achieving responsive and intensive ESD. Regardless of the geographical setting, adhering to evidence-based selection criteria, promoting an interdisciplinary skillset and supporting the role of rehabilitation assistants, allowed teams to manage capacity issues and maximise therapy time. Gaps in the stroke care pathway, however, meant that teams had to problem solve beyond their remit to cater for the complex needs of patients with severe disabilities. Adjusting MDT structures and processes was seen as key in addressing challenges posed by travel times and rural geography.

CONCLUSIONS

Despite variations in the wider service model of operation and geographical location, the adoption of core components of ESD helped teams manage the pressures and deliver services that met evidence-based standards. Findings point to a well-recognised gap in service provision in England for stroke survivors who do not meet the ESD criteria and emphasise the need for a more integrated and comprehensive stroke service provision. Transferable lessons could be drawn to inform improvement interventions aimed at promoting evidence-based service delivery in different settings.

TRIAL REGISTRATION

ISRCTN: 15,568,163, registration date: 26 October 2018.

Diagnostic radiography students' perspectives on cultural competence and safety

INTRODUCTION

Cultural competency and safety are essential components to consider in the provision of person-centred equitable healthcare. Therefore, student radiographers' learning should include the necessary knowledge, skill sets and competence to recognise the patient's unique characteristics to enable culturally competent and safe medical imaging services. Therefore, this study explored undergraduate and postgraduate diagnostic radiography students' perspectives on cultural competency and safety.

METHODS

A qualitative phenomenological design with a hermeneutic phenomenological approach was followed to explore student perspectives. Student radiographers (second and third-year undergraduate and first and second-year postgraduate) from the study site were purposively and conveniently recruited to participate in focus group interviews. Fifteen focus group interviews were conducted, recorded and transcribed verbatim before undergoing thematic analysis.

RESULTS

Thematic analysis identified two themes. Theme one centred around the cultural competence and safety learnt by student radiographers at university and the second theme cultural competence and safety learnt in workplace learning.

CONCLUSION

This study demonstrated the importance of cultural competence and safe practice in examining patients of different cultures. It highlights the importance of creating awareness among students of their own abilities and capabilities of cultural sensitivity and safe practice as part of their learning. Future health professionals should be empowered to address and respond to patients' unique needs in a competent, safe and professional manner to reduce health disparities.

IMPLICATIONS FOR PRACTICE

Cultural competence and safety are integral to person-centred care. Including these concepts in radiography education is therefore vital to ensure optimal patient outcomes.

Comparison of a Daily Smartphone App and Retrospective Questionnaire Measures of Adherence to Nicotine Replacement Therapy Among Pregnant Women: Observational Study

BACKGROUND

Few studies have investigated how to best measure adherence to smoking cessation medications, but continuous usage measures are recommended.

OBJECTIVE

In this first study of its kind, we compared methods for measuring adherence to nicotine replacement therapy (NRT) among pregnant women, investigating the completeness and validity of data collected from daily assessments using a smartphone app versus data collected from retrospective questionnaires.

METHODS

Women aged ≥16 years who were daily smokers and <25 weeks pregnant were offered smoking-cessation counseling and encouraged to use NRT. For 28 days after setting a quit date (QD), women were asked to report NRT use daily to a smartphone app and to questionnaires administered in person or remotely at 7 and 28 days. For both data collection methods, we provided up to £25 (~US $30) as compensation for the time taken providing research data. Data completeness and NRT use reported to the app and in questionnaires were compared. For each method, we also correlated mean daily nicotine doses reported within 7 days of the QD with Day 7 saliva cotinine concentrations.

RESULTS

Of the 438 women assessed for eligibility, 40 participated and 35 accepted NRT. More participants (31/35) submitted NRT usage data to the app by Day 28 (median 25, IQR 11 days) than completed the Day 28 questionnaire (24/35) or either of the two questionnaires (27/35). Data submitted to the app showed a lower reported duration of NRT use compared to that indicated in the questionnaire (median for app 24 days, IQR 10.25; median for questionnaire 28 days, IQR 4.75; P=.007), and there appeared to be specific cases of overreporting to the questionnaire. Mean daily nicotine doses between the QD and Day 7 were lower when calculated using app data (median for app 40 mg, IQR 52.1; median for questionnaire 40 mg, IQR 63.1; P=.001), and some large outliers were evident for the questionnaire. Mean daily nicotine doses, adjusted for cigarettes smoked, were not associated with cotinine concentrations for either method (app r_s=0.184, P=.55; questionnaire r_s=0.031, P=.92), but the small sample size meant that the analysis was likely underpowered.

CONCLUSIONS

Daily assessment of NRT use via a smartphone app facilitated more complete data (a higher response rate) than questionnaires, and reporting rates over 28 days were encouraging among pregnant women. App data had better face validity; retrospective questionnaires appeared to overestimate NRT use for some participants.

Do the research priorities identified in SAGES Delphi studies resonate with rural general surgeons: a Washington state perspective

BACKGROUND

Rural surgeons operate in an environment significantly different from that of their colleagues, and as such they face unique challenges. We hypothesized the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) research agenda (as identified in the results of the 2014 Delphi study) will differ in its priorities from those identified by rural surgeons. We aimed to pilot a study in Washington state that could be replicated in other areas of the USA and the world.

METHODS

We identified general surgeons working at rural critical access hospitals in the state of Washington. We then conducted virtual, semi-structured interviews and followed up with surveys and site visits. The survey included the 2014 SAGES Delphi-ranked research priorities. We asked rural surgeons to rank their top 5 of these 40 priorities and to detail any additional which were not on the list.

RESULTS

We contacted 79 surgeons with a 30% response rate. We conducted 25 semi-structured interviews and received 18 completed follow-up surveys. These interviews were followed by site visits at 4 of the 23 sites. Of the original Delphi research priorities, those most cited by rural surgeons were #8 ("What is the best method for incorporating new techniques and technology for surgeons of variable levels of experience or training?") and #1 ("How do we best train, assess, and maintain proficiency of surgeons and surgical trainees in flexible endoscopy, laparoscopy, and open surgery?"). Four surgeons included the last SAGES priority (#40 "Is quality of life improved after ventral hernia repair?") among their top 5.

CONCLUSION

This study suggests that although rural surgeons' research priorities align with the published SAGES Delphi survey, these surgeons rank the priorities differently. This may be because the predominant study population of the Delphi is SAGES membership who work in urban and academic centers. Plans for future SAGES Delphi survey could capture these unique priorities by intentional involvement of rural and community surgeons.

Missense mutations in PIEZO1, which encodes the Piezo1 mechanosensor protein, define Er red blood cell antigens

Despite the identification of the high-incidence red cell antigen Era nearly 40 years ago, the molecular background of this antigen, together with the other 2 members of the Er blood group collection, has yet to be elucidated. Whole exome and Sanger sequencing of individuals with serologically defined Er alloantibodies identified several missense mutations within the PIEZO1 gene, encoding amino acid substitutions within the extracellular domain of the Piezo1 mechanosensor ion channel. Confirmation of Piezo1 as the carrier molecule for the Er blood group antigens was demonstrated using immunoprecipitation, CRISPR/Cas9-mediated gene knockout, and expression studies in an erythroblast cell line. We report the molecular bases of 5 Er blood group antigens: the recognized Era, Erb, and Er3 antigens and 2 novel high-incidence Er antigens, described here as Er4 and Er5, establishing a new blood group system. Anti-Er4 and anti-Er5 are implicated in severe hemolytic disease of the fetus and newborn. Demonstration of Piezo1, present at just a few hundred copies on the surface of the red blood cell, as the site of a new blood group system highlights the potential antigenicity of even low-abundance membrane proteins and contributes to our understanding of the in vivo characteristics of this important and widely studied protein in transfusion biology and beyond.

Mechanistic insight into female predominance in Alzheimer's disease based on aberrant protein S-nitrosylation of C3

Protein S-nitros(yl)ation (SNO) is a posttranslational modification involved in diverse processes in health and disease and can contribute to synaptic damage in Alzheimer's disease (AD). To identify SNO proteins in AD brains, we used triaryl phosphine (SNOTRAP) combined with mass spectrometry (MS). We detected 1449 SNO proteins with 2809 SNO sites, representing a wide range of S-nitrosylated proteins in 40 postmortem AD and non-AD human brains from patients of both sexes. Integrative protein ranking revealed the top 10 increased SNO proteins, including complement component 3 (C3), p62 (SQSTM1), and phospholipase D3. Increased levels of S-nitrosylated C3 were present in female over male AD brains. Mechanistically, we show that formation of SNO-C3 is dependent on falling β-estradiol levels, leading to increased synaptic phagocytosis and thus synapse loss and consequent cognitive decline. Collectively, we demonstrate robust alterations in the S-nitrosoproteome that contribute to AD pathogenesis in a sex-dependent manner.