Application of Bifacial Semitransparent CuInSe2 Absorber to the Bottom Cell in Bifacial Semitransparent Perovskite/CuInSe2 Tandem Solar Cell for Albedo Environment

Although various types of bifacial solar cells exist, few studies have been conducted on bifacial semitransparent CuInSe2 solar cells (BS-CISe SCs) despite the attractive potential in power generation from both sides in an albedo environment. The optimized BS-CISe SCs with 300 and 800 nm-thick absorber via a streamlined single-stage co-evaporation process exhibit a power conversion efficiency (PCE) of 6.32% and 10.6%, respectively. When double-sided total 2.0 sun illumination is assumed in an albedo environment, the bifacial power generation densities (BPGD) of them increases to 9.41% and 13.9%. Four-terminal bifacial semitransparent tandem solar cells (4T-BST SCs) are fabricated to increase the BPGD by mechanically stacking a BS-perovskite (PVK) top cell on top of a BS-CISe bottom cell with the 300 and 800 nm-thick absorber layers. When summed up, the best top and bottom cell PCEs of the 4T-BST SC with 300 and 800 nm-thick BS-CISe SC are 18.8% and 21.1%, respectively. However, the practical BPGD values of the 4T-BST SC under total 2 sun illumination are interestingly 23.4% and 24.4%, respectively. This is because the BS-CISe bottom cell's thickness affects how much rear-side illumination is transmitted to the BS-PVK top cell, increasing its current density and BPGD.

Correction: Associations between Social Isolation Index and changes in grip strength, gait speed, bone mineral density (BMD), and self-reported incident fractures among older adults: Results from the Canadian Longitudinal Study on Aging (CLSA)

[This corrects the article DOI: 10.1371/journal.pone.0292788.].

Achievement of Target Gain Larger than Unity in an Inertial Fusion Experiment

On December 5, 2022, an indirect drive fusion implosion on the National Ignition Facility (NIF) achieved a target gain G_{target} of 1.5. This is the first laboratory demonstration of exceeding "scientific breakeven" (or G_{target}>1) where 2.05 MJ of 351 nm laser light produced 3.1 MJ of total fusion yield, a result which significantly exceeds the Lawson criterion for fusion ignition as reported in a previous NIF implosion [H. Abu-Shawareb et al. (Indirect Drive ICF Collaboration), Phys. Rev. Lett. 129, 075001 (2022)PRLTAO0031-900710.1103/PhysRevLett.129.075001]. This achievement is the culmination of more than five decades of research and gives proof that laboratory fusion, based on fundamental physics principles, is possible. This Letter reports on the target, laser, design, and experimental advancements that led to this result.

Associations between Osteosarcopenia and Falls, Fractures, and Frailty in Older Adults: Results From the Canadian Longitudinal Study on Aging (CLSA)

OBJECTIVE

To explore if older adults with osteosarcopenia are at a greater risk of falls, fractures, frailty, and worsening life satisfaction and activities of daily living (ADL) compared to those with normal bone mineral density (BMD) and without sarcopenia.

DESIGN

The baseline and 3-year follow-up of a longitudinal study.

SETTING AND PARTICIPANTS

Community-dwelling people aged 65 years or older in Canada.

METHODS

Caucasian participants 65 years or older that completed the Canadian Longitudinal Study on Aging (CLSA) 2015 baseline interview, physical measurements and 3-year follow-up were included. Osteopenia/osteoporosis was defined as BMD T score below -1 SD according to the World Health Organization, and sarcopenia was defined as low grip strength and/or low gait speed according to the Sarcopenia Definition Outcomes Consortium. Osteosarcopenia was defined as the coexistence of osteopenia/osteoporosis and sarcopenia. Self-reported incident falls and fractures in the last 12 months before the 3-year follow-up were measured. Frailty was assessed through the Rockwood Frailty Index (FI); life satisfaction through the Satisfaction With Life Scale (SWLS); and ADL through the Older American Resources and Services modules. Multivariable logistic and linear regression, including subgroup analyses by sex, were conducted.

RESULTS

The sample of 8888 participants (49.1% females) had a mean age (SD) of 72.7 (5.6) years. At baseline, neither osteopenia/osteoporosis nor sarcopenia (reference group) was present in 30.1%, sarcopenia only in 18.4%, osteopenia/osteoporosis only in 29.2%, and osteosarcopenia in 22.3%. Osteosarcopenia was significantly associated with incident falls and fractures in males [adjusted odds ratio (aOR), 1.90, 95% CI 1.15, 3.14, and aOR 2.60, 95% CI 1.14, 5.91, respectively] compared to males without osteopenia/osteoporosis or sarcopenia. Participants with osteosarcopenia had worsening ADL of 0.110 (estimated β coefficient 0.110, 95% CI 0.029, 0.192) and a decrease in their SWLS by 0.660 (estimated β coefficient -0.660, 95% CI -1.133, -0.187), compared to those without. Osteosarcopenia was not associated with frailty for both males and females.

CONCLUSIONS AND IMPLICATIONS

Osteosarcopenia was associated with self-reported incident falls and fractures in males and worse life satisfaction and ADL for all participants. Assessing and identifying osteosarcopenia is essential for preventing falls and fractures. Furthermore, it improves life satisfaction and ADL.

Onboarding of siponimod in secondary progressive multiple sclerosis patients in Australia: Novel, real-world evidence from the MSGo digital support programme

Background

Siponimod is approved for use in people with secondary progressive multiple sclerosis (pwSPMS). An integrated digital platform, MSGo, was developed for pwSPMS and clinicians to help navigate the multiple steps of the pre-siponimod work-up.

Objective

To explore real-world onboarding experiences of siponimod amongst pwSPMS in Australia.

Methods

Retrospective, non-interventional, longitudinal, secondary analysis of data extracted from MSGo (20 April 2022). The primary endpoint was the average time for siponimod onboarding; secondary endpoints were adherence and sub-group analyses of variables influencing onboarding.

Results

Mixed-cure modelling estimated that 58% of participants (N = 368, females 71%, median age of 59 years) registered in MSGo would ever initiate siponimod. The median time to initiation was 56 days (95% CI [47-59] days). Half of the participants cited 'waiting for vaccination' as the reason for initiation delay. Cox regression analyses found participants with a nominated care partner had faster onboarding (HR 2.1, 95% CI [1.5-3.0]) and were more likely to continue self-reporting daily siponimod dosing than were those without a care partner (HR 2.2, 95% CI [1.3-3.7]).

Conclusions

Despite the limitations of self-reported data and the challenges of the COVID-19 pandemic, this study provides insights into siponimod onboarding in Australia and demonstrates the positive impact of care partner support.

Using SUpported Motivational InTerviewing (SUMIT) to increase physical activity for people with knee osteoarthritis: a pilot, feasibility randomised controlled trial

OBJECTIVE

The objective of this study was to determine the feasibility and effectiveness of using SUpported Motivational InTerviewing (SUMIT) to increase physical activity in people with knee osteoarthritis (KOA).

DESIGN

Randomised controlled trial.

SETTING

We recruited people who had completed Good Life with osteoArthritis Denmark (GLA:D) from private, public and community settings in Victoria, Australia.

INTERVENTIONS

Participants were randomised participants to receive SUMIT or usual care. SUMIT comprised five motivational interviewing sessions targeting physical activity over 10 weeks, and access to a multimedia web-based platform.

PARTICIPANTS

Thirty-two participants were recruited (17 SUMIT, 15 control) including 22 females (69%).

OUTCOME MEASURES

Feasibility outcomes included recruitment rate, adherence to motivational interviewing, ActivPAL wear and drop-out rate. Effect sizes (ESs) were calculated for daily steps, stepping time, time with cadence >100 steps per minute, time in bouts >1 min; 6 min walk distance, Knee Osteoarthritis Outcome Score (KOOS) subscales (pain, symptoms, function, sport and recreation, and quality of life (QoL)), Euroqual, systolic blood pressure, body mass index, waist circumference, 30 s chair stand test and walking speed during 40 m walk test.

RESULTS

All feasibility criteria were achieved, with 32/63 eligible participants recruited over seven months; with all participants adhering to all motivational interviewing calls and achieving sufficient ActivPAL wear time, and only two drop-outs (6%).12/15 outcome measures showed at least a small effect (ES>0.2) favouring the SUMIT group, including daily time with cadence >100 steps per minute (ES=0.43). Two outcomes, walking speed (ES= 0.97) and KOOS QoL (ES=0.81), showed a large effect (ES>0.8).

CONCLUSION

SUMIT is feasible in people with knee osteoarthritis. Potential benefits included more time spent walking at moderate intensity, faster walking speeds and better QoL.

TRIAL REGISTRATION NUMBER

ACTRN12621000267853.

Anesthesiology resident preferences regarding learning to perform epidural anesthesia procedures in obstetrics: a qualitative phenomenological study

BACKGROUND

Learning to perform neuraxial techniques in obstetrics is considered one of the most difficult skills for anesthesiology trainees to acquire and no consensus exists regarding the best practices for teaching these procedures. Utilizing a qualitative, phenomenological approach, we aimed to explore what trainees perceive as the best approaches to teaching epidural anesthesia techniques; identify how these perceptions align or differ from those of faculty anesthesiologists; and examine how these approaches fit into the cognitive apprenticeship framework, which describes a process of reflection on how learning occurs in the authentic environment.

METHODS

Semi-scripted interviews were conducted with 10 residents and three faculty members from the division of obstetric anesthesiology at an academic center. Interviews were transcribed, de-identified, fragmented, and coded. A thematic analysis was conducted, and codes re-organized into the cognitive apprenticeship framework of (1) content, (2) method (including subcategories modeling, coaching, scaffolding, articulation, reflection, and exploration), (3) sequence, and (4) sociology (including situated learning and culture of expert practice).

RESULTS

Trainees valued a staged approach to learning epidural techniques, independent trouble-shooting, graded independence, focused feedback, and a calm instructor. The challenges of learning and teaching epidural techniques identified by trainees and instructors included the tactile nature of the procedure, teaching on awake, non-sedated patients, limited teaching time, and creating an environment of psychological safety.

CONCLUSION

Trainee and instructor preferences for teaching epidural procedures in obstetrics aligned with the cognitive apprenticeship framework. These concepts may be applied to curriculum design, evaluation, feedback, self-assessment and faculty development.

Impact of socio-economic conditions and perinatal factors on risk of becoming a child looked after: a whole population cohort study using routinely collected data in Wales

OBJECTIVES

Between 1997 and 2021, the number of children looked after (CLA) in Wales, UK, increased steadily, with stark inequalities. We aimed to assess how deprivation and maternal and child perinatal characteristics influence the risk of becoming CLA in Wales.

STUDY DESIGN

We constructed a prospective longitudinal cohort of children born in Wales between April 2006 and March 2021 (n = 395,610) using linked administrative records.

METHODS

Survival models examined the risk of CLA from birth by small-area deprivation and maternal and child perinatal characteristics. Population attributable fractions quantify the potential impact of action on modifiable risk factors.

RESULTS

Children from the most deprived fifth of the population were 3.4 times more likely to enter care than those in the least deprived (demographic adjusted hazard ratios [aHRs] 3.40, 95% confidence interval [CI] 3.08, 3.74). Maternal mental health problems in pregnancy (fully aHR, 2.03, 95% CI 1.88, 2.19) and behavioural factors, such as smoking (aHR 2.46, 95% CI 2.34-2.60), alcohol problems (aHR 2.35, 95% CI 1.70-3.23) and substance use in pregnancy (aHR 5.72, 95% CI 5.03-6.51), as well as child congenital anomalies (aHR 1.46, 95% CI 1.16-1.84), low birth weight (aHR 1.28, 95% CI 1.17, 1.39) and preterm birth (aHR 1.16, 95% CI 1.06, 1.26), were associated with higher risk of CLA status. The risk of CLA in the population may be reduced by 35% (95% CI 0.33, 0.38) if children in the two most deprived fifths of the population experienced the conditions of those in the least deprived.

CONCLUSIONS

Deprivation and perinatal maternal health are important modifiable risk factors for children becoming CLA. Our analysis provides insight into the mechanisms of intergenerational transfer of disadvantage in a vulnerable section of the child population and identifies targets for public health action.

Distillers dried grains with soluble and enzyme inclusion in the diet effects broilers performance, intestinal health, and microbiota composition

This study tested the effect of distillers dried grains with soluble (DDGS) inclusion in a broiler diet, with or without supplementation of exogenous enzymes, on the microbiota composition, intestinal health, diet digestibility and performance. A total of 288 one-day-old chickens was assigned to 6 treatments (8 replicate of 6 birds each) according to a completely randomized design with a 3 × 2 factorial scheme with 3 DDGS levels (0, 7 and 14%) and 2 inclusions of exogenous enzymes (with or without a multicarbohydrase complex + phytase [MCPC]). The results exhibited that DDGS inclusion up to 14% did not impair broilers performance up to 28 d, however, DDGS-fed animals exhibited significant improvement with the MCPC supplementation. No effects of the enzymes in the ileal digestibility were found at 21 d. DDGS inclusion in the diet affected dry matter and gross energy digestibility. Broilers fed diets with MCPC were found to have less intestinal histological alteration thus better gut health. No effect of DDGS, enzyme or interaction of those were observed for intestinal permeability and in the serum inflammatory biomarker (calprotectin) at 7 and 28 d. The increase of DDGS percentage in the diet reduced the diversity of the ileal microbiota but increased the cecal microbiota diversity. The inclusion of DDGS showed positive effects on microbiota composition due to a reduction of Proteobacteria phylum in the ileum at 28d and a reduction in the presence of Enterococcaceae family in the ileum at 14 and 28d. The inclusion of MCPC complex might promote beneficial changes in the ileal and cecal microbiota due reduce of Proteobacteria, Bacillaceae and Enterobacteriaceae. The supplementation of xylanase, β-glucanase, arabinofuranosidase and phytase to a DDGS diet improves performance and intestinal health allowing the use of these subproduct in the poultry nutrition.

Associations between Social Isolation Index and changes in grip strength, gait speed, bone mineral density (BMD), and self-reported incident fractures among older adults: Results from the Canadian Longitudinal Study on Aging (CLSA)

BACKGROUND

The aim is to investigate whether social isolation and loneliness are associated with changes in grip strength, gait speed, BMD, and fractures.

METHODS

Canadian Longitudinal Study on Aging (CLSA) Comprehensive Cohort participants aged 65 years and older at baseline (2012-2015) who completed the three-year follow-up interview (2015-2018) were included in this analysis (n = 11,344). Social isolation and loneliness were measured using the CLSA social isolation index (CLSA-SII, range 0-10). We calculated absolute and percent change in grip strength (kg) and gait speed (m/s) and annualized absolute (g/cm2) and percent change in femoral neck and total hip BMD during the three-year follow-up. Self-reported incident fractures of all skeletal sites in the previous 12 months were measured at three-year follow-up. Multivariable analyses were conducted. Odd ratio (OR) and 95% confidence interval (CI) are reported.

RESULTS

The mean age (standard deviation [SD]) was 72.9 (5.6) years and 49.9% were female. The mean (SD) of CLSA-SII at baseline was 3.5 (1.4). Mean absolute and percentage change (SD) in grip strength (kg) and gait speed (m/s) were -1.33 (4.60), -3.02% (16.65), and -0.05 (0.17), -3.06% (19.28) during the three-year follow-up, respectively. Mean annualized absolute (g/cm2) and percentage change (SD) in femoral neck and total hip BMD were -0.004 (0.010), -0.47% (1.43) and -0.005 (0.009), -0.57% (1.09), respectively. 345 (3.1%) participants had incident fractures. As CLSA-SII increased (per one unit change), participants had 1.13 (adjusted OR 1.13, 95% CI 1.01-1.27) times greater odds for incident fractures. The interaction term between the CLSA-SII and centre for epidemiology studies depression 9 scale (CES-D 9) for self-reported incident fractures was shown (interaction OR 1.02, 95% CI 1.00-1.04).

CONCLUSIONS

Socially isolated and lonely older adults were more likely to have had incident fractures, but social isolation was not associated with the three-year changes in grip strength, gait speed, or BMD.

Stereotactic Boost and Short-Course Radiotherapy for p16-Associated Oropharynx Cancer (SHORT-OPC): First Planned Interim Safety Analysis from a Randomized Phase II Trial

PURPOSE/OBJECTIVE(S)

There is a need for safe treatment de-intensification in p16+ oropharynx cancer (OPC). The standard of care (SOC) radiotherapy (RT) regimen is cumbersome and associated with high toxicity. Stereotactic radiotherapy (SBRT) and multimodality image guidance is an opportunity to precisely target the gross tumor while safely reducing elective irradiation dose. We aim to assess the safety and efficacy of a short course RT for p16+ OPC, consisting of an SBRT boost to the gross tumor volume (GTV) followed by de-escalated elective irradiation.

MATERIALS/METHODS

In this randomized phase II trial, patients with p16-positive, stage I-II OPSCC with primary tumor <30 cc (8th Ed AJCC) are planned with combined CT, MRI and FDG-PET, and randomized to 1) SBRT boost (14 Gy in 2 fractions) to the GTV followed with de-escalated RT (+/- Cisplatin) to a dose of 40 Gy in 20 fractions, or 2) SOC RT (+/- Cisplatin) to a dose of 70 Gy in 33 fractions to the GTV and 59.4-54Gy (or equivalent) to the intermediate-to-low dose elective region. Patients are stratified by stage (I vs. II) and use of chemotherapy. The primary endpoint of the trial is locoregional control at 2 years, powered for a sample size of 100 patients. A Bayesian adaptive design includes 2 planned safety interim analysis using grade ≥ 3 subacute toxicities >40% as a stopping criterion, and 1 planned futility analysis. Acute adverse events (AE) are defined as those occurring ≤ 60 days from RT, subacute AE between 60-180 days after RT, and late AE >180 days from RT. This is the first planned toxicity analysis.

RESULTS

Twenty-one patients were randomly assigned and eligible (11 in SOC and 10 in experimental arm). Median age was 69 years (range 49-84); 29% and 71% had stage T1 and T2, while 10%, 85% and 1 patient had N0, N1 and N2 disease, respectively. RT alone and chemoradiation was administered in 67% and 33% of patients, respectively. At a median follow-up of 11 months (range 1.7-17.6), there was 1 local recurrence at the primary tumor site in the SOC arm (at 10 month) and no recurrence in the experimental arm. All enrolled patients remain alive at the time of analysis. There was a 54.5% rate of grade 3 acute AE in the SOC arm and 30.0% rate of grade 3 acute AE in the experimental arm. More specifically, 1, 5 (45%), 2 (18%), and 2 (18%) versus 0, 1, 1 and 1 patient developed acute grade 3 dysphagia, mucositis, pain and dermatitis in the SOC and experimental arm, respectively. There was no acute grade 4 or 5 toxicity. There was no grade ≥ 3 subacute toxicity or late toxicity in both arms.

CONCLUSION

This primary safety analysis showed that SBRT boost followed by a short course of de-escalated elective irradiation in p16+ OPC has limited early toxicity and meets criteria for study continuation.

Clinical Acceptability of Automatically Generated Elective Lymph Node Volumes for Head and Neck Cancer Patients

PURPOSE/OBJECTIVE(S)

Manual contouring of head and neck lymph node levels is a time-intensive process prone to provider-specific variation. The purpose of this work is to generate a clinical segmentation tool while minimizing the amount of manual effort required by physicians to develop training datasets and review contours. Here we investigate an approach to curate, develop, and clinically validate an auto-contouring model for standard cervical lymph node volumes in the head and neck using a publicly available deep learning architecture. This model updates our previously validated tool to reflect modern practices in lymph node segmentation.

MATERIALS/METHODS

With the assistance of a resident physician, five radiation oncologists manually contoured individual lymph node levels on CT scans for three separate patients treated definitively with radiation or chemoradiation for oropharynx cancer, resulting in 15 unique ground truth cases. These cases were then used to train an nnUnet deep-learning model to generate automated contours for 32 additional cases. These 32 cases were reviewed, manually edited, and used to create the final model. Finally, the model was used to generate contours on the original 15 CT scans (testing cohort), and providers compared these automated contours with the ground-truth (manual) contours. Two blinded studies were performed. In a double-blinded fashion, providers were first asked to select which set of contours they would prefer to use in clinical practice as a starting point for actual cases. Second, they scored each contour on a Likert scale (1-5) to indicate clinical acceptability, ranging from completely unusable to usable without modification.

RESULTS

Across all lymph node levels (IA, IB, II, III, IV, V, RP), average Dice Similarity Coefficient ranged from 0.77 to 0.89 for AI vs manual contours in the testing cohort. These AI and manual lymph node contours were reviewed by 5 physicians each, resulting in 525 preference scores. Across all lymph nodes, the AI contour was superior to or equally preferred to the manual contours at rates ranging from 75% to 91% in the first blinded study. In the second blinded study, physician preference for the manual vs AI contour was statistically different for only the RP contours (p < 0.01). Thus, there was not a significant difference in clinical acceptability for nodal levels I-V for manual versus AI contours. Across all physician-generated contours, 82% were rated as usable with stylistic to no edits, and across all AI-generated contours, 92% were rated as usable with stylistic to no edits.

CONCLUSION

An approach to generate clinically acceptable automated contours for cervical lymph node levels in the head and neck was demonstrated. Furthermore, for nodal levels I-V, there was no significant difference in clinical acceptability in manual vs AI contours. Because we were able to generate and validate a model for each lymph node level individually, the output is applicable to a complete range of disease in which cervical lymph nodes are treated.

Integration of disease surveillance in the English context: a qualitative study

OBJECTIVES

The world is experiencing increasing threats from infectious diseases and environmental hazards. Integration of disease surveillance systems has been put forth as one way to ensure more timely analysis of data and response. This study sought to explore the current context and state of integration of disease surveillance in England, including the barriers and facilitators to integration, as well as opportunities for improvement.

STUDY DESIGN

Qualitative study with focus groups and key informant interviews.

METHODS

Focus group discussions (FGDs) and key informant interviews (KIIs) were conducted with key national, regional, and local stakeholders involved in surveillance activities in August and September 2022. These discussions and interviews were recorded, transcribed, and coded using a within-case content and thematic analysis.

RESULTS

In total, five FGDs and 10 KIIs were conducted with 27 participants. Participants had different views on what integration is, though mostly agreed that surveillance systems in England are not integrated. Lack of standardisation, governance and oversight, and structural and financial barriers were hindering the current system from being more integrated. The additional benefits of integration above and beyond the 'status quo' during response activities were questioned by some.

CONCLUSION

England does not have a single integrated disease surveillance system but has a range of disease-specific surveillance systems that have evolved largely independently to meet operational needs. Greater integration may be desired and to a certain extent is important, but it is essential that it is understood as a means to an end and the overall purpose of surveillance is kept in mind.

Proton Based Stereotactic Radiotherapy for Skull Base Patients: Dosimetric Comparison to 4 Modern Radiation Treatment Modalities

PURPOSE/OBJECTIVE(S)

Re-irradiation with ablative doses to a smaller target volume and strict critical structure constraint is a challenge for modern radiation planning and delivery systems. Several advanced radiation treatment techniques can be used for fractionated stereotactic ablative radiosurgery (FSRS) in select patients with unresectable recurrent head and neck tumors. In this study, in order to better understand the dosimetry advantage of each technique, we compare the stereotactic treatment plans of our new small spot size Hitachi proton treatment unit to those of CyberKnife stereotactic radiosurgery (CK), Gamma Knife radiosurgery (GK), volumetric modulated arc therapy (VMAT), and MR Linac radiotherapy (MRL).

MATERIALS/METHODS

Ten FSRS skull base patients treated at our institution using VMAT (n = 5) or GK (n = 5) techniques. Intensity-modulated proton therapy (IMPT) plans were created in Raystation using Monte Carlo dose calculation algorithm. VMAT, CK, GK and MRL plans were generated in RayStation, Accuray Precision, Leksell Gamma Plan, and Monaco treatment planning systems, separately. Planning goals were to achieve the best target coverage of prescribed dose without compromising the critical organs at risk dose volume constraints of the clinical treatment plans. Plans were compared based on percent CTV coverage, Paddick conformity index (PCI), gradient index (GI, V50/V100), dose homogeneity index (HI, (D2-D98)/D50), low dose bath volume (LDBV, ratio of total volume irradiated between 20% and 50% prescription dose and the target volume), beam-on-time (BOT), and mean/maximum doses to brainstems.

RESULTS

The median target volume was 15.5 cm3 (range 1.0 - 36.23 cm3). The prescription was 45 Gy in 5 fractions for VMAT patients, and 21 - 27 Gy in 3 fractions for GK patients. The comparison of the treatment plans of these 5 delivery modalities was shown in table. All techniques achieved comparable CTV coverage. GI was superior for GK plans and outstanding in CK and IMPT plans. IMPT plans were also outstanding in regard to BOT and PCI. Significantly improved HI, LDBV and brainstem mean doses were achieved in IMPT plans. For adjacent brainstem and other OARs, maximum doses were comparable among all techniques.

CONCLUSION

In these five advanced radiation therapy modalities, proton therapy SBRT showed dosimetric advantage over other modalities to spare nearby OARs without sacrifice of target coverage. Further studies are needed to utilize this clinical benefit and investigate plan robustness.

Requirements for anti-aquaporin 5 autoantibody production in a mouse model

Several oral bacteria, including Prevotella melaninogenica (Pm), have aquaporin (AQP) proteins homologous to human AQP5, a major water channel protein targeted in Sjogren's syndrome. This study aimed to understand the antigenic characteristics that induce autoantibodies against an AQP5 "E" epitope (AQP5E) in a mouse model using C57BL/6 mice. Immunization with a PmE-L peptide derived from Pm AQP, which contains amino acid mismatches both at the B- and T-cell epitopes, efficiently induced anti-AQP5E autoantibodies accompanied by increased germinal center (GC) B and follicular helper T cells in the draining lymph nodes. However, PmE, a peptide lacking a T-cell epitope, and AQP5E-L, an AQP5-derived self-peptide, hardly induced either anti-AQP5E autoantibodies or GC responses. Surprisingly, OTII-AQP5E, a peptide that replaced the self T-cell epitope of AQP5E-L with an ovalbumin-derived foreign T-cell epitope, was not any better than AQP5E-L in the induction of anti-AQP5E autoantibodies and GC response, despite the substantial expansion of CD4+ T cells and production of anti-OTII-AQP5E antibodies. The complex of biotinylated PmE-L peptide and highly immunogenic streptavidin (SA) induced a strong extrafollicular B-cell response skewed toward the expansion of SA-specific B cells. However, the expansion of AQP5E-specific GC B cells was limited, resulting in the inefficient induction of anti-AQP5E autoantibodies. Collectively, our results have demonstrated that anti-AQP5E autoantibody production is only allowed when foreign B- and T-cell epitopes drive a strong GC response of AQP5E-specific B cells for affinity maturation. This study helps explain why cross-reactive anti-AQP5 autoantibodies are not produced during the immune response to Pm in most healthy people.

Fractionated Stereotactic Radiotherapy in the Management of Dural Recurrence of Olfactory Neuroblastoma

PURPOSE/OBJECTIVE(S)

Treatment protocols for dural recurrence among esthesioneuroblastoma patients have not been standardized. We assess the outcomes of fractionated stereotactic radiotherapy (FSR) for patients with olfactory neuroblastoma (ONB) dura-based recurrences.

MATERIALS/METHODS

We identified ONB patients with dura-based recurrences treated with FSR after prior radiotherapy who were enrolled between 2013 and 2022 in our prospective head and neck reirradiation and skull base registries. In-field tumor control (within 2 cm of prescribed radiotherapy volume) and out-of-field tumor control (non-contiguous or contralateral dura, nodal, or distant metastases) were analyzed.

RESULTS

Thirteen patients with 28 dural lesions were included in this analysis. All patients were initially treated with surgery to their primary paranasal sinus disease; 69% with a craniofacial approach followed by adjuvant radiotherapy to a median dose of 63 Gy (range 60-72.4 Gy) prescribed to the resected tumor bed. Patients re-presented with dural recurrence at median 58.3 months (range 35.0 - 163.0 months) from completion of their initial treatment. Two patients underwent dural resections. On presentation of recurrence, 4 patients had 1 lesion treated, with a median of 2 lesions treated (range 1-4 lesions). All dural based tumors were treated with FSR to a median dose of 27 Gy in 3 fractions delivered QOD. 68Ga-DOTATATE PET/CT was utilized for FSR treatment planning in 31% of cases. The median follow up from FSR was 23.3 months (range: 13.1 - 51.6 months). The 1-year overall survival and progression free survival was 75% and 38%, respectively. The 1- and 2-year in-field control rate was 85% and 75%, respectively. Among treated lesions, 25 of 28 (89%) responded or remained stable following FSR. Two patients (3 lesions) had evidence of in-field radiographic progression at 17 and 9 months, respectively. Five patients (38%) experienced progression in the contralateral or non-contiguous dura, and 5 patients (38%) developed distant metastases. The overall out-of-field progression rate was 58% at 1 year. There was no grade 3 or higher toxicity observed. Three patients (23%) developed asymptomatic changes on MRI consistent with brain necrosis, all of which occurred in a previously irradiated region.

CONCLUSION

In the largest single institution study of FSR reirradiation for ONB dural recurrence to date, high local control rates with minimal toxicity are attainable. However, subsequent out-of-field dural recurrences and/or distant metastases remain problematic.

Disease Control and Toxicity Outcomes after Intraoperative HDR Brachytherapy for Neck Recurrences in Patients Previously Irradiated Head and Neck Cancer

PURPOSE/OBJECTIVE(S)

Despite recent advances in local and systemic therapies for head and neck squamous cell carcinomas (HNSCC), the most common types of treatment failure remain local and regional. Patients with HNSCC also have a higher risk of developing secondary head and neck tumors due to a field cancerization phenomenon. Treatment of these recurrences poses a challenge, particularly in patients having previously received full dose external beam radiotherapy (EBRT) to the head and neck region. This study evaluates the clinical outcomes of intraoperative Harrison-Anderson-Mick applicator (HAM) HDR brachytherapy (BT) after salvage neck dissection for neck recurrences in patients previously irradiated for HNSCC.

MATERIALS/METHODS

All patients having received HAM BT for HNSCC neck recurrences at a single institution were identified. Demographic, treatment, disease control and toxicity data were collected retrospectively. Toxicity was graded as per Common Terminology Criteria for Adverse events version 5. The Kaplan Meier method was used to assess overall survival (OS) and ipsilateral regional control (IRC) from the time of HAM BT.

RESULTS

Nineteen patients with regional recurrence of HNSCC were treated with HAM BT Ir-192 between July 2006 and June 2022, with a median follow-up for survival of 51.4 months (range: 2.5-186.7). The median BT dose was 12.5 Gy delivered intraoperatively at 5 mm tissue depth/1 cm from source. Fifteen patients (78.9%) also received postoperative EBRT to a median dose of 46 Gy in 23 fractions and 13 (68.4%) received systemic therapy. Six patients (31.6%) developed ipsilateral neck recurrences (4 who had adjuvant EBRT and 2 who did not), 2 patients had primary site recurrences and 5 patients developed distant metastases. In terms of acute toxicity, 4 patients had grade 3 dysphagia requiring feeding tube (FT) placement and one patient required surgical intervention for wound necrosis. In terms of late toxicity, 2 additional patients required FT placement and 1 was able to have it removed. No grade 4+ late toxicities were noted. The IRC at the site of HAM BT at 1 year was 71.5% and 63.6% at 5 years. The 1-year OS was 81.3% and 5-year OS was 40.9%.

CONCLUSION

Intraoperative HAM BT resulted in favorable rates of IRC with acceptable toxicity in the reirradiation setting for HNSCC.

Tolerability of Metastasis-Directed Stereotactic Body Radiotherapy with Short-Course Triple-Agent Androgen Annihilation Therapy in Recurrent Oligometastatic Prostate Cancer: Secondary Analysis of a Phase II Study

PURPOSE/OBJECTIVE(S)

A majority of patients with oligometastatic prostate cancer experience relapse within 12 months of metastasis-directed therapy. Intense, triple-agent androgen annihilation therapy (AAT) with leuprolide, abiraterone acetate plus prednisone (AAP), and apalutamide may improve efficacy, but long courses of AAT have been shown to be associated with increased rates of grade≥3 toxicity. The purpose of this secondary analysis of this study is to characterize the tolerability of a short, six-month course of AAT added to metastasis-directed therapy.

MATERIALS/METHODS

All 28 patients enrolled on this phase II study were included in this analysis. All patients had oligometastatic prostate cancer after initial radical prostatectomy, defined by the presence of 1-5 extrapelvic metastases on prostate-specific membrane antigen (PSMA) PET/CT. Patients were started on six months of AAT. After the first month, patients received stereotactic body radiotherapy (SBRT) in 1, 3, or 5 fractions to metastases with or without radiotherapy to the prostate bed and pelvic lymph nodes. Physician-scored toxicities were graded according to Common Terminology Criteria for Adverse Events (CTCAE), Version 5.0.

RESULTS

Median follow-up time was 11.4 months. Twenty patients (71.4%) completed AAT with all three agents. Six patients (21.4%) completed six months of therapy but discontinued at least one agent [4 patients (14.3%) discontinued apalutamide, 1 patient (3.6%) discontinued AAP, and 1 patient (3.6%) discontinued both apalutamide and AAP]. Two patients (7.1%) withdrew from the trial due to adverse events and did not complete therapy. Grade 2 and grade 3 toxicity rates from AAT were each 21.4%. Of the 6 cases of grade 3 toxicity, 3 were skin rashes, 2 were hypertension, and 1 was hepatic toxicity. At the time of SBRT, 1 patient had withdrawn from the study and 1 patient declined radiation therapy. All 26 remaining patients completed SBRT. Grade 2 and grade 3 toxicity rates from SBRT were 7.7% and 0%, respectively.

CONCLUSION

A majority of patients were able to tolerate and complete AAT in combination with metastasis-directed SBRT. Some patients experienced acute grade 3 toxicities, the most common being drug-related skin rashes and hypertension. While efficacy data are needed to evaluate the oncologic benefit, these data suggest a short course of AAT is considerably better tolerated than longer courses of AAT, with grade 3 toxicity rates similar to long courses of single-agent androgen deprivation therapy alone.

High-Dose Rate Brachytherapy Alone for Treatment of Unfavorable Intermediate Risk Prostate Cancer: A Propensity-Score Matched Analysis

PURPOSE/OBJECTIVE(S)

To demonstrate the feasibility of high-dose rate brachytherapy (HDR BT) as monotherapy for unfavorable intermediate risk (UIR) prostate cancer by comparing survival outcomes of HDR BT alone against external beam radiation therapy (EBRT) + HDR BT boost, +/- androgen deprivation therapy (ADT) using propensity-score matched (PSM) data.

MATERIALS/METHODS

This retrospective study queried two data registries collecting patient data from 1991 to present. 633 patients with UIR prostate cancer treated with HDR BT alone, HDR BT+EBRT or HDR+EBRT+ADT were included. HDR BT patients received 42-45Gy/6 fractions (fx) or 27 Gy/2 fx. For HDR BT+EBRT, the HDR dose was 20-24 Gy/2 fx, 24 Gy/4 fx, or 15 Gy/1 fx. EBRT patients received 45 Gy/25 fx to the prostate +/- pelvic nodes. GU/GI toxicities were graded according to the Common Terminology Criteria for Adverse Events (CTCAE) v5.0. Time-to-event analyses were carried out to evaluate the relationship between treatments and five primary endpoints of interest: freedom from biochemical recurrence (FFBC), freedom from distant metastasis (FFDM), freedom from local failure (FFLF), cancer specific survival (CSS), and overall survival (OS) at 5 years. PSM was performed with one-to-n matching. Logistic regression was used to estimate the respective propensity scores. The five potential confounders identified were T-stage, Gleason score, pre-treatment PSA, age, and percent positive cores. Balance was checked using the standardized mean difference of covariates. Univariate and multivariate analyses were conducted on the matched data. Toxicity analysis was performed via association between a change in pre- and post-treatment GU/GI toxicity status and the treatment group, as well as incidence of post-treatment severe GI/GU toxicity (grade 3 or higher) and the treatment group.

RESULTS

Univariate analysis with Kaplan-Meier method and log rank test comparison between the three cohorts demonstrated no significant difference in all survival outcomes FFBC, FFDM, FFLF, CSS, OS (p = 0.15, 0.19, 0.29, 0.57, 0.28, respectively). Multivariate analysis with Cox proportional hazard regression showed no differences in HR for FFBC and OS (p = 0.95, 0.11) with addition of EBRT, or with EBRT+ADT (p = 0.17, 0.24); no fit was obtainable for FFDM, CSS, FFLF. Toxicities between the three cohorts were not significantly different when comparing post-treatment and baseline GI/GU symptoms (p = 0.53/1). No Grade 2 or 3 GI toxicities were identified, while 8%/1% HDR patients, 10%/1% HDR+EBRT patients, and 12%/2% HDR+EBRT+ADT patients experienced Grade 2/3 GU toxicities. The incidence of grade 3 or higher GU toxicities between the three groups was not significantly different (p = 0.91).

CONCLUSION

This propensity-score matched study demonstrates the feasibility of HDR BT alone for effective treatment of UIR prostate cancer when compared to HDR+EBRT or HDR+EBRT+ADT, while potentially minimizing the added toxicities of EBRT and the undesirable side effect profile of ADT.

Unpacking the Broad Landscape of Intraoperative Stressors for Clinical Personnel: A Mixed-Methods Systematic Review

Purpose

The main goals of this mixed-methods systematic review are to identify what types of intraoperative stressors for operating room personnel have been reported in collected studies and examine the characteristics of each intraoperative stressor.

Methods

With a systematic literature search, we retrieved empirical studies examining intraoperative stress published between 2010 and 2020. To synthesize findings, we applied two approaches. First, a textual narrative synthesis was employed to summarize key study information of the selected studies by focusing on surgical platforms and study participants. Second, a thematic synthesis was employed to identify and characterize intraoperative stressors and their subtypes.

Results

Ninety-four studies were included in the review. Regarding the surgical platforms, the selected studies mainly focused on minimally invasive surgery and few studies examined issues around robotic surgery. Most studies examined intra-operative stress from surgeons' perspectives but rarely considered other clinical personnel such as nurses and anesthetists. Among seven identified stressors, technical factors were the most frequently examined followed by individual, operating room environmental, interpersonal, temporal, patient, and organizational factors.

Conclusion

By presenting stressors as multifaceted elements affecting collaboration and interaction between multidisciplinary team members in the operating room, we discuss the potential interactions between stressors which should be further investigated to build a safe and efficient environment for operating room personnel.

Long COVID prevalence and associated characteristics among a South Alabama population

OBJECTIVES

Long COVID can significantly impact a patient's quality of life. Defined as persistence or emergence of symptoms 4+ weeks after initial COVID-19 diagnosis, long COVID can result in functional impairments, pulmonary issues, and neuropsychiatric conditions, among others. This study aims to identify long COVID risk factors and prevalence in a south Alabama (US) patient population.

STUDY DESIGN

This was a longitudinal cohort study.

METHODS

Postdiagnosis standardized phone interviews (baseline, 6 months, and 12 months) from April 2020 to July 2021 with patients testing positive through a large healthcare system. Interviews gathered data on sociodemographics, comorbidities, acute illness, and long COVID. Relationships between 1+ ongoing symptoms and variables of interest were assessed using a generalized estimating equation to conduct multivariate analysis.

RESULTS

Of the 516 participants, most were female (65%) and African American (57%, n = 293), with a median (interquartile range) age of 41.1 (25.3-54.6) years. Retention was 70% (n = 359) at 6 months and 58% (n = 301) at 12 months. Participants reporting 1+ persistent symptoms were 20% and 17% at 6 and 12 months, respectively. Illness severity (P < 0.0001) and COVID-related emergency room visit with hospital admission at the time of diagnosis (P = 0.0018) were significantly associated with increased long COVID risk.

CONCLUSIONS

This study found substantial rates of long COVID within our population, with stable rates at 6 and 12 months, indicating illness persistence. Our findings support growing concern for long COVID as a persistent issue within the medical community, with potential to impact patient health for years. Larger, more uniform studies are required to further characterize disease risk factors and clinical course to inform the disease management.

New Zealand and Australian MRI technologists' (radiographers) MRI safety knowledge and confidence levels

INTRODUCTION

The MRI technologist (radiographer) is at the frontline of MRI safety decision-making and has the primary responsibility to provide high quality, efficient and safe patient care in the MRI environment. As MRI technology advances and new safety issues emerge, this study aimed to provide a snapshot of the preparedness of MRI technologists in New Zealand (NZ) and Australia to practise confidently and safely.

METHOD

An online questionnaire, administered via Qualtrics and covering a range of MRI safety topics, was distributed in 2018 via the New Zealand MR Users Group, the MRI Australia-NZ Group Facebook, and relevant professional bodies.

RESULTS

A total of 312 MRI technologists attempted the questionnaire, with 246 surveys being fully completed. Of these, 61% (n = 149) were in Australia, 36% (n = 89) in NZ, and 3% (n = 8) from other countries. Findings indicated that current MRI education is preparing MRI technologists in NZ and Australia to practise safely. However, while these technologists are confident in their MRI safety decision-making, accuracy levels within some groups need addressing.

CONCLUSION

To develop a consistent level of safe practice, it is proposed that a minimum level of MRI-specific education is defined and mandated to practise. Continuing professional development focussing on MRI safety must be encouraged and, if audited as part of registration, could also be mandated. Implementation of a supporting regulatory framework similar to NZ is recommended for other countries.

IMPLICATIONS FOR PRACTICE

All MRI technologists are responsible for the safety of their patients and staff. Employers must support and ensure MRI-specific education has been completed. Ongoing engagement in MRI safety events provided by MRI safety experts, professional bodies and/or universities is essential to remain up-to-date.

The role of pandemic planning in the management of COVID-19 in England from an infection prevention and control perspective: results of a national survey

OBJECTIVES

This national survey aimed to explore how existing pandemic preparedness plans (PPP) accounted for the demands placed on infection prevention and control (IPC) services in acute and community settings in England during the first wave of the COVID-19 pandemic.

STUDY DESIGN

This was a cross-sectional survey of IPC leaders working within National Health Service Trusts or clinical commissioning groups/integrated care systems in England.

METHODS

The survey questions related to organisational COVID-19 preparedness pre-pandemic and the response provided during the first wave of the pandemic (January to July 2020). The survey ran from September to November 2021, and participation was voluntary.

RESULTS

In total, 50 organisations responded. Seventy-one percent (n = 34/48) reported having a current PPP in December 2019, with 81% (n = 21/26) indicating their plan was updated within the previous 3 years. Around half of IPC teams were involved in previous testing of these plans via internal and multi-agency tabletop exercises. Successful aspects of pandemic planning were identified as command structures, clear channels of communication, COVID-19 testing, and patient pathways. Key deficiencies were lack of personal protective equipment, difficulties with fit testing, keeping up to date with guidance, and insufficient staffing.

CONCLUSIONS

Pandemic plans need to consider the capability and capacity of IPC services to ensure they can contribute their critical knowledge and expertise to the pandemic response. This survey provides a detailed evaluation of how IPC services were impacted during the first wave of the pandemic and identifies key areas, which need to be included in future PPP to better manage the impact on IPC services.

Local Anaesthesia for Enzymatic Debridement of Cutaneous Burns: A Prospective Analysis of 27 Cases

Enzymatic debridement (ED) is increasingly used for cutaneous burns. Compared with surgical debridement, ED has better preservation of viable dermis, less blood loss and autografting, however ED is painful. Current recommendations suggest local anaesthesia (LA) is useful for minor burns, but the evidence base is minimal. In our centre, we routinely use LA with good analgesic effect. This study was a single-centre, prospective analysis conducted at the Queen Victoria Hospital (UK). Patients had at least superficial partial thickness burns and received subcutaneous LA prior to ED during a 1-year period (October 2019-September 2020). Pain was assessed using a numeric scale of 1-10, recorded before, during and after the procedure. In total, 27 patients were included (n=17 males) with a median age of 47 (18-88 years). The mean total burn surface area was 1.5% (0.3-5.0). Treated sites included head and neck (1), trunk (5), upper limb (9) and lower limb (16). The most used LAwas bupivacaine 0.25% (n=25), followed by lidocaine 1% (n=2). Some required additional oral analgesia (n=8) or a regional blockade (n=2). Average pain score during debridement was 1.9 We have found LA effective, with favourable pain scores in comparison to previous studies with oral analgesia or regional blockade. LA is quick and easy to perform, as opposed to nerve blocks, which require trained personnel with ultrasound guidance. LA is a useful analgesic for patients with minor cutaneous burns undergoing ED. In some cases, it is sufficient without additional oral analgesia or regional blockade.

Predictors of long-term survival in 5,680 patients admitted to a UK major trauma centre with thoracic injuries

INTRODUCTION

The long-term outcomes of chest trauma are largely unknown. We sought to determine the predictors of in-hospital and long-term survival in patients admitted to a major trauma centre (MTC) with chest injuries and to evaluate spatial patterns of injury in our network area.

METHODS

Retrospective analysis of data collected on the National Trauma Audit Research Network (TARN) database using multivariate analysis and Cox regression analysis. Spatial analysis was performed using ArcGis 10.7.1.

RESULTS

Some 5,680 patients were admitted with chest trauma between December 1999 and December 2019. Median patient age was 45 years and the median Injury Severity Score (ISS) was 20. The proportion of patients who had an operation was 39.8%. Age, blood transfusion, head injury, shock, emergency thoracotomy and heart disease were predictors of hospital mortality (p < 0.05). However, having an operation on concomitant injuries was protective. ISS and Glasgow Coma Score were discriminators of in-hospital mortality (C-indices 0.76 and 0.80, respectively). The 10-year survival values for patients who survived to discharge from hospital and who were aged <40, 50, 60, 70, 80 and >80 years were 99%, 93%, 95%, 87%, 75% and 43%, respectively. Preadmission lung disease and alcohol/drug misuse were poor predictors of long-term survival (p < 0.05). Hotspot analysis revealed the areas with the highest incidents were all close to the MTC.

CONCLUSIONS

The MTC is geographically central to areas with high numbers of trauma incidents. Although emergency thoracotomy was a predictor of poor in-hospital outcomes, having surgery for concomitant injuries improved outcomes. Patients surviving to discharge have good long-term survivals.

Novel model for chronic intestinal inflammation in chickens: (2) Immunologic mechanism behind the inflammatory response

Intestinal inflammation in poultry is a complex response that involves immune and intestinal cells which is still not fully understood. Thus, to better understand the mechanisms that drive the chronic intestinal inflammation in fowl we conducted an experiment applying a previously established nutritional model of low-grade chronic intestinal inflammation to evaluate cytokine and chemokine profiles in the chicken intestine. For this, we placed 90 one-day chickens into two treatments: (1) a control group (CNT) fed a corn-soybean diet, and (2) a group fed a diet high in non-starch polysaccharides (NSP). At days 14, 22, 28 and 36 of age, 6 birds from each treatment were euthanized, jejunal and ileal samples were collected for histological examination and cytokine measurements. The cytokines interferon-alpha (IFN-α), IFN-γ, interleukin-16 (IL-16), IL-10, IL-21, IL-6, macrophage-colony stimulating factor (M-CSF), chemokine C-C motif ligand 20 (CCL20), CCL4, CCL5 and vascular endothelial growth factor (VEGF) were quantified in the intestinal tissue. Histologically, both jejunum and ileum of broilers fed NSP diet showed marked infiltration of mononuclear immune cells into the villi. Further, these birds exhibited a significant (P < 0.05) increase in CCL20 concentration in the jejunum at 14d, but a dramatic reduction of M-CSF at 14 and 21d. Later at 28d and 36d, birds fed the NSP diet exhibited increased IL-16 concentration in the jejunum. Since M-CSF is a monocyte stimulatory cytokine and CCL20 a chemokine of T-cells, the reduced M-CSF and increased production of CCL20 may indicate the involvement of the adaptive immune response, specifically driven by T-cells, occurring around the third week of age in the NSP model. Lastly, as a result of the mononuclear cell infiltration and activation of T-cells, IL-16, a pro-inflammatory T-cell cytokine, increased. Therefore, the current work indicates the importance of adaptive immune cells, especially T-cells, in the chronic intestinal inflammation in broiler chicken.

When patients teach students empathy: a systematic review of interventions for promoting medical student empathy

BACKGROUND

Despite growing emphasis on empathic care, numerous studies demonstrate diminishing empathy in medical students. Involving patient educators in medical curricula may be a solution. Therefore, we conducted a systematic review to evaluate patient-involved interventions that promote empathy among medical students.

METHOD

A literature search of MEDLINE, Embase, PsycINFO, and ERIC databases was performed using the keywords "empathy," "medical student," and their synonyms. Results were independently screened in duplicate. Conflicts were resolved by group consensus. All English studies describing interventions that promote empathy in medical students engaging patient educators were included. Relevant data was extracted and summarized.

RESULTS

1467 studies were screened. 14 studies were included, of which 10 were pilot studies. Studies included patient involved interventions such as storytelling (5/14), shadowing patients (3/14), recorded videos (3/14), or combinations of methods (3/14). Qualitative measurements of empathy included written feedback and group discussions. Quantitative measurements included validated scales measuring empathy. All studies demonstrated increase in empathy among medical students. Participants reported satisfaction with training and patients reported being proud of giving back by training future physicians.

CONCLUSION

Interventions engaging patient educators were shown to have a positive impact on medical student empathy. Furthermore, patient-led education was shown to increase medical student understanding of subject and knowledge retention while empowering patients. Further implementation of patient-involved education is an important step forward in patient-partnered care and may identify additional advantages of patient engagement in medical education.

Effect of a mobile app on breastfeeding among cesarean deliveries: A randomized controlled trial

Aim

Cesarean section has negative impacts on breastfeeding rates. This study is to evaluate the effect of a mobile application on breastfeeding outcomes among mothers who had cesarean section using a randomized control trial in Vietnam in 2020 - 2022.

Methods

A triple-blinded randomized trial of a mobile application was conducted. The mobile application was tailored to Vietnamese culture with two separate versions for the intervention and the control group. The intervention version auto-generated three messages per week and linked the information in the library content to improve breastfeeding while the control version sent messages on maternal and child health care. Pregnant mothers were recruited during their antenatal visits and randomly assigned to two groups. Outcomes of interest included early initiation of breastfeeding and exclusive breastfeeding rates.

Results

A total of 275 mothers in the control and 293 in the intervention group who had undergone a cesarean section were included in the analyses. Significant increases were observed for early initiated breastfeeding within two hours (aOR= 1.51, 95%CI: 1.01 to 2.27) and exclusive breastfeeding during hospital stay (aOR=1.59, 95%CI: 1.02 to 2.49).

Conclusions

Our results support the use of a theory-based design mobile phone application as a part of a promising intervention to improve breastfeeding outcomes.

Key messages

• A mobile phone application could be a widely accessible, acceptable, and effective intervention to improve breastfeeding outcomes.

• To improve exclusive breastfeeding rates, comprehensive interventions at different levels of sociocultural and market contexts, settings, and individuals are needed.

Association among cognition, frailty, and falls and self‐reported incident fractures: results from the Canadian Longitudinal Study on Aging ( CLSA )

Cognition, frailty, and falls have been examined independently as potential correlates of fracture risk, but not simultaneously. Our objective was to explore the association between cognition, frailty, and falls and self‐reported incident fractures to determine if these factors show significant independent associations or interactions. We included participants who completed the Canadian Longitudinal Study on Aging (CLSA) 2012–2015 baseline comprehensive assessment, did not experience any self‐reported fractures in the year prior to cohort recruitment, and completed the follow‐up questionnaire at year 3 (n = 26,982). We compared all baseline cognitive measures available in the CLSA, the Rockwood Frailty Index (FI), and presence of self‐reported falls in the past 12 months in those with versus without self‐reported incident fractures in year 3 of follow‐up. We used multivariable logistic regression adjusted for covariates and examined two‐way interactions between cognition, frailty, and prior falls. CLSA specified analytic weights were applied. The mean ± standard error (SE) age of participants was 59.5 ± 0.1 years and 52.2% were female. A total of 715 participants (2.7%) self‐reported incident fractures at 3‐year follow‐up. Participants who experienced incident fractures had similar baseline cognition scores (mean ± SE; Rey Auditory Verbal Learning Test [RAVLT]: Immediate recall 6.1 ± 0.1 versus 5.9 ± 0.0; standardized difference [d] 0.124); higher FI scores (mean ± SE; FI 0.134 ± 0.005 versus 0.116 ± 0.001; d 0.193), and a greater percentage had fallen in the past 12 months (weighted n [%] 518 [7.2] versus 919 [3.5]; d 0.165). FI (each increment of 0.08) was associated with a significantly increased risk of self‐reported incident fractures in participants of all ages and those aged 65 years or older (adjusted odd ratio [OR] 1.24, 95% confidence limit [CL] 1.10–1.40; adjusted OR 1.44, 95% CL 1.11–1.52, respectively). The adjusted odds for self‐reported incident fractures in participants of all ages was also significantly associated with falls in the past 12 months prior to baseline (adjusted OR 1.83; 95% CL 1.13–2.97), but not in those aged 65 years or older. No interactions between cognition, frailty, and prior falls were found. However, considering the relatively young age of our cohort, it may be appropriate to make strong inferences in individuals older than 65 years of age. © 2022 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

420 Thoracic Physiotherapy Requirements in Anatomical Lung Resections

Objective

Consideration of the effectiveness of thoracic physiotherapy interventions in anatomical lung resections.

Method

Prospective cohort of 119 anatomical lung resections and assessment of physiotherapy interventions in a busy teaching hospital over a 6-month period.

Results

119 patients were included, with median age of 69 (28–89). There was no obvious difference between genders (F: 52% vs M: 48%). 56% were assessed to be of performance status 0. Most were resections for adenocarcinoma (48%) and squamous cell carcinoma (10%). 61% were resected by VATS and 39% through other approaches (including open thoracotomies). A minority had no comorbidities (18%), with hypertension (41%) and previous solid tumours (33%) being most common. Average length of stay was 4 days for the cohort (3.4 for VATS and 4.9 for others). The average length of stay for patients who were seen day 1 post-op on a weekend is 4.4 (vs 5.1 if there were not seen on day 1). This is also in contrast with the average length of stay of 3.5 days if they were seen day 1 post-op on a weekday, as opposed to 4 days of average stay if they were not seen. The biggest barrier to closing this discrepancy remains weekend physiotherapy staffing.

Conclusion

We found that elective thoracic patients are more likely to have a reduced length of stay when reviewed day 1 post-op. This highlights the need for potential service developments within our weekend and Level 2/3 elective thoracic caseloads to optimise our care.

Estrogen-related receptor gamma regulates mitochondrial and synaptic genes and modulates vulnerability to synucleinopathy

Many studies implicate mitochondrial dysfunction as a key contributor to cell loss in Parkinson disease (PD). Previous analyses of dopaminergic (DAergic) neurons from patients with Lewy-body pathology revealed a deficiency in nuclear-encoded genes for mitochondrial respiration, many of which are targets for the transcription factor estrogen-related receptor gamma (Esrrg/ERRγ). We demonstrate that deletion of ERRγ from DAergic neurons in adult mice was sufficient to cause a levodopa-responsive PD-like phenotype with reductions in mitochondrial gene expression and number, that partial deficiency of ERRγ hastens synuclein-mediated toxicity, and that ERRγ overexpression reduces inclusion load and delays synuclein-mediated cell loss. While ERRγ deletion did not fully recapitulate the transcriptional alterations observed in postmortem tissue, it caused reductions in genes involved in synaptic and mitochondrial function and autophagy. Altogether, these experiments suggest that ERRγ-deficient mice could provide a model for understanding the regulation of transcription in DAergic neurons and that amplifying ERRγ-mediated transcriptional programs should be considered as a strategy to promote DAergic maintenance in PD.

Lawson Criterion for Ignition Exceeded in an Inertial Fusion Experiment

For more than half a century, researchers around the world have been engaged in attempts to achieve fusion ignition as a proof of principle of various fusion concepts. Following the Lawson criterion, an ignited plasma is one where the fusion heating power is high enough to overcome all the physical processes that cool the fusion plasma, creating a positive thermodynamic feedback loop with rapidly increasing temperature. In inertially confined fusion, ignition is a state where the fusion plasma can begin "burn propagation" into surrounding cold fuel, enabling the possibility of high energy gain. While "scientific breakeven" (i.e., unity target gain) has not yet been achieved (here target gain is 0.72, 1.37 MJ of fusion for 1.92 MJ of laser energy), this Letter reports the first controlled fusion experiment, using laser indirect drive, on the National Ignition Facility to produce capsule gain (here 5.8) and reach ignition by nine different formulations of the Lawson criterion.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.