Impact of the COVID-19 Pandemic on Outcomes for Patients with Lung Cancer Receiving Curative-intent Radiotherapy in the UK

AIMS

Previous work found that during the first wave of the COVID-19 pandemic, 34% of patients with lung cancer treated with curative-intent radiotherapy in the UK had a change to their centre's usual standard of care treatment (Banfill et al. Clin Oncol 2022;34:19-27). We present the impact of these changes on patient outcomes.

MATERIALS AND METHODS

The COVID-RT Lung database was a prospective multicentre UK cohort study including patients with stage I-III lung cancer referred for and/or treated with radical radiotherapy between April and October 2020. Data were collected on patient demographics, radiotherapy and systemic treatments, toxicity, relapse and death. Multivariable Cox and logistic regression were used to assess the impact of having a change to radiotherapy on survival, distant relapse and grade ≥3 acute toxicity. The impact of omitting chemotherapy on survival and relapse was assessed using multivariable Cox regression.

RESULTS

Patient and follow-up forms were available for 1280 patients. Seven hundred and sixty-five (59.8%) patients were aged over 70 years and 603 (47.1%) were female. The median follow-up was 213 days (119, 376). Patients with stage I-II non-small cell lung cancer (NSCLC) who had a change to their radiotherapy had no significant increase in distant relapse (P = 0.859) or death (P = 0.884); however, they did have increased odds of grade ≥3 acute toxicity (P = 0.0348). Patients with stage III NSCLC who had a change to their radiotherapy had no significant increase in distant relapse (P = 0.216) or death (P = 0.789); however, they did have increased odds of grade ≥3 acute toxicity (P < 0.001). Patients with stage III NSCLC who had their chemotherapy omitted had no significant increase in distant relapse (P = 0.0827) or death (P = 0.0661).

CONCLUSION

This study suggests that changes to radiotherapy and chemotherapy made in response to the COVID-19 pandemic did not significantly affect distant relapse or survival. Changes to radiotherapy, namely increased hypofractionation, led to increased odds of grade ≥3 acute toxicity. These results are important, as hypofractionated treatments can help to reduce hospital attendances in the context of potential future emergency situations.

Exploring medical and veterinary student perceptions and communication preferences related to antimicrobial resistance in Ontario, Canada using qualitative methods

BACKGROUND

Antimicrobial resistance (AMR) threatens our ability to treat and prevent infectious diseases worldwide. A significant driver of AMR is antimicrobial use (AMU) in human and veterinary medicine. Therefore, education and awareness of AMR among antimicrobial prescribers is critical. Human and animal health professionals play important roles in the AMR issue, both as contributors to the emergence of AMR, and as potential developers and implementers of effective solutions. Studies have shown that engaging stakeholders prior to developing communication materials can increase relevance, awareness, and dissemination of research findings and communication materials. As future antimicrobial prescribers, medical and veterinary students' perspectives on AMR, as well as their preferences for future communication materials, are important. The first objective of this study was to explore medical and veterinary student perceptions and understanding of factors associated with emergence and spread of AMR. The second objective was to identify key messages, knowledge translation and transfer (KTT) methods, and dissemination strategies for communication of AMR information to these groups.

METHODS

Beginning in November 2018, focus groups were conducted with medical and veterinary students in Ontario, Canada. A semi-structured format, using standardized open-ended questions and follow-up probing questions was followed. Thematic analysis was used to identify and analyze patterns within the data.

RESULTS

Analyses showed that students believed AMR to be an important global issue and identified AMU in food-producing animals and human medicine as the main drivers of AMR. Students also highlighted the need to address society's reliance on antimicrobials and the importance of collaboration between different sectors to effectively reduce the emergence and transmission of AMR. When assessing different communication materials, students felt that although infographics provide easily digestible information, other KTT materials such as fact sheets are better at providing more information without overwhelming the target audiences (e.g., professional or general public).

CONCLUSION

Overall, the study participants felt that AMR is an important issue and emphasized the need to develop different KTT tools for different audiences. This research will help inform the development of future communication materials, and support development of AMR-KTT tools tailored to the needs of different student and professional groups.

Ethnicity and paediatric healthcare utilisation: Improving the quality of quantitative research

Background

The COVID-19 pandemic highlighted the stark health inequities affecting minority ethnic populations in Europe. However, research on ethnic inequities and healthcare utilisation in children has seldom entered the policy discourse. A scoping review was conducted in the UK, summarising and appraising the quantitative evidence on ethnic differences (unequal) and inequities (unequal and unfair or disproportionate to healthcare needs) in paediatric healthcare utilisation.

Methods

Embase, Medline and grey literature sources were searched for studies published 2001-2021. Studies that found differences and inequities were mapped by ethnic group and healthcare utilisation outcome. They were appraised using the National Institute for Health and Care Excellence appraisal checklists. The distribution of studies was described across various methodological parameters.

Results

Of the 61 included studies, most found evidence of ethnic variations in healthcare utilisation (n = 54, 89%). Less than half attempted to distinguish between ethnic differences and inequities (n = 27, 44%). Studies were concentrated on primary and preventive care and hospitalisation, with minimal evidence on emergency and outpatient care. The quality of studies was often limited by a lack of theory underpinning analytical decisions, resulting in conflation of difference and inequity, and heterogeneity in ethnic classification. The majority of studies examined children's ethnicity but overlooked parent/caregiver ethnicity, and also didn't investigate patterns across age, year or location.

Conclusions

To improve the validity, generalisability and comparability of research on ethnicity and paediatric healthcare utilisation, findings from this scoping review were used to develop recommendations for future research. These lessons could be applied more broadly across the European context to improve evidence generation and evidence-based policy-making to reduce inequities in healthcare.

Key messages

• Quantitative studies of ethnicity and paediatric healthcare utilisation in the UK lack the use of sound theoretical frameworks, and often do not distinguish between ethnic differences and inequities.

• The quality of future studies can be improved with greater attention to how ethnicity is classified and analysed, alongside specific considerations for examining healthcare utilisation in children.

Changes in the Management of Patients having Radical Radiotherapy for Lung Cancer during the First Wave of the COVID-19 Pandemic in the UK

AIMS

In response to the COVID-19 pandemic, guidelines on reduced fractionation for patients treated with curative-intent radiotherapy were published, aimed at reducing the number of hospital attendances and potential exposure of vulnerable patients to minimise the risk of COVID-19 infection. We describe the changes that took place in the management of patients with stage I-III lung cancer from April to October 2020.

MATERIALS AND METHODS

Lung Radiotherapy during the COVID-19 Pandemic (COVID-RT Lung) is a prospective multicentre UK cohort study. The inclusion criteria were: patients with stage I-III lung cancer referred for and/or treated with radical radiotherapy between 2nd April and 2nd October 2020. Patients who had had a change in their management and those who continued with standard management were included. Data on demographics, COVID-19 diagnosis, diagnostic work-up, radiotherapy and systemic treatment were collected and reported as counts and percentages. Patient characteristics associated with a change in treatment were analysed using multivariable binary logistic regression.

RESULTS

In total, 1553 patients were included (median age 72 years, 49% female); 93 (12%) had a change to their diagnostic investigation and 528 (34%) had a change to their treatment from their centre's standard of care as a result of the COVID-19 pandemic. Age ≥70 years, male gender and stage III disease were associated with a change in treatment on multivariable analysis. Patients who had their treatment changed had a median of 15 fractions of radiotherapy compared with a median of 20 fractions in those who did not have their treatment changed. Low rates of COVID-19 infection were seen during or after radiotherapy, with only 21 patients (1.4%) developing the disease.

CONCLUSIONS

The COVID-19 pandemic resulted in changes to patient treatment in line with national recommendations. The main change was an increase in hypofractionation. Further work is ongoing to analyse the impact of these changes on patient outcomes.

AMR-Intervene: a social-ecological framework to capture the diversity of actions to tackle antimicrobial resistance from a One Health perspective

The global threat of antimicrobial resistance (AMR) requires coordinated actions by and across different sectors. Increasing attention at the global and national levels has led to different strategies to tackle the challenge. The diversity of possible actions to address AMR is currently not well understood from a One Health perspective. AMR-Intervene, an interdisciplinary social-ecological framework, describes interventions to tackle AMR in terms of six components: (i) core information about the publication; (ii) social system; (iii) bio-ecological system; (iv) triggers and goals; (v) implementation and governance; and (vi) assessment. AMR-Intervene provides a broadly applicable framework, which can inform the design, implementation, assessment and reporting of interventions to tackle AMR and, in turn, enable faster uptake of successful interventions to build societal resilience to AMR.

Building Social-Ecological System Resilience to Tackle Antimicrobial Resistance Across the One Health Spectrum: Protocol for a Mixed Methods Study

BACKGROUND

Antimicrobial resistance (AMR) is an escalating global crisis with serious health, social, and economic consequences. Building social-ecological system resilience to reduce AMR and mitigate its impacts is critical.

OBJECTIVE

The aim of this study is to compare and assess interventions that address AMR across the One Health spectrum and determine what actions will help to build social and ecological capacity and readiness to sustainably tackle AMR.

METHODS

We will apply social-ecological resilience theory to AMR in an explicit One Health context using mixed methods and identify interventions that address AMR and its key pressure antimicrobial use (AMU) identified in the scientific literature and in the gray literature using a web-based survey. Intervention impacts and the factors that challenge or contribute to the success of interventions will be determined, triangulated against expert opinions in participatory workshops and complemented using quantitative time series analyses. We will then identify indicators using regression modeling, which can predict national and regional AMU or AMR dynamics across animal and human health. Together, these analyses will help to quantify the causal loop diagrams (CLDs) of AMR in the European and Southeast Asian food system contexts that are developed by diverse stakeholders in participatory workshops. Then, using these CLDs, the long-term impacts of selected interventions on AMR will be explored under alternate future scenarios via simulation modeling and participatory workshops. A publicly available learning platform housing information about interventions on AMR from a One Health perspective will be developed to help decision makers identify promising interventions for application in their jurisdictions.

RESULTS

To date, 669 interventions have been identified in the scientific literature, 891 participants received a survey invitation, and 4 expert feedback and 4 model-building workshops have been conducted. Time series analysis, regression modeling of national and regional indicators of AMR dynamics, and scenario modeling activities are anticipated to be completed by spring 2022. Ethical approval has been obtained from the University of Waterloo's Office of Research Ethics (ethics numbers 40519 and 41781).

CONCLUSIONS

This paper provides an example of how to study complex problems such as AMR, which require the integration of knowledge across sectors and disciplines to find sustainable solutions. We anticipate that our study will contribute to a better understanding of what actions to take and in what contexts to ensure long-term success in mitigating AMR and its impact and provide useful tools (eg, CLDs, simulation models, and public databases of compiled interventions) to guide management and policy decisions.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/24378.

Evidence for action: a One Health learning platform on interventions to tackle antimicrobial resistance

Improving evidence for action is crucial to tackle antimicrobial resistance. The number of interventions for antimicrobial resistance is increasing but current research has major limitations in terms of efforts, methods, scope, quality, and reporting. Moving the agenda forwards requires an improved understanding of the diversity of interventions, their feasibility and cost-benefit, the implementation factors that shape and underpin their effectiveness, and the ways in which individual interventions might interact synergistically or antagonistically to influence actions against antimicrobial resistance in different contexts. Within the efforts to strengthen the global governance of antimicrobial resistance, we advocate for the creation of an international One Health platform for online learning. The platform will synthesise the evidence for actions on antimicrobial resistance into a fully accessible database; generate new scientific insights into the design, implementation, evaluation, and reporting of the broad range of interventions relevant to addressing antimicrobial resistance; and ultimately contribute to the goal of building societal resilience to this central challenge of the 21st century.

Factors that antimicrobial resistance in food systems: a participatory modelling approach

Background

Antimicrobial resistance (AMR) emerges from a complex web of factors; understanding their dynamics is key to determining sustainable solutions. Thus, we aimed to create a model of the diverse factors influencing AMR in two food systems and model the impacts of interventions.

Methods

We built a causal loop diagram (CLD) of the factors driving AMR in the food chain via 4 participatory workshops (2 in Sweden; 2 in Malaysia) with diverse stakeholders. The CLD became the structure of a compartmental model, which was populated using data from multiple sources (e.g., interviews, surveillance data). Using fuzzy set theory, quantitative and qualitative data were converted to categorical variables. The compartmental model was created in AnyLogic and was used to test how expert-selected solutions (e.g., taxation) might impact AMR under different scenarios.

Results

Factors identified as influencing AMR across Europe and Southeast Asia clustered around key themes: on-farm (e.g., biosecurity); social (e.g., consumer demand); research (e.g., alternatives to antimicrobials [AMs]); economic (e.g., agricultural production levels); policy (e.g., trade agreements); and environment (e.g., waste management). Differences were identified between regions, for example, regulations and standards regarding imports or food safety were more relaxed in Southeast Asia than in Europe. Identified interventions included: AMR education in schools, training diverse stakeholders in AM stewardship, increased on-farm biosecurity measures to limit disease and the need for AMs, and taxing AM-containing products.

Conclusions

Our model captured a range of multi-level, interlinked factors that impact AMR in the European and Southeast Asian food system contexts. Preliminary findings suggest that different principles need to be cultivated (e.g., polycentric governance, cross-sector partnerships) to ensure that interventions addressing AMR are sustainable over time.

Key messages

Our study visually characterized the interlinked factors that impact AMR transmission and emergence in food systems. Our approach provides a tool to model impacts of potential interventions.

Monitoring of Farm-Level Antimicrobial Use to Guide Stewardship: Overview of Existing Systems and Analysis of Key Components and Processes

The acknowledgment of antimicrobial resistance (AMR) as a major health challenge in humans, animals and plants, has led to increased efforts to reduce antimicrobial use (AMU). To better understand factors influencing AMR and implement and evaluate stewardship measures for reducing AMU, it is important to have sufficiently detailed information on the quantity of AMU, preferably at the level of the user (farmer, veterinarian) and/or prescriber or provider (veterinarian, feed mill). Recently, several countries have established or are developing systems for monitoring AMU in animals. The aim of this publication is to provide an overview of known systems for monitoring AMU at farm-level, with a descriptive analysis of their key components and processes. As of March 2020, 38 active farm-level AMU monitoring systems from 16 countries were identified. These systems differ in many ways, including which data are collected, the type of analyses conducted and their respective output. At the same time, they share key components (data collection, analysis, benchmarking, and reporting), resulting in similar challenges to be faced with similar decisions to be made. Suggestions are provided with respect to the different components and important aspects of various data types and methods are discussed. This overview should provide support for establishing or working with such a system and could lead to a better implementation of stewardship actions and a more uniform communication about and understanding of AMU data at farm-level. Harmonization of methods and processes could lead to an improved comparability of outcomes and less confusion when interpreting results across systems. However, it is important to note that the development of systems also depends on specific local needs, resources and aims.

Antimicrobials Used for the Therapy of Necrotic Enteritis and Coccidiosis in Broiler Chickens and Turkeys in Canada, Farm Surveillance Results (2013-2017)

Since 2013, the Canadian Integrated Program for Antimicrobial Resistance Surveillance (CIPARS) has collected antimicrobial use (AMU) and antimicrobial resistance data from sentinel broiler chicken flocks (Br, five provinces) and sentinel turkey flocks (Tk, one province 2013-2015, three provinces 2016-2017). The objectives of this paper were to describe various preventive strategies aimed at controlling necrotic enteritis (NE) and coccidiosis in the broiler chicken and turkey flocks participating in CIPARS and FoodNet Canada Farm Surveillance Program between 2013 and 2017, to quantify and identify trends in antimicrobials used in feed, and to describe temporal changes in the diagnoses of bacterial and protozoal diseases in relation to antimicrobial use in feed. Comprehensive data were collected (by questionnaire) enabling AMU assessment by various count-based metrics (i.e., frequency and number of medicated rations), weight-based metrics (i.e., inclusion rate in feed and kilograms consumed), and technical indicators (i.e., milligrams per population correction unit [mg/PCU]). Qualitative information such as reasons for use and frequency of diagnosed diseases provided context to the trends in AMU. Between 2013 and 2017, 646 broiler flocks (14.9 million kg biomass) and 234 turkey flocks (12.4 million kg biomass) were surveyed. Overall, antimicrobials used for the prevention of Clostridium perfringens infections (NE) contributed to 85% (109/128 mg/PCU_Br) and 95% (59/62 mg/PCU_Tk) of the quantity of antimicrobials administered via feed in broiler chickens and turkeys, respectively. Three NE programs were used: either 1, 2, or ≥3 antimicrobials administered throughout the production cycle. The treatment protocol in which a single antimicrobial was used throughout the cycle was the most frequent NE preventive program for broiler chickens (58%) and turkeys (76%). Bacitracin and virginiamycin were the top two most frequently used antimicrobials in both species for NE. For coccidiosis control, ionophores and chemical coccidiostats contributed to 66% (3091 kg) and 68% (1561 kg) of the total feed antimicrobial exposures in broiler chickens and turkeys, respectively. Documented coccidiosis programs included continuous or straight (1 drug/cycle), shuttle or dual control (≥2 drugs/cycle), and vaccination. Variations in coccidiosis programs between species were noted: broiler chickens frequently used a shuttle or dual-control program (68%), whereas turkey flocks used primarily a continuous or straight program (74%). Flocks raised without antibiotics and organic farms (10.3% of broiler chickens and 9.8% turkey flocks) used vaccines to prevent coccidiosis. A small number of broiler flocks (n = 6) used a combination of a vaccination and a coccidiostat during the cycle. During the surveillance timeframe used for this paper, the total feed AMU decreased over time in broiler chickens from 136 to 120 mg/PCU_Br and in turkeys from 85 to 62 mg/ PCU_Tk, with no remarkable changes in the frequency of flocks diagnosed with bacterial and protozoal diseases. Surveillance findings such as these will be used as valid reference points in light of the upcoming changes in Canadian federal AMU regulations and industry-led initiatives aimed at reducing AMU.

Ceftiofur-resistant Salmonella enterica serovar Heidelberg of poultry origin - a risk profile using the Codex framework

Codex published the 'Guidelines for Risk Analysis of Foodborne Antimicrobial Resistance' to standardise the approach for evaluating risk posed by foodborne antimicrobial-resistant bacteria. One of the first steps in the guidelines is to compile a risk profile, which provides the current state of knowledge regarding a food safety issue, describes risk management options and recommends next steps. In Canada, ceftiofur/ceftriaxone-resistant Salmonella enterica subsp. enterica serovar Heidelberg from poultry was identified as an antimicrobial resistance (AMR) food safety issue. The first objective of this article was to contextualise this food safety issue, using the risk profile format of the Codex Guidelines. A second objective was to evaluate the applicability of the Codex Guidelines. This risk profile indicated that ceftiofur/ceftriaxone-resistant S. Heidelberg (CSH) was commonly isolated from poultry and was associated with severe disease in humans. Ceftiofur use in poultry hatcheries temporally mirrored the prevalence of CSH from poultry meat at retail and from people with salmonellosis. The evidence was sufficient to indicate the need for risk management options, such as restricting the use of ceftiofur in poultry. The Codex Guidelines provided a useful approach to summarise data for decision-makers to evaluate an AMR food safety issue.

A within-flock model of Salmonella Heidelberg transmission in broiler chickens

As part of the development of a quantitative microbial risk assessment (QMRA) model of third-generation cephalosporins (3GC)-resistant Salmonella Heidelberg, a compartmental (SEIR) model for S. Heidelberg transmission within a typical Canadian commercial broiler chicken flock was developed. The model was constructed to estimate the within-flock prevalence and the bacterial concentration in the barn environment at pre-harvest, and to assess the effect of selected control measures. The baseline scenario predicted an average within-flock prevalence of 23.5 % (95 % tolerance interval: 15.7-31.4) and an average bacterial concentration of 3.579 (0-4.294) log CFU/g of feces in the barn environment at pre-harvest (on the day the flock is sent to slaughter). Because vertical introduction of S. Heidelberg into the barn was already uncommon in the baseline scenario, vaccination of broiler parent flocks appeared to have a negligible effect, while vaccination of broiler chicken flocks substantially reduced the bacterial concentration at pre-harvest. Cleaning and disinfection between batches markedly reduced the within-flock prevalence at pre-harvest, but the effect on bacterial concentration was limited outside of the beginning of the production period. Extending downtime between batches by 7 days had little effect on within-flock prevalence or bacterial concentration of S. Heidelberg when compared to the baseline scenario. This study provides a basis to describe S. Heidelberg dynamics within a broiler chicken flock and to predict the within-flock prevalence and bacterial concentration at pre-harvest, and includes a description of the limitations and data gaps. The results of these analyses and associated uncertainties are critical information for populating QMRA models of the downstream impacts on public health from on-farm and other food-chain practices. Specifically, the study findings will be integrated into a broader farm-to-fork QMRA model to support the risk-based control of S. Heidelberg resistant to 3GC in broiler chicken in Canada.

Factors potentially linked with the occurrence of antimicrobial resistance in selected bacteria from cattle, chickens and pigs: A scoping review of publications for use in modelling of antimicrobial resistance (IAM.AMR Project)

Antimicrobial resistance is a complex issue with a large volume of published literature, and there is a need for synthesis of primary studies for an integrated understanding of this topic. Our research team aimed to have a more complete understanding of antimicrobial resistance in Canada (IAM.AMR Project) using multiple methods including the literature reviews and quantitative modelling. To accomplish this goal, qualitative features of publications (e.g., geographical location, study population) describing potential relationships between the occurrence of antimicrobial resistance and factors (e.g., antimicrobial use; management system) were of particular interest. The objectives of this review were to (a) describe the available peer-reviewed literature reporting potential relationships between factors and antimicrobial resistance; and (b) to highlight data gaps. A comprehensive literature search and screening were performed to identify studies investigating factors potentially linked with antimicrobial resistance in Campylobacter species, Escherichia coli and Salmonella enterica along the farm-to-fork pathway (farm, abattoir (slaughter houses) and retail meats) for the major Canadian livestock species (beef cattle, broiler chicken and pigs). The literature search returned 14,966 potentially relevant titles and abstracts. Following screening of titles, abstracts and full-text articles, the qualitative features of retained studies (n = 28) were extracted. The most common factors identified were antimicrobial use (n = 13 studies) and type of farm management system (e.g., antibiotic-free, organic; n = 8). Most studies were conducted outside of Canada and involved investigations at the farm level. Identified data gaps included the effect of vaccination, industry-specific factors (e.g., livestock density) and factors at sites other than farm along the agri-food chain. Further investigation of these factors and other relevant industry activities are needed for the development of quantitative models that aim to identify effective interventions to mitigate the occurrence of antimicrobial resistance along the agri-food chain.

Identifying non-traditional stakeholders with whom to engage, when mitigating antimicrobial resistance in foodborne pathogens (Canada)

Objective

Antimicrobial resistance (AMR) is a critical public health issue that involves interrelationships between people, animals, and the environment. Traditionally, interdisciplinary efforts to mitigate AMR in the food chain have involved public health, human and veterinary medicine, and agriculture stakeholders. Our objective was to identify a more diverse range of stakeholders, beyond those traditionally engaged in AMR mitigation efforts, via diagramming both proximal and distal factors impacting, or impacted by, use and resistance along the Canadian food chain.

Results

We identified multiple stakeholders that are not traditionally engaged by public health when working to mitigate AMR in the food chain, including those working broadly in the area of food (e.g., nutrition, food security, international market economists) and health (e.g., health communication, program evaluation), as well as in domains as diverse as law, politics, demography, education, and social innovation. These findings can help researchers and policymakers who work on issues related to AMR in the food chain to move beyond engaging the ‘traditional’ agri-food stakeholders (e.g., veterinarians, farmers), to also engage those from the wider domains identified here, as potential stakeholders in their AMR mitigation efforts.

Exposure to antimicrobial-resistant Escherichia coli through the consumption of ground beef in Western Canada

Emergence and dissemination of antimicrobial resistance (AMR) in food-borne bacteria is a public health issue. Retail meat is considered an important carrier for antimicrobial-resistant Escherichia coli. Currently, resistance of E. coli strains to third generation cephalosporins are of particular concern, with significant potential animal and public health consequences. Resistance to tetracyclines is also a concern, due to high prevalence of this resistance and important co-resistance patterns. However, the actual likelihood of exposure to antimicrobial-resistant bacteria via the consumption of retail meats, beyond the simple frequencies of resistance found in samples of meat at the grocery store, in Canada remains to be investigated. This study was conducted to estimate the potential human exposure to ceftriaxone- and tetracycline-resistant E.coli (CREC and TREC; the hazards of interest) through the consumption of ground beef in Western Canada. Our exposure assessment simulation model included five modules: 1) estimation of prevalence and concentration of the hazards of interest in retail ground beef samples collected by the Canadian Integrated Program for Antimicrobial Resistance Surveillance (CIPARS), 2011-2014; 2) potential growth of the hazards during transportation from retail to home; 3) potential growth or reduction of the hazards during home storage; 4) thermal inactivation of the hazards due to cooking; and 5) consumption. The outputs of the model were presented as the probability of consumers' exposure to various threshold levels of the hazards [10 to 10⁶ colony forming units (CFU)] in one serving of cooked ground beef. Overall, the probabilities of exposure to high threshold levels of the hazards (>4 log₁₀ CFU/serving) were estimated to be lower than 0.12% in the study population (2011-2014). The mean probabilities of exposure to at least 1 log₁₀ CFU CREC and TREC in a single meal containing cooked ground beef were 0.067% (SD: 0.001%) and 1.20% (SD: 0.02%), respectively. This probability substantially decreased as the threshold level of exposure increased to ≥6 log₁₀ CFU. The probability of exposure to TREC was consistently greater than that for CREC. Cooking led to a prominent drop in the mean concentration of the hazards (4.7 log₁₀ CFU/g). The findings from this research could inform the policy-making process and provide suggestions for adjustments in future retail surveillance plans. In addition, important knowledge gaps in this area have been highlighted.

Exclusive breastfeeding duration and infant infection

BACKGROUND/OBJECTIVES

We estimated the risk of infection associated with the duration of exclusive breastfeeding (EBF).

SUBJECT/METHODS

We analysed the data on 15 809 term, singleton infants from the UK Millennium Cohort Study. Infants were grouped according to months of EBF: never, <2, 2-4, 4-6 and 6 (the latter being World Health Organisation (WHO) policy since 2001: 'post-2001 WHO policy'). Among those EBF for 4-6 months, we separated those who started solids, but not formula, before 6 months, and were still breastfeeding at 6 months (that is, WHO policy before 2001: 'pre-2001 WHO policy'), from other patterns. Outcomes were infection in infancy (chest, diarrhoeal and ear).

RESULTS

EBF was not associated with the ear infection, but was associated with chest infection and diarrhoea. EBF for <4 months was associated with a significantly increased risk of chest infection (adjusted risk ratios (RR) 1.24-1.28) and diarrhoea (adjusted RRs 1.42-1.66) compared with the pre-2001 WHO policy. There was an excess risk of the chest infection (adjusted RR 1.19, 95% confidence interval (CI): 0.97-1.46) and diarrhoea (adjusted RR 1.66, 95% CI: 1.11, 2.47) among infants EBF for 4-6 months, but who stopped breastfeeding by 6 months, compared with the pre-2001 WHO policy. There was no significant difference in the risk of chest infection or diarrhoea in those fed according to the pre-2001 versus post-2001 WHO policy.

CONCLUSIONS

There is an increased risk of infection in infants EBF for <4 months or EBF for 4-6 months who stop breastfeeding by 6 months. These results support current guidelines of EBF for either 4-6 or 6 months, with continued breastfeeding thereafter.

An assessment of antimicrobial resistant disease threats in Canada

BACKGROUND

Antimicrobial resistance (AMR) of infectious agents is a growing concern for public health organizations. Given the complexity of this issue and how widespread the problem has become, resources are often insufficient to address all concerns, thus prioritization of AMR pathogens is essential for the optimal allocation of risk management attention. Since the epidemiology of AMR pathogens differs between countries, country-specific assessments are important for the determination of national priorities.

OBJECTIVE

To develop a systematic and transparent approach to AMR risk prioritization in Canada.

METHODS

Relevant AMR pathogens in Canada were selected through a transparent multi-step consensus process (n=32). Each pathogen was assessed using ten criteria: incidence, mortality, case-fatality, communicability, treatability, clinical impact, public/political attention, ten-year projection of incidence, economic impact, and preventability. For each pathogen, each criterion was assigned a numerical score of 0, 1, or 2, and multiplied by criteria-specific weighting determined through researcher consensus of importance. The scores for each AMR pathogen were summed and ranked by total score, where a higher score indicated greater importance. A sensitivity analysis was conducted to determine the effects of changing the criteria-specific weights.

RESULTS

The AMR pathogen with the highest total weighted score was extended spectrum B-lactamase-producing (ESBL) Enterobacteriaceae (score=77). When grouped by percentile, ESBL Enterobacteriaceae, Clostridium difficile, carbapenem-resistant Enterobacteriaceae, and methicillin-resistant Staphylococcus aureus were in the 80-100th percentile.

CONCLUSION

This assessment provides useful information for prioritising public health strategies regarding AMR resistance at the national level in Canada. As the AMR environment and challenges change over time and space, this systematic and transparent approach can be adapted for use by other stakeholders domestically and internationally. Given the complexity of influences, resource availability and multiple stakeholders, regular consideration of AMR activities in the public health realm is essential for appropriate and responsible prioritisation of risk management that optimises the health and security of the population.

Functional expression of KCNQ (Kv7) channels in guinea pig bladder smooth muscle and their contribution to spontaneous activity

Background and Purpose

The aim of the study was to determine whether KCNQ channels are functionally expressed in bladder smooth muscle cells (SMC) and to investigate their physiological significance in bladder contractility.

Experimental Approach

KCNQ channels were examined at the genetic, protein, cellular and tissue level in guinea pig bladder smooth muscle using RT-PCR, immunofluorescence, patch-clamp electrophysiology, calcium imaging, detrusor strip myography, and a panel of KCNQ activators and inhibitors.

Key Results

KCNQ subtypes 1–5 are expressed in bladder detrusor smooth muscle. Detrusor strips typically displayed TTX-insensitive myogenic spontaneous contractions that were increased in amplitude by the KCNQ channel inhibitors XE991, linopirdine or chromanol 293B. Contractility was inhibited by the KCNQ channel activators flupirtine or meclofenamic acid (MFA). The frequency of Ca²⁺-oscillations in SMC contained within bladder tissue sheets was increased by XE991. Outward currents in dispersed bladder SMC, recorded under conditions where BK and K_ATP currents were minimal, were significantly reduced by XE991, linopirdine, or chromanol, and enhanced by flupirtine or MFA. XE991 depolarized the cell membrane and could evoke transient depolarizations in quiescent cells. Flupirtine (20 μM) hyperpolarized the cell membrane with a simultaneous cessation of any spontaneous electrical activity.

Conclusions and Implications

These novel findings reveal the role of KCNQ currents in the regulation of the resting membrane potential of detrusor SMC and their important physiological function in the control of spontaneous contractility in the guinea pig bladder.

Antimicrobial therapy of selected diseases in turkeys, laying hens, and minor poultry species in Canada

This paper identifies common poultry diseases requiring antimicrobial therapy, antimicrobials deemed efficacious to treat these diseases, and antimicrobial resistance (AMR) in these commodity-pathogen combinations, and describes current residue issues and minor use minor species (MUMS) guidelines. Veterinarians with turkey/layer expertise and diagnosticians were surveyed to determine the bacterial and protozoal diseases diagnosed in the last 5 years. Avian pathogenic Escherichia coli, Staphylococcus aureus, and Ornithobacterium rhinotracheale were the 3 most frequently diagnosed pathogens of turkeys. In layers, E. coli-peritonitis, and Clostridium perfringens/Eimeria spp. infections were the most common diagnoses. A literature review identified 32 antimicrobials as efficacious and/or recommended for treating these diseases. Surveillance and monitoring indicate the presence of enteric resistant organisms from some of these avian species (including resistance to antimicrobials of very high importance to human medicine). This paper highlights the need for surveillance of pathogen frequency, antimicrobial use (AMU), and AMR particularly in turkeys.

Asthma in children born after infertility treatment: findings from the UK Millennium Cohort Study

STUDY QUESTION

Is asthma more common in children born after subfertility and assisted reproduction technologies (ART)?

SUMMARY ANSWER

Yes. Asthma, wheezing in the last year and anti-asthmatic medication were all more common in children born after a prolonged time to conception (TTC). This was driven specifically by an increase in children born after ART.

WHAT IS KNOWN ALREADY

Few studies have investigated any association between ART and asthma in subsequent children, and findings to date have been mixed. A large registry-based study found an increase in asthma medication in ART children but suggests underlying infertility is the putative risk factor. Little is known about asthma in children after unplanned or mistimed conceptions.

STUDY DESIGN, SIZE, DURATION

The Millennium Cohort Study is a UK-wide, prospective study of 18 818 children recruited at 9 months of age. Follow-up is ongoing. This study analyses data from follow-up surveys at 5 and 7 years of age (response rates of 79 and 70%, respectively).

PARTICIPANTS/MATERIALS, SETTING, METHODS

Singleton children whose natural mothers provided follow-up data were included. Mothers reported whether their pregnancy was planned; planners provided TTC and details of any ART. The population was divided into 'unplanned' (unplanned and unhappy), 'mistimed' (unplanned but happy), 'planned' (planned, TTC < 12 months), 'untreated subfertile' (planned, TTC >12 months), 'ovulation induced' (received clomiphene citrate) and 'ART' (IVF or ICSI). The primary analysis used the planned children as the comparison group; secondary analysis compared the treatment groups to the children born to untreated subfertile parents. Outcomes were parent report of asthma and wheezing at 5 and 7 years, derived from validated questions in the International Study of Asthma and Allergies in Childhood, plus use of anti-asthmatic medications. A total of 13 041 (72%) children with full data on asthma and confounders were included at 5 years of age, and 11 585 (64%) at 7 years.

MAIN RESULTS AND THE ROLE OF CHANCE

Compared with planned children, those born to subfertile parents were significantly more likely to experience asthma, wheezing and to be taking anti-asthmatics at 5 years of age [adjusted odds ratio (OR): 1.39 (95% confidence interval (CI): 1.07, 1.80), OR: 1.27 (1.00, 1.63) and OR: 1.90 (1.32,2.74), respectively]. This association was mainly related to an increase among children born after ART (adjusted OR: 2.65 (1.48, 4.76), OR: 1.97, (1.10, 3.53) and OR: 4.67 (2.20, 9.94) for asthma, wheezing and taking anti-asthmatics, respectively). The association was also present, though reduced, at the age of 7 years.

LIMITATIONS, REASONS FOR CAUTION

The number of singletons born after ART was relatively small (n = 104), and as such the findings should be interpreted with caution. However, data on a wide range of possible confounding and mediating factors were available and analysed. The data were weighted for non-response to minimize selection bias.

WIDER IMPLICATIONS OF THE FINDINGS

The findings add to the growing body of evidence suggesting an association between subfertility, ART and asthma in children. Further work is needed to establish causality and elucidate the underlying mechanism. These findings are generalizable to singletons only, and further work on multiples is needed.

Review of antimicrobial therapy of selected bacterial diseases in broiler chickens in Canada

This paper reviews common therapeutic applications of antimicrobials in broiler chicken production in relation to Canadian guidelines, surveillance data, and emerging public health concerns about antimicrobial use (AMU). Escherichia coli, Clostridium perfringens, and Staphylococcus spp., were reviewed because of their animal health and economic significance. Enterococcus cecorum and Salmonella were included because of their importance in antimicrobial resistance (AMR) surveillance. This review identified that i) antimicrobials are available in Canada to treat infections by these agents, but may be through over the counter or extra-label use, ii) prevalence rates for these diseases are unknown, iii) antimicrobial use estimates in broilers are lacking, and iv) AMR has emerged in clinical isolates, though data are very sparse. This review highlights the need for surveillance of AMU and AMR in broiler chickens in Canada.

Effect of pregnancy planning and fertility treatment on cognitive outcomes in children at ages 3 and 5: longitudinal cohort study

OBJECTIVE

To investigate how pregnancy planning, time to conception, and infertility treatment influence cognitive development at ages 3 and 5.

DESIGN

Prospective population based cohort study.

SETTING

Millennium Cohort Study in the United Kingdom.

PARTICIPANTS

18,818 children recruited at 9 months and followed up at 3 and 5 years. 11,790 singletons with available data on pregnancy, cognitive outcomes, and confounders were included in analyses at age 3 and 12,136 at age 5. Exposure measures Mothers reported whether the pregnancy was planned, and their feelings when first pregnant; those in whom the pregnancy was planned provided time to conception, and details of any assisted reproductive technologies. The population was divided into "unplanned" (unplanned and unhappy), "mistimed" (unplanned but happy), "planned" (planned, time to conception <12 months), "subfertile" (planned, time to conception ≥ 12 months), "induced ovulation" (received clomiphene citrate), and "assisted reproduction" (in vitro fertilisation or intracytoplasmic sperm injection). The "planned" group was the comparison group in all analyses.

OUTCOME MEASURES

Three components of the British Ability Scales (BAS II). Naming vocabulary assessed verbal ability at age 3; this test was repeated at age 5 with the picture similarities and pattern construction subscales, which measure non-verbal and spatial abilities.

RESULTS

In unadjusted analyses, the scores on all scales in children from unplanned pregnancies were significantly lower than in those from planned pregnancies-for example, the difference in mean verbal ability score at age 3 was -4.8 (95% confidence interval -6.0 to -3.7; P<0.05), equivalent to an average delay of four months. After adjustment for sociodemographic factors these differences were attenuated: -0.3 (-1.3 to 0.7), equivalent to no delay. Children born after assisted reproduction performed consistently better in verbal ability tests (3.8 (-0.2 to 7.9) at age 3 and 3.5 (0.2 to 6.8) at age 5), which suggests that on average these children are three to four months ahead; this difference did not completely disappear with adjustment for confounders. Children born after infertility treatment had lower mean scores in non-verbal tests (-1.2 (-4.1 to 1.6) after assisted reproduction and -1.5 (-3.5 to 0.4) after induced ovulation) and in spatial ability tests (-2.7 (-6.9 to 1.6) after assisted reproduction), though the differences were not significant.

CONCLUSIONS

Pregnancy planning, subfertility, or assisted reproduction do not adversely affect children's cognitive development at age 3 or 5. The differences observed in the unadjusted analyses are almost entirely explained by marked inequalities in socioeconomic circumstances between the groups.

Restoration of spinal alignment and disk mechanics following polyetheretherketone wafer kyphoplasty with StaXx FX

BACKGROUND AND PURPOSE

EPFs sustained during VCFs degrade the disk's ability to develop IDP under load. This inability to develop pressure in combination with residual kyphotic deformity increases the risk for adjacent vertebral fractures. We tested the hypothesis that StaXx FX reduces kyphosis and endplate deformity following vertebral compression fracture, restoring disk mechanics.

MATERIALS AND METHODS

Eight thoracolumbar, 5-vertebrae segments were tested. A void was selectively created in the middle vertebra. The specimens were compressed until EPF and to a grade I-II VCF. PEEK wafer kyphoplasty was then performed. The specimens were then tested in flexion-extension (±6 Nm) under 400-N preload intact, after EPF, VCF, and kyphoplasty. Endplate deformity, kyphosis, and IDP adjacent to the fractured body were measured.

RESULTS

Vertebral body height at the point of maximal endplate deformity decreased after EPF and VCF and was partially corrected after StaXx FX, remaining less than intact (P = .047). Anterior vertebral height decreased after VCF (P = .002) and was partially restored with StaXx FX, remaining less than intact (P = .015). Vertebral kyphosis increased after VCF (P < .001) and reduced after StaXx FX, remaining greater than intact (P = .03). EPF reduced IDP in the affected disk in compression-flexion loading (P < .001), which was restored after StaXx FX (P = 1.0). IDP in the unaffected disk did not change during testing (P > .3).

CONCLUSIONS

StaXx FX reduced endplate deformity and kyphosis, and significantly increased anterior height following VCF. Although height and kyphosis were not fully corrected, the disk's ability to pressurize under load was restored.

The potential for a two-stage diabetes risk algorithm combining non-laboratory-based scores with subsequent routine non-fasting blood tests: results from prospective studies in older men and women

AIM

To develop strategies based on simple clinical assessment and blood markers to identify older individuals at high risk for Type 2 diabetes.

METHODS

A prospective study of non-diabetic men (n = 3523) and women (n = 3404) aged 60-79 years followed for 7 years, during which there were 297 incident cases of Type 2 diabetes. Logistic regression was used to develop scores to predict incident cases, starting with clinical predictors and adding blood markers that predicted the incidence of diabetes. Receiving operating characteristic analyses were used to assess improvement in prediction.

RESULTS

The area under the curve for a simple clinical assessment score, which included age, sex, family history of diabetes, smoking status, BMI, waist circumference, hypertension and recall of doctor diagnosis of coronary heart disease was 0.765 (0.740, 0.791); sensitivity and specificity in the top quintile of the score were 50.3 and 81.4%, respectively. Addition of simple fasting blood markers HDL cholesterol, triglyceride and glucose improved prediction [area under the curve = 0.817 (0.793, 0.840), P < 0.0001; sensitivity 63.8%; specificity 82.0%]. An alternative model adding blood markers not dependent on fasting yielded similar results. Further addition of C-reactive protein made no improvement. Blood measurements made small differences to reclassification of risk in those in the lowest three quintiles of the non-laboratory score.

CONCLUSION

In large population settings, simple clinical assessments could be used in the first instance to identify older adults who would benefit from further testing with routine (non-fasting) blood markers to identify those at most likely to be at elevated diabetes risk.

Assessing prediction of diabetes in older adults using different adiposity measures: a 7 year prospective study in 6,923 older men and women

AIMS/HYPOTHESIS

The aim of this study was to examine whether waist circumference (WC) or WHR improve diabetes prediction beyond body mass index in older men and women, and to define optimal cut-off points.

METHODS

In this prospective study, non-diabetic men (n = 3,519) and women (n = 3,404) aged 60-79 years were followed up for 7 years. There were 169 and 128 incident cases of type 2 diabetes in men and women, respectively.

RESULTS

BMI, WC and WHR all showed strong associations with incident type 2 diabetes independent of potential confounders. In men, the adjusted relative risks (top vs lowest quartile) were 4.71 (95% CI 2.45-9.03) for BMI, 3.53 (95% CI 1.92-6.48) for WC and 2.76 (95% CI 1.58-4.82) for WHR. For women, the corresponding relative risks were 4.10 (95% CI 2.16-7.79), 12.18 (95% CI 4.83-30.74) and 5.61 (95% CI 2.84-11.09) for BMI, WC and WHR, respectively. Receiver-operating characteristic curve analysis revealed similar associations for BMI and WC in predicting diabetes in men (AUC = 0.726 and 0.713, respectively); WHR was the weakest predictor (AUC = 0.656). In women, WC was a significantly stronger predictor (AUC = 0.780) than either BMI (AUC = 0.733) or WHR (AUC = 0.728; p < 0.01 for both). Inclusion of both WC and BMI did not improve prediction beyond BMI alone in men or WC alone in women. Optimal sensitivity and specificity for the prediction of type 2 diabetes was observed at a WC of 100 cm in men and 92 cm in women.

CONCLUSIONS/INTERPRETATION

In older men, BMI and WC yielded similar prediction of risk of type 2 diabetes, whereas WC was clearly a superior predictor in older women.

Novel use of stir bar sorptive extraction (SBSE) as a tool for isolation of oviposition site attractants for gravid Culex quinquefasciatus

Mosquitoes such as Culex quinquefasciatus Say (Diptera: Culicidae) are important vectors of organisms that cause disease in humans. Research into the development of effective standardized odour baits for blood-fed females (oviposition attractants), to enable entomological monitoring of vector populations, is hampered by complex protocols for extraction of physiologically active volatile chemicals from natural breeding site water samples, which have produced inconsistent results. Air entrainment and solvent extraction are technically demanding methods and are impractical for use in resource poor environments where mosquito-borne disease is most prevalent. This study reports the first use of a simple, robust extraction technique, stir bar sorptive extraction (SBSE), to extract behaviourally active small lipophilic molecules (SLMs) present in water samples collected from Cx. quinquefasciatus breeding sites in Tanzania. Extracts from a pit latrine and from a cess pool breeding site attracted more gravid Cx. quinquefasciatus in pair choice bioassays than control extracts, and coupled gas chromatography-electroantennography (GC-EAG) allowed tentative identification of 15 electrophysiologically active chemicals, including the known oviposition attractant, skatole (3-methylindole). Here, we have demonstrated, using simple pair choice bioassays in controlled laboratory conditions, that SBSE is effective for the extraction of behaviourally and electrophysiologically active semiochemicals from mosquito breeding site waters. Further research is required to confirm that SBSE is an appropriate technique for use in field surveys in the search for oviposition cues for Cx. quinquefasciatus.

Cognitive development following ART: effect of choice of comparison group, confounding and mediating factors

BACKGROUND

Epidemiological studies have examined the health of children born after assisted reproductive technology (ART), with contradictory results. In this article, we address the question ‘Do singletons born after ART have a poorer cognitive developmental outcome at 3 years of age?’ We assess the implications of using different comparison groups, and discuss appropriate analytical approaches for the control of confounding and mediating variables.

METHODS

Data were drawn from the Millennium Cohort Study. Interviews captured sociodemographic, behavioural and pregnancy information. Developmental assessments conducted at age three included the British Ability Scales II Naming Vocabulary (BAS-NV) instrument. We compared ART infants (born after IVF or ICSI) to four comparison groups: a ‘matched’ group; a ‘subfertile’ group (time to conception >12 months); a ‘fertile’ group (time to conception <12 months); and an ‘any spontaneous conceptions’ group. Linear regression provided estimates of the difference in mean BAS-NV scores in the ART and comparison groups; both unadjusted estimates and those adjusted for confounding and mediating factors are presented.

RESULTS

In the unadjusted analyses, ART children gained significantly better BAS-NV test results than did the comparison group children. When converted to an estimate of developmental age gap, ART children were 2.5, 2.7, 3.6 and 4.5 months ahead of the ‘matched’, ‘subfertile’, ‘fertile’ and ‘spontaneous conception’ children, respectively. After adjusting for confounding and mediating factors, the differences were reduced, and were not statistically significant.

CONCLUSIONS

ART is not associated with poorer cognitive development at 3 years. We have highlighted methodological considerations for researchers planning to study the effect of infertility and ART on childhood outcomes.

Secondhand smoke (SHS) exposure is associated with circulating markers of inflammation and endothelial function in adult men and women

AIMS

Secondhand smoke (SHS) exposure is associated with elevated CHD risks. Yet the pathways through which this may operate have not been investigated in epidemiologic studies with objective SHS exposure measures and a wide range of CHD risk factors associated with active smoking. Therefore we investigate associations between SHS exposure and CHD risk factors, to clarify how SHS exposure may raise risk of CHD.

METHODS

Cross-sectional population-based study of 5029 men and women aged 59-80 years from primary care practices in Great Britain. Smoking, behavioural and demographic information was reported in questionnaires; nurses made physical measurements and took blood samples for analysis of serum cotinine and markers of inflammation, hemostasis and endothelial dysfunction.

RESULTS

Active cigarette smokers had lower albumin and higher triglycerides, CRP, IL-6, white cell count, fibrinogen, blood viscosity, factor VIII, VWF and t-PA than non-smokers. Among non-smokers, serum cotinine levels were independently positively associated with CRP, fibrinogen, factor VIII, VWF and t-PA and inversely associated with albumin, after adjustment for age, gender, social and behavioural factors. The differences in CRP, fibrinogen and albumin between cotinine < or =0.05 and >0.7 ng/ml were one-third to one half the size of differences between cotinine < or =0.05 ng/ml and current smokers, but were of similar magnitude for VWF and t-PA.

CONCLUSIONS

Endothelial, inflammatory and haemostatic markers related to CHD risk showed independent associations with SHS exposure in the same direction as those for active smoking. Results aid understanding of the associations between SHS exposure and elevated CHD risks.

Life-course socio-economic position, area deprivation and Type 2 diabetes: findings from the British Women's Heart and Health Study

OBJECTIVES

We examined whether area deprivation influenced risk of Type 2 diabetes, fasting blood glucose and insulin resistance over and above the effect of individual socio-economic position (SEP) measured across the life course.

METHODS

A cross-sectional analysis of 4286 women aged 60 to 79 years from 457 British electoral wards in 23 towns.

RESULTS

Area deprivation was positively associated with diagnosed [odds ratio (OR) 1.32, 95% confidence interval (CI) 1.13, 1.53, per quintile of area deprivation, n = 2895], but not undiagnosed Type 2 diabetes after adjustment for individual life-course SEP. This association was robust to adjustment for adult health behaviours and physiological risk factors. Insulin resistance [homeostasis model assessment (HOMA) score] increased by 1.90% (95% CI 0.01, 3.82, n = 2526) per quintile of area deprivation after adjustment for individual SEP, while fasting blood glucose increased by 0.69% (95% CI 0.16, 1.22, n = 2875) after adjustment for individual SEP.

CONCLUSIONS

Area level deprivation independently influences diagnosed Type 2 diabetes, insulin resistance and fasting blood glucose. Examination of more specific characteristics of places is needed to understand the mechanisms by which these effects arise.