Clinical experience of a tattoo application device

Introduction

The use of tattoos for radiation therapy (RT) treatment is common practice. The Comfort Marker 2.0 (CQ Medical, Iowa, USA) has been designed to apply tattoos with a controlled depth injection, potentially resulting in tattoos that fade over time. The aim of this study was to investigate the clinical implementation of the Comfort Marker 2.0 tattoo device including the patient experience and clinical workflow.

Methods

Patients undergoing RT treatment for breast cancer were invited to participate in this prospective pilot study. Patients completed a questionnaire after the planning session rating the level of pain experienced during tattoo application. Staff rated ease of use after each patient recording any feedback regarding the device. To evaluate tattoo fading, patients were followed up at 6 and 12 months after treatment to assess if tattoos could be visualised.

Results

Between August and December 2021, 50 breast cancer patients were recruited to the study. All patients received at least 3 tattoos. The majority of patients (80%) rated their pain between not hurting or hurting a little. More than 85% of staff indicated the device was easy or very easy to use. The three most common areas staff identified for improvement were: cordless device (39.1%), pen size (20.3%) and consumable rubbish (13.0%). All tattoos remained visible at the final follow up appointment.

Conclusion

Clinical implementation of the Comfort Marker tattoo device has been successful. Overall, patients found the process reasonably painless and staff found the device easy to use, providing a consistent result.

Correction to "Solvent-Free Nonthermal Destruction of PFAS Chemicals and PFAS in Sediment by Piezoelectric Ball Milling"

[This corrects the article DOI: 10.1021/acs.estlett.2c00902.].

History of Rectal Product Use and Country of Residence Influence Preference for Rectal Microbicide Dosage Forms Among Young Sexual and Gender Minorities: A Multi-country Trial Comparing Placebo Douche, Suppository, and Insert Products

The DESIRE Study (MTN-035) explored product preference among three placebo rectal microbicide (RM) formulations, a rectal douche (RD), a suppository, and an insert, among 210 sexually active transgender people and men who have sex with men in five counties: the United States, Peru, Thailand, South Africa, and Malawi. Participants used each product prior to receptive anal sex (RAS) for 1 month, following a randomly assigned sequence, then selected their preferred product via computer assisted self-interview. In-depth interviews examined reasons for preference. We compared product preference and prior product use by country to explore whether geographic location and experience with the similar products impacted preference. A majority in the United States (56%) and Peru (58%) and nearly half in South Africa (48%) preferred the douche. Most in Malawi (59%) preferred the suppository, while half in Thailand (50%) and nearly half in South Africa (47%) preferred the insert. Participants who preferred the douche described it as quick and easy, already routinized, and serving a dual purpose of cleansing and protecting. Those who preferred the insert found it small, portable, discreet, with quick dissolution. Those who preferred the suppository found the size and shape acceptable and liked the added lubrication it provided. Experience with product use varied by country. Participants with RD experience were significantly more likely to prefer the douche (p = 0.03). Diversifying availability of multiple RM dosage forms can increase uptake and improve HIV prevention efforts globally.

Deficiencies in cluster-2 ALA lipid flippases result in salicylic acid-dependent growth reductions

P4 ATPases (i.e., lipid flippases) are eukaryotic enzymes that transport lipids across membrane bilayers. In plants, P4 ATPases are named Aminophospholipid ATPases (ALAs) and are organized into five phylogenetic clusters. Here we generated an Arabidopsis mutant lacking all five cluster-2 ALAs (ala8/9/10/11/12), which is the most highly expressed ALA subgroup in vegetative tissues. Plants harboring the quintuple knockout (KO) show rosettes that are 2.2-fold smaller and display chlorotic lesions. A similar but less severe phenotype was observed in an ala10/11 double KO. The growth and lesion phenotypes of ala8/9/10/11/12 mutants were reversed by expressing a NahG transgene, which encodes an enzyme that degrades salicylic acid (SA). A role for SA in promoting the lesion phenotype was further supported by quantitative PCR assays showing increased mRNA abundance for an SA-biosynthesis gene ISOCHORISMATE SYNTHASE 1 (ICS1) and two SA-responsive genes PATHOGENESIS-RELATED GENE 1 (PR1) and PR2. Lesion phenotypes were also reversed by growing plants in liquid media containing either low calcium (~0.1 mM) or high nitrogen concentrations (~24 mM), which are conditions known to suppress SA-dependent autoimmunity. Yeast-based fluorescent lipid uptake assays revealed that ALA10 and ALA11 display overlapping substrate specificities, including the transport of LysoPC signaling lipids. Together, these results establish that the biochemical functions of ALA8-12 are at least partially overlapping, and that deficiencies in cluster-2 ALAs result in an SA-dependent autoimmunity phenotype that has not been observed for flippase mutants with deficiencies in other ALA clusters.

A conjoint experiment of three placebo rectal products used with receptive anal sex: results from MTN-035

INTRODUCTION

End-user perspectives are vital to the design of new biomedical HIV prevention products. Conjoint analysis can support the integration of end-user perspectives by examining their preferences of potential pre-exposure prophylaxis (PrEP) products. The Microbicides Trial Network (MTN) 035 protocol examined three placebo rectal dosage forms (insert, enema and suppository) that could deliver PrEP prior to receptive anal sex (RAS).

METHODS

Between April 2019 and July 2020, we enrolled 217 HIV-negative, cisgender men who have sex with men (MSM; n = 172; 79.3%) and transgender people (n = 47; 20.7%) ages 18-35 into a randomized cross-over trial across Malawi, Peru, South Africa, Thailand and the United States. Participants used each product prior to RAS over 4-week periods. Participants completed a conjoint experiment where they selected between random profiles using seven features (dosage form, timing of use before sex, side effects, duration of protection, effectiveness, frequency of use and need for a prescription).

RESULTS

Effectiveness was the strongest determinant of choice (30.4%), followed by modality (18.0%), potential side effects (17.2%), frequency of use (10.8%), duration of protection (10.4%), timing of use before sex (7.4%) and need for a prescription (5.9%). Relative utility scores indicated that the most desirable combination of attributes was a product with 95% efficacy, used 30 minutes before sex, offering a 3- to 5-day protection window, used weekly, having no side effects, in the form of an enema and available over-the-counter.

CONCLUSIONS

Choice in next-generation PrEP products is highly desired by MSM and transgender people, as no one-size-fits-all approach satisfies all the preferences. MTN-035 participants weighed product features differently, recognizing the need for diverse, behaviourally congruent biomedical options that fit the needs of intended end-users.

Maternal COVID-19 Vaccination and Prevention of Symptomatic Infection in Infants

BACKGROUND AND OBJECTIVES

Maternal vaccination may prevent infant coronavirus disease 2019 (COVID-19). We aimed to quantify protection against infection from maternally derived vaccine-induced antibodies in the first 6 months of an infant's life.

METHODS

Infants born to mothers vaccinated during pregnancy with 2 or 3 doses of a messenger RNA COVID-19 vaccine (nonboosted or boosted, respectively) had full-length spike (Spike) immunoglobulin G (IgG), pseudovirus 614D, and live virus D614G, and omicron BA.1 and BA.5 neutralizing antibody (nAb) titers measured at delivery. Infant severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection was determined by verified maternal-report and laboratory confirmation through prospective follow-up to 6 months of age between December 2021 and July 2022. The risk reduction for infection by dose group and antibody titer level was estimated in separate models.

RESULTS

Infants of boosted mothers (n = 204) had significantly higher Spike IgG, pseudovirus, and live nAb titers at delivery than infants of nonboosted mothers (n = 271), and were 56% less likely to acquire infection in the first 6 months (P = .03). Irrespective of boost, for each 10-fold increase in Spike IgG titer at delivery, the infant's risk of acquiring infection was reduced by 47% (95% confidence interval 8%-70%; P = .02). Similarly, a 10-fold increase in pseudovirus titers against Wuhan Spike, and live virus nAb titers against D614G, and omicron BA.1 and BA.5 at delivery were associated with a 30%, 46%, 56%, and 60% risk reduction, respectively.

CONCLUSIONS

Higher transplacental binding and nAb titers substantially reduced the risk of SARS-CoV-2 infection in infants, and a booster dose amplified protection during a period of omicron predominance. Until infants are age-eligible for vaccination, maternal vaccination provides passive protection against symptomatic infection during early infancy.

To degas or not to degas? The effectiveness of pharmaceuticals in reducing the impact of bowel volume variations during liver SBRT treatment

The indications for liver stereotactic body radiation therapy (SBRT) continue to expand in the management of liver cancer due to the improved rates of local control with acceptable normal tissue toxicity. Changes in internal anatomy, such as the bowel, may negatively impact the precision of treatment delivery of SBRT liver treatment by influencing daily image matching. Institutions have developed various approaches to promoting bowel volume consistency. One such strategy is the administration of pharmaceuticals. The administration of pharmaceuticals, such as Simethicone, has been adopted by the Princess Alexandra Hospital Radiation Oncology Department (ROPAIR) as a method to promote consistency in the amount of bowel gas observed in liver cancer patients. This case series examines a group of patients treated at ROPAIR with liver SBRT to determine whether current practices effectively reduce the impact of bowel volume variations for liver cancer patients. Initial observations from this hypothesis generating research suggest potential improved consistency of the small bowel's anatomical position for liver SBRT patients who were administered Simethicone (Bowel bag dice similarity coefficient - Simethicone group = 0.79-0.92, Standard group = 0.24-0.93). However, it appeared that this strategy alone may not be entirely effective achieving consistency in the amount of bowel gas present throughout the duration of treatment. Further investigation into the refinement of liver SBRT pre-treatment preparation is therefore recommended.

The first clinical implementation of real-time 6 degree-of-freedom image-guided radiotherapy for liver SABR patients

PURPOSE

Multiple survey results have identified a demand for improved motion management for liver cancer IGRT. Until now, real-time IGRT for liver has been the domain of dedicated and expensive cancer radiotherapy systems. The purpose of this study was to clinically implement and characterise the performance of a novel real-time 6 degree-of-freedom (DoF) IGRT system, Kilovoltage Intrafraction Monitoring (KIM) for liver SABR patients.

METHODS/MATERIALS

The KIM technology segmented gold fiducial markers in intra-fraction x-ray images as a surrogate for the liver tumour and converted the 2D segmented marker positions into a real-time 6DoF tumour position. Fifteen liver SABR patients were recruited and treated with KIM combined with external surrogate guidance at three radiotherapy centres in the TROG 17.03 LARK multi-institutional prospective clinical trial. Patients were either treated in breath-hold or in free breathing using the gating method. The KIM localisation accuracy and dosimetric accuracy achieved with KIM + external surrogate were measured and the results were compared to those with the estimated external surrogate alone.

RESULTS

The KIM localisation accuracy was 0.2±0.9 mm (left-right), 0.3±0.6 mm (superior-inferior) and 1.2±0.8 mm (anterior-posterior) for translations and -0.1◦±0.8◦ (left-right), 0.6◦±1.2◦ (superior-inferior) and 0.1◦±0.9◦ (anterior-posterior) for rotations. The cumulative dose to the GTV with KIM + external surrogate was always within 5% of the plan. In 2 out of 15 patients, >5% dose error would have occurred to the GTV and an organ-at-risk with external surrogate alone.

CONCLUSIONS

This work demonstrates that real-time 6DoF IGRT for liver can be implemented on standard radiotherapy systems to improve treatment accuracy and safety. The observations made during the treatments highlight the potential false assurance of using traditional external surrogates to assess tumour motion in patients and the need for ongoing improvement of IGRT technologies.

Effectiveness of the Modified Vaccinia Ankara Vaccine Against Mpox in Men Who Have Sex With Men: A Retrospective Cohort Analysis, Seattle, Washington

Background

Data on modified Vaccinia Ankara (MVA) vaccine effectiveness against mpox in real-world settings are limited.

Methods

We performed a retrospective cohort analysis using Cox proportional hazards regression to estimate the association between vaccination and laboratory-confirmed mpox incidence. Study subjects included all men who have sex with men seen in a sexual health clinic in Seattle, Washington, between 1 January 2020 and 31 December 2022. Subjects' receipt of vaccine and diagnosis with mpox were ascertained from public health vaccine registry and surveillance data. Analyses were adjusted for demographic factors, human immunodeficiency virus (HIV) status, and sexual risk behaviors.

Results

The incidence of mpox per 100 person-years was 8.83 among patients with 0 doses, 3.32 among patients with 1 dose, and 0.78 among patients with 2 doses of MVA vaccine. Mpox diagnosis was significantly associated with age category 30-39 and 40-51 years, HIV positivity, syphilis diagnosis in the prior year, >10 sex partners in the last year, and having a clinic visit in the last year. In the multivariate model adjusting for these factors, vaccine effectiveness was 81% for 1 dose and 83% for 2 doses.

Conclusions

These data support the effectiveness of the MVA vaccine-including a single dose of the vaccine-in preventing mpox disease and highlight the appropriateness of risk factor-based prioritization of immunization early in the epidemic. The durability of MVA vaccine-induced immunity is unknown, and at-risk persons should receive 2 doses of MVA.

Efficacy of Messenger RNA-1273 Against Severe Acute Respiratory Syndrome Coronavirus 2 Acquisition in Young Adults From March to December 2021

Background

The efficacy of messenger RNA (mRNA)-1273 against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is not well defined, particularly among young adults.

Methods

Adults aged 18-29 years with no known history of SARS-CoV-2 infection or prior vaccination for coronavirus disease 2019 (COVID-19) were recruited from 44 US sites from 24 March to 13 September 2021 and randomized 1:1 to immediate vaccination (receipt of 2 doses of mRNA-1273 vaccine at months 0 and 1) or the standard of care (receipt of COVID-19 vaccine). Randomized participants were followed up for SARS-CoV-2 infection measured by nasal swab testing and symptomatic COVID-19 measured by nasal swab testing plus symptom assessment and assessed for the primary efficacy outcome. A vaccine-declined observational group was also recruited from 16 June to 8 November 2021 and followed up for SARS-CoV-2 infection as specified for the randomized participants.

Results

The study enrolled 1149 in the randomized arms and 311 in the vaccine-declined group and collected >122 000 nasal swab samples. Based on randomized participants, the efficacy of 2 doses of mRNA-1273 vaccine against SARS-CoV-2 infection was 52.6% (95% confidence interval, -14.1% to 80.3%), with the majority of infections due to the Delta variant. Vaccine efficacy against symptomatic COVID-19 was 71.0% (95% confidence interval, -9.5% to 92.3%). Precision was limited owing to curtailed study enrollment and off-study vaccination censoring. The incidence of SARS-CoV-2 infection in the vaccine-declined group was 1.8 times higher than in the standard-of-care group.

Conclusions

mRNA-1273 vaccination reduced the incidence of SARS-CoV-2 infection from March to September 2021, but vaccination was only one factor influencing risk.

Clinical Trials Registration

NCT04811664.

Evolution of fatty acid taste in drosophilids

Comparative studies of related but ecologically distinct species can reveal how the nervous system evolves to drive behaviors that are particularly suited to certain environments. Drosophila melanogaster is a generalist that feeds and oviposits on most overripe fruits. A sibling species, D. sechellia, is an obligate specialist of Morinda citrifolia (noni) fruit, which is rich in fatty acids (FAs). To understand evolution of noni taste preference, we characterized behavioral and cellular responses to noni-associated FAs in three related drosophilids. We find that mixtures of sugar and noni FAs evoke strong aversion in the generalist species but not in D. sechellia. Surveys of taste sensory responses reveal noni FA- and species-specific differences in at least two mechanisms-bitter neuron activation and sweet neuron inhibition-that correlate with shifts in noni preference. Chemoreceptor mutant analysis in D. melanogaster predicts that multiple genetic changes account for evolution of gustatory preference in D. sechellia.

A Technology-Informed Approach to Clinical Trial Equity

PURPOSE/OBJECTIVE(S)

Despite efforts to increase participation of diverse communities in clinical trials, ethnic/racial minorities remain underrepresented. One such determinant may be lack of access to a comprehensive cancer center that conducts clinical research. Historically, our institution has had low accrual from rural regions further away from our cancer center, with Hispanic or Latino (HL) patients (pts) being especially underrepresented in our clinical research. In this study, we explored the impact of a clinical trial that allowed pts to receive chemotherapy (chemo) with their local oncologist. We hypothesize that allowing pts to receive chemo locally will lead to higher rates of enrollment from populations under-represented in clinical trials.

MATERIALS/METHODS

We conducted a study for pts with rectal cancer to undergo short-course radiation followed by 4 months of chemo with the option to pursue watch and wait if pts achieve a clinical complete response. Radiation was administered at our institution while pts could receive standard-of-care chemo closer to home with their local oncologist. For pts who received chemo locally, the research coordinator and co-investigators held video visits with the pts prior to each chemo infusion to review adverse events (AE), labs, and chemo dosing. We compared demographic data of pts on this trial with that of pts enrolled across all adult therapeutic oncologic clinical trials over the same time period at our institution. Distance to our institution was calculated based on pts' primary residence zip code. Protocol compliance with AE reporting for pts who received chemo locally was assessed by chart review.

RESULTS

Between May 2020 and January 2023, 24/35 enrolled pts completed both radiation and chemo on trial. 13/24 pts (54%) received chemo locally. Of the 24 pts, 16 were White (67%), 7 Asian (29%), 1 Native Hawaiian/ Pacific Islander (4%). Of all enrolled patients, 4 were HL (16.7%), compared to our institutional average of 16.5%. All enrolled HL pts received their chemo locally. The average distance traveled by non-HL pts from their home to our institution was 87.7 miles (range 5.1 - 308). In contrast, HL pts traveled an average of 147.8 miles (range 110 - 249), 68% further than their non-HL counterparts. There was 100% compliance with AE reporting among those pts who received their chemo locally.

CONCLUSION

Although the percentage of HL participation in our study was consistent with our institutional average, all HL pts enrolled on the trial received treatment locally and lived substantially further from our institution than non-HL. By allowing pts to receive this part of treatment locally, we provided pts who live further away an opportunity to engage in clinical research without the associated financial and time toxicities related with traveling for treatment. By decentralizing clinical trials and leveraging telemedicine, we can promote the participation of under-represented groups in clinical trials.

SARS-CoV-2 vaccination and infection in ozanimod-treated participants with relapsing multiple sclerosis

OBJECTIVE

To investigate the serologic response, predictors of response, and clinical outcomes associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination and infection in ozanimod-treated participants with relapsing multiple sclerosis (RMS) from DAYBREAK.

METHODS

DAYBREAK (ClinicalTrials.gov-NCT02576717), an open-label extension study of oral ozanimod 0.92 mg, enrolled participants aged 18-55 years with RMS who completed phase 1-3 ozanimod trials. Participants who were fully vaccinated against SARS-CoV-2 with mRNA or non-mRNA vaccines, were unvaccinated, and/or had COVID-19-related adverse events (AEs, with or without vaccination) and postvaccination serum samples were included (n = 288). Spike receptor binding domain (RBD) antibody levels (seroconversion: ≥0.8 U/mL) and serologic evidence of SARS-CoV-2 infection (nucleocapsid IgG: ≥1 U/mL) were assessed (Roche Elecsys/Cobas e411 platform).

RESULTS

In fully vaccinated participants (n = 148), spike RBD antibody seroconversion occurred in 90% (n = 98/109) of those without serologic evidence of prior SARS-CoV-2 exposure (100% [n = 80/80] seroconversion after mRNA vaccination) and in 100% (n = 39/39) of participants with serologic evidence of viral exposure. mRNA vaccination predicted higher spike RBD antibody levels, whereas absolute lymphocyte count (ALC), age, body mass index, and sex did not. COVID-19-related AEs were reported in 10% (n = 15/148) of fully vaccinated participants-all were nonserious and not severe; all participants recovered.

INTERPRETATION

Most ozanimod-treated participants with RMS mounted a serologic response to SARS-CoV-2 vaccination and infection, regardless of participant characteristics or ALC levels. In this analysis, all COVID-19-related AEs post-full vaccination in participants taking ozanimod were nonserious and not severe.

A Brief Nutrition Questionnaire for Children With Newly Diagnosed Type 1 Diabetes

Carbohydrate counting is an important component of type 1 diabetes management that is taught at the time of diagnosis. We implemented and validated a nutrition quiz to assess fundamental carbohydrate counting and nutrition knowledge in newly diagnosed patients. An interactive standard assessment for newly diagnosed type 1 diabetes patients was feasible and reliable to implement for patients and caregivers, but participants with public insurance scored lower overall. This assessment may help to identify nutrition knowledge gaps and provide opportunities for timely education, and providers should place additional focus on nutrition education for patients with public insurance.

Socio-demographic and clinical characteristics of migrants to Ireland presenting with a first episode of psychosis

OBJECTIVES

When presenting with a first episode of psychosis (FEP), migrants can have different demographic and clinical characteristics to the native-born population and this was examined in an Irish Early Intervention for Psychosis service.

METHODS

All cases of treated FEP from three local mental health services within a defined catchment area were included. Psychotic disorder diagnoses were determined using the SCID and symptom and functioning domains were measured using validated and reliable measures.

RESULTS

From a cohort of 612 people, 21.1% were first-generation migrants and there was no difference in the demographic characteristics, diagnoses, symptoms or functioning between migrants and those born in the Republic of Ireland, except that migrants from Africa presented with less insight. Of those admitted, 48.6% of admissions for migrants were involuntary compared to 37.7% for the native-born population (p = 0.09).

CONCLUSIONS

First-generation migrants now make up a significant proportion of people presenting with a FEP to an Irish EI for psychosis service. Broadly the demographic and clinical characteristics of migrants and those born in the Republic of Ireland are similar, except for less insight in migrants from Africa and a trend for a higher proportion of involuntary admissions in the total migrant group.

Flexor tenotomies for the treatment of bilateral wrist contracture after traumatic brain injury: A case report

Traumatic brain injuries have the potential to cause the development of long-term complications. We aim to show that the use of flexor tenotomies in the treatment of flexion contractures following traumatic brain injury is a viable solution.

Stepwise Add-On and Endotype-informed Targeted Combination Therapy to Treat Obstructive Sleep Apnea: A Proof-of-Concept Study

Rationale: Oral appliance therapy (OAT) is an effective treatment for many people with obstructive sleep apnea (OSA). However, OSA pathogenesis is heterogeneous, and, in ∼50% of cases, OAT does not fully control OSA. Objectives: This study aimed to control OSA in individuals with an incomplete response to OAT alone by using additional targeted therapies informed by OSA endotype characterization. Methods: Twenty-three people with OSA (apnea-hypopnea index [AHI], 41 ± 19 events/h) not fully resolved (AHI, >10 events/h) with OAT alone were prospectively recruited. OSA endotypes were characterized pretherapy during a detailed physiology study night. Initially, an expiratory positive airway pressure (EPAP) valve and supine avoidance device therapy were added to target the impaired anatomical endotype. Those with residual OSA (AHI, >10 events/h) then received one or more nonanatomical interventions based on endotype characterization. This included O2 (4 L/min) to reduce high loop gain (unstable respiratory control) and 80/5 mg atomoxetine-oxybutynin to increase pharyngeal muscle activity. Finally, if required, OAT was combined with EPAP and continuous positive airway pressure (CPAP) therapy. Results: Twenty participants completed the study. OSA was successfully controlled (AHI, <10 events/h) with combination therapy in all but one participant (17 of 20 without CPAP). OAT plus EPAP and supine avoidance therapy treated OSA in 10 (50%) participants. OSA was controlled in five (25%) participants with the addition of O2 therapy, one with atomoxetine-oxybutynin, and one required O2 plus atomoxetine-oxybutynin. Two participants required CPAP for their OSA, and another was CPAP intolerant. Conclusions: These novel prospective findings highlight the potential of precision medicine to inform targeted combination therapy to treat OSA. Clinical trial registered with the Australian New Zealand Clinical Trials Registry (ACTRN12618001995268).

An evaluation of isocentre shift magnitude and treatment site on image-guided radiation therapy online decision analysis times

INTRODUCTION

The ability to capture more anatomical detail in cone-beam computed tomography (CBCT) imaging compared to kilovoltage (kV) and megavoltage (MV) imaging, has seen a documented shift towards CBCT image verification and staff adopting more extensive image analysis processes. The timeframe associated with assessing online CBCT images, termed the online decision analysis time, if drawn out, can affect treatment efficiency and accuracy. This study aimed to determine the current CBCT online decision analysis time at Radiation Oncology Princess Alexandra Ipswich Road (ROPAIR) and investigate the influence of isocentre shift magnitude and treatment site considerations on this timeframe.

METHODS

This retrospective clinical audit collected treatment parameters from 202 CBCT images over 2 treatment days. The online decision analysis time was calculated by subtracting the image acquisition timestamp from the image verification shift application timestamp. The quantitative data were analysed using mean, standard deviation, and range in the following categories: all CBCTs, CBCTs grouped by isocentre shift magnitude and CBCTs grouped by treatment site. Content analysis was performed on staff comments made during image analysis.

RESULTS

The average online decision analysis time was 2:37 ± 1:28 min. On average approximately, head and neck, spine and extremity treatment sites measured 1 min, pelvis, breast, and chest measured 2-3 min with abdomen measuring 4 min. Common categories reported in staff comments included anatomical changes, repositioning, and organs at risk size.

CONCLUSION

The results provide baseline online decision analysis times. Further refinement is required to determine if the image match method, treatment site considerations, and rotational discrepancies influence this timeframe.

Innate and Conditioned Taste Processing in Drosophila

Peripheral detection of tastants allows animals to detect the dietary value of food and its potential toxicity. Many tastants such as sugars and fats elicit reflexive appetitive responses, whereas other foods such as quinine induce aversion. The relative value of food can change in accordance with an animal's internal state and prior experience. Understanding the neural and genetic bases for the detection and response to tastants, as well as how these behaviors change with experience, is central to sensory neuroscience. The presentation of attractive tastants to the proboscis or legs of the fruit fly Drosophila melanogaster induces a robust and reflexive proboscis-extension response (PER). This quantifiable response can be used to study the receptors underlying taste detection, the neural circuits involved in sensory processing, and the musculature required for a simple feeding behavior. Furthermore, we have developed a memory assay pairing appetitive and bitter tastants, resulting in aversive taste conditioning, in which the PER response to attractive tastants is diminished. Unlike many memory assays, this assay does not require specialized equipment and can be readily implemented in teaching and research laboratories. Here, we introduce protocols for studying the PER feeding response and aversive taste memory in Drosophila.

Measurement of Taste Memory in Drosophila

The ability to modify behavior as a result of previous experience allows an organism to adapt to changes in its environment. Even innate behaviors, like feeding initiation, can change if previously associated with a noxious stimulus. Here, we describe a taste memory assay pairing appetitive and bitter tastants, resulting in aversive taste conditioning. By training a fly to associate sweet sucrose applied to the tarsus with bitter quinine applied to the proboscis, flies quickly learn to suppress the reflexive proboscis extension to sucrose, providing a bioassay for behavioral and molecular plasticity. This single-fly taste memory assay may be applied to adult Drosophila of any genetic background and allows for interrogation of the neural circuitry and molecular processes encoding memories while simultaneously measuring behavior. Unlike many other memory assays, this system requires few custom components, and therefore can be easily established in laboratories with minimal expertise in the study of fly behavior.

Measurement of Reflexive Feeding Response in Drosophila

The ability to distinguish between food sources that are good and provide nutrients and those that are potentially dangerous is crucial to the survival of an organism. Here, we describe a taste assay that measures the reflexive feeding response to a given tastant. To examine taste preference for a soluble compound, an appetitive tastant is applied to the proboscis, and the proportion of proboscis extensions are recorded. This single-fly assay may be applied to adult Drosophila of any genetic background and facilities examination of the neural circuitry and molecular processes encoding the reflexive taste response. Furthermore, this assay requires few custom components and therefore can be easily established in laboratories with minimal expertise in the study of fly behavior.

Health & Housing in Delaware:: Matching Medicaid Claims and Encounters and the Community Management Information System Databases

This study draws upon data from two databases: claims and encounters that were reimbursed by the state's Division of Medicaid and Medical Assistance (DMMA) and the Homeless Management Information System (HMIS) database that collects homeless services data on individuals experiencing homelessness. Records from both sets are matched to identify 838 adults who both experienced homelessness and were Medicaid eligible in 2019, and to select, through propensity score matching, an equal set of control observations who were similarly Medicaid-eligible but had no record of homelessness. Outcomes are compared based upon scores on the Charlson Elixhauser Comorbidity index, incidence of substance use disorder, inpatient, emergency department, and outpatient visits, and inpatient, emergency department, and outpatient costs. Using ordinary least squares regression models, we estimate homelessness (as indicated by use of homeless services) to be associated with excess costs of $4,611 (non-chronic homelessness) to $5,218 (chronic homelessness) per person over the course of 2019, compared to similar Medicaid enrollees who were housed.

A randomized trial of safety, acceptability and adherence of three rectal microbicide placebo formulations among young sexual and gender minorities who engage in receptive anal intercourse (MTN-035)

Efforts to develop a range of HIV prevention products that can serve as behaviorally congruent viable alternatives to consistent condom use and oral pre-exposure prophylaxis (PrEP) remain crucial. MTN-035 was a randomized crossover trial seeking to evaluate the safety, acceptability, and adherence to three placebo modalities (insert, suppository, enema) prior to receptive anal intercourse (RAI). If participants had no RAI in a week, they were asked to use their assigned product without sex. We hypothesized that the modalities would be acceptable and safe for use prior to RAI, and that participants would report high adherence given their behavioral congruence with cleansing practices (e.g., douches and/or enemas) and their existing use to deliver medications (e.g., suppositories; fast-dissolving inserts) via the rectum. Participants (N = 217) were sexual and gender minorities enrolled in five different countries (Malawi, Peru, South Africa, Thailand, and the United States of America). Mean age was 24.9 years (range 18-35 years). 204 adverse events were reported by 98 participants (45.2%); 37 (18.1%) were deemed related to the study products. The proportion of participants reporting "high acceptability" was 72% (95%CI: 65% - 78%) for inserts, 66% (95%CI: 59% - 73%) for suppositories, and 73% (95%CI: 66% - 79%) for enemas. The proportion of participants reporting fully adherent per protocol (i.e., at least one use per week) was 75% (95%CI: 69% - 81%) for inserts, 74% (95%CI: 68% - 80%) for suppositories, and 83% (95%CI: 77% - 88%) for enemas. Participants fully adherent per RAI-act was similar among the three products: insert (n = 99; 58.9%), suppository (n = 101; 58.0%) and enema (n = 107; 58.8%). The efficacy and effectiveness of emerging HIV prevention drug depends on safe and acceptable delivery modalities that are easy to use consistently. Our findings demonstrate the safety and acceptability of, and adherence to, enemas, inserts, and suppositories as potential modalities through which to deliver a rectal microbicide.

Precision nephrology identified tumor necrosis factor activation variability in minimal change disease and focal segmental glomerulosclerosis

The diagnosis of nephrotic syndrome relies on clinical presentation and descriptive patterns of injury on kidney biopsies, but not specific to underlying pathobiology. Consequently, there are variable rates of progression and response to therapy within diagnoses. Here, an unbiased transcriptomic-driven approach was used to identify molecular pathways which are shared by subgroups of patients with either minimal change disease (MCD) or focal segmental glomerulosclerosis (FSGS). Kidney tissue transcriptomic profile-based clustering identified three patient subgroups with shared molecular signatures across independent, North American, European, and African cohorts. One subgroup had significantly greater disease progression (Hazard Ratio 5.2) which persisted after adjusting for diagnosis and clinical measures (Hazard Ratio 3.8). Inclusion in this subgroup was retained even when clustering was limited to those with less than 25% interstitial fibrosis. The molecular profile of this subgroup was largely consistent with tumor necrosis factor (TNF) pathway activation. Two TNF pathway urine markers were identified, tissue inhibitor of metalloproteinases-1 (TIMP-1) and monocyte chemoattractant protein-1 (MCP-1), that could be used to predict an individual's TNF pathway activation score. Kidney organoids and single-nucleus RNA-sequencing of participant kidney biopsies, validated TNF-dependent increases in pathway activation score, transcript and protein levels of TIMP-1 and MCP-1, in resident kidney cells. Thus, molecular profiling identified a subgroup of patients with either MCD or FSGS who shared kidney TNF pathway activation and poor outcomes. A clinical trial testing targeted therapies in patients selected using urinary markers of TNF pathway activation is ongoing.

Solvent-Free Nonthermal Destruction of PFAS Chemicals and PFAS in Sediment by Piezoelectric Ball Milling

Studies on the destruction of solid per- and polyfluoroalkyl substances (PFAS) chemicals and PFAS-laden solid wastes significantly lag behind the urgent social demand. There is a great need to develop novel treatment processes that can destroy nonaqueous PFAS at ambient temperatures and pressures. In this study, we develop a piezoelectric-material-assisted ball milling (PZM-BM) process built on the principle that ball collisions during milling can activate PZMs to generate ∼kV potentials for PFAS destruction in the absence of solvents. Using boron nitride (BN), a typical PZM, as an example, we successfully demonstrate the complete destruction and near-quantitative (∼100%) defluorination of solid PFOS and perfluorooctanoic acid (PFOA) after a 2 h treatment. This process was also used to treat PFAS-contaminated sediment. Approximately 80% of 21 targeted PFAS were destroyed after 6 h of treatment. The reaction mechanisms were determined to be a combination of piezo-electrochemical oxidation of PFAS and fluorination of BN. The PZM-BM process demonstrates many potential advantages, as the degradation of diverse PFAS is independent of functional group and chain configurations and does not require caustic chemicals, heating, or pressurization. This pioneering study lays the groundwork for optimizing PZM-BM to treat various PFAS-laden solid wastes.

Threaded intramedullary headless nail fixation for fractures requiring carpometacarpal stabilization

Carpometacarpal (CMC) fracture-dislocations are uncommon hand injuries, with few studies available regarding their treatment. The current operative treatment options include fixation with K-wires, mini-screws, or plates, though there is no standardized approach because of varying injury patterns and complications associated with each device. The INnate™ threaded intramedullary nail is a relatively novel treatment option that has shown promise in metacarpal fracture fixation by facilitating faster mobilization and recovery with enhanced rotational stability and no compression to prevent fracture displacement and shortening. This study assesses the efficacy of the INnate™ nail for fixation of CMC fracture-dislocations of the second through fifth joints. Nine patients with fourteen CMC fracture-dislocations treated with the INnate™ nail at the University Medical Center between 2019 and 2021 were enrolled in the study. We evaluated postoperative outcomes in terms of pain, total active range of motion (TAM), and return to normal activities. Of the nine patients, seven returned for follow-up. The average time to radiographic union was 11.5 weeks. At final follow-up, no patient reported pain (n = 6). Four patients had 100% TAM, 1 had 95% TAM, and 1 had 25% TAM. The average percentage of normal activity resumed was 84.0% (n = 5). No significant complications were reported. One patient had a dorsal spanning plate; hence, we were unable to record outcomes measures regarding the CMC injury. An additional patient had diminished ROM of the injured hand, but his last follow-up was only 1 month postop. Our pilot data overall suggest that the INnate™ threaded intramedullary nail has the potential to improve treatment algorithms for CMC fracture-dislocations.

Enhancing untargeted metabolomics using metadata-based source annotation

Human untargeted metabolomics studies annotate only ~10% of molecular features. We introduce reference-data-driven analysis to match metabolomics tandem mass spectrometry (MS/MS) data against metadata-annotated source data as a pseudo-MS/MS reference library. Applying this approach to food source data, we show that it increases MS/MS spectral usage 5.1-fold over conventional structural MS/MS library matches and allows empirical assessment of dietary patterns from untargeted data.

Research demographics of Australian medical radiation practitioners

INTRODUCTION

Advancement within the Medical Radiation Profession has seen an increased need for Medical Radiation Practitioners (MRPs) to develop research skills to provide and access relevant and accurate information to maintain best practice. The aim of this study was to ascertain the current research demographics of Australian Medical Radiation Practitioners (MRPs), determine perceived barriers to participating in research and to establish needs-based initiatives to support MRPs in undertaking research.

METHODS

A quantitative and qualitative cross-sectional survey of Australian MRPs using an electronic survey tool was distributed between November and December 2020. Participants were recruited via an invitation email sent to Australian Society of Medical Imaging and Radiation Therapy (ASMIRT) members. A chain-referral sampling technique was adopted for data collection.

RESULTS

A total of 431 participants responded to the survey, representing 2.3% of Australian MRPs. The majority of respondents had a bachelor's degree or higher (71.9%) with 8.4% having postgraduate research qualifications (PhD- 3.2%; Professional Doctorate- 0.7%; Masters- 4.5%). Of the respondents, 15.4% plan to undertake postgraduate research in the future, with 68.2% having no plans for postgraduate research. Respondents identified lack of time (47.0%), lack of interest (33.4%), cost (24.2%) and workplace support (23.9%) as contributing factors for not undertaking postgraduate research.

CONCLUSION

The number of MRPs who have been awarded or will be awarded a postgraduate degree has increased over recent decades. However, many still indicate a lack of interest in being actively involved in research. Targeted support mechanisms should be implemented to address perceived or real barriers to continue to grow research capacity within the profession.

Learning from the implementation of a quality improvement intervention in Australian general practice: a qualitative analysis of participants views of a CVD preventive care project

Background

Quality improvement collaborative projects aim to reduce gaps in clinical care provided in the healthcare system. This study evaluated the experience of key participants from a Quality Improvement Program (QPulse) that focussed on cardiovascular disease assessment and management. The study goal was to identify critical barriers and factors enabling the implementation of a quality improvement framework in Australian general practice.

Methods

This qualitative study examined in-depth semi-structured interviews with nineteen purposively-selected participants of the QPulse project. Interviewees were from General Practices and the local supporting organisation, a Primary Health Network. Interviews were analysed thematically using the Complex Systems Improvement framework, focusing on five domains: strategy, culture, structure, workforce and technology.

Results

Despite reported engagement with QPulse objectives to improve cardiovascular preventive care, implementation barriers associated with this program were considerable for all interviewees. Adoption of the quality improvement process was reliant on designated leadership, aligned practice culture, organised systems for clear communication, tailored education and utilisation of clinical audit and review processes. Rather than practice size and location, practice culture and governance alignment to quality improvement predicted successful implementation. Financial incentives for both general practice and the Primary Health Network were also identified as prerequisites for systematised quality improvement projects in the future, along with individualised support and education for each general practice. Technology was both an enabler and a barrier, and the Primary Health Network was seen as key to assisting the successful utilisation of the available tools.

Conclusions

Implementation of Quality Improvement programs remains a potential tool for achieving better health outcomes in General Practice. However, enablers such as financial incentives, individualised education and support provided via a supporting organisation, and IT tools and support are crucial if the full potential of Quality Improvement programs are to be realised in the Australian healthcare setting.

Trial registration

ACTRN12615000108516, UTN U1111-1163–7995.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-022-01692-0.

EPID-12. REGIONAL VARIATIONS IN THE INCIDENCE OF BRAIN GLIOMA IN ADULTS IN ALABAMA

BACKGROUND

Gliomas are the most common primary brain tumor in adults in the US with an annual age-adjusted incidence rate (AAA-IR) of 4.67 to 5.73 per 100,000 persons. There are several sources of carcinogenic contaminants in northeast Alabama and western Georgia with the Coosa River serving as the region’s primary water source. We aimed to examine the incidence rate of glioma, as well as tumor characteristics and overall survival, in northeast Alabama compared to the rest of the state.

METHODS

This is a retrospective cohort study using the UAB Neuro-Oncology clinic database including adult patients ( ≥ 20 years at diagnosis) with histologically confirmed diagnosis of glioma (ICD10: 71.9) residing in the state of Alabama at the time of diagnosis between January 2015 and December 2019. We calculated AAA-IR among residents in counties intersected by the Coosa River in northeast Alabama (exposed group) compared to the rest of the state (non-exposed group). The electronic medical records of the participants were reviewed for patient demographics, insurance status, tumor grade and molecular markers, as well as the vital status. The overall survival was graphically examined using Kaplan-Meier.

RESULTS

A total of 660 patients were included in this study (528 non-exposed, and 132 exposed). The AAA-IR of glioma in the exposed group was 4.76 per 100,000 persons vs 3.14 per 100,000 persons in the non-exposed group with a 50 % higher incidence rate of glioma in the exposed group (RR = 1.50; 95% CI, 1.22-1.89). There was no statistically significant difference between the two groups with respect to age at diagnosis, sex, race, surgery type, tumor grade, IDH status, or overall survival.

CONCLUSIONS

Our findings indicate a higher incidence of glioma in northeast Alabama. Future geospatial and population-based epidemiological investigations are needed to identify possible regional environmental risk factors and examine temporal sequence.

Use of community engagement interventions to improve child immunisation in low-income and middle-income countries: a systematic review and meta-analysis

OBJECTIVE

To support evidence informed decision-making, we systematically examine the effectiveness and cost-effectiveness of community engagement interventions on routine childhood immunisation outcomes in low-income and middle-income countries (LMICs) and identify contextual, design and implementation features associated with effectiveness.

DESIGN

Mixed-methods systematic review and meta-analysis.

DATA SOURCES

21 databases of academic and grey literature and 12 additional websites were searched in May 2019 and May 2020.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

We included experimental and quasi-experimental impact evaluations of community engagement interventions considering outcomes related to routine child immunisation in LMICs. No language, publication type, or date restrictions were imposed.

DATA EXTRACTION AND SYNTHESIS

Two independent researchers extracted summary data from published reports and appraised quantitative risk of bias using adapted Cochrane tools. Random effects meta-analysis was used to examine effects on the primary outcome, full immunisation coverage.

RESULTS

Our search identified over 43 000 studies and 61 were eligible for analysis. The average pooled effect of community engagement interventions on full immunisation coverage was standardised mean difference 0.14 (95% CI 0.06 to 0.23, I2=94.46). The most common source of risk to the quality of evidence (risk of bias) was outcome reporting bias: most studies used caregiver-reported measures of vaccinations received by a child in the absence or incompleteness of immunisation cards. Reasons consistently cited for intervention success include appropriate intervention design, including building in community engagement features; addressing common contextual barriers of immunisation and leveraging facilitators; and accounting for existing implementation constraints. The median intervention cost per treated child per vaccine dose (excluding the cost of vaccines) to increase absolute immunisation coverage by one percent was US$3.68.

CONCLUSION

Community engagement interventions are successful in improving outcomes related to routine child immunisation. The findings are robust to exclusion of studies assessed as high risk of bias.

Coelenterazine sulfotransferase from Renilla muelleri

The luciferin sulfokinase (coelenterazine sulfotransferase) of Renilla was previously reported to activate the storage form, luciferyl sulfate (coelenterazine sulfate) to luciferin (coelenterazine), the substrate for the luciferase bioluminescence reaction. The gene coding for the coelenterazine sulfotransferase has not been identified. Here we used a combined proteomic/transcriptomic approach to identify and clone the sulfotransferase cDNA. Multiple isoforms of coelenterazine sulfotransferase were identified from the anthozoan Renilla muelleri by intersecting its transcriptome with the LC-MS/MS derived peptide sequences of coelenterazine sulfotransferase purified from Renilla. Two of the isoforms were expressed in E. coli, purified, and partially characterized. The encoded enzymes display sulfotransferase activity that is comparable to that of the native sulfotransferase isolated from Renilla reniformis that was reported in 1970. The bioluminescent assay for sensitive detection of 3'-phosphoadenosine 5'-phosphate (PAP) using the recombinant sulfotransferase is demonstrated.

Efficacy and safety of a single dose of casirivimab and imdevimab for the prevention of COVID-19 over an 8-month period: a randomised, double-blind, placebo-controlled trial

BACKGROUND

There is an unmet need for COVID-19 prevention in patient populations who have not mounted or are not expected to mount an adequate immune response to complete COVID-19 vaccination. We previously reported that a single subcutaneous 1200 mg dose of the monoclonal antibody combination casirivimab and imdevimab (CAS + IMD) prevented symptomatic SARS-CoV-2 infections by 81·4% in generally healthy household contacts of SARS-CoV-2-infected individuals over a 1-month efficacy assessment period. Here we present additional results, including the 7-month follow-up period (months 2-8), providing additional insights about the potential for efficacy in pre-exposure prophylaxis settings.

METHODS

This was a randomised, double-blind, placebo-controlled trial done in the USA, Romania, and Moldova in 2020-2021, before the emergence of omicron (B.1.1.529) and omicron-lineage variants. Uninfected and unvaccinated household contacts of infected individuals, judged by the investigator to be in good health, were randomly assigned (1:1) to receive 1200 mg CAS + IMD or placebo by subcutaneous injection according to a central randomisation scheme provided by an interactive web response system; randomisation was stratified per site by the test results of a local diagnostic assay for SARS-CoV-2 and age group at baseline. COVID-19 vaccines were prohibited before randomisation, but participants were allowed to receive COVID-19 vaccination during the follow-up period. Participants who developed COVID-19 symptoms during the follow-up period underwent RT-PCR testing. Prespecified endpoints included the proportion of previously uninfected and baseline-seronegative participants (seronegative-modified full analysis set) who had RT-PCR-confirmed COVID-19 in the follow-up period (post-hoc for the timepoints of months 2-5 and 6-8 only) and underwent seroconversion (ie, became seropositive, considered a proxy for any SARS-CoV-2 infections [symptomatic and asymptomatic]; prespecified up to day 57, post-hoc for all timepoints thereafter). We also assessed the incidence of treatment-emergent adverse events. This study is registered with ClinicalTrials.gov, NCT04452318.

FINDINGS

From July 13, 2020, to Oct 4, 2021, 2317 participants who were RT-PCR-negative for SARS-CoV-2 were randomly assigned, of whom 1683 (841 assigned to CAS + IMD and 842 assigned to placebo) were seronegative at baseline. During the entirety of the 8-month study, CAS + IMD reduced the risk of COVID-19 by 81·2% (nominal p<0·0001) versus placebo (prespecified analysis). During the 7-month follow-up period, protection was greatest during months 2-5, with a 100% relative risk reduction in COVID-19 (nominal p<0·0001; post-hoc analysis). Efficacy waned during months 6-8 (post-hoc analysis). Seroconversion occurred in 38 (4·5%) of 841 participants in the CAS + IMD group and in 181 (21·5%) of 842 in the placebo group during the 8-month study (79·0% relative risk reduction vs placebo; nominal p<0·0001). Six participants in the placebo group were hospitalised due to COVID-19 versus none who received CAS + IMD. Serious treatment-emergent adverse events (including COVID-19) were reported in 24 (1·7%) of 1439 participants receiving CAS + IMD and in 23 (1·6%) of 1428 receiving placebo. Five deaths were reported, none of which were due to COVID-19 or related to the study drugs.

INTERPRETATION

CAS + IMD is not authorised in any US region as of Jan 24, 2022, because data show that CAS + IMD is not active against omicron-lineage variants. In this study, done before the emergence of omicron-lineage variants, a single subcutaneous 1200 mg dose of CAS + IMD protected against COVID-19 for up to 5 months of community exposure to susceptible strains of SARS-CoV-2 in the pre-exposure prophylaxis setting, in addition to the post-exposure prophylaxis setting that was previously shown.

FUNDING

Regeneron Pharmaceuticals, F Hoffmann-La Roche, US National Institute of Allergy and Infectious Diseases, US National Institutes of Health.

Synergistic Use of Novel Technological Advances in Burn Care Significantly Reduces Hospital Length of Stay Below Predicted: A Case Series

Length of stay is an important metric in healthcare systems, primarily because it reflects the cost of care provided. In the US, as in many countries, inpatient hospital stays are significantly more expensive than outpatient care across all healthcare conditions [1], so earlier discharge and transition to outpatient care is crucial to help control the ever-increasing cost of healthcare. In burn patients, length of stay has traditionally been estimated at 1 day per 1% total body surface area of burn. This estimation was first described in a round table discussion in 1986.[2] However, since that time there has been significant evolution in the quality of care available to burn patients, in both the operating room and ICU. The use of new harvesting techniques, synthetic dermal substitution, and autologous epidermal skin cell suspension are allowing large, deep burns to be excised and covered in much quicker time frames than historically were possible. Examples include the skin harvesting and wound debridement device for grafting and excision, biodegradable temporizing matrix as a fully synthetic dermal template, and regenerative epidermal suspension concerning cell harvesting. Although these modalities can all be used separately, we believe that using them in conjunction has allowed us to shorten the length of stay in patients with severe partial and full-thickness burns. We present an initial case series of 3 patients with anticipated hospital lengths of stay of 54.5, 55, and 51 days, who were ready for discharge in 37, 35, and 43 days, respectively.

Use of community engagement interventions to improve child immunisation in low- and middle-income countries: A systematic review and meta-analysis

Immunisation is one of the most cost-effective interventions to prevent and control life-threatening infectious diseases. Nonetheless, rates of routine vaccination of children in low- and middle-income countries (LMICs) are strikingly low or stagnant. In 2019, an estimated 19.7 million infants did not receive routine immunisations. Community engagement interventions are increasingly being emphasised in international and national policy frameworks as a means to improve immunisation coverage and reach marginalised communities. This systematic review examines the effectiveness and cost-effectiveness of community engagement interventions on outcomes related to childhood immunisation in LMICs and identifies contextual, design and implementation features that may be associated with effectiveness. We identified 61 quantitative and mixed methods impact evaluations and 47 associated qualitative studies related to community engagement interventions for inclusion in the reteview. For cost-effectiveness analysis 14 of the 61 studies had the needed combination of cost and effectiveness data. The 61 included impact evaluations were concentrated in South Asia and Sub-Saharan Africa and spread across 19 LMICs. The review found that community engagement interventions had a small but significant, positive effect on all primary immunisation outcomes related to coverage and their timeliness. The findings are robust to exclusion of studies assessed as high risk of bias. Qualitative evidence indicates appropriate intervention design, including building in community engagement features; addressing common contextual barriers of immunisation and leveraging facilitators; and accounting for existing implementation constraints and practicalities on the ground are consistently cited as reasons for intervention success. Among the studies for which we were able to calculate cost-effectiveness, we find that the median non-vaccine cost per dose of intervention to increase immunisation coverage by 1% was US $3.68. Given the broad scope of the review in terms of interventions and outcomes, there is significant variation in findings. Among the various types of community engagement interventions, those that involve creation of community buy-in or development of new cadres of community-based structures were found to have consistent positive effect on more primary vaccination coverage outcomes than if the engagement is limited to the design or delivery of an intervention or is a combination of the various types. The evidence base for sub-group analysis for female children was sparse (only two studies) and the effect on coverage of both full immunisation and third dose of diphtheria pertussis tetanus for this group was insignificant.

Tetraplegic obstructive sleep apnoea patients dilate the airway similarly to able-bodied obstructive sleep apnoea patients

Context/objective: Obstructive sleep apnoea (OSA) develops soon after cervical spinal cord injury (SCI) at rates higher than the general population, but the mechanisms are not understood. This study aimed to determine whether OSA in SCI is associated with altered pharyngeal muscle dilatory mechanics during quiet breathing, as has been observed in the non-SCI injured with obstructive sleep apnoea.Design: Cross sectional imaging study.Setting: Medical research institute.Participants: Eight cervical SCI patients with OSA were recruited and compared to 13 able-bodied OSA patients and 12 able-bodied healthy controls of similar age and BMI.Interventions and outcome measures: 3T MRI scans of upper airway anatomy and tagged-MRI to characterize airway muscle motion during quiet breathing were collected for analysis.Results: Considerable variation in the patterns of inspiratory airway muscle motion was observed in the SCI group, with some participants exhibiting large inspiratory airway dilatory motions, and others exhibiting counterproductive narrowing during inspiration. These patterns were not dissimilar to those observed in the able-bodied OSA participants. The increase in airway cross-sectional area of able-bodied control participants was proportional to increase in BMI, and a similar, but not significant, relationship was present in all groups.Conclusion: Despite the limited sample size, these data suggest that SCI OSA patients have heterogeneous pharyngeal dilator muscle responses to the negative pressures occurring during inspiration but, as a group, appear to be more similar to able-bodied OSA patients than healthy controls of similar age and BMI. This may reflect altered pharyngeal pressure reflex responses in at least some people with SCI.

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.

O-305 SPIRIT long-term extension study: two-year efficacy and safety of relugolix combination therapy in women with endometriosis-associated pain

Study question

To assess the long-term efficacy and safety of once-daily Relugolix combination therapy (Relugolix-CT) in the treatment of endometriosis-associated pain over two years.

Summary answer

Relugolix-CT previously demonstrated sustained improvement of endometriosis-associated pain and was generally well tolerated over 52 weeks. Research is ongoing: two-year results will be reported.

What is known already

SPIRIT 1&2 were international, Phase 3, replicate, randomized, double-blind, placebo-controlled studies of Relugolix-CT (relugolix 40mg, estradiol 1mg, norethisterone acetate 0.5mg) in premenopausal women with moderate-to-severe endometriosis-associated pain, which were followed by the open-label, 80-week, long-term extension. 52-week results showed sustained improvement in dysmenorrhea and non-menstrual pelvic pain (NMPP) with 84.8% and 73.3% of responders, respectively. Efficacy was evidenced by reductions in dysmenorrhea (82.8%,) NMPP (62.9%,) proportion of women using opioids, and improvements in function. Relugolix-CT was generally well tolerated. Bone mineral density (BMD) assessment showed minimal initial decline (&lt;1%) from baseline followed by stabilization from Week 24 to 52.

Study design, size, duration

Women who completed the 24-week pivotal studies (SPIRIT 1&2) were eligible to enroll in an 80-week open-label, single-arm, long-term extension study of safety and efficacy, representing up to 104 weeks of treatment in total. All women enrolled in the long-term extension study received once-daily oral Relugolix-CT. Analyses were performed based on the initial randomized treatment groups in pivotal studies: Relugolix-CT, delayed Relugolix-CT (relugolix 40mg alone for 12 weeks, then Relugolix-CT for 12 weeks), or placebo.

Participants/materials, setting, methods

Primary endpoints are proportion of dysmenorrhea and NMPP responders at Weeks 52 and 104 based on daily Numerical Rating Scale (NRS) scores (0=no pain, 10=worst pain imaginable) and analgesic use. Responders are women who achieved a predefined, clinically meaningful reduction from baseline in NRS score and no increase in analgesic use. Secondary efficacy endpoints include change in Endometriosis Health Profile-30 pain domain scores, use of opioids/analgesics. Safety endpoints include adverse events and BMD (percent change).

Main results and the role of chance

Of 1251 randomized patients in SPIRIT 1&2, 1044 (83.4%) completed the pivotal studies; 802 (76.8%) enrolled in the long-term extension, and 681 (84.9%) completed 52 weeks of treatment. Baseline demographics and clinical characteristics of the long-term extension population were consistent with those of the pivotal study population. The study remains ongoing at the time of writing. Efficacy and safety data with Relugolix-CT for up to Week 104, will be presented at the scientific session of the 2022 congress.

Limitations, reasons for caution

The study was conducted as an open-label study without a control group over the 80 weeks of the extension period.

Wider implications of the findings

Through 52 weeks of treatment, Relugolix-CT demonstrated sustained improvement of dysmenorrhea, NMPP, function, and reduced need for opiates in women with endometriosis-associated pain. No new safety concerns were identified, and treatment was associated with BMD loss &lt;1%. Data from 104 weeks of treatment will be presented at the 2022 congress.

Trial registration number

NCT03654274

Acute toxicity and patient-reported outcomes in anal canal cancer: results of a pilot study

INTRODUCTION

Anal canal cancer (ACC) is uncommon. The gold standard of care is chemoradiotherapy treatment. However, this treatment is associated with considerable acute and late side effects. The aim of this pilot study was to evaluate acute toxicity and patient-reported outcomes (PRO) in these patients from planning to 3 months after treatment.

METHODS

Sixteen patients were recruited to this prospective observational study from March 2015 to December 2017. All patients received volumetric modulated arc therapy (VMAT) in 30#. Toxicity data were graded by a Radiation Oncologist using the Common Terminology Criteria for Adverse Effects (CTCAE) version 4 at planning, weekly during treatment, 6-week and 3-month post-treatment. PRO data were collected using the EORTC QLQ C30 and CR29 questionnaires completed by patients at planning, mid and end treatment and 3-month post-treatment.

RESULTS

The majority of toxicity and PRO items peaked in severity at the end of treatment (week 6). Skin was the only item where >50% of patients had ≥ grade 2 toxicity at any point with 75% having ≥ grade 2 at week 6. Patient-reported embarrassment significantly increased over time (P < 0.001). No meaningful relationships were found between PRO and CTCAE results.

CONCLUSION

After reaching their maximum severity at the end of treatment, the majority of toxicity and PRO items approached baseline levels by 3-month post-treatment. The results of this study suggest that PROs are an important complementary tool to CTCAE and provide greater understanding of patients' perception of treatment side effects.

970 FRAILTY IS INVERSELY CORRELATED WITH SERUM ALBUMIN IN ACUTE HIP FRACTURE

Introduction

Frailty and sarcopenia have been shown to significantly increase the risk of falls, traumatic hip fractures and all-cause mortality in the elderly. The assessment of frailty using a validated clinical frailty scale such as that proposed by Rockwood et al., therefore, continues to remain an important step in determining post-operative prognosis in patients undergoing hip fracture surgery. The purpose of this study was to examine the relationship between frailty and serum albumin—an independent biochemical predictor of survival in hip fracture patients (1).

Method

This retrospective cross-sectional study analysed 190 patients, aged above 60 years, admitted to Queen’s Hospital Burton (QHB) between the 1st January and 28th December 2019 with a newly diagnosed hip fracture. Pre-operative serum albumin levels (g/L) and Rockwood clinical frailty scores (rCFS) were recorded from electronic medical records (EMR). Using the SPSS 27 statistical package, Pearson’s correlation co-efficient and linear regression analysis were carried out using these variables.

Results

A total of 190 patients were included in the study (57 male, 133 female). Mean patient age was 82.2 ± 8.47 years. More than 50% of patients had a Rockwood CFS ≥5. Mean serum albumin (g/L) was 37.3 ± 6.56. A statistically significant inverse correlation was demonstrated between pre-operative serum albumin levels and Rockwood CFS (r = −0.243, p &lt; 0.001).

Conclusion

This study showed how serum albumin, a negative acute phase reactant and marker of chronic malnutrition, is inversely associated with frailty in hip fracture patients and the important role of Rockwood CFS and pre-operative serum albumin levels in the prognostication of hip fractures in the elderly. References 1) Bohl D, Shen M, Hannon C, Fillingham Y, Darrith B, Della Valle C. Serum Albumin Predicts Survival and Postoperative Course Following Surgery for Geriatric Hip Fracture. Journal of Bone and Joint Surgery. 2017;99(24):2110–2,118.

The relationship between mandibular advancement, tongue movement, and treatment outcome in obstructive sleep apnea

Study Objectives

To characterize how mandibular advancement enlarges the upper airway via posterior tongue advancement in people with obstructive sleep apnea (OSA) and whether this is associated with mandibular advancement splint (MAS) treatment outcome.

Methods

One-hundred and one untreated people with OSA underwent a 3T magnetic resonance (MRI) scan. Dynamic mid-sagittal posterior tongue and mandible movements during passive jaw advancement were measured with tagged MRI. Upper airway cross-sectional areas were measured with the mandible in a neutral position and advanced to 70% of maximum advancement. Treatment outcome was determined after a minimum of 9 weeks of therapy.

Results

Seventy-one participants completed the study: 33 were responders (AHI&lt;5 or AHI≤10 events/hr with &gt;50% AHI reduction), 11 were partial responders (&gt;50% AHI reduction but AHI&gt;10 events/hr), and 27 nonresponders (AHI reduction&lt;50% and AHI≥10 events/hr). Responders had the greatest naso- and oropharyngeal tongue anterior movement (0.40 ± 0.08 and 0.47 ± 0.13 mm, respectively) and oropharyngeal cross-sectional area enlargement (6.41 ± 2.12%) per millimeter of mandibular advancement. A multivariate model that included tongue movement and percentage of airway enlargement per millimeter of mandibular advancement along with baseline AHI correctly classified 69.2% (5-fold cross-validated 62.5%, n = 39) of participants in response categories when the jaw was advanced in the range that would usually be regarded as sufficient for clinical efficacy (&gt; 4 mm). In comparison, a model using only baseline AHI correctly classified 50.0% of patients (5-fold cross-validated 52.5%, n = 40).

Conclusions

Tongue advancement and upper airway enlargement with mandibular advancement in conjunction with baseline AHI improve treatment response categorization to a satisfactory level (69.2%, 5-fold cross-validated 62.5%).