Aquatic connectivity: challenges and solutions in a changing climate

The challenge of managing aquatic connectivity in a changing climate is exacerbated in the presence of additional anthropogenic stressors, social factors, and economic drivers. Here we discuss these issues in the context of structural and functional connectivity for aquatic biodiversity, specifically fish, in both the freshwater and marine realms. We posit that adaptive management strategies that consider shifting baselines and the socio-ecological implications of climate change will be required to achieve management objectives. The role of renewable energy expansion, particularly hydropower, is critically examined for its impact on connectivity. We advocate for strategic spatial planning that incorporates nature-positive solutions, ensuring climate mitigation efforts are harmonized with biodiversity conservation. We underscore the urgency of integrating robust scientific modelling with stakeholder values to define clear, adaptive management objectives. Finally, we call for innovative monitoring and predictive decision-making tools to navigate the uncertainties inherent in a changing climate, with the goal of ensuring the resilience and sustainability of aquatic ecosystems.

Evaluating patient perspectives of endovascular created arteriovenous fistulas for dialysis access (EndoAVF)

BACKGROUND

Patient reported experience measures are contemporary quality indicators that focus on evaluation of healthcare delivery processes. While surgical arteriovenous fistulas (otherAVF) are preferred for haemodialysis vascular access, fears about surgery and complications often result in refusal/delays. A new technique of endovascular arteriovenous fistula creation (EndoAVF) has been developed and as part of it's ongoing introduction into our unit, the patient perspective was felt critical to its evaluation. The Vascular Access Questionnaire (VAQ) provides a mechanism for identifying and scoring perceptions in this setting.

METHOD

Patients who had previously undergone EndoAVF formation were approached to undertake the VAQ as part of a service evaluation of their experience. In addition to the components of the VAQ, data questions relating to the patient's perception of their access were gathered. Results were compared with a matched historical cohort of surgically created fistulas (otherAVF) patients.

RESULTS

Patient satisfaction and self-reported ease of use with EndoAVF were high. Overall VAQ scores were similar between the EndoAVF and the surgically created cohort. Functionally, there was no significant difference in perception of their fistula by patients, irrespective of them being created surgically or radiologically.

CONCLUSION

Although numbers in this report are small limiting exploration of preserved inherent heterogeneity, we provide a useful initial patient reported experience and perspectives on comparative functional use of radiologically and surgically created AVFs. As real world experience gathers, future larger cohorts with adequate sampling may allow exploration of patient reported experiences and outcome measures.

Editorial: Clinical Education Research and Dental Public Health

The central premise of Dental Public Health (DPH) is striving to change the oral health of the nation for the better and as Leo Buscaglia, the 19th century historian, elegantly stated; 'Change is the end result of all true learning'. The two primary goals of DPH; promoting oral health and preventing oral disease, have at their very heart the education of the general public and patients. Similarly, in seeking to recruit, train and retain an effective dental workforce, with a focus on oral health-related quality of life improvements, close attention to the education of those practitioners is imperative.

Minimizing Sample Failure Rates for Challenging Clinical Tumor Samples

Identification of somatic variants in cancer by high-throughput sequencing has become common clinical practice, largely because many of these variants may be predictive biomarkers for targeted therapies. However, there can be high sample quality control (QC) failure rates for some tests that prevent the return of results. Stem-loop inhibition mediated amplification (SLIMamp) is a patented technology that has been incorporated into commercially available cancer next-generation sequencing testing kits. The claimed advantage is that these kits can interrogate challenging formalin-fixed, paraffin-embedded tissue samples with low tumor purity, poor-quality DNA, and/or low-input DNA, resulting in a high sample QC pass rate. The study aimed to substantiate that claim using Pillar Biosciences oncoReveal Solid Tumor Panel. Forty-eight samples that had failed one or more preanalytical QC sample parameters for whole-exome sequencing from the Australian Translational Genomics Center's ISO15189-accredited diagnostic genomics laboratory were acquired. XING Genomic Services performed an exploratory data analysis to characterize the samples and then tested the samples in their ISO15189-accredited laboratory. Clinical reports could be generated for 37 (77%) samples, of which 29 (60%) contained clinically actionable or significant variants that would not otherwise have been identified. Eleven samples were deemed unreportable, and the sequencing data were likely dominated by artifacts. A novel postsequencing QC metric was developed that can discriminate between clinically reportable and unreportable samples.

The immediate effect of water treadmill walking exercise on overground in-hand walking locomotion in the horse

Water treadmill (WT) exercise is frequently used for training/rehabilitation of horses but the effect of WT exercise on short-term movement patterns is yet to be investigated. The objective of this study was to determine the immediate effect of WT exercise on overground limb and back kinematics. Six horses (mean ± standard deviation., age 15±6.5 years, height 164±2 cm and weight 539±37 kg) walked twice in a straight line, led from both sides, before and after a standardised WT exercise session (19 min duration; speed 1.6 m/s; water depths: 0.0/7.5/21.0/32.0/47.0 cm) on a flat concrete surface. Horses wore five inertial-measurement-units to determine poll/wither/pelvic displacement, and 10 anatomical markers to determine fetlock/carpal/tarsal joint angles at specific stride points. Degree of mediolateral tarsal oscillation during stance was graded. Wilcoxon-signed-rank tests were used to investigate differences between pre- and post-WT exercise for each variable. Post-WT exercise, there was a significant decrease in hindlimb fetlock extension at mid-stance compared with pre-WT exercise. No significant changes in movement patterns of the poll/withers/pelvis were detected post-WT exercise. In all horses there was greater mediolateral tarsal oscillation during the stance phase of the stride post-WT exercise, which could relate to muscle fatigue. The results suggest that a 19-min WT session has an effect on immediately-following overground in-hand walking locomotion patterns. Further work is required to determine the duration of this effect, and how different WT speeds and water depths affect locomotion patterns.

Evaluate the safety and efficacy of dura sealant patch in reducing cerebrospinal fluid leakage following elective cranial surgery (ENCASE II): study protocol for a randomized, two-arm, multicenter trial

BACKGROUND

Cerebrospinal fluid (CSF) leakage is a frequent and challenging complication in neurosurgery, especially in the posterior fossa, with a prevalence of 8%. It is associated with substantial morbidity and increased healthcare costs. A novel dural sealant patch (LIQOSEAL) was developed for watertight dural closure. The objective of this study is to clinically assess the safety and effectiveness of LIQOSEAL as a means of reducing intra- as well as postoperative CSF leakage in patients undergoing elective posterior fossa intradural surgery with a dural closure procedure compared to the best currently available dural sealants.

METHODS

We will conduct a two-arm, randomized controlled, multicenter study with a 90-day follow-up. A total of 228 patients will be enrolled in 19 sites, of which 114 will receive LIQOSEAL and 114 an FDA-approved PEG sealant. The composite primary endpoint is defined as intraoperative CSF leakage at PEEP 20 cm H₂O, percutaneous CSF leakage within 90 days of, wound infection within 90 days of or pseudomeningocele of more than 20cc on MRI or requiring intervention. We hypothesize that the primary endpoint will not be reached by more than 10 patients (9%) in the investigational arm, which will demonstrate non-inferiority of LIQOSEAL compared to control.

DISCUSSION

This trial will evaluate whether LIQOSEAL is non-inferior to control as a means of reducing CSF leakage and safety TRIAL REGISTRATION: ClinicalTrials.gov NCT04086550 . Registered on 11 September 2019.

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.

Reducing pre-analytical sample QC failure rates for cancer molecular genetic assays with SLIMamp technology

e15034

Background: Identification of somatic variants in cancer by high-throughput sequencing has become common clinical practice largely because many of these variants may be predictive biomarkers for targeted therapies. However, there can be high sample QC failure rates for some assays (sometimes up to 40%), preventing the return of results that may affect patient treatment decisions. Pillar Biosciences has incorporated their patented SLIMamp technology into commercially available cancer NGS testing kits with the claim that these kits can successfully interrogate challenging formalin-fixed paraffin-embedded tissue (FFPET) samples with low tumor purity, poor DNA quality, and/or low input DNA, resulting in a high sample QC pass rate. The aim of this study was to substantiate that claim using Pillar’s amplicon-based oncoReveal Solid Tumor Panel. Methods: We acquired 48 tumor samples that had failed one or more pre-analytical QC sample parameters for whole exome sequencing (WES) from ATGC’s ISO15189 accredited diagnostic genomics laboratory. XING Genomic Services performed an exploratory data analysis using our pre-analytical QC assays to characterise the samples and then sequenced the samples in our ISO15189 accredited laboratory using the validated oncoReveal Solid Tumor Panel. Results: We were able to achieve high sequencing coverage (>3000X) for all 48 samples and explored the determinants of sample “success”. We were able to generate clinical reports for 45 samples (94%), of which 38 (79%) contained clinically actionable or significant variants that would not have otherwise been identified. Ten samples had a higher number of total variant calls with over-representation of C>T transitions representing stochastically-amplified, formalin-induced artefacts in samples with very low input template DNA. Of these, 7 cases had reportable variants and 3 were deemed unreportable. We demonstrated that DNA integrity is the major determinant of success even in samples with low input DNA or low tumor purity and were able to further refine pre-analytical and post-analytical QC metrics to better identify samples with poor quality DNA that can be sequenced reliably. Conclusions: In this study, we showed that the Pillar Biosciences oncoReveal Solid Tumor Panel, which uses SLIMam technology, was able to generate reliable, interpretable results for 94% of samples that failed pre-analytical QC for WES, substantiating Pillar’s claim.

POS1510-HPR IDENTIFYING THEORY-DRIVEN THERAPEUTIC CONTENT FOR A SMARTPHONE APP FOR THE SELF-MANAGEMENT OF SJOGREN’S SYNDROME

Background

Technology-supported self-management of long-term conditions (e.g., through the use of smartphone apps) provides easily accessible support. However, currently there are no systematically developed, evidence-based smartphone apps for Sjogren’s Syndrome. We took an agile approach to developing such an app: instead of starting “from scratch” we deemed it more efficient and scientifically sound to digitalise relevant components from existing, evidence-based interventions for the symptoms of SS.

Objectives

The present study was desk research, which aimed to deconstruct interventions and resources down to units of theory-driven therapeutic content, to then select from, for the inclusion in an app for the self-management of SS.

Methods

We used deductive and inductive content analysis, to identify behaviour change techniques (BCTs)[1] and behaviour change methods (BCMs)[2]. The materials consisted of published fatigue, pain and sleep interventions (e.g. [3] and [4]), as well as private-facing clinician notes and public facing resources on self-management from Versus Arthritis and the UK NHS’s CRESTA fatigue clinic.

Results

We found 38 active ingredients from the BCT Taxonomy and the BCM intervention mapping approach frameworks, of which at least 14 were overlapping in function. Importantly we noted that BCTs and BCMs were formulated in various ways pertaining to how the interventions should be delivered (form of delivery-FoD) [5]. Further qualitative analysis revealed 6 themes relating to FoD. The theme Interactivity involved presenting information in ways that would involve the reader in actively responding to it in various ways. The theme Reflection was about engaging the recipient in in-depth consideration of their own experience with symptoms and self-management processes. The theme Validation encompassed all the ways in which the illness and management experience was socialised and normalised to remove stigma and sense of isolation. The theme Treatment Rationale was about providing an a-priory transparent, sound, and compelling justification for the self-management actions required from recipients. The theme Discourse pertained to how information was being communicated, e.g., with language that is warm, simple, assertive, etc. Finally, the theme Approaches was about the therapeutic origins of the active ingredients, e.g. Second and Third Wave CBT. These themes indicate that meaningful therapeutic content is missing from commonly used theoretical frameworks for the development of interventions.

Conclusion

Our findings indicate that meaningful therapeutic content is missing from commonly used theoretical frameworks for the development of interventions.

Interventions should not just include BCTs and methods, but also active ingredients pertaining to how these techniques and methods are delivered, i.e., active ingredients relating to FoD. Reflection deserves particular attention in self-management, as it is unclear empirically in apps what is the most effective way to produce the most useful psychological and behavioural insight, and for whom. FoD is a component of intervention development that requires systematising and the present findings can contribute to such efforts.

References

[1]S. Michie, et al. Annals of Behav Med 2013. 46:1

[2]G. Kok, et al. Health Psych Rev 2016. 10:3

[3]S. Hewlett, et al. Ann. Rheum. Dis 2019. 78: 4.

[4]S. D. Kyle, et al. Sleep Med Rev 2015. 23.

[5]S. U. Dombrowski, et al. Brit. J Health Psych 2016. 21: 4

Acknowledgements

I have no acknowledgments to declare.

Disclosure of Interests

None declared

Observation of diffuse scattering in scanning helium microscopy

By studying well defined geometries (microspheres) in scanning helium microscopy (SHeM) the default scattering distribution for technological surfaces in SHeM is found to be diffuse and approximately cosine.

Arrhythmia patterns in patients with COVID-19 infection during and post hospitalization detected via a patch-based mobile cardiac telemetry system

Background

Coronavirus infection (COVID-19) is the cause of the current world-wide pandemic. Cardiovascular complications occur in 20–30% of patients with COVID-19 infection including myocardial injury and arrhythmias. Current understanding of specific arrhythmia type and frequency is limited. In response to COVID-19 pandemic and overwhelmed hospital critical care and telemetry recourses, patch-based cardiac monitoring system received emergency Food and Drug Administration (FDA) approval for inpatient monitoring. A patch-based cardiac telemetry system has been shown to be useful for patient management during the COVID-19 pandemic and provides detailed analysis of cardiac rhythms.

Purpose

To analyze arrhythmia type and frequency in patients with COVID-19 infection, identifying arrhythmia patterns over time during hospitalization and after discharge.

Methods

A prospective cohort study during the COVID-19 pandemic was performed. We included patients hospitalized with COVID-19 infection who had a patch-based mobile telemetry device placed for cardiac monitoring. A quantitative analysis including type, frequency and duration of detected arrhythmias was performed at the end of the monitoring period.

Results

A total of 103 patients hospitalized with COVID-19 diagnosis underwent monitoring. Quantitative reports for 59 patients were available for analysis, among those 59% were males, median age 65 (IQR 56–76) yrs. Mean wear time was 6.8±5.0 days. Arrhythmias were detected in 72.9% of patients. Majority of arrhythmias were SVT (59.3% of patients) and AF (22.0%). Episodes of AF duration >30 min were detected in 12 patients. New onset AF was noted in 15.0% of patients and was significantly associated with age (OR 1.4 for 5 yrs difference; 95% CI 1.01–2.05). Brady arrhythmias (2nd degree, 3rd degree AV bock, pause≥3 seconds) were seen in 18.7% of patients. Arrhythmias were consistently detected throughout the monitoring period in 52.9%-89.5% of patients daily (Figure 1). In 9 patients who were discharged with continued patch monitoring, 3 patients (33.3%) had arrhythmic events during their outpatient monitoring period.

Conclusion

A majority of patients hospitalized with COVID-19 infection had arrhythmias detected by patch cardiac monitor. Arrhythmias were observed throughout hospitalization with a consistent daily frequency. Patients continued to exhibit cardiac arrhythmias after hospital discharge of a type similar to that seen during hospitalization. New onset AF often occurred and was associated with older age. Inpatient application of a patch cardiac telemetry with continued monitoring as outpatient is feasible and effective in detecting occult arrhythmias in patients with COVID-19 infection.

Funding Acknowledgement

Type of funding sources: None.

An online Sexual Health and Rehabilitation eClinic (TrueNTH SHAReClinic) for prostate cancer patients: a feasibility study

Purpose

The primary objective was to determine the feasibility of implementing the TrueNTH SHAReClinic as a pan-Canadian sexual health and rehabilitation intervention for patients treated for localized prostate cancer.

Methods

The feasibility study was designed to evaluate the accessibility and acceptability of the intervention. Participants from five institutions across Canada were enrolled to attend one pre-treatment and five follow-up online clinic visits over 1 year following their prostate cancer (PC) treatment.

Results

Sixty-five patients were enrolled in the intervention. Website analytics revealed that 71% completed the intervention in its entirety, including the educational modules, with an additional 10% completing more than half of the intervention. Five thousand eighty-three views of the educational modules were made along with 654 views of the health library items. Over 1500 messages were exchanged between participants and their sexual health coaches. At 12 months, the intervention received an overall average participant rating of 4.1 out of 5 on a single item satisfaction measure.

Conclusion

Results support the TrueNTH SHAReClinic as highly acceptable to participants as defined by intervention adherence and engagement. The TrueNTH SHAReClinic demonstrated promise for being a feasible and potentially resource-efficient approach to effectively improving the sexual well-being of patients after PC treatment.

Low-energy electron ionization mass spectrometer for efficient detection of low mass species

The design of a high-efficiency mass spectrometer is described, aimed at residual gas detection of low mass species using low-energy electron impact, with particular applications in helium atom microscopy and atomic or molecular scattering. The instrument consists of an extended ionization volume, where electrons emitted from a hot filament are confined using a solenoidal magnetic field to give a high ionization probability. Electron space charge is used to confine and extract the gas ions formed, which are then passed through a magnetic sector mass filter before reaching an ion counter. The design and implementation of each of the major components are described in turn, followed by the overall performance of the detector in terms of mass separation, detection efficiency, time response, and background count rates. The linearity of response with emission current and magnetic field is discussed. The detection efficiency for helium is very high, reaching as much as 0.5%, with a time constant of (198 ± 6) ms and a background signal equivalent to an incoming helium flux of (8.7 ± 0.2) × 10⁶ s^-1.

OP0281 EXCESS GIANT CELL ARTERITIS CASES ARE ASSOCIATED WITH PEAKS IN COVID-19 PREVALENCE

Background:

Immediately following the first wave of the COVID-19 pandemic, the number of giant cell arteritis (GCA) diagnoses noticeably increased at the Royal National Hospital for Rheumatic Diseases in Bath, UK. Furthermore, there was an increase in the proportion of patients with visual complications [1]. The finding supports the viral hypothesis of GCA aetiopathogenesis as previously described [2]. This not only has ramifications for understanding the underlying disease mechanisms in GCA but also has implications for the provision of local GCA services which may have already be affected by the pandemic.

Objectives:

The objective of the study was to estimate the incidence of giant cell arteritis during the COVID-19 pandemic years of 2020 – 2021 and compare it to 2019 data. Given that there have now been two distinct peaks of COVID-19 as reflected by hospital admissions of COVID-19-positive patients this has allowed us to investigate if there is a temporal relationship between the prevalence of COVID-19 and the incidence of GCA.

Methods:

The incidence of GCA was calculated by assessing emailed referrals to the GCA service and the hospital electronic medical records to identity positive cases from 2019 to the current date. Local COVID-19 prevalence was estimated by measuring the number of hospital beds taken up by COVID-19 positive patients, available publicly in a UK Government COVID-19 dataset [3].

Results:

There were 61 (95% Poisson distribution confidence interval [CI] 47 - 78) probable or definite GCA diagnoses made in 2020 compared to 28 (CI 19 – 40) in 2019 (Figure 1). This is an excess of 33 cases in 2020, or an increase in 118%. Given that 41% of the hospital’s catchment population is over 50, this equates to an annual incidence rate of 13.7 per 100,000 in 2019 and 29.8 per 100,000 in 2020. This compares to a previously estimated regional incidence rate of 21.6 per 100,000 for the South West of the UK [4].

Figure 1.

Prevalence of hospital COVID-19 and incidence of GCA (2019 – 2021). Graph showing the number of hospital beds occupied by COVID-19-positive patients in 2020 – 2021 (blue circles), number of daily GCA diagnoses in 2020 – 2021 (red circles), and previous GCA diagnoses in 2019 (green circles). The broken lines represent moving averages with a period of 7 days for COVID-19 cases and 28 days for GCA diagnoses.

A peak in COVID-19-positive inpatients was seen on 10th April 2020 with a corresponding peak of GCA diagnoses on 29th May 2020, giving a lag period of approximately 6 weeks between these peaks (Figure 1).

Conclusion:

The incidence of GCA in Bath was significantly increased in 2020 compared to 2019. This may be the result of the widespread infection of the local population with the COVID-19 virus as a precipitating factor. Possible mechanisms include, but are not limited to, endothelial disruption by the virus, immune system priming towards T helper cell type 1 (Th1) cellular immunity and/or activation of the monocyte-macrophage system. More work is currently underway to assess the causal relationship between the two diseases.

There was a lag period of 6 weeks between the peak during the first wave of the pandemic and the rise in GCA cases. We shall be closely monitoring the number of referrals that follow the current wave of the pandemic.

References:

[1]Luther R, Skeoch S, Pauling JD, et al. Increased number of cases of giant cell arteritis and higher rates of ophthalmic involvement during the era of COVID-19. Rheumatol Adv Pract 2020;4:1–4. doi:10.1093/rap/rkaa067

[2]Russo MG, Waxman J, Abdoh AA, et al. Correlation between infection and the onset of the giant cell (temporal) arteritis syndrome. Arthritis Rheum 1995;38:374–80. doi:10.1002/art.1780380312

[3]England PH. GOV.UK Coronavirus (COVID-19) in the UK. 2021.https://coronavirus.data.gov.uk/details/download (accessed 25 Jan 2021).

[4]Smeeth L, Cook C, Hall AJ. Incidence of diagnosed polymyalgia rheumatica and temporal arteritis in the United Kingdom, 1990-2001. Ann Rheum Dis 2006;65:1093–8. doi:10.1136/ard.2005.046912

Disclosure of Interests:

Ben Mulhearn Speakers bureau: Novartis UK, 2019, Grant/research support from: Chugai, 2019, Jessica Ellis: None declared, Sarah Skeoch: None declared, John Pauling: None declared, Sarah Tansley: None declared

Meta-epidemiological study of publication integrity, and quality of conduct and reporting of randomized trials included in a systematic review of low back pain

OBJECTIVE

To comprehensively describe the quality of conduct, reporting, and publication integrity characteristics for all trials included in a large Cochrane review, comparing those published by presumed predatory publishers with those published by nonpredatory publishers.

DESIGN

Cross-sectional meta-epidemiological study.

STUDY SELECTION

Two hundred seventy-nine studies (25,704 participants) eligible for the recent update of the "Exercise therapy for chronic low back pain" Cochrane review were included.

DATA EXTRACTION

Study and manuscript characteristics, including predatory publication status and other quality and integrity characteristics were extracted along with treatment effect.

RESULTS

Nine percent of trials included were in presumed predatory publications; 12% in the period since 2010. We found frequency of other concerning characteristics to range from low (eg, plagiarism, 5%) to common (eg, lack of evidence of trial registration or protocol publication [75%]; insufficient sample size [84%]) in included studies. Studies published by presumed predatory publishers consistently had inferior conduct, reporting and publication integrity characteristics. Presumed predatory publication was associated with missing conflict of interest statement (OR 7.6, 95% CI 3.0-19.1), inadequate follow-up duration (OR 11.2, 95% CI 3.7-33.7), incomplete study methods (OR 12.1, 95% CI 2.8-52.2) and baseline reporting (OR 4.3, 95% CI 1.6-11.7), and high risk of bias (OR 2.7, 95% CI 1.2-6.3). All (100%) presumed predatory publications were missing trial registrations (vs. 72%) and had inadequate sample sizes (vs. 82%). Trials published in presumed predatory journals did not appear to have inflated effect sizes.

CONCLUSIONS

Predatory publishers pose a distinct challenge to the consumption and synthesis of randomized controlled trials. More work is needed in other clinical areas to understand the potential impact of randomized controlled trials published in predatory publications, and as a result, the potential impact on evidence from systematic reviews that include these studies.

Six-year experience of detection and investigation of possible Middle East Respiratory Syndrome coronavirus cases, England, 2012-2018

OBJECTIVES

Surveillance for Middle East Respiratory Syndrome (MERS) has been undertaken in the UK since September 2012. This study describes the surveillance outcomes in England from 2012 to 2018.

STUDY DESIGN

This was a descriptive study using surveillance data.

METHODS

Local health protection teams in England report possible MERS cases to the National Infection Service with clinical and laboratory data.

RESULTS

A total of 1301 possible MERS cases were identified in the study period. Five cases were laboratory-confirmed MERS. The majority of cases had travelled to Saudi Arabia (56.7%) and United Arab Emirates (25.9%). Fifty-four percent of cases were men and 43.7% were women. The majority of cases (65.1%) were aged 45 years or older. The number of tests increased in the period after Hajj each year. Laboratory-confirmed alternative diagnoses were available for 513 (39.4%) cases; influenza was the most common virus detected (n = 255, 52.4%).

CONCLUSIONS

Our study highlights the importance of differential diagnosis of influenza and other respiratory pathogens and early influenza antiviral treatment.

Implementing a social network intervention: can the context for its workability be created? A quasi-ethnographic study

Background

Policy makers and researchers recognise the challenges of implementing evidence-based interventions into routine practice. The process of implementation is particularly complex in local community environments. In such settings, the dynamic nature of the wider contextual factors needs to be considered in addition to capturing interactions between the type of intervention and the site of implementation throughout the process. This study sought to examine how networks and network formation influence the implementation of a self-management support intervention in a community setting.

Methods

An ethnographically informed approach was taken. Data collection involved obtaining and analysing documents relevant to implementation (i.e. business plan and health reports), observations of meetings and engagement events over a 28-month period and 1:1 interviews with implementation-network members. Data analysis utilised the adaptive theory approach and drew upon the Consolidated Framework for Implementation Research. The paper presents the implementation events in chronological order to illustrate the evolution of the implementation process.

Results

The implementation-network was configured from the provider-network and commissioning-network. The configuration of the implementation-network was influenced by both the alignment between the political landscape and the intervention, and also the intervention having a robust evidence base. At the outset of implementation, the network achieved stability as members were agreed on roles and responsibilities. The stability of the implementation-network was threatened as progress slowed. However, with a period of reflection and evaluation, and with a flexible and resilient network, implementation was able to progress.

Conclusions

Resilience and creativity of all involved in the implementation in community settings is required to engage with a process which is complex, dynamic, and fraught with obstacles. An implementation-network is required to be resilient and flexible in order to adapt to the dynamic nature of community contexts. Of particular importance is understanding the demands of the various network elements, and there is a requirement to pause for "reflection and evaluation" in order to modify the implementation process as a result of learning.

The role of seagrass vegetation and local environmental conditions in shaping benthic bacterial and macroinvertebrate communities in a tropical coastal lagoon

We investigated the influence of seagrass canopies on the benthic biodiversity of bacteria and macroinvertebrates in a Red Sea tropical lagoon. Changes in abundance, number of taxa and assemblage structure were analyzed in response to seagrass densities (low, SLD; high, SHD; seagrasses with algae, SA), and compared with unvegetated sediments. Biological and environmental variables were examined in these four habitats (hereafter called treatments), both in the underlaying sediments and overlaying waters, at three randomly picked locations in March 2017. Differences between treatments were more apparent in the benthic habitat than in the overlaying waters. The presence of vegetation (more than its cover) and changes in sedimentary features (grain size and metals) at local scales influenced the observed biological patterns, particularly for macroinvertebrates. Of note, the highest percentage of exclusive macroinvertebrate taxa (18% of the gamma diversity) was observed in the SHD treatment peaking in the SA for bacteria. Benthic macroinvertebrates and bacteria shared a generally low number of taxa across treatments and locations; approximately, 25% of the gamma diversity was shared among all treatments and locations for macrofauna, dropping to 11% for bacteria. Given the low overlap in the species distribution across the lagoon, sustaining the connectivity among heterogeneous soft sediment habitats appears to be essential for maintaining regional biodiversity. This study addresses a current scientific gap related to the relative contributions of vegetated and unvegetated habitats to biodiversity in tropical regions.

0456 Natural History of Insomnia: Sleep Reactivity Predicts New-Onset Acute Insomnia

Introduction

Greater vulnerability to stress-related sleep disturbance (i.e., sleep reactivity) is a risk factor for chronic insomnia (CI). What has not been investigated is whether greater sleep reactivity, as assessed by the Ford Insomnia Response to Stress Test (FIRST), predicts the onset of acute insomnia (AI), and more, whether greater sleep reactivity predicts the transition from AI to CI.

Methods

A national cohort of 1,222 good sleeper subjects (68% female; mean age=53.2 years) were prospectively assessed to estimate the incidence of AI and CI. The FIRST was completed at baseline and sleep diaries were completed on a daily basis for a period of one year. Subjects were categorized based on their FIRST scores (high, FIRST>16; low, FIRST≤16). Subjects were also grouped based on whether they developed AI (two consecutive weeks with a frequency of ≥ 3 nights per week of sleep initiation or maintenance problems) or maintained good sleep (GS; n=896). For those subjects that transitioned to AI (n=326), they were also grouped based on whether or not they developed CI (insomnia ≥ 3 nights/week for at least three months; n=23). Chi-square analyses were performed to determine if higher FIRST scores at baseline predicted the incidence of AI or CI.

Results

32.5% of subjects in the high FIRST group met criteria for AI at some point during the one-year interval, whereas 22.5% of subjects in the low FIRST group experienced AI (χ 2=15.2, p<.001). In contrast, FIRST did not predict CI status (low FIRST, 8.5% CI, high FIRST, 5.6% CI; χ 2=1.1, p=.30).

Conclusion

Greater sleep reactivity predicted incident AI but not the onset of CI. While these findings suggest that sleep reactivity may be a predisposing factor for AI, data are not consistent with previous findings showing FIRST scores are predictive of the development of CI. It’s possible that the present study was underpowered to detect these differences, given that the incidence of CI was low (less than 2% of the total sample). Additional analyses are ongoing to evaluate the temporal association between stressful life events and AI in subjects with high and low FIRST scores.

Support

Perlis: NIH R01AG041783, K24AG055602

Optimising and profiling pre-implementation contexts to create and implement a public health network intervention for tackling loneliness

Background

The implementation of complex interventions experiences challenges that affect the extent to which they become embedded and scaled-up. Implementation at scale in complex environments like community settings defies universal replication. Planning for implementation in such environments requires knowledge of organisational capacity and structure. Pre-implementation work is an important element of the early phase of preparing the setting for the introduction of an intervention, and the factors contributing towards the creation of an optimal pre-implementation community context are under-acknowledged.

Methods

To explore the factors contributing towards the creation of an optimal pre-implementation context, a quasi-ethnographic approach was taken. The implementation of a social network intervention designed to tackle loneliness in a community setting acts as the case in example. Observations (of meetings), interviews (with community partners) and documentary analysis (national and local policy documents and intervention resources) were conducted. Layder’s adaptive theory approach was taken to data analysis, with the Consolidated Framework for Implementation Research (CFIR) and a typology of third-sector organisations used to interpret the findings.

Results

Community settings were found to sit along a continuum with three broad categories defined as Fully Professionalised Organisations; Aspirational Community, Voluntary and Social Enterprises; and Non-Professionalised Community-Based Groups. The nature of an optimal pre-implementation context varied across these settings. Using the CFIR, the results illustrate that some settings were more influenced by political landscape (Fully professional and Aspirational setting) and others more influenced by their founding values and ethos (Non-Professionalised Community-Based settings). Readiness was achieved at different speeds across the categories with those settings with more resource availability more able to achieve readiness (Fully Professional settings), and others requiring flexibility in the intervention to help overcome limited resource availability (Aspirational and Non-Professionalised Community-Based settings).

Conclusions

The CFIR is useful in highlighting the multiple facets at play in creating the optimal pre-implementation context, and where flex is required to achieve this. The CFIR illuminates the similarities and differences between and across settings, highlighting the complexity of open system settings and the important need for pre-implementation work.

Trial registration

ISRCTN19193075

A scoping review of initiatives to reduce inappropriate or non-beneficial hospital admissions and bed days in people nearing the end of their life: much innovation, but limited supporting evidence

Background

Hospitalisation during the last weeks of life when there is no medical need or desire to be there is distressing and expensive. This study sought palliative care initiatives which may avoid or shorten hospital stay at the end of life and analysed their success in terms reducing bed days.

Methods

Part 1 included a search of literature in PubMed and Google Scholar between 2013 and 2018, an examination of governmental and organisational publications plus discussions with external and co-author experts regarding other sources. This initial sweep sought to identify and categorise relevant palliative care initiatives. In Part 2, we looked for publications providing data on hospital admissions and bed days for each category.

Results

A total of 1252 abstracts were reviewed, resulting in ten broad classes being identified. Further screening revealed 50 relevant publications describing a range of multi-component initiatives. Studies were generally small and retrospective. Most researchers claim their service delivered benefits. In descending frequency, benefits identified were support in the community, integrated care, out-of-hours telephone advice, care home education and telemedicine. Nurses and hospices were central to many initiatives. Barriers and factors underpinning success were rarely addressed.

Conclusions

A wide range of initiatives have been introduced to improve end-of-life experiences. Formal evidence supporting their effectiveness in reducing inappropriate/non-beneficial hospital bed days was generally limited or absent.

Trial registration

N/A

Abstract P4-07-07: Establishing whole-exome sequencing for breast cancer patient care

Background. Next-generation sequencing (NGS) technology enables profiling of individual tumours and to measure the increasing number of biomarkers relevant to the management of breast cancer patients. The Australian Translational Genomics Centre (ATGC) is a collaboration between the healthcare sector (Metro South Hospital and Health Service), higher education sector (Queensland University of Technology) and a government-run pathology service (Pathology Queensland) to provide genomic profiling of breast cancer patients at the Princess Alexandra Hospital. The program was developed to integrate the ordering, processing and interpretation of large-scale NGS into clinical practice.

Methods. Patients were consented for somatic testing and ordering was integrated into the hospital’s electronic ordering system. Samples were derived from fresh tissue biopsies after surgeries (47%) or from FFPE histology sections. No selection criteria were applied during the initial phase and the cohort was representative of newly presenting patients at the hospitals breast cancer clinic. Patients were sequenced using a NATA-accredited ISO15189 program using whole-exome sequencing (WES) combined with a high-coverage spike-in panel of known cancer genes. Clinical reports included the calculation of tumour purity, tumour mutational burden (TMB), the assessment of copy number events and somatic mutations down to 3% allele frequency.

Standard molecular testing in Australia includes ER, PR and HER2 status, and additional testing included testing of Tier 1-2 somatic variants in the genes ABCC3, AKT1, CCND1, CCNE1, CDKN2A, ERBB2, ESR1, FGF3, FGFR1, FGFR2, MTOR, NCOA3, NF2, PIK3CA, PIK3R1, PTEN, RB1, RSF1, SF3B1, TP53. Results. Seventy-one patients were tested by WES/panel, and an average of 1.5 clinically significant Tier 1- 2 mutations were detected per patient. In 77% of cases, the molecular profiling could stratify patients to those with either PI3K/Akt/mTOR pathway activation (by PIK3CA activating mutations, AKT, MTOR mutations or PTEN loss) or CDK4/6 activation (by CCND1 expansion or CDKN2A loss). The most frequently observed mutations were PIK3CA activation (40%) and CCND1 copy number expansions (24%). A small proportion (n=3) were found to have mTOR or TCS1/2 mutations reported to have association with a durable response to mTOR inhibitors. Additionally, 11 patients (15%) had a high TMB (TMB, >6.8 mutations/megabase) with 6 having >10 mutations/Mb. Within this high-TMB cohort, 3 were found to be ER-PR-HER-, however, the majority (n=7) were ER+PR+HER2- patients. Calculation of the tumour purity indicated that, despite expert resection of the biopsies to isolate the most tumour dense regions, tumour purity was not significantly enriched. In 58% of cases, the tumour purity was less than 50%, and in 13% of samples, it was less than 25%, indicating that in clinical practice the method of sequencing must be robust, as many samples have significant amounts of contaminating stroma.

Conclusion. We demonstrate that integration of WES/panel testing into clinical practice is practical and provides multiplexed testing of current and emerging biomarkers in a significant number of tested patients. While a high proportion of patients had mutations that could stratify them to targeted therapies in the event of metastatic disease, the somatic molecular profiles did not modify first line therapy decision-making. Training of clinical staff for patient consent and the dissemination of findings, the development of a dedicated molecular tumour board, and decision protocols to identify patients of metastatic risk were identified as key developments in this clinical program. The program identified previously unidentified subsets of patients including a subset of ER+ patients with high TMB for which for there are no effective treatments option in Australia.

Citation Format: Kate Roberts, Paul J Leo, Jeremy Khoo, Alice Febery, Jonathan Ellis, Mhairi Clout, Lawrie Wheeler, Lisa Anderson, Matthew Brown, Ian Bennett. Establishing whole-exome sequencing for breast cancer patient care [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P4-07-07.

Effectiveness of influenza vaccine in children in preventing influenza associated hospitalisation, 2018/19, England

2013/14 saw the start of the introduction of a new live attenuated influenza vaccine (LAIV) programme for children in England. 2018/19 saw co-circulation of both A(H1N1)pdm09 and A(H3N2), when LAIV was offered to all healthy children 2-9 years of age. LAIV effectiveness against influenza hospitalisation is not well described. This paper presents the 2018/19 end-of-season adjusted vaccine effectiveness (aVE) against laboratory confirmed influenza related hospitalisation in children aged 2-17. The test negative case control approach was used to estimate aVE by influenza A subtype and vaccine type. Cases and controls were selected from a sentinel laboratory surveillance system which collates details of individuals tested for influenza with reverse-transcription polymerase chain reaction (RT-PCR) on respiratory samples. Vaccine and clinical history was obtained from general practitioners of study participants. There were 307 hospitalised cases and 679 hospitalised controls. End-of-season influenza aVE was 53.0% (95% CI: 33.3, 66.8) against influenza confirmed hospitalisation; 63.5% (95% CI: 34.4, 79.7) against influenza A(H1N1)pdm09 hospitalisation and 31.1% (95% CI: -53.9, 69.2) against influenza A(H3N2). LAIV aVE was 49.1% (95% CI: 25.9, 65.0) for any influenza and 70.7% (95% CI: 41.8, 85.3) for A(H1N1)pdm09, whereas for those receiving quadrivalent inactivated influenza vaccine (QIV), aVE was 64.4% (95% CI: 29.4, 82.0) and 44.4% (95% CI: -51.9, 79.6) respectively. We provide evidence of overall significant VE for both LAIV and QIV against influenza associated hospitalisation in children 2-17 years of age, most notably against influenza A(H1N1)pdm09, with non-significant protection against A(H3N2).

1386Reduction of mitral regurgitation in patients with heart failure and secondary mitral regurgitation: relationship between changes in brain natriuretic peptide and outcomes from the COAPT trial

Background

Brain natriuretic peptide (BNP) is a well-established predictor of hospitalization and death in patients with heart failure (HF). In the COAPT trial, treatment of patients with HF and secondary mitral regurgitation (SMR) with transcatheter mitral valve repair (TMVr) reduced the 2-year rates of all-cause mortality and HF hospitalization compared with maximally-tolerated guideline-directed medical therapy (GDMT) alone. Whether these improvements in outcomes were reflected in serial changes in BNP levels has not been reported.

Purpose

Herein, we report the first results of serial changes in BNP levels by treatment group in patients from the COAPT trial.

Methods

614 patients with HF and 3+ or 4+ SMR were randomized 1:1 to TMVr + GDMT or GDMT alone. Key inclusion criteria included NYHA functional class II-IVa (ambulatory), ischemic or non-ischemic cardiomyopathy with LVEF 20%-50% and LVESD ≤70 mm. Baseline BNP or NT-proBNP levels were drawn at baseline and at 6 and 12 months. For the present analysis NT-proBNP (pg/ml) values were converted to BNP values (pg/ml) using a ratio of 7 to 1.

Results

At baseline, mean values of BNP were not significantly different between treatment groups (945 pg/ml vs. 964 pg/ml in the TMVr + GDMT and GDMT groups respectively, p=0.84). At 6 months, mean values of BNP in the TMVr + GDMT group were significantly lower than in the GDMT alone group (690 pg/ml vs 893 pg/ml, p=0.02) but not at 12 months (584 pg/ml vs. 728 pg/ml, p=0.22). By analysis of covariance, BNP decreased to a greater degree after TMVr + GDMT compared with GDMT only at both 6 and 12 months (least squares mean differences of −121 pg/ml and −166 pg/ml respectively, both p<0.05) (Figure).

Change in BNP level from baseline

Conclusions

In patients with HF and 3+ or 4+ SMR enrolled in the COAPT trial, reduction of SMR with TMVr reduced BNP compared with maximally-tolerated GDMT only, a change which paralleled the reductions noted in all-cause mortality and HF hospitalizations with TMVr.

Acknowledgement/Funding

Abbott

A method for constrained optimisation of the design of a scanning helium microscope

We describe a method for obtaining the optimal design of a normal incidence Scanning Helium Microscope (SHeM). Scanning helium microscopy is a recently developed technique that uses low energy neutral helium atoms as a probe to image the surface of a sample without causing damage. After estimating the variation of source brightness with nozzle size and pressure, we perform a constrained optimisation to determine the optimal geometry of the instrument (i.e. the geometry that maximises intensity) for a given target resolution. For an instrument using a pinhole to form the helium microprobe, the source and atom optics are separable and Lagrange multipliers are used to obtain an analytic expression for the optimal parameters. For an instrument using a zone plate as the focal element, the whole optical system must be considered and a numerical approach has been applied. Unlike previous numerical methods for optimisation, our approach provides insight into the effect and significance of each instrumental parameter, enabling an intuitive understanding of effect of the SHeM geometry. We show that for an instrument with a working distance of 1 mm, a zone plate with a minimum feature size of 25 nm becomes the advantageous focussing element if the desired beam standard deviation is below about 300 nm.

The vascular access questionnaire: a single centre UK experience

Background

Haemodialysis is capable of prolonging life in patients with end stage renal disease, however this therapy comes with significant negative impact on quality of life. For patients requiring haemodialysis, the need for an adequately functioning vascular access (VA) is an everyday concern. The Vascular Access Questionnaire (VAQ) provides a mechanism for identifying and scoring factors in haemodialysis that impact on patients’ quality of life and perception of their therapy.

Methods

Between April 2017–18 the VAQ was administered to prevalent haemodialysis patients at 10 units in the West Midlands via structured interviews.

Results

749 of 920 potentially eligible patients completed the survey. The mean VAQ score was seen to improve significantly with age (7.7 in < 55 vs. 3.8 in 75+) and the duration of access (8.9 if less than 1 month old vs. 5.0 at a year). Better average scores were demonstrated for Arteriovenous fistulas (AVF) than other modalities (AVF 5.1 vs. AVG (arteriovenous grafts) 7.2 vs. CVC (central venous catheter) 6.6). There was no significant difference in scores between fistulas on non-dominant or dominant arms, with both having a mean of 5.2 (p = 0.341).

Conclusions

Overall, better satisfaction scores were seen in AVF. The presence of an AVF on the non-dominant arm was not a concern for the majority of patients and did not affect the VAQ score. A number of factors were identified that can influence VAQ satisfaction score.

Electronic supplementary material

The online version of this article (10.1186/s12882-019-1493-9) contains supplementary material, which is available to authorized users.

A29 Genetic heterogeneity of influenza A (H3N2) viruses in the United Kingdom, 2016–8

For the last four influenza seasons in the UK, genetic characterization of seasonal influenza viruses has shifted from single hemagglutinin (HA) and neuraminidase (NA) genes to whole genome (WG) analysis, allowing for better insight into the evolutionary dynamics of this virus. Sequences (WG or HA/NA) were obtained from >900A (H3N2) viruses sampled in the UK during influenza seasons 2016/7 and 2017/8 and the inter-seasonal period. Viral RNA was extracted from clinical samples and amplified using a multi-segment RT-PCR. Amplicons were sequenced using Nextera library preparation for Illumina MiSeq sequencing. Sequence data ????were processed using BAM-SAM tools and PHE in-house scripts. Phylogenetic analysis of the HA gene indicates that they belong to genetic group 3C.2a, which has circulated since 2014. Season 2016/7 was characterized by the emergence of cluster 3C.2a.1; further genetic heterogeneity was seen with 6 new subclusters within 3C.2a and 3C.2a.1, with predominance of those characterized by amino acid changes N121K and S144K (3C.2a) and N121K, N171K, I406K, G484E (3C.2a.1). The NA genes clustered with a similar topology to the HA. Season 2017/8 was characterized by persistence of some clades from previous season with further diversification. Three of the 3C.2a clusters continued to circulate, with predominance of clade showing T131K, R142K, and R261Q (clade 3C.2a.2). The majority of HA sequences in 3C.2a1 fall into a new subcluster which has become predominant within this subgroup, with amino acid changes E62G, K92R, and T135K (3C.2a.1b). The topology of NA and internal gene trees showed evidence of reassortment events occurring at some point between the two seasons, with group 3C.2a2 acquiring NA and some internal genes from 3C.2a1 lineage viruses. The predominance of this group during 2017–8 might be due to fitness advantage related to the new genetic constellation. Emerging viruses from group 3C.3a also have acquired genes from lineage 3C.2a1, which could be the reason for their increased frequency to 20 per cent by the end of season 2017–8. Molecular epidemiology indicates emerging genetic diversity in A(H3N2) viruses during the period of study, leading to co-circulation of variants. The frequency of circulating HA genetic groups was quite variable, with rapidly changing patterns of predominance. Evidence of reassortment events was observed which could be responsible for the rise and predominance of some clades, and might predict the emergence of other variants.

Help seeking for antibiotics; is the influence of a personal social network relevant?

BACKGROUND

Health policy focuses on reducing antibiotic prescribing that in order to succeed requires the public to hold similar attitudes towards judicious use. Social network influences on health behaviour and attitudes are well established and yet these influences are not sufficiently acknowledged in the UK's antibiotic stewardship programmes. Therefore, the aim of this study was to evaluate individuals' attitudes and behaviours towards antibiotics and also identify the social network influences on these in the process of help seeking for self-limiting illnesses.

METHODS

From a social network approach the methods used were a personal community mapping exercise which was carried out ahead of a semi-structured interview. A purposive sample was drawn from across the Wessex region and participants were recruited via GP practices and pharmacists. In total 14 adults, and 10 parents of children, who had received a prescription for antibiotics for a self-limiting illness within the 3 months preceding the interview were recruited and interviewed.

RESULTS

Three network types were identified; diverse, family and friend and restricted. The type of network an individual has appears to have an influence on antibiotic attitudes and behaviours. Most notably, the more diverse a network the more likely the individual will delay in help seeking from healthcare professionals as they draw upon self-care strategies advised by network members. The role of the GP varies according to network type too. Individuals' with diverse networks draw upon GP network members to provide clarity and certainty following a period of self-care. People with restricted networks are more reliant upon the GP, seek help quicker and also more likely to prioritise the GPs advice over other sources of information.

CONCLUSION

The understanding a social network approach brings to help seeking behaviour for antibiotics could help practitioners modify their consultation approach to mitigate some uncertainties and perceptions around prescribing behaviour.

Can We Accurately Predict Cost Effectiveness Without Access to Overall Survival Data? The Case Study of Nivolumab in Combination with Ipilimumab for the Treatment of Patients with Advanced Melanoma in England

BACKGROUND

Nivolumab with ipilimumab (the Regimen) is the first immuno-oncology combination treatment to demonstrate long-term clinical benefit for advanced melanoma patients. We evaluated the cost effectiveness of the Regimen in this population, with and without the availability of overall survival (OS) data.

METHODS

A partitioned survival model and a Markov state-transition model were developed to estimate the lifetime costs and benefits of the Regimen versus ipilimumab. These models were built with and without the availability of OS data, as only progression-free survival data were available from the head-to-head, phase III trial against ipilimumab at the time of the National Institute for Health and Care Excellence (NICE) submission. Patient utilities and resource use data were sourced from trial data or the literature.

RESULTS

Incremental cost-effectiveness ratios (ICERs) and absolute costs were similar between the models with and without OS data, but the model with OS data generated more than 1 additional quality-adjusted life-year (QALY) across both treatment arms. In both models, based on list prices, the Regimen was the most cost-effective treatment.

CONCLUSIONS

The analyses show that the Regimen is a cost-effective treatment for advanced melanoma patients in England, and methods to overcome the lack of OS can give reasonable estimates of QALYs gained and ICERs.

Correction to: Can We Accurately Predict Cost Effectiveness Without Access to Overall Survival Data? The Case Study of Nivolumab in Combination with Ipilimumab for the Treatment of Patients with Advanced Melanoma in England

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Embedding leadership in undergraduate medical students: an active approach

Introduction

The inclusion of leadership within the General Medical Council Outcomes has encouraged UK medical schools to incorporate leadership into curricula, although it is often delivered in classroom environments. In order to illustrate to our clinical students that leadership skills are useful irrespective of positional authority, the University of Buckingham Medical School has developed a week-long programme illustrating the impact that junior and trainee doctors can have on the National Health Service environment (in a week).

Methods

Students received lectures on leadership principles and conducted focus groups and 1 min interviews to assess the values at Milton Keynes University Hospital (MKUH). Students collated the responses, and all MKUH staff, including the executive board, were invited to hear the feedback.

Findings and conclusions

The students concluded that a review of the hospital’s values was required and the executive board committed to a review which has been completed, with the values redefined and reworded. At the end of the week, 92.3% of students felt their perspective had been broadened and some reported feeling empowered by the impact that a weeks’ work could achieve. This short course has illustrated that an active approach to leadership can demonstrate to students that leadership is not just for those in positions of responsibility and change can be achieved by anyone with ambition.

Are UK graduates equipped with the skill set required to meet the demands of the UK's edentulous population?

As the UK witnesses a decline in the number of edentulous adults, there is a simultaneous reduction in the number of cases available to undergraduate dental students for the teaching of complete dentures. When edentulous adults are unable to function with conventional complete dentures, particularly pertaining to the mandibular denture, an implant-supported mandibular overdenture has been evidenced as the gold standard for edentulous patients. The evidence in favour of mandibular implant-supported overdentures is one of the most robust evidence bases for any clinical treatment and similarly it has been shown that undergraduate students are equally as capable in the provision of implant-supported overdentures as experienced prosthodontists. Yet there appears to be a disparity in the General Dental Council's undergraduate learning outcomes pertaining to care for edentulous adults. Furthermore, the UK seems to be falling behind in this respect in comparison to our European, American and Australian colleagues. This review looks at the evidence for the provision of implant-supported overdentures in the setting of the undergraduate dental curriculum, the potential barriers within this teaching forum and how well prepared UK undergraduates are for the clinical management of edentulous patients in the future.

Rare, potentially pathogenic variants in 21 keratoconus candidate genes are not enriched in cases in a large Australian cohort of European descent

Many genes have been suggested as candidate genes for keratoconus based on their function, their proximity to associated polymorphisms or due to the identification of putative causative variants within the gene. However, very few of these genes have been assessed for rare variation in keratoconus more broadly. In contrast, VSX1 and SOD1 have been widely assessed, however, the vast majority of studies have been small and the findings conflicting. In a cohort of Australians of European descent, consisting of 385 keratoconus cases and 396 controls, we screened 21 keratoconus candidate genes: BANP, CAST, COL4A3, COL4A4, COL5A1, FOXO1, FNDC3B, HGF, IL1A, IL1B, ILRN, IMMP2L, MPDZ, NFIB, RAB3GAP1, RAD51, RXRA, SLC4A11, SOD1, TF and VSX1. The candidate genes were sequenced in these individuals by either whole exome sequencing or targeted gene sequencing. Variants were filtered to identify rare (minor allele frequency <1%), potentially pathogenic variants. A total of 164 such variants were identified across the two groups with no variants fulfilling these criteria in cases in IL1RN, BANP, IL1B, RAD51 or SOD1. The frequency of variants was compared between cases and controls using chi-square or Fishers' Exact tests for each gene with at least one rare potentially pathogenic variant identified in the case cohort. The number of rare potentially pathogenic variants per gene ranged from three (RXRA) to 102 (MPDZ), however for all genes, there was no difference in the frequency between the cases and controls. We conclude that rare potentially pathogenic variation in the 21 candidate genes assessed do not play a major role in keratoconus susceptibility and pathogenesis.