The Defence General Practitioner: an Updated Definition and Model

The geopolitical setting has changed significantly since the definition of UK Armed Forces General Practice was published in 2012. New operating models require medical services to provide smaller teams operating at greater reach from secondary care and logistical support. The Defence Medical Services have reorganised to meet these changing needs. Defence general practices (DGPs) are key enablers of the Defence strategic effort, both integral to deployed units, in preparing forces for deployment and managing their rehabilitation back to fitness. A formal role performance statement (RPS) has been created to guide the training and development of DGPs to meet these changing requirements. The RPS details the additional scope of practice, beyond the national GP licensing standard, in which DGPs work. In this article, we compare and contrast the RPS with the previous definition of a DGP. The resultant updated model recharacterises the extended roles into five themes of DGP built on the foundation of the Royal College of General Practitioners curriculum. This new model provides the platform on which to develop the clinical specialty over the next decade and highlights avenues for educational interventions to develop future generations of DGPs.

The Harvard Macy Institute Art Museum-based Health Professions Education Fellowship: Transformational faculty development through the arts

Museum-based education for health professionals can lead to a variety of important learning outcomes within the domain of skills development, personal insight, perspective-taking and social advocacy. The Harvard Macy Institute's Art Museum-based Health Professions Education Fellowship was designed to develop faculty expertise in art museum-based practices, encourage scholarship, and cultivate a cohesive and supportive community of educators. The Fellowship was piloted from January to May 2019 with twelve interprofessional Fellows. Two in-person experiential sessions were held at Boston-area museums with intervening virtual learning. Fellows were introduced to a variety of approaches used in art museum-based education and developed a project for implementation at their home institution. A qualitative formative evaluation assessed immediate and 6-month post-Fellowship outcomes. Outcomes are reported in four categories: (1) Fellows' personal and professional development; (2) Institutional projects and curriculum development; (3) Community of practice and scholarly advancement of the field; and (4) Development of Fellowship model. A follow-up survey was performed four years after the conclusion of the pilot year, documenting Fellows' significant accomplishments in museum-based education, reflections on the Fellowship and thoughts on the future of the field.

Evaluation of Sentinel Lymph Node Drainage Patterns in Early-Stage Oral Cavity Cancer

PURPOSE/OBJECTIVE(S)

Surgery is the mainstay for squamous cell carcinoma of the oral cavity (OSCC), which includes an elective neck dissection. To limit morbidity of neck dissection, sentinel lymph biopsy (SLNB) has been introduced to identify patients at risk for nodal metastasis. While the data has thoroughly examined the relationship between SLNB in patients with unilateral lymph node drainage, little information exists on the rate of bilateral lymph node drainage patterns in lateralized OSCC. This study sought to examine the incidence of bilateral lymph node drainage patterns using sentinel node mapping in early stage OSCC.

MATERIALS/METHODS

This retrospective review of the electronic medical records at Rush University Medical Center focused on patients who underwent a SLNB based on CPT codes 38724, 38900, 38542, and 38510. From this cohort, we limited our analysis to patients with primary clinical T1 or T2 OSCC. Primary outcome was the rate of bilateral nodal drainage on sentinel node mapping based on the SPECT-CT.

RESULTS

A total of 54 patients were diagnosed with clinical T1/T2N0 OSCC and underwent a SLNB with SPECT-CT. (1) From the cohort of 54, 15 patients (27.78%) had bilateral sentinel lymph node drainage on SPECT-CT, while 39 patients (72.22%) had unilateral sentinel lymph node drainage. (2) Eleven patients (73.3%) from the bilateral drainage cohort completed appropriate SLN mapping with bilateral nodal assessments. (3) Four patients who had SPECT-CT evidence of bilateral drainage completed unilateral nodal assessment alone. (4) Of the patients with bilateral nodal assessment, 1 (9.1%) patient had a positive sentinel node on the ipsilateral side, 2 (18.2%) were found to have a positive sentinel node in the contralateral neck. (5) Overall, 3 patients (20%) had local-regional recurrence in the bilateral sentinel lymph drainage cohort.

CONCLUSION

Management of early-stage OSCC has evolved to include SLN mapping and biopsy. Our results found that contralateral drainage occurs in 18% of our patients with 2 patients having positive sentinel node in the contralateral neck. Therefore, the rate of contralateral drainage is not clinically insignificant and this result furthers the importance of lymphatic mapping in the early-stage OSCC treatment algorithm.

Deep-learning-based image segmentation for image-based computational hemodynamic analysis of abdominal aortic aneurysms: a comparison study

Computational hemodynamics is increasingly being used to quantify hemodynamic characteristics in and around abdominal aortic aneurysms (AAA) in a patient-specific fashion. However, the time-consuming manual annotation hinders the clinical translation of computational hemodynamic analysis. Thus, we investigate the feasibility of using deep-learning-based image segmentation methods to reduce the time required for manual segmentation. Two of the latest deep-learning-based image segmentation methods, ARU-Net and CACU-Net, were used to test the feasibility of automated computer model creation for computational hemodynamic analysis. Morphological features and hemodynamic metrics of 30 computed tomography angiography (CTA) scans were compared between pre-dictions and manual models. The DICE score for both networks was 0.916, and the correlation value was above 0.95, indicating their ability to generate models comparable to human segmentation. The Bland-Altman analysis shows a good agreement between deep learning and manual segmentation results. Compared with manual (computational hemodynamics) model recreation, the time for automated computer model generation was significantly reduced (from ∼2 h to ∼10 min). Automated image segmentation can significantly reduce time expenses on the recreation of patient-specific AAA models. Moreover, our study showed that both CACU-Net and ARU-Net could accomplish AAA segmentation, and CACU-Net outperformed ARU-Net in terms of accuracy and time-saving.

Computerized Differentiation of Growth Status for Abdominal Aortic Aneurysms: A Feasibility Study

Fast-growing abdominal aortic aneurysms (AAA) have a high rupture risk and poor outcomes if not promptly identified and treated. Our primary objective is to improve the differentiation of small AAAs' growth status (fast versus slow-growing) through a combination of patient health information, computational hemodynamics, geometric analysis, and artificial intelligence. 3D computed tomography angiography (CTA) data available for 70 patients diagnosed with AAAs with known growth status were used to conduct geometric and hemodynamic analyses. Differences among ten metrics (out of ninety metrics) were statistically significant discriminators between fast and slow-growing groups. Using a support vector machine (SVM) classifier, the area under receiving operating curve (AUROC) and total accuracy of our best predictive model for differentiation of AAAs' growth status were 0.86 and 77.50%, respectively. In summary, the proposed analytics has the potential to differentiate fast from slow-growing AAAs, helping guide resource allocation for the management of patients with AAAs.

Effects of source of supplementary trace minerals in pre- and postpartum diets on reproductive biology and performance in dairy cows

Our objectives were to evaluate the effects of complete replacement of inorganic salts of trace minerals (STM) with organic trace minerals (OTM) in both pre- and postpartum diets on ovarian dynamics, estrous behavior measured by sensors, preimplantation conceptus development, and reproductive performance in dairy cows. Pregnant cows and heifers (n = 273) were blocked by parity and body condition score and randomly assigned to either STM or OTM diets at 45 ± 3 d before their expected calving. Pre- and postpartum diets were formulated to meet 100% of recommended levels of each trace mineral in both treatments, taking into consideration both basal and supplemental levels. The final target concentrations of Co, Cu, Mn, Se, and Zn were, respectively, 0.25, 13.7, 40.0, 0.3, and 40.0 mg/kg in the prepartum diet, and 0.25, 15.7, 40.0, 0.3, and 63.0 mg/kg in the postpartum diet. The STM group was supplemented with Co, Cu, Mn, and Zn sulfates and sodium selenite, while the OTM group was supplemented with Co, Cu, Mn, and Zn proteinates and selenized yeast. Treatments continued until 156 d in milk (DIM) and were assigned to individual cows using automatic feeding gates. Starting at 21 DIM, ultrasonography examinations of the ovaries were performed weekly to determine the presence of a corpus luteum and postpartum resumption of ovarian cyclicity. Cows were presynchronized with 2 injections of PGF_2α at 42 and 56 DIM. Estrous behavior was monitored using electronic activity tags that indirectly measured walking activity. Cows detected in estrus after the second PGF_2α were inseminated, and those not detected in estrus by 67 DIM were enrolled in a synchronization program. Cows that returned to estrus after artificial insemination (AI) were reinseminated. Pregnancy diagnosis was performed 33 d after AI, and nonpregnant cows were resynchronized. Transcript expression of interferon-stimulated genes in peripheral blood leukocytes was performed in a subgroup of cows (STM, n = 67; OTM, n = 73) on d 19 after AI. A different subgroup of cows (28 STM, 29 OTM) received uterine flushing 15 d after AI for recovery of conceptuses and uterine fluid for analyses of transcriptomics and metabolomics, respectively. In addition, dominant follicle diameter, luteal size and blood flow, and concentration of progesterone in plasma were measured on d 0, 7, and 15 relative to AI. After flushing, PGF_2α was given and the dominant follicle was aspirated 2 d later to measure the concentration of trace minerals by mass spectrometry. Estrous behavior, size of the dominant follicle and corpus luteum, concentration of progesterone, time to pregnancy, and proportion of cows pregnant by 100 d of the breeding period did not differ between treatments. A greater proportion of cows supplemented with OTM had a corpus luteum detected before presynchronization (64.3 vs. 75.2%), and primiparous cows supplemented with OTM tended to resume cyclicity earlier than their STM counterparts. Cows supplemented with OTM had a greater concentration of Cu in follicular fluid than cows supplemented with STM (0.89 vs. 0.77 µg/mL, respectively). In pregnant multiparous cows, expression of receptor transporter protein 4 in peripheral blood leukocytes was 42% greater in the OTM group. Conceptuses of the 2 treatments had 589 differentially expressed transcripts, with many indicating advanced conceptus elongation and greater transcript expression of selenoproteins in the OTM group. In pregnant cows, 24 metabolites were more abundant in the uterine fluid of OTM, including spermidine, sucrose, and cholesterol. In conclusion, replacing STM with OTM caused modest improvements to resumption of ovarian cyclicity and important changes in preimplantation conceptus development, but it did not alter conception risk and pregnancy rate.

Uncertainty in phosphorus fluxes and budgets across the U.S. long-term agroecosystem research network

Phosphorus (P) budgets can be useful tools for understanding nutrient cycling and quantifying the effectiveness of nutrient management planning and policies; however, uncertainties in agricultural nutrient budgets are not often quantitatively assessed. The objective of this study was to evaluate uncertainty in P fluxes (fertilizer/manure application, atmospheric deposition, irrigation, crop removal, surface runoff, leachate) and the propagation of these uncertainties to annual P budgets. Data from 56 cropping systems in the P-FLUX database, which spans diverse rotations and landscapes across the U.S. and Canada, were evaluated. Results showed that across cropping systems, average annual P budget was 22.4 kg P ha^-1 (range = -32.7 to 340.6 kg P ha^-1 ), with an average uncertainty of 13.1 kg P ha^-1 (range = 1.0 to 87.1 kg P ha^-1 ). Fertilizer/manure application and crop removal were the largest P fluxes across cropping systems and, as a result, accounted for the largest fraction of uncertainty in annual budgets (61 and 37%, respectively). Remaining fluxes individually accounted for <2% of the budget uncertainty. Uncertainties were large enough that determining whether P was increasing, decreasing, or not changing was inconclusive in 39% of the budgets evaluated. Findings indicate that more careful and/or direct measurements of inputs, outputs, and stocks are needed. Recommendations for minimizing uncertainty in P budgets based on the results of the study were developed. Quantifying, communicating, and constraining uncertainty in budgets among production systems and multiple geographies is critical for engaging stakeholders, developing local and national strategies for P reduction, and informing policy. This article is protected by copyright. All rights reserved.

Effects of replacing inorganic salts of trace minerals with organic trace minerals in the diet of prepartum cows on quality of colostrum and immunity of newborn calves

Our objectives were to evaluate the impact of supplementary trace mineral (TM) form-inorganic salts (STM; Co, Cu, Mn, Zn sulfates, and Na selenite) or organic (OTM; Co, Cu, Mn, Zn proteinates, and selenized yeast)-in the prepartum diet on quantity and quality of colostrum, passive immunity, antioxidant biomarkers, cytokine responses to lipopolysaccharide (LPS), health, and growth of newborn calves. Pregnant heifers (n = 100) and cows (n = 173) were enrolled at 45 d before calving, blocked by parity and body condition score, and allocated randomly to STM (50 heifers; 86 cows) or OTM (50 heifers; 87 cows) supplementation. Cows in both treatments were fed the same diet, except for the source of supplementary TM. Within 2 h of calving, dams and calves were separated, colostrum was harvested, the yield was measured, and a sample was saved for posterior analyses of colostrum quality. A subgroup of calves (n = 68) had a blood sample collected before colostrum feeding. After colostrum feeding, all samples and data collection were limited to 163 calves (STM = 82; OTM = 81) fed 3 L of good quality (Brix% >22) maternal colostrum via nipple bottle minutes after harvesting. Concentration of IgG in colostrum and serum was determined 24 h after colostrum feeding using radial immunodiffusion. Concentration of TM in colostrum and serum were performed by inductively coupled plasma mass spectrometry. Activity of glutathione peroxidase, ferric reducing ability of plasma, and concentration of superoxide dismutase were evaluated in plasma by colorimetric assays. Ex vivo whole blood stimulation with LPS was performed on d 7 of life to evaluate cytokine responses in a subgroup of 66 calves. Health events were recorded from birth to weaning, and body weight was recorded at birth (all calves) and on d 30 and 60 (heifers only). Continuous variables were analyzed by ANOVA and binary responses were analyzed by logistic regression. Complete replacement of STM by OTM in prepartum diet resulted in greater concentration of Se (461 vs. 543 ± 7 μg/g; ± SEM) but did not alter the concentration or total mass of other TM and IgG in colostrum. Female calves of the OTM group had greater concentration of Se in serum at birth (0.23 vs. 0.37 ± 0.05 μg/mL), were lighter in weight at birth (40.9 vs. 38.8 ± 0.6 kg) and weaning (93.2 vs. 89.7 ± 1.6 kg) than those of the STM group. Maternal treatments did not affect passive immunity or antioxidant biomarkers. On d 7, basal concentrations (log₁₀ of concentration in pg/mL) of IFNγ (0.70 vs. 0.95 ± 0.083) and LPS-stimulated concentrations of CC chemokine ligand 2 (CCL2; 2.45 vs. 2.54 ± 0.026), CC chemokine ligand 3 (CCL3; 2.63 vs. 2.76 ± 0.038), IL-1α (2.32 vs. 2.49 ± 0.054), and IL-1β (3.62 vs. 3.86 ± 0.067) were greater in OTM than in STM. Supplementation with OTM in pregnant heifers, but not in pregnant cows, reduced the incidence of preweaning health problems in their calves (36.4 vs. 11.5%). Complete replacement of STM by OTM in the prepartum diet did not cause major changes in colostrum quality, passive immunity, and antioxidant capacity, but increased cytokine and chemokine responses to LPS on d 7 of life and benefited preweaning health of calves born to primiparous cows.

Supporting decision making on public health and social measures in response to COVID-19- The PHSM calibration tool

 

Public health and social measures (PHSM) are preventative measures taken by individuals, communities and government institutions at national and local levels to prevent and reduce transmission of an infectious disease - in this instance SARS-CoV-2. The decision to introduce, adapt or lift PHSM should be based primarily on a situational assessment of the intensity of transmission of SARS-CoV-2 and the capacity of the health system to respond to subsequent increases in hospital admissions, but must also consider the effects these measures may have on the general welfare of society and individuals. The WHO Regional Office for Europe developed an online public health and social measures (PHSM) calibration tool to assist Member States in decision-making relating to PHSM implementation during the COVID-19 pandemic. The tool, designed to be used primarily by policy-makers in national and local government authorities, provides guidance based on a situational-level assessment framework that is determined by the level of community transmission and the overall capacity of health systems and public health services within a country or region to respond. By using a combination of country-reported and user-input data, the tool automatically generates a situational assessment and corresponding PHSM guidance for users, summarized in a downloadable report.

Reference

https://phsm.euro.who.int/calibrationTool

Urban Roadway Runoff Is Lethal to Juvenile Coho, Steelhead, and Chinook Salmonids, But Not Congeneric Sockeye

We compared the sensitivity of closely related Pacific salmon and steelhead (Oncorhynchus spp.) to untreated urban stormwater runoff across three storm events. Juvenile coho, sockeye, steelhead, and Chinook were exposed for 24 h to untreated urban runoff and then transferred to clean water for 48 h. As anticipated from previous studies, coho were highly susceptible to runoff toxicity, with cumulative mortality rates ranging from 92%-100% across the three storms. By contrast, juvenile sockeye were unaffected (100% survival), and cumulative mortality rates were intermediate for steelhead (4%-42%) and Chinook (0%-13%). Furthermore, coho died rapidly following the onset of stormwater exposure (generally <4 h), whereas mortality in Chinook and steelhead was delayed by 1-2 days. Similar to previous findings for coho, steelhead and Chinook did not recover when transferred to clean water. Lastly, significant mortality occurred in coho even when roadway runoff was diluted by 95% in clean water. Our findings extend the urban runoff mortality syndrome in salmonids and point to a near-term need for sublethal studies in steelhead and Chinook to more precisely understand stormwater risks to threatened species recovery efforts in the western United States.

Effects of replacing inorganic salts of trace minerals with organic trace minerals in pre- and postpartum diets on feeding behavior, rumen fermentation, and performance of dairy cows

Our objectives were to evaluate the effects of complete replacement of supplementary inorganic salts of trace minerals (STM) by organic trace minerals (OTM) in both pre- and postpartum diets on feeding behavior, ruminal fermentation, rumination activity, energy metabolism, and lactation performance in dairy cows. Pregnant cows and heifers (n = 273) were blocked by parity and body condition score and randomly assigned to either STM or OTM diets at 45 ± 3 d before their expected calving date. Both groups received the same diet, except for the source of trace minerals (TM). The STM group was supplemented with Co, Cu, Mn, and Zn sulfates and Na selenite, whereas the OTM group was supplemented with Co, Cu, Mn, and Zn proteinates and selenized yeast. Treatments continued until 156 days in milk and pre- and postpartum diets were formulated to meet 100% of recommended levels of each TM in both treatments, taking into consideration both basal and supplemental levels. Automatic feed bins were used to assign treatments to individual cows and to measure feed intake and feeding behavior. Rumination activity was monitored by sensors attached to a collar from wk -3 to 3 relative to calving. Blood metabolites were evaluated on d -21, -10, -3, 0, 3, 7, 10, 14, 23, and 65 relative to calving. Ruminal fluid samples were collected using an ororuminal sampling device on d -21, 23, and 65 relative to calving, for measurement of ruminal pH and concentration of volatile fatty acids. Cows were milked twice a day and milk components were measured monthly. Cows supplemented with OTM tended to have longer daily feeding time (188 vs. 197 min/d), and greater dry matter intake (DMI; 12.9 vs. 13.3 kg), and had a more positive energy balance (3.6 vs. 4.2 Mcal/d) and shorter rumination time per kg of dry matter (DM; 40.1 vs. 37.5 min/kg of DM) than cows supplemented with STM during the prepartum period. In the postpartum period, OTM increased DMI in multiparous cows (24.1 vs. 24.7 kg/d) but not in primiparous cows (19.1 vs. 18.7 kg/d). The difference in DMI of multiparous cows was more evident in the first 5 wk of lactation, when it averaged 1 kg/d. Milk yield was not affected by treatment in multiparous cows (44.1 vs. 44.2 kg/d); however, primiparous cows supplemented with OTM had lesser yields than primiparous cows supplemented with STM (31.9 vs. 29.8 kg/d). Cows supplemented with OTM had a greater percentage of protein in milk (3.11 vs. 3.17%), reduced concentration of nonesterified fatty acids in serum (0.45 vs. 0.40 mmol/L), and rumination activity (30.1 vs. 27.8 min/kg of DM) than cows supplemented with STM. At the end of the transition period, cows supplemented with OTM had reduced molar proportion of acetate, reduced pH, and tended to have a greater concentration of total volatile fatty acids in ruminal fluid. In conclusion, complete replacement of STM by OTM caused modest changes in rumen fermentation, feeding behavior, energy metabolism, and performance of dairy cows, improving postpartum DMI in multiparous cows and reducing circulating levels of nonesterified fatty acids. The pre-absorptive effects of TM source and the parity specific responses on performance warrant further research.

O-283 Evidence based management of endometriosis – what has changed since 2013?

In 2005, under the auspices of ESHRE, a group of international experts evaluated the existing best evidence and published the first European guideline on the management of endometriosis. This highly successful project was the first guideline by ESHRE and was adopted by many counties as their national standard. A second, fully-updated edition was presented in 2013.

For the new ESHRE Endometriosis Guideline, published in February 2022, all available evidence for twelve chosen topics was gathered by a senior research specialist. Subgroups comprised of patient representatives and experts in healthcare, reproductive science and epidemiology evaluated the data according to GRADE criteria. Each subgroup wrote a chapter and formulated their recommendations which were then presented by a representative to the core group. There, a provisional document was generated and made available for stakeholder review. The resulting comments were taken into account and where relevant incorporated into the final guideline document for which approval was sought and gained from the ESHRE Executive Committee.

35 PICO (Patients, Interventions, Comparison, Outcome) and seven narrative questions were addressed resulting in 78 Research Recommendations were formulated. Where sufficient scientific evidence was lacking and the Guideline Development Group (GDG) was of the opinion that an important topic needed to be highlighted Good Clinical Practice Points where created based on experts’ experience.

During the process of reviewing the literature it became apparent that large knowledge gaps of the best clinical approach to endometriosis exist. As a result, 30 research recommendations were also produced.

One of the main differences to the 2013 version of the ESHRE guidelines is that laparoscopy is no longer the gold standard for endometriosis per se as there exist sufficient data to support the use of transvaginal ultrasound performed by an experienced operator or MRI can equally identify or rule out ovarian and most of deep endometriosis. However, it is recognised by the GDG that the required imaging standards are not ubiquitously available and for peritoneal disease both sensitivity and specificity using either imaging modalities are still poor. As opposed to the 2013 recommendation, the GDG does not anymore recommend an ultralong protocol for the women with rASRM stage III/IV endometriosis to improve IVF success rates. Furthermore, gonadotropin releasing hormone antagonists seem to be effective in the treatment of endometriosis-associate pain and, where available, could be considered as second-line treatment.

Other changes were specific chapters on endometriosis in adolescents and in menopausal women as the GDG strongly felt that these groups are concerningly underrepresented in clinical care and research. Finally, a chapter focussing on the association of endometriosis with certain forms of cancer namely subgroups of ovarian cancer, breast and thyroid cancer was added to give both patients and clinicians a better insight into the current evidence of this complex topic.

The GDG hope that the new ESHRE Endometriosis Guideline will improve the clinical management of a highly prevalent and heterogenous disease and that the freely-available patient-friendly version of the guideline empowers symptomatic and asymptomatic women to seek the best available advice, support and treatment.

Does Loosening the Inclusion Criteria of the CROSS Trial Impact Outcomes in the Curative-Intent Trimodality Treatment of Oesophageal and Gastroesophageal Cancer Patients?

AIM

To determine the efficacy of preoperative chemoradiotherapy as per the CROSS protocol for oesophageal/gastroesophageal junction cancer (OEGEJC), when expanded to patients outside of the inclusion/exclusion criteria defined in the original clinical trial.

MATERIALS AND METHODS

Data were collected retrospectively on 229 OEGEJC patients referred for curative-intent preoperative chemoradiotherapy. Outcomes including pathological complete response (pCR), overall survival (OS), cancer-specific survival and recurrence-free survival (RFS) of patients who met CROSS inclusion criteria (MIC) versus those who failed to meet criteria (FMIC) were determined.

RESULTS

In total, 42.8% of patients MIC, whereas 57.2% FMIC; 16.6% of patients did not complete definitive surgery. The MIC cohort had higher rates of pCR, when compared with the FMIC cohort (33.3% versus 20.6%, P = 0.039). The MIC cohort had a better RFS, cancer-specific survival and OS compared with the FMIC cohort (P = 0.006, P = 0.004 and P = 0.009, respectively). Age >75 years and pretreatment weight loss >10% were not associated with a poorer RFS (P = 0.541 and 0.458, respectively). Compared with stage I-III patients, stage IVa was associated with a poorer RFS (hazard ratio (HR) = 2.158; 95% confidence interval (CI) = 1.339-3.480, P = 0.001). Tumours >8 cm in length or >5 cm in width had a trend towards worse RFS (HR = 2.060; 95% CI = 0.993-4.274, P = 0.052).

CONCLUSION

Our study showed that the robust requirements of the CROSS trial may limit treatment for patients with potentially curable OEGEJC and can be adapted to include patients with a good performance status who are older than 75 years or have >10% pretreatment weight loss. However, the inclusion of patients with celiac nodal metastases or tumours >8 cm in length or >5 cm in width may be associated with poor outcomes.

P-FLUX: A phosphorus budget dataset spanning diverse agricultural production systems in the United States and Canada

Quantifying spatial and temporal fluxes of phosphorus (P) within and among agricultural production systems is critical for sustaining agricultural production while minimizing environmental impacts. To better understand P fluxes in agricultural landscapes, P-FLUX, a detailed and harmonized dataset of P inputs, outputs, and budgets, as well as estimated uncertainties for each P flux and budget, was developed. Data were collected from 24 research sites and 61 production systems through the Long-term Agroecosystem Research (LTAR) network and partner organizations spanning 22 U.S. states and 2 Canadian provinces. The objectives of this paper are to (a) present and provide a description of the P-FLUX dataset, (b) provide summary analyses of the agricultural production systems included in the dataset and the variability in P inputs and outputs across systems, and (c) provide details for accessing the dataset, dataset limitations, and an example of future use. P-FLUX includes information on select site characteristics (area, soil series), crop rotation, P inputs (P application rate, source, timing, placement, P in irrigation water, atmospheric deposition), P outputs (crop removal, hydrologic losses), P budgets (agronomic budget, overall budget), uncertainties associated with each flux and budget, and data sources. Phosphorus fluxes and budgets vary across agricultural production systems and are useful resources to improve P use efficiency and develop management strategies to mitigate environmental impacts of agricultural systems. P-FLUX is available for download through the USDA Ag Data Commons (https://doi.org/10.15482/USDA.ADC/1523365).

Transmantle Pressure Computed from MR Imaging Measurements of Aqueduct Flow and Dimensions

BACKGROUND AND PURPOSE

Measuring transmantle pressure, the instantaneous pressure difference between the lateral ventricles and the cranial subarachnoid space, by intracranial pressure sensors has limitations. The aim of this study was to compute transmantle pressure noninvasively with a novel nondimensional fluid mechanics model in volunteers and to identify differences related to age and aqueductal dimensions.

MATERIALS AND METHODS

Brain MR images including cardiac-gated 2D phase-contrast MR imaging and fast-spoiled gradient recalled imaging were obtained in 77 volunteers ranging in age from 25-92 years of age. Transmantle pressure was computed during the cardiac cycle with a fluid mechanics model from the measured aqueductal flow rate, stroke volume, aqueductal length and cross-sectional area, and heart rate. Peak pressures during caudal and rostral aqueductal flow were tabulated. The computed transmantle pressure, aqueductal dimensions, and stroke volume were estimated, and the differences due to sex and age were calculated and tested for significance.

RESULTS

Peak transmantle pressure was calculated with the nondimensional averaged 14.4 (SD, 6.5) Pa during caudal flow and 6.9 (SD, 2.8) Pa during rostral flow. It did not differ significantly between men and women or correlate significantly with heart rate. Peak transmantle pressure increased with age and correlated with aqueductal dimensions and stroke volume.

CONCLUSIONS

The nondimensional fluid mechanics model for computing transmantle pressure detected changes in pressure related to age and aqueductal dimensions. This novel methodology can be easily used to investigate the clinical relevance of the transmantle pressure in normal pressure hydrocephalus, pediatric communicating hydrocephalus, and other CSF disorders.

Dynamics of lipid droplets in the endometrium and fatty acids and oxylipins in the uterine lumen, blood, and milk of lactating cows during diestrus

Our objective was to investigate the lipid content of uterus, blood plasma, and milk at early, mid, and late diestrus. Lactating cows (n = 30) had the estrous cycle and ovulation synchronized by administration of exogenous hormones. Cows were blocked by parity and assigned randomly to receive transcervical uterine flushing and biopsy on d 5 (early diestrus), 10 (mid diestrus) or 15 (late diestrus) of the estrous cycle. Flushing and endometrial biopsy were performed in the uterine horn ipsilateral to the corpus luteum. The recovered flushing was used for analyses of lipid composition by liquid chromatography-tandem mass spectrometry and the biopsy was used for investigation of lipid droplet abundance in endometrial cryosections using a neutral lipid fluorescent dye. In addition, blood and milk samples were collected from all cows on d 5, 10, and 15. All blood samples were used to measure the concentration of progesterone in plasma, and all milk samples were used to determine milk composition. Subsamples of blood plasma and milk were also used to evaluate the composition of fatty acids and oxylipins using the same methodology used for uterine flushing samples. The abundance of lipid droplets in the endometrium increased 1.9-fold from d 5 to 10, and 2-fold from d 10 to 15. Concentration of long-chain fatty acids and oxylipins in uterine flushing were, on average, 2.2 and 2.5 times greater in samples collected on d 15 compared with those collected on d 5 and 10. These differences were not observed in blood and milk, suggesting that accumulation of fatty acids and oxylipins in the uterus is regulated locally. In addition to concentration, the profile of individual fatty acids and oxylipins in uterine lumen changed substantially during diestrus. The main categories with increased abundance at late diestrus were mono- and polyunsaturated fatty acids, and oxylipins derived from arachidonic acid, dihomo-γ-linolenic acid, and docosahexaenoic acid. In conclusion, fatty acids and oxylipins accumulate in the uterine lumen during diestrus and might work as a mechanism to supply these lipids to the developing conceptus at late diestrus, when the onset of elongation occurs and substantial synthesis of biomass and cell signaling by lipid mediators are required.

Revisiones Sistemáticas Exploratorias como metodología para la síntesis del conocimiento científico

Introducción: En la actualidad los sistemas de salud alrededor del mundo apuestan por una toma decisiones clínicas basadas en la evidencia científica. Para ello, es necesario que los profesionales de la salud consulten los resultados de las investigaciones científicas. Sin embargo, dada la gran cantidad de literatura, los investigadores han desarrollado metodologías de revisión para compilar los estudios científicos dentro de un área específica. Aun cuando existen más de 10 tipos de metodologías para la revisión de la literatura, la Revisión Sistemática Exploratoria (RSE) ha recibido poca atención en la literatura sobre métodos de investigación científica de habla hispana. Objetivo: Detallar la metodología de la RSE, sus propósitos y las fases para su desarrollo. Desarrollo: Este trabajo detalla las generalidades de la RSE basándose en la metodología propuesta por Arksey & O’Malley. Así mismo, se describen las áreas o ámbitos donde este tipo de revisión se puede emplear, las fases para desarrollar la revisión y ejemplos de las RSE. Conclusiones: Las RSE tienen la fortaleza de hacer saber a los profesionales de la salud sobre un tema en específico que permita incidir en las políticas públicas. Al igual que las Revisiones Sistemáticas, las RSE utilizan una metodología clara y replicable, aportando datos confiables y científicos para los profesionales de la salud.

Protocol of a two arm randomised, multi-centre, 12-month controlled trial: evaluating the impact of a Cognitive Behavioural Therapy (CBT)-based intervention Supporting UPtake and Adherence to antiretrovirals (SUPA) in adults with HIV

Background

Delay to start antiretroviral therapy (ART) and nonadherence compromise the health and wellbeing of people living with HIV (PLWH), raise the cost of care and increase risk of transmission to sexual partners. To date, interventions to improve adherence to ART have had limited success, perhaps because they have failed to systematically elicit and address both perceptual and practical barriers to adherence. The primary aim of this study is to determine the efficacy of the Supporting UPtake and Adherence (SUPA) intervention.

Methods

This study comprises 2 phases. Phase 1 is an observational cohort study, in which PLWH who are ART naïve and recommended to take ART by their clinician complete a questionnaire assessing their beliefs about ART over 12 months. Phase 2 is a randomised controlled trial (RCT) nested within the observational cohort study to investigate the effectiveness of the SUPA intervention on adherence to ART. PLWH at risk of nonadherence (based on their beliefs about ART) will be recruited and randomised 1:1 to the intervention (SUPA intervention + usual care) and control (usual care) arms. The SUPA intervention involves 4 tailored treatment support sessions delivered by a Research Nurse utilising a collaborative Cognitive Behavioural Therapy (CBT) and Motivational Interviewing (MI) approach. Sessions are tailored to individual needs and preferences based on the individual patient’s perceptions and practical barriers to ART. An animation series and intervention manual have been developed to communicate a rationale for the personal necessity for ART and illustrate concerns and potential solutions. The primary outcome is adherence to ART measured using Medication Event Monitoring System (MEMS). Three hundred seventy-two patients will be sufficient to detect a 15% difference in adherence with 80% power and an alpha of 0.05. Costs will be compared between intervention and control groups. Costs will be combined with the primary outcome in cost-effectiveness analyses. Quality adjusted life-years (QALYs) will also be estimated over the follow-up period and used in the analyses.

Discussion

The findings will enable patients, healthcare providers and policy makers to make informed decisions about the value of the SUPA intervention.

Trial registration

The trial was retrospectively registered 21/02/2014, ISRCTN35514212.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-6893-z) contains supplementary material, which is available to authorized users.

Subject-Specific Studies of CSF Bulk Flow Patterns in the Spinal Canal: Implications for the Dispersion of Solute Particles in Intrathecal Drug Delivery

BACKGROUND AND PURPOSE

Recent flow dynamics studies have shown that the eccentricity of the spinal cord affects the magnitude and characteristics of the slow bulk motion of CSF in the spinal subarachnoid space, which is an important variable in solute transport along the spinal canal. The goal of this study was to investigate how anatomic differences among subjects affect this bulk flow.

MATERIALS AND METHODS

T2-weighted spinal images were obtained in 4 subjects and repeated in 1 subject after repositioning. CSF velocity was calculated from phase-contrast MR images for 7 equally spaced levels along the length of the spine. This information was input into a 2-time-scale asymptotic analysis of the Navier-Stokes and concentration equations to calculate the short- and long-term CSF flow in the spinal subarachnoid space. Bulk flow streamlines were shown for each subject and position and inspected for differences in patterns.

RESULTS

The 4 subjects had variable degrees of lordosis and kyphosis. Repositioning in 1 subject changed the degree of cervical lordosis and thoracic kyphosis. The streamlines of bulk flow show the existence of distinct regions where the fluid particles flow in circular patterns. The location and interconnectivity of these recirculating regions varied among individuals and different positions.

CONCLUSIONS

Lordosis, kyphosis, and spinal cord eccentricity in the healthy human spine result in subject-specific patterns of bulk flow recirculating regions. The extent of the interconnectivity of the streamlines among these recirculating regions is fundamental in determining the long-term transport of solute particles along the spinal canal.

Facilitators and Barriers to Successful Engagement in a Complex Care Management Program: Patient and Care Manager Perspectives

Complex care management (CCM) interventions have been developed across the United States to address the challenges of high-need, high-cost patients. Though their heterogeneity makes it challenging to determine their general effectiveness, there are calls in the literature to continue to implement and evaluate them. This article presents CCM patient and care manager perspectives on facilitators and barriers to success in such a program in a safety-net hospital. Our findings suggest that motivated patients, team-based care, and the ability to form trusting, supportive relationships are important contributors to success in a CCM program while patients' own mental health and socioeconomic challenges impede success. Given the relatively short-term nature of most CCM programs and the complicated challenges faced by many CCM patients, this work poses larger questions to consider around the general alignment of the program model to the patient population and the definition of success for CCM programs.

Abstract P1-13-02: Real world outcomes of adjuvant FECD, ddACT and ACT for the treatment of early stage breast cancer - A multicenter retrospective analysis

Background: Adjuvant chemotherapy combining anthracyclines and taxanes for early stage breast cancer (ESBC) have demonstrated disease-free survival (DFS) and overall survival (OS) benefits. Among the 3rd generation regimens, 2 options have been favoured: FEC-Docetaxel (FECD) and AC-Paclitaxel (ACT). ACT may be delivered with dose-dense (ddACT) or weekly taxane scheduling (ddACWT), compared to traditional every 3-weekly (q3ACT) scheduling. Despite literature supporting both FECD and (dd)ACT regimens in the management of ESBC, no direct prospective trial has evaluated their comparative effectiveness.

Methods: A retrospective review of the BC Cancer Breast Cancer Outcomes Unit (BCOU) and the Alberta Health Services (AHS) databases was performed to identify patients with HER2 negative, stage 1-3 ESBC, who received adjuvant chemotherapy between 2007-2014. The primary endpoint was OS and the secondary endpoint was RFS, defined as freedom from local (invasive), regional or distant recurrence or breast cancer death. Outcome comparisons were made between FECD, ddACT/ddACWT and q3ACT using the Kaplan Meier method. Treatment arms were compared using a log-rank test for univariate analysis. A multivariate analysis was also conducted for OS comprising age, stage, grade, receptor status and type of chemotherapy received (FECD vs combined ACT group).

Results: A total of 4047 patients met inclusion criteria, including 2685 FECD, 1259 ddACT and 103 ACT. Median age was 53 (24-77) in the FECD group vs 52 (26-68) in the ddACT/ddACWT group and 58 (43-78) in the q3ACT group. The majority had stage 2 disease, 51.3%, 53.5% and 50.5% in the FECD, ddACT/ddACWT and q3ACT groups, respectively. Most were HR+, 84.5% in the FECD group vs 66.9% in both the ddACT/ddACWT and q3ACT groups. In the FECD group, 42.8% had a grade 2 tumour and 48.2% a grade 3 tumour vs 35.4% and 56.4% in the ddACT/ddACWT group and 35.0% and 58.3% in the q3ACT group. Lymphovascular invasion (LVI) was present in 40.7% of patients who received FECD vs 39.7% for ddACT/ddACWT and 26.2% for ACT. 5-year OS, for the FECD group was 90.3% (95%CI 89.1,91.4) vs 87.0% (95%CI 84.3,89.2) for the ddACT/ddACWT and 84.9% (95%CI 75.5,90.8) for the q3ACT groups, p=0.0907. 5-year RFS was 85.5% (95%CI 84.0-86.8) with FECD vs 84.4% (95% 81.9,86.6) for ddACT/ddACWT and 87.7% (95%CI 79.2,92.8) with q3ACT,p=0.4200. In multivariate analysis: age, stage and grade were significantly associated with OS whereas type of chemotherapy received (FECD vs ACT) was not (p=0.165). Finally, OS rates were compared across provinces and no significant differences were identified, 87.0% vs 88.0% (p=0.6294). Subgroup analyses by receptor type, comparing HR+ and TNBC are ongoing.

Conclusions: The use of FECD as compared to ACT based chemotherapy did not reveal significant differences in OS or RFS in this population-based study. Further, chemotherapy regimen was not associated with differences in overall survival, as compared to other well recognized prognostic factors. While the results were obtained from a retrospective analysis, conclusive prospective data is lacking. These results may therefore reassure physicians and patients alike on a comparable efficacy of these regimens in a real-life setting.

Citation Format: LeVasseur N, Veitch Z, Diocee RM, Gondara L, Cheung W, Khan O, Cossetti R, Gelmon KA, King K, Lupichuk S, Chia SK, Tang P, Simmons C. Real world outcomes of adjuvant FECD, ddACT and ACT for the treatment of early stage breast cancer - A multicenter retrospective analysis [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-13-02.

Abstract P6-17-29: Withdrawn

This abstract was withdrawn by the authors.

Citation Format: Veitch ZW, Bedard P, Tang PA, Conway JL, Ribnikar D, Albaba H, King K, Lupichuk S, Cescon D. Withdrawn [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-17-29.

Abstract P4-16-12: Does initial cardiac imaging impact clinical outcomes in patients with breast cancer?

Background: Echocardiography (echo) and multigated acquisition (MUGA) scans are the most commonly used modalities to assess cardiac function during breast cancer (BC) treatment. However, a case series of 176 patients with cancer suggests enhanced cardiac care with echo surveillance. We hypothesized that patients with early BC imaged by echo have improved cardiac outcomes compared to those imaged by MUGA.

Methods: Consecutive patients with stage I to III breast cancer undergoing pre-treatment echo or MUGA were retrospectively screened from January 2010 to December 2014. Patients participating in clinical trials with mandated imaging and/or cardiac reviews were excluded. Demographics, medical history and clinical events were collected via chart review and electronic health records. All patients had a minimum 1 year of follow-up. The primary outcome was a composite of death, cardiac hospitalization or cardiac emergency room visit.

Results: 598 patients were identified as having a baseline echo and 636 had had baseline MUGA. Mean follow-up was 4.5±1.4 years. Patients undergoing MUGA were younger, had more advanced stage of disease and received more anthracycline and trastuzumab (table1). Patients imaged by MUGA had lower cardiac function at baseline compared to echo, LVEF 64% vs. LVEF 65% respectively, P &lt;0.001. Cancer therapy related cardiac dysfunction was similar between groups, 10% vs. 11%, p=0.81. Patients in the echo group were more likely to be seen by cardiology, 7% vs. 3%, p&lt;0.0001, and to be initiated on beta blocker, 4% vs. 1%, p=0.006, or angiotensin converting enzyme inhibitor, 3% vs. 1%, p=0.002.However, there was no difference between groups for the primary outcome, 10% event rate in each group, even after adjustment for age, BC stage, chemotherapy and cardiac medications, hazard ratio 1.04 (CI 0.72-1.49), p=0.842.

Conclusion: For patients with early stage BC, the choice of cardiac imaging modality at baseline does not impact adverse cardiac events. However, patients undergoing echo were more likely to be evaluated and managed by cardiology.

Table 1.Baseline Characteristics Echo (N=598)MUGA (N=636)Age mean54±1053±10*BMI mean29±629±7Cardiovascular HistoryDiabetes66(11%)56(9%)Hypertension154(26%)155(24%)Dyslipidemia83(14%)75(12%)CAD9(2%)6(1%)CHF7(1%)4(1%)Beta Blocker22(4%)28(4%)ACE-Inhibitor51(9%)64(10%)Angiotensin Receptor Blocker69(12%)44(7%)*Cancer HistoryStage*Stage I65(11%)56(9%)Stage II377(63%)361(57%)Stage III155(26%)219(34%)Receptor StatusTriple negative64(11%)76(12%)HER2 negative, hormone positive342(58%)387(61%)HER2 positive192(32%)173(27%)Cancer TherapyChemotherapy (any)528(88%)594(93%)*Anthracycline310(52%)394(62%)*Trastuzumab170(28%)148(23%)*Anthracycline & trastuzumab6(1%)19(3%)*Hormone therapy459(77%)487(77%)Radiation (any)487(81%)527(83%)Radiation left side237(49%)259(49%)Surgery597(100%)633(100%)* p&lt;0.05 for comparison between echo and MUGA groups

Citation Format: Parent S, Xu L, Becher H, Mackey J, King K, Pituskin E, Paterson I. Does initial cardiac imaging impact clinical outcomes in patients with breast cancer? [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-16-12.

Identical and Nonidentical Twins: Risk and Factors Involved in Development of Islet Autoimmunity and Type 1 Diabetes

OBJECTIVE

There are variable reports of risk of concordance for progression to islet autoantibodies and type 1 diabetes in identical twins after one twin is diagnosed. We examined development of positive autoantibodies and type 1 diabetes and the effects of genetic factors and common environment on autoantibody positivity in identical twins, nonidentical twins, and full siblings.

RESEARCH DESIGN AND METHODS

Subjects from the TrialNet Pathway to Prevention Study (N = 48,026) were screened from 2004 to 2015 for islet autoantibodies (GAD antibody [GADA], insulinoma-associated antigen 2 [IA-2A], and autoantibodies against insulin [IAA]). Of these subjects, 17,226 (157 identical twins, 283 nonidentical twins, and 16,786 full siblings) were followed for autoantibody positivity or type 1 diabetes for a median of 2.1 years.

RESULTS

At screening, identical twins were more likely to have positive GADA, IA-2A, and IAA than nonidentical twins or full siblings (all P < 0.0001). Younger age, male sex, and genetic factors were significant factors for expression of IA-2A, IAA, one or more positive autoantibodies, and two or more positive autoantibodies (all P ≤ 0.03). Initially autoantibody-positive identical twins had a 69% risk of diabetes by 3 years compared with 1.5% for initially autoantibody-negative identical twins. In nonidentical twins, type 1 diabetes risk by 3 years was 72% for initially multiple autoantibody-positive, 13% for single autoantibody-positive, and 0% for initially autoantibody-negative nonidentical twins. Full siblings had a 3-year type 1 diabetes risk of 47% for multiple autoantibody-positive, 12% for single autoantibody-positive, and 0.5% for initially autoantibody-negative subjects.

CONCLUSIONS

Risk of type 1 diabetes at 3 years is high for initially multiple and single autoantibody-positive identical twins and multiple autoantibody-positive nonidentical twins. Genetic predisposition, age, and male sex are significant risk factors for development of positive autoantibodies in twins.

SHORT-TERM EFFECTS OF TRIGGER POINT DRY NEEDLING ON PAIN AND DISABILITY IN SUBJECTS WITH PATELLOFEMORAL PAIN SYNDROME

BACKGROUND

Patellofemoral pain syndrome (PFPS) is a prevalent knee disorder. A novel yet increasingly popular treatment for PFPS is trigger point dry needling (DN).

PURPOSE

The purpose of this study was to determine if DN is more effective at reducing pain and disability than a sham treatment in individuals with PFPS.

STUDY DESIGN

Randomized trial.

MATERIALS/METHODS

Sixty military health care beneficiaries (36 males) with a clinical diagnosis of PFPS were recruited and completed the study. Subjects underwent a standardized clinical examination and were randomized into a DN or sham treatment group. DN treatment consisted of insertion of an acupuncture-like needle into six sites in the quadriceps femoris muscles of the symptomatic lower extremity based on a palpation examination. The sham grouped received a simulated treatment with a sharp object and needle guide tube without puncturing the skin. Self-reports of pain, disability, and overall status were collected before treatment, immediately after treatment and at 72 hours. Data were analyzed with separate 2x2 repeated measures analysis of variance, with independent variables being Group (DN vs. sham) and Time (pre-treatment vs. immediately post-treatment, and pre-treatment vs. 72 hours). The hypothesis of interest in each case was the Group*Time interaction. The alpha-level was set a priori to .05 using 2-tailed tests.

RESULTS

Both groups exhibited a clinically meaningful reduction in pain based on numeric pain rating scale scores immediately post-treatment and at 72 hours, but there was no statistically significant difference between groups (p = 0.219, 0.310). There was no significant difference between groups for any other outcome measures.

CONCLUSION

These data suggest that DN treatment is not more effective than a sham DN treatment at reducing short-term pain and disability in individuals with PFPS when used as an isolated treatment approach.

LEVEL OF EVIDENCE

2.