Study of High-Transverse-Momentum Higgs Boson Production in Association with a Vector Boson in the qqbb Final State with the ATLAS Detector

This Letter presents the first study of Higgs boson production in association with a vector boson (V=W or Z) in the fully hadronic qqbb final state using data recorded by the ATLAS detector at the LHC in proton-proton collisions at sqrt[s]=13  TeV and corresponding to an integrated luminosity of 137  fb^{-1}. The vector bosons and Higgs bosons are each reconstructed as large-radius jets and tagged using jet substructure techniques. Dedicated tagging algorithms exploiting b-tagging properties are used to identify jets consistent with Higgs bosons decaying into bb[over ¯]. Dominant backgrounds from multijet production are determined directly from the data, and a likelihood fit to the jet mass distribution of Higgs boson candidates is used to extract the number of signal events. The VH production cross section is measured inclusively and differentially in several ranges of Higgs boson transverse momentum: 250-450, 450-650, and greater than 650 GeV. The inclusive signal yield relative to the standard model expectation is observed to be μ=1.4_{-0.9}^{+1.0} and the corresponding cross section is 3.1±1.3(stat)_{-1.4}^{+1.8}(syst)  pb.

Measurement of the Centrality Dependence of the Dijet Yield in p+Pb Collisions at sqrt[s_{NN}]=8.16 TeV with the ATLAS Detector

ATLAS measured the centrality dependence of the dijet yield using 165  nb^{-1} of p+Pb data collected at sqrt[s_{NN}]=8.16  TeV in 2016. The event centrality, which reflects the p+Pb impact parameter, is characterized by the total transverse energy registered in the Pb-going side of the forward calorimeter. The central-to-peripheral ratio of the scaled dijet yields, R_{CP}, is evaluated, and the results are presented as a function of variables that reflect the kinematics of the initial hard parton scattering process. The R_{CP} shows a scaling with the Bjorken x of the parton originating from the proton, x_{p}, while no such trend is observed as a function of x_{Pb}. This analysis provides unique input to understanding the role of small proton spatial configurations in p+Pb collisions by covering parton momentum fractions from the valence region down to x_{p}∼10^{-3} and x_{Pb}∼4×10^{-4}.

Search for New Phenomena in Two-Body Invariant Mass Distributions Using Unsupervised Machine Learning for Anomaly Detection at sqrt[s]=13 TeV with the ATLAS Detector

Searches for new resonances are performed using an unsupervised anomaly-detection technique. Events with at least one electron or muon are selected from 140  fb^{-1} of pp collisions at sqrt[s]=13  TeV recorded by ATLAS at the Large Hadron Collider. The approach involves training an autoencoder on data, and subsequently defining anomalous regions based on the reconstruction loss of the decoder. Studies focus on nine invariant mass spectra that contain pairs of objects consisting of one light jet or b jet and either one lepton (e,μ), photon, or second light jet or b jet in the anomalous regions. No significant deviations from the background hypotheses are observed. Limits on contributions from generic Gaussian signals with various widths of the resonance mass are obtained for nine invariant masses in the anomalous regions.

Observation of WZγ Production in pp Collisions at sqrt[s]=13 TeV with the ATLAS Detector

This Letter reports the observation of WZγ production and a measurement of its cross section using 140.1±1.2  fb^{-1} of proton-proton collision data recorded at a center-of-mass energy of 13 TeV by the ATLAS detector at the Large Hadron Collider. The WZγ production cross section, with both the W and Z bosons decaying leptonically, pp→WZγ→ℓ^{'}^{±}νℓ^{+}ℓ^{-}γ (ℓ^{(^{'})}=e, μ), is measured in a fiducial phase-space region defined such that the leptons and the photon have high transverse momentum and the photon is isolated. The cross section is found to be 2.01±0.30(stat)±0.16(syst)  fb. The corresponding standard model predicted cross section calculated at next-to-leading order in perturbative quantum chromodynamics and at leading order in the electroweak coupling constant is 1.50±0.06  fb. The observed significance of the WZγ signal is 6.3σ, compared with an expected significance of 5.0σ.

Combined Measurement of the Higgs Boson Mass from the H→γγ and H→ZZ^{*}→4ℓ Decay Channels with the ATLAS Detector Using sqrt[s]=7, 8, and 13 TeV pp Collision Data

A measurement of the mass of the Higgs boson combining the H→ZZ^{*}→4ℓ and H→γγ decay channels is presented. The result is based on 140  fb^{-1} of proton-proton collision data collected by the ATLAS detector during LHC run 2 at a center-of-mass energy of 13 TeV combined with the run 1 ATLAS mass measurement, performed at center-of-mass energies of 7 and 8 TeV, yielding a Higgs boson mass of 125.11±0.09(stat)±0.06(syst)=125.11±0.11  GeV. This corresponds to a 0.09% precision achieved on this fundamental parameter of the Standard Model of particle physics.

Search for Dark Photons in Rare Z Boson Decays with the ATLAS Detector

A search for events with a dark photon produced in association with a dark Higgs boson via rare decays of the standard model Z boson is presented, using 139  fb^{-1} of sqrt[s]=13  TeV proton-proton collision data recorded by the ATLAS detector at the Large Hadron Collider. The dark boson decays into a pair of dark photons, and at least two of the three dark photons must each decay into a pair of electrons or muons, resulting in at least two same-flavor opposite-charge lepton pairs in the final state. The data are found to be consistent with the background prediction, and upper limits are set on the dark photon's coupling to the dark Higgs boson times the kinetic mixing between the standard model photon and the dark photon, α_{D}ϵ^{2}, in the dark photon mass range of [5, 40] GeV except for the ϒ mass window [8.8, 11.1] GeV. This search explores new parameter space not previously excluded by other experiments.

Measurement of Suppression of Large-Radius Jets and Its Dependence on Substructure in Pb+Pb Collisions at sqrt[s_{NN}]=5.02 TeV with the ATLAS Detector

This letter presents a measurement of the nuclear modification factor of large-radius jets in sqrt[s_{NN}]=5.02  TeV Pb+Pb collisions by the ATLAS experiment. The measurement is performed using 1.72  nb^{-1} and 257  pb^{-1} of Pb+Pb and pp data, respectively. The large-radius jets are reconstructed with the anti-k_{t} algorithm using a radius parameter of R=1.0, by reclustering anti-k_{t} R=0.2 jets, and are measured over the transverse momentum (p_{T}) kinematic range of 158 Collapse

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Measurement of the Sensitivity of Two-Particle Correlations in pp Collisions to the Presence of Hard Scatterings

A key open question in the study of multiparticle production in high-energy pp collisions is the relationship between the "ridge"-i.e., the observed azimuthal correlations between particles in the underlying event that extend over all rapidities-and hard or semihard scattering processes. In particular, it is not known whether jets or their soft fragments are correlated with particles in the underlying event. To address this question, two-particle correlations are measured in pp collisions at sqrt[s]=13  TeV using data collected by the ATLAS experiment at the LHC, with an integrated luminosity of 15.8  pb^{-1}, in two different configurations. In the first case, charged particles associated with jets are excluded from the correlation analysis, while in the second case, correlations are measured between particles within jets and charged particles from the underlying event. Second-order flow coefficients, v_{2}, are presented as a function of event multiplicity and transverse momentum. These measurements show that excluding particles associated with jets does not affect the measured correlations. Moreover, particles associated with jets do not exhibit any significant azimuthal correlations with the underlying event, ruling out hard processes contributing to the ridge.

Observation of an Excess of Dicharmonium Events in the Four-Muon Final State with the ATLAS Detector

A search is made for potential ccc[over ¯]c[over ¯] tetraquarks decaying into a pair of charmonium states in the four muon final state using proton-proton collision data at sqrt[s]=13  TeV, corresponding to an integrated luminosity of 140  fb^{-1} recorded by the ATLAS experiment at LHC. Two decay channels, J/ψ+J/ψ→4μ and J/ψ+ψ(2S)→4μ, are studied. Backgrounds are estimated based on a hybrid approach involving Monte Carlo simulations and data-driven methods. Statistically significant excesses with respect to backgrounds dominated by the single parton scattering are seen in the di-J/ψ channel consistent with a narrow resonance at 6.9 GeV and a broader structure at lower mass. A statistically significant excess is also seen in the J/ψ+ψ(2S) channel. The fitted masses and decay widths of the structures are reported.

Test of CP Invariance in Higgs Boson Vector-Boson-Fusion Production Using the H→γγ Channel with the ATLAS Detector

A test of CP invariance in Higgs boson production via vector-boson fusion has been performed in the H→γγ channel using 139  fb^{-1} of proton-proton collision data at sqrt[s]=13  TeV collected by the ATLAS detector at the LHC. The optimal observable method is used to probe the CP structure of interactions between the Higgs boson and electroweak gauge bosons, as described by an effective field theory. No sign of CP violation is observed in the data. Constraints are set on the parameters describing the strength of the CP-odd component in the coupling between the Higgs boson and the electroweak gauge bosons in two effective field theory bases: d[over ˜] in the HISZ basis and c_{HW[over ˜]} in the Warsaw basis. The results presented are the most stringent constraints on CP violation in the coupling between Higgs and weak bosons. The 95% C.L. constraint on d[over ˜] is derived for the first time and the 95% C.L. constraint on c_{HW[over ˜]} has been improved by a factor of 5 compared to the previous measurement.

93 Are NSAIDs Being Prescribed First Line to Manage Renal Colic Pain? A Complete Audit

Introduction

NICE recommends NSAIDs as first line analgesia for renal colic pain. The aim of this audit was to evaluate NSAID prescribing at Salford Royal Hospital in this patient cohort against NICE guidelines.

Method

Using electronic patient records, patients admitted with renal colic pain over a 3-week period were identified. Data regarding the type and order of analgesia prescriptions from the time of surgical clerking were collected retrospectively. Patients with a documented contraindication to NSAIDs were excluded. A local renal colic pathway was published by the Urology Department, and we followed this with additional interventions, namely an email reminder to the juniors and a poster with a renal colic analgesia ladder illustration as an aide-memoire. Subsequently, a re-audit was undertaken.

Results

Cycle 1 identified 22 patients admitted with renal colic pain with most diagnoses supported radiologically. Only 38% of patients were found to be prescribed an NSAID for analgesia around the time of surgical clerking. In the re-audit, 50% of patients had an NSAID prescribed at the time of surgical clerking.

Conclusions

NSAIDs are clearly being underused as first line analgesia in renal colic pain despite NICE guidelines. A newly published trust renal colic pathway and targeted interventions have shown to increase their use, but further QI work is needed.

5 Cervical Spine Pedicle Screw Accuracy in Open Fluoroscopic, Navigated and Template Guided Systems- a Systematic Review

Aim

Pedicle screws provide excellent fixation for a wide range of indications; their adoption in the cervical spine has been slower than in the thoracic and lumbar spine, largely due to the smaller pedicle sizes and proximity to neurovascular structures in the neck. Recent years have seen the development of technology to improve accuracy and thereby safety in cervical pedicle screw placement over traditional fluoroscopic techniques, including intraoperative 3D navigation, computer assisted systems and physical templates with screw guides. We have performed a systematic review into the accuracy rates of the various systems.

Method

PubMed and Cochrane Library databases were searched; keywords "pedicle screw cervical spine" were searched; 9 valid papers involving 1427 screws were found.

Results

Accuracy rates were 80.6% for fluoroscopy, 91.4% for navigation methods, and 96.7% for templates.

Conclusions

Superior results for templates are complemented by reduced radiation exposure to patient and surgeon; however, the technology requires prolonged pre-operative planning to create the bespoke template, and the development of an infrastructure to allow for their rapid production and delivery is needed before they become more widely available.

Two broad methods of navigation currently exist: intraoperative CT scanning providing real-time 3D navigation and preoperative CT registration in relation to a fixed reference with intraoperative computer assistance. At present, these methods are more commonly used, due to their proven improved accuracy rates over fluoroscopy, availability in emergencies and alongside minimally invasive techniques.

Despite their novelty and limitations, templates provide promising accuracy scores, although practical considerations may inhibit their proliferation.

834 What’s The SCORE? Surgeons’ Approach to Treating Symptomatic, Clinically Occult, Radiologically Evident Inguinal Hernias

Introduction

The management of symptomatic, clinically occult, radiologically evident inguinal hernias (SCORE-IH) is challenging. This pathology lacks a validated definition and a standardised treatment paradigm to prevent risks of operative management. This study explores current practice amongst surgeons treating SCORE-IH.

Method

STEER collaborators disseminated a validated online survey amongst their UK consultants. Responses to the survey were collated on a spreadsheet and analysed with basic percentages.

Results

Seventy-three responses were received, including six (8%) international surgeons. UGI and colorectal surgeons were the predominant sub-specialities at 33% and 32%, respectively. Only 26% reported they performed more than 100 IH repairs annually. Less than half of the responders (41%) of surgeons reported more than 50% laparoscopic IH repairs. Nearly two thirds (62%) were unaware of guidelines on the management of SCORE-IH. Imaging chose to manage SCORE-IH included US, MRI, and CT at 71%, 44% and 29%, respectively. Only 14% of surgeons reported they would not consider any imaging. Only 19% would manage conservatively, while 37% would manage operatively.

Conclusions

There is skill diversity when treating IH. A lack of guidance and consensus amongst the surveyed surgeons is evident by the heterogeneity in imaging utilisation and varied treatment pathways offered to SCORE-IH patients.

879 Establishing the First Eoe Deanery-Wide Trainee Led Virtual Journal Club: Keeping Up Morale by Encouraging Trainee Interaction and Continuous Professional Development During the Hiatus to Teaching Activities Enforced by Coronavirus

Introduction

Over the initial COVID months and with the cancellation of several teaching programs / courses/ conferences; we identified a NEED for trainee interaction and continuous professional development, despite staff redeployments. We since established a deanery-wide trainee led VIRTUAL journal club, run by the Surgical Trainees of East of England Research collaborative (STEER) group.

Method

Following decision in May2020, the STEER group collated curriculum topics and related landmark papers, drafting a programmed-schedule for sessions (45mins – 1hour). CPD accreditation was sought and received from RCSEd prior to some sessions. Sessions were delivered using the Microsoft Teams app (via desktop/tablet/phone). Targeted audience included FYs, CTs, STs, JCFs, SCFs (candidates preparing for MRCS/FRCS or interested in academia). Live polling / feedback forms and attendance certificates were distributed.

Results

Six journal club sessions have been run to-date. A minimum of 15-20 participants attended each session with spread of junior/senior trainees. Sessions were video recorded for repeat playback for those unable to attend. Feedback was overwhelmingly positive, with good engagement from participants.

Conclusions

A deanery wide virtual journal club was positively received by trainees and benefits included: critique and dissemination of evidence (especially recently with COVID-related literature), trainee interaction and keeping up-to-date and understanding and analysing information.

778 Management of Colorectal Anastomotic leaks: The East of England Experience

Introduction

Colorectal anastomotic leaks (AL) are an unfortunate occurrence and are associated with a high mortality. The aim of this multi-centre study is to explore the different management strategies used and compare outcomes in the management of AL.

Method

All patients who had an AL were included at seven hospitals across the East of England. Morbidity, mortality, and survival were compared across the different management strategies.

Results

A total of 247 consecutive patients were included of which 60.3% were male and the median age was 68 (IQR 57-77). Half of patients were initially managed conservatively, a further 10.5% had a radiological procedure. 39.7% required surgery as an initial treatment. Of those who initially did not have a surgical intervention (n = 149), 10.7% (n = 16/149) eventually required laparotomy. Ultimately, 42.7% (n = 106/248) required a laparotomy. The 30- and 90-day across the entire population mortality were 3.6% and 4.9% respectively. There were no significant differences in mortality or long-terms survival between the different initial treatment modalities.

Conclusions

Despite initial conservative, antibiotic and radiological intervention being successful in the majority of patients, two out of five patients will still require a laparotomy. A consensus approach is required to standardise management in these difficult scenarios.

Current technical surgical practice of emergency appendicectomy: a cross-sectional survey of surgical registrars in the UK

INTRODUCTION

Appendicectomy remains one of the most commonly performed procedures in general surgery. The aim of this study was to explore variation in operative techniques of an appendicectomy among surgical registrars in England.

MATERIALS AND METHODS

An anonymised survey was sent out to surgical registrars in the UK via email and social media. Subgroup analyses were performed comparing respondents based on their level of seniority and subspecialty background.

RESULTS

A total of 168 respondents completed the survey, of whom 77.4% (130/168) were specialty trainees years 3-8 and 44.6% (75/168) were colorectal trainees. The majority (98.8%) preferred a laparoscopic approach to appendicectomy. Overall, 73.2% opted to use diathermy to divide an uninflamed mesoappendix. Half of the respondents (50%) preferentially used diathermy to control the appendicular artery, followed by 44% preferring use of metal or polymeric clips. The appendicular stump was most often secured with Endoloops (85.7%) when removing a macroscopically uninflamed appendix but less readily used in the visibly inflamed appendix (75.6%, p = 0.01). Colorectal and upper gastrointestinal registrars were more likely to use diathermy on the mucosa of the appendix stump compared with other subspecialties (p = 0.03). The majority (82.1%) of respondents extracted the appendix via a retrieval bag. Regarding skin closure, most respondents (69%) adopted absorbable subcuticular sutures. Preferential duration of postoperative antibiotic use following appendicectomy for complicated appendicitis varied among the respondents.

CONCLUSION

There are similarities and differences across surgical registrars in terms of technical practice in appendicectomy, partially attributed to prior experience and training.

Oncologic outcomes of patients with incidental prostate cancer who underwent RARC: a comparison between nerve sparing and non-nerve sparing approach

BACKGROUND

Incidental Prostate cancer (iPCa) is a relatively common finding during histopathological evaluation of radical cystectomy (RC) specimens. To reduce the high impact of RC on erectile function, several sexual-preserving techniques have been proposed. The aim of this study was to evaluate and compare the oncologic outcomes of patients with iPCa who underwent nerve spring and no-nerve sparing robot-assisted radical cystectomy (RARC).

METHODS

The clinicopathologic data of male patients who underwent RARC at our institution between 2006 and 2016 were retrospectively analysed. Patients with iPCa at definitive pathological examinations were stratified in two groups, according to the preservation of the neurovascular bundles (nerve sparing vs no nerve sparing). Significant PCa was defined as any Gleason score ≥ 3 + 4. Biochemical recurrence (BR) was defined as a sustained PSA level > 0.2 ng/mL on two or more consecutive appraisals. BR rate was assessed only in patients with incidental prostate cancer and at least 2 years of follow-up. Differences in categorical and continuous variables were analysed using the chi-squared test and the Mann-Withney U test, respectively. Biochemical recurrence curves were generated using the Kaplan-Meier method and compared with the Log-rank test.

RESULTS

Overall, 343 male patients underwent RARC for bladder cancer within the study period. Nerve-sparing surgery was performed in 143 patients (41%), of these 110 had at least 2 years of follow up after surgery. Patients who underwent nerve-sparing surgery were significantly younger (p < 0.001). Clinically significant PCa was found in 24% of patients. No significant differences regarding preoperative PSA value (p = 0.3), PCa pathological stage (p = 0.5), Gleason score (p = 0.3) and positive surgical margin rates (p = 0.3) were found between the two groups. After a median follow-up of 51 months only one patient, in the no-nerve-sparing group had developed a biochemical recurrence (p = 0.4).

CONCLUSIONS

In our series most of the iPca detected in RC specimens can be considered as insignificant with a low rate of BR (0.9%). Nerve-sparing RARC is a safe procedure which did not affect oncological outcomes of patients with iPCa.

Does intra-operative flexible endoscopy reduce anastomotic complications following left-sided colonic resections? A systematic review and meta-analysis

AIM

Postoperative anastomotic leakage (AL) or bleeding (AB) significantly impacts on patient outcome following colorectal resection. To minimize such complications, surgeons can utilize different techniques perioperatively to assess anastomotic integrity. We aim to assess published anastomotic complication rates following left-sided colonic resection, comparing the use of intra-operative flexible endoscopy (FE) against conventional tests used to assess anastomotic integrity.

METHODS

PubMed/MEDLINE and Embase online databases were searched for non-randomized and randomized case-control studies that investigated postoperative AL and/or AB rates in left-sided colonic resections, comparing intra-operative FE against conventional tests. Data from eligible studies were pooled, and a meta-analysis using Review Manager 5.3 software was performed to assess for differences in AL and AB rates.

RESULTS

Data from six studies were analysed to assess the impact of FE on postoperative AL and AB rates (1084 and 751 patients respectively). Use of FE was associated with reduced postoperative AL and AB rates, from 6.9% to 3.5% and 5.8% to 2.4% respectively. Odds ratios favoured intra-operative FE: 0.37 (95% CI 0.21-0.68, P = 0.001) for AL and 0.35 (95% CI 0.15-0.82, P = 0.02) for AB.

CONCLUSION

This meta-analysis showed that the use of intra-operative FE is associated with a reduced rate of postoperative AL and AB, compared to conventional anastomotic testing methods.

Non-Invasive Assessment of Graft Fibrosis After Living Donor Liver Transplantation: Is There Still a Role for Liver Biopsy?

Non-invasive methods have evolved as a surrogate for liver biopsy such as indirect markers (aspartate transaminase to platelet ratio index, fibro-α score), transient elastography (TE), and magnetic resonance elastography (MRE). The aim of this study is to prospectively compare the value of MRE, TE, and indirect markers in detecting and staging allograft fibrosis compared to liver biopsies in patients who have undergone living donor liver transplantation for complications related to hepatitis C virus. A total of 31 living donor liver transplantation recipients with hepatitis C virus recurrence underwent a liver biopsy, TE, and MRE within 3 months of a liver biopsy. Fibrosis was assessed according to the biopsy and staged according to Metavir criteria. There was a significant correlation between both MRE and fibro-α scores, as well as histologic classification by liver biopsy (P = .02, .002). The diagnostic accuracy of MRE and fibro-α scores in diagnosing significant fibrosis (F ≥ 3) was measured as the area under the curve (.708 and .833, respectively). Both methods showed good diagnostic performance. TE and aspartate transaminase to platelet ratio index were insignificantly correlated with the degree of fibrosis in liver biopsy (P value of .134, .535). At a cutoff value of 5.5 kPa, MRE predicted graft fibrosis (Metavir stage ≥ 3) with 71.43% sensitivity, 75% specificity, 45.5% positive predictive value, and 90% negative predictive value; at a cutoff value  > 1.47, fibro-α scores predicted significant graft fibrosis (Metavir stage ≥ 3) with 85.7% sensitivity and 70.83% specificity, with a positive predictive value of 46.2% and a negative predictive value of 94.4%. These data suggest that non-invasive methods could be considered a reliable tool in assessing significant graft fibrosis post-living donor liver transplantation.

Increased natural killer cell subsets with inhibitory cytokines and inhibitory surface receptors in patients with recurrent miscarriage and decreased or normal subsets in kidney transplant recipients late post-transplant

Patients with recurrent miscarriage (RM) show up-regulated cytotoxic natural killer (NK) cells that are suspected to play a causal role in abortion. In the present study, we investigated counter-regulating inhibitory mechanisms and compared the results in RM patients with those of healthy controls (HC), patients with end-stage renal disease (ESRD) and kidney transplant recipients late post-transplant (TX). NK, NK T and T cell subsets were analysed in the peripheral blood of 31 RM, 14 female ESRD and nine female TX patients as well as 21 female HC using eight-colour fluorescence flow cytometry. Compared with HC, RM patients showed significantly higher absolute numbers of CD56⁺ NK cells co-expressing the phenotype interferon (IFN)-γR⁺ , IL-4⁺ , transforming growth factor (TGF)-β⁺ , IL-4⁺ human leucocyte antigen D-related (HLA-DR)⁺ , TGF-β⁺ HLA-DR⁺ , IL-4⁺ TGF-β⁺ , IL-4⁺ TGF-β^- , IFN-γ⁺ and/or IL-10^- IFN-γ⁺ (all P ≤ 0·01), more IL-17⁺ CD56^bright (P = 0·028) NK cells and more CD56^dim CD16⁺ NK cells co-expressing IFN-γR, IFN-γ, IL-4 and/or TGF-β (all P ≤ 0·01). When the same cell subsets were analysed in ESRD or TX patients, cytokine-producing NK cell subsets were not significantly different from those of HC. RM patients showed significantly higher absolute numbers of CD158a⁺ , CD158b⁺ , CD158a^- CD158e⁺ (all P < 0·05), NKG2D⁺ NKG2A⁺ , NKG2D ⁺ NKG2A^- , NKG2D⁺ and/or NKG2A⁺ (all P ≤ 0·01) CD56⁺ NK cells and higher CD158a⁺ , CD158b⁺ (all P < 0·05), NKG2D⁺ and/or NKG2A⁺ (all P < 0·01) CD56^dim+ CD16⁺ NK cells than HC. In contrast, ESRD patients had normal and TX recipients had lower CD158a⁺ and NKG2D⁺ NKG2A^- CD56⁺ NK cells and lower CD158a⁺ CD56^dim+ CD16⁺ NK cells (all P < 0·05) than HC. RM patients have abnormally high circulating NK cells expressing inhibitory cytokines and inhibitory surface receptors which might contribute to the pathogenesis of RM.

Association of peripheral NK cell counts with Helios+ IFN-γ- Tregs in patients with good long-term renal allograft function

Little is known about a possible interaction of natural killer (NK) cells with regulatory T cells (T_reg ) in long-term stable kidney transplant recipients. Absolute counts of lymphocyte and T_reg subsets were studied in whole blood samples of 136 long-term stable renal transplant recipients and 52 healthy controls using eight-colour fluorescence flow cytometry. Patients were 1946 ± 2201 days (153-10 268 days) post-transplant and showed a serum creatinine of 1·7 ± 0·7 mg/dl. Renal transplant recipients investigated > 1·5 years post-transplant showed higher total NK cell counts than recipients studied < 1·5 years after transplantation (P = 0·006). High NK cells were associated with high glomerular filtration rate (P = 0·002) and low serum creatinine (P = 0·005). Interestingly, high NK cells were associated with high CD4⁺ CD25⁺ CD127^- forkhead box protein 3 (FoxP3⁺ ) T_reg that co-express the phenotype Helios⁺ interferon (IFN)-γ^- and appear to have stable FoxP3 expression and originate from the thymus. Furthermore, high total NK cells were associated with T_reg that co-express the phenotypes interleukin (IL)-10^- transforming growth factor (TGF)-β⁺ (P = 0·013), CD183⁺ CD62L^- (P = 0·003), CD183⁺ CD62⁺ (P = 0·001), CD183^- CD62L⁺ (P = 0·002), CD252^- CD152⁺ (P < 0·001), CD28⁺ human leucocyte antigen D-related (HLA-DR^- ) (P = 0·002), CD28⁺ HLA-DR⁺ (P < 0·001), CD95⁺ CD178^- (P < 0·001) and CD279^- CD152⁺ (P < 0·001), suggesting that these activated T_reg home in peripheral tissues and suppress effector cells via TGF-β and cytotoxic T lymphocyte-associated protein 4 (CTLA-4). The higher numbers of NK and T_reg cell counts in patients with long-term good allograft function and the statistical association of these two lymphocyte subsets with each other suggest a direct or indirect (via DC) interaction of these cell subpopulations that contributes to good long-term allograft acceptance. Moreover, we speculate that regulatory NK cells are formed late post-transplant that are able to inhibit graft-reactive effector cells.

Prostate cancer screening in men aged 50 to 69 years (STHLM3): A prospective population-based diagnostic study. Grönberg H, Adolfsson J, Aly M, Nordström T, Wiklund P, Brandberg Y, Thompson J, Wiklund F, Lindberg J, Clements M, Egevad L, Eklund M.Lancet Oncol. 2015 Dec;16(16):1667-76. [Epub 2015 Nov 10]. doi: 10.1016/S1470-2045(15)00361-7

BACKGROUND

The prostate-specific antigen (PSA) test is used to screen for prostate cancer but has a high false-positive rate that translates into unnecessary prostate biopsies and overdiagnosis of low-risk prostate cancers. We aimed to develop and validate a model to identify high-risk prostate cancer (with a Gleason score of at least 7) with better test characteristics than that provided by PSA screening alone.

METHODS

The Stockholm 3 (STHLM3) study is a prospective, population-based, paired, screen-positive, diagnostic study of men without prostate cancer aged 50 to 69 years randomly invited by date of birth from the Swedish Population Register kept by the Swedish Tax Agency. Men with prostate cancer at enrolment were excluded from the study. The predefined STHLM3 model (a combination of plasma protein biomarkers [PSA, free PSA, intact PSA, hK2, MSMB, MIC1], genetic polymorphisms [232 SNPs], and clinical variables [age, family, history, previous prostate biopsy, prostate exam]), and PSA concentration were both tested in all participants enrolled. The primary aim was to increase the specificity compared with PSA without decreasing the sensitivity to diagnose high-risk prostate cancer. The primary outcomes were number of detected high-risk cancers (sensitivity) and the number of performed prostate biopsies (specificity). The STHLM3 training cohort was used to train the STHLM3 model, which was prospectively tested in the STHLM3 validation cohort. Logistic regression was used to test for associations between biomarkers and clinical variables and prostate cancer with a Gleason score of at least 7. This study is registered with ISCRTN.com, number ISRCTN84445406.

FINDINGS

The STHLM3 model performed significantly better than PSA alone for detection of cancers with a Gleason score of at least 7 (P<0.0001), the area under the curve was 0·56 (95% CI: 0·55-0·60) with PSA alone and 0·74 (95% CI: 0·72-0·75) with the STHLM3 model. All variables used in the STHLM3 model were significantly associated with prostate cancers with a Gleason score of at least 7 (P<0·05) in a multiple logistic regression model. At the same level of sensitivity as the PSA test using a cutoff of≥3ng/ml to diagnose high-risk prostate cancer, use of the STHLM3 model could reduce the number of biopsies by 32% (95% CI: 24-39) and could avoid 44% (35-54) of benign biopsies.

INTERPRETATION

The STHLM3 model could reduce unnecessary biopsies without compromising the ability to diagnose prostate cancer with a Gleason score of at least 7, and could be a step towards personalised risk-based prostate cancer diagnostic programmes.

FUNDING

Stockholm County Council (Stockholms Läns Landsting).

Local Expansion of Donation After Circulatory Death Kidney Transplant Activity Improves Waitlisted Outcomes and Addresses Inequities of Access to Transplantation

In the United Kingdom, donation after circulatory death (DCD) kidney transplant activity has increased rapidly, but marked regional variation persists. We report how increased DCD kidney transplant activity influenced waitlisted outcomes for a single center. Between 2002-2003 and 2011-2012, 430 (54%) DCD and 361 (46%) donation after brain death (DBD) kidney-only transplants were performed at the Cambridge Transplant Centre, with a higher proportion of DCD donors fulfilling expanded criteria status (41% DCD vs. 32% DBD; p = 0.01). Compared with U.K. outcomes, for which the proportion of DCD:DBD kidney transplants performed is lower (25%; p < 0.0001), listed patients at our center waited less time for transplantation (645 vs. 1045 days; p < 0.0001), and our center had higher transplantation rates and lower numbers of waiting list deaths. This was most apparent for older patients (aged >65 years; waiting time 730 vs. 1357 days nationally; p < 0.001), who received predominantly DCD kidneys from older donors (mean donor age 64 years), whereas younger recipients received equal proportions of living donor, DBD and DCD kidney transplants. Death-censored kidney graft survival was nevertheless comparable for younger and older recipients, although transplantation conferred a survival benefit from listing for only younger recipients. Local expansion in DCD kidney transplant activity improves survival outcomes for younger patients and addresses inequity of access to transplantation for older recipients.

Complex genetic control of host susceptibility to coxsackievirus B3-induced myocarditis

The pathogenesis of viral myocarditis is a multifactorial process involving host genetics, viral genetics and the environment in which they interact. We have used a model of infection with coxsackievirus B3 (CVB3) to characterize the contribution of host genetics to viral myocarditis in mice of different genetic backgrounds but with a common H2 haplotype: A/J and B10.A-H2(a). Here we have used Evans blue dye as a quantitative biomarker for susceptibility to CVB3-induced myocarditis in addition to histopathological semiquantitative measures. We have found evidence of linkage between susceptibility to viral myocarditis and three loci. A locus on chromosome 1 centered on D1Mit200 was linked to sarcolemmal disruption in males (P=0.00005), a second locus on chromosome 4 centered on D4Mit81 was also linked to sarcolemmal disruption in males (P=0.0022). A third locus on distal chromosome 3 centered on D3Mit19 was linked to myocardial infiltration, with a logarithm of odds (LOD) score of 4.7 (P=0.0045), as well as sarcolemmal disruption in females (P=0.0015). These results provide strong evidence for the presence of loci contributing to the susceptibility of mice to viral myocarditis.

Learner-control vs. program-control instructional multimedia: a comparison of two interactions when teaching principles of orthodontic appliances

BACKGROUND

Many studies have compared computer assisted learning (CAL) to more traditional learning formats and have shown CAL to be as effective as or superior to the alternative resources. However, there are only scarce attempts to show which style of CAL leads to the best learning outcomes in orthodontics.

AIM

To compare the effectiveness of a learner-control (group A) vs. program-control (group B) multimedia learning environment courseware packages regarding knowledge, understanding and transfer of content when applied to teaching principles of orthodontic appliances to undergraduate students.

METHODS

Pre- and post-test assessments of undergraduate dental students (n = 30) who either studied a learner-control multimedia learning environment courseware package (n = 15) or a program-control version (n = 15) on equivalent material of the orthodontic appliances curriculum. Both groups were evaluated by means of multiple-choice questions covering knowledge, understanding and application. A one-way ANOVA was carried out in order to check for statistical difference between the two groups. The P-value was set at 0.05.

RESULTS

There was no difference in prior knowledge between both groups at baseline. Although, both groups significantly improved their scores after having studied the course, no significant difference was found between both groups in relation to answers to questions about knowledge, understanding and application.

CONCLUSIONS

In this study, the learner-control instructional multimedia program was found to be as effective as the program-control version when teaching principles of the orthodontic appliances to undergraduate students. The focus needs to be on improving the value of CAL. Comparative evaluations of how different CAL approaches compare with or complement one another are certainly needed.