Non-pharmaceutical interventions to reduce COVID-19 transmission in the UK: a rapid mapping review and interactive evidence gap map

BACKGROUND

Non-pharmaceutical interventions (NPIs) were crucial in the response to the COVID-19 pandemic, although uncertainties about their effectiveness remain. This work aimed to better understand the evidence generated during the pandemic on the effectiveness of NPIs implemented in the UK.

METHODS

We conducted a rapid mapping review (search date: 1 March 2023) to identify primary studies reporting on the effectiveness of NPIs to reduce COVID-19 transmission. Included studies were displayed in an interactive evidence gap map.

RESULTS

After removal of duplicates, 11 752 records were screened. Of these, 151 were included, including 100 modelling studies but only 2 randomized controlled trials and 10 longitudinal observational studies.Most studies reported on NPIs to identify and isolate those who are or may become infectious, and on NPIs to reduce the number of contacts. There was an evidence gap for hand and respiratory hygiene, ventilation and cleaning.

CONCLUSIONS

Our findings show that despite the large number of studies published, there is still a lack of robust evaluations of the NPIs implemented in the UK. There is a need to build evaluation into the design and implementation of public health interventions and policies from the start of any future pandemic or other public health emergency.

Imaging the acute abdomen in pregnancy: a radiological decision-making tool and the role of MRI

Acute abdominal pain in pregnancy poses a significant diagnostic challenge. The differential diagnosis is wide, clinical assessment is difficult, and the use of conventional imaging methods is restricted due to risks to the fetus. This can lead to delay in diagnosis, which increases the risk of maternal and fetal harm. Imaging techniques not involving ionising radiation are preferred. Sonography remains first line, but anatomical visualisation can be limited due to displacement of adjacent structures by the gravid uterus. MRI provides excellent cross-sectional soft-tissue assessment of the abdomen and pelvis, and no study to date has demonstrated significant deleterious effects to the fetus at any gestation; however, there remains a theoretical risk of tissue heating by radiofrequency pulses, and there must be consideration of benefit versus potential risk for any use of magnetic resonance imaging (MRI) in pregnancy. With a limited protocol of sequences, a broad spectrum of pathologies can be evaluated. Computed tomography carries the highest exposure of ionising radiation to the fetus, but may be necessary, particularly in cases of trauma. The patient must be kept informed and any potential risks to the patient and fetus should be clearly explained. We present a radiological decision-making tool to guide choice of imaging and best establish the underlying diagnosis in the acute pregnant abdomen. In addition, using illustrative examples from our practice at a large tertiary centre, we review the advantages and disadvantages of each imaging method, with particular focus on the utility of MRI.

Addition of nintedanib or placebo to neoadjuvant gemcitabine and cisplatin in locally advanced muscle-invasive bladder cancer (NEOBLADE): a double-blind, randomised, phase 2 trial

BACKGROUND

Recurrence is common after neoadjuvant chemotherapy and radical treatment for muscle-invasive bladder cancer. We investigated the effect of adding nintedanib to neoadjuvant chemotherapy on response and survival in muscle-invasive bladder cancer.

METHODS

NEOBLADE was a parallel-arm, double-blind, randomised, placebo-controlled, phase 2 trial of neoadjuvant gemcitabine and cisplatin chemotherapy with nintedanib or placebo in locally advanced muscle-invasive bladder cancer. Patients aged 18 years or older, with an Eastern Cooperative Oncology Group performance status of 0-1, were recruited from 15 hospitals in the UK. Patients were randomly assigned (1:1) to nintedanib or placebo using permuted blocks with random block sizes of two or four, stratified by centre and glomerular filtration rate. Treatments were allocated using an interactive web-based system, and patients and investigators were masked to treatment allocation throughout the study. Patients received oral nintedanib (150 mg or 200 mg twice daily for 12 weeks) or placebo, in addition to usual neoadjuvant chemotherapy with intravenous gemcitabine 1000 mg/m2 on days 1 and 8 and intravenous cisplatin 70 mg/m2 on day 1 of a 3-weekly cycle. The primary endpoint was pathological complete response rate, assessed at cystectomy or at day 8 of cyclde 3 (plus or minus 7 days) if cystectomy did not occur. Primary analyses were done in the intention-to-treat population. The trial is registered with EudraCT, 2012-004895-01, and ISRCTN, 56349930, and has completed planned recruitment.

FINDINGS

Between Dec 4, 2014, and Sept 3, 2018, 120 patients were recruited and were randomly allocated to receive nintedanib (n=57) or placebo (n=63). The median follow-up for the study was 33·5 months (IQR 14·0-44·0). Pathological complete response in the intention-to-treat population was reached in 21 (37%) of 57 patients in the nintedanib group and 20 (32%) of 63 in the placebo group (odds ratio [OR] 1·25, 70% CI 0·84-1·87; p=0·28). Grade 3 or worse toxicities were observed in 53 (93%) of 57 participants who received nintedanib and 50 (79%) of 63 patients in the placebo group (OR 1·65, 95% CI 0·74-3·65; p=0·24). The most common grade 3 or worse adverse events were thromboembolic events (17 [30%] of 57 patients in the nintedanib group vs 13 [21%] of 63 patients in the placebo group [OR 1·63, 95% CI 0·71-3·76; p=0·29]) and decreased neutrophil count (22 [39%] in the nintedanib group vs seven [11%] in the placebo group [5·03, 1·95-13·00; p=0·0006]). 45 treatment-related serious adverse events occurred in the nintedanib group and 43 occurred in the placebo group. One treatment-related death occurred in the placebo group, which was due to myocardial infarction.

INTERPRETATION

The addition of nintedanib to chemotherapy was safe but did not improve the rate of pathological complete response in muscle-invasive bladder cancer.

FUNDING

Boehringer Ingelheim.

Real-world evidence from a single U.K. cancer center for atezolizumab in second-line setting in advanced urothelial cancer: Moving beyond clinical trials

461

Background: Atezolizumab is approved for use in advanced urothelial cancer in second line setting after platinum based chemotherapy. We conducted a retrospective study to evaluate clinical outcomes in patients treated in a single UK cancer centre with Atezolizumab for advanced urothelial cancer. Methods: Data was collected from electronic records for patients treated with Atezolizumab for advanced urothelial cancer patients between January 2019 to June 2021. Patients with histologically proven advanced urothelial cancer, PS 0-1, GFR > 30 ml/min by Cockcroft-Gault formula, who had progressed after platinum based chemotherapy were eligible. Maximum duration of treatment allowed was 24 months as per National Cancer Drugs Fund criteria. Initially 3 weekly cycles using Atezolizumab at a dose of 1200 mg was used, patients received 4 weekly dose once 1680 mg dose was available. Kaplan Meier survival estimates were used to calculate progression free survival and overall survival. Results: 32 patients received Atezolizumab between Jan 2019 to June 2021. The mean age was 70.6 years (range 44-88). 10 patients had ECOG PS 0, 22 patients had PS 1. Male 19, Female 13. At the time of analysis, 9 out of 32 patients were alive, 2 patients had completed 24 months of treatment and had no evidence of disease progression. Total 297 cycles of Atezolizumab were delivered (190 cycles were delivered at 3 weekly intervals, while 107 were delivered 4 weekly). The median progression free survival was 24.290 weeks (95% CI: 23.202-25.378), and the median overall survival was 40.860 weeks (95% CI: 19.788-61.932). 10 patients (31.2%) were alive at 12 months, 8 patients (25%) were alive at 18 months. The number of patients with toxicity of grade ≥3 were 4.There were no treatment related deaths. Conclusions: Atezolizumab is effective and well tolerated in patients with advanced urothelial cancer in second line setting. Durable responses were noted with 25% of patients alive at 18 months.

Tangent vector-based gradient method with l12-regularization: Iterative half thresholding algorithm for CS-MRI

OBJECT

This paper presents a new method using tangent vector-based l₁₂-regularization for compressed sensing MR image reconstruction.

MATERIALS AND METHODS

The proposed method with l₁₂-regularization is tested on four datasets: (i) 1-D sparse signal (ii) numerical cardiac phantom, (iii & iv) two sets of in-vivo cardiac MRI datasets acquired using 30 receiver coil elements with Cartesian and radial trajectories on 3T scanner. The results are compared with standard CS reconstruction, which utilizes l₁-regularization. The experiments were also conducted for two different types of samplings: (i) cartesian sub-sampling and (ii) 2D random Gaussian sub-sampling.

RESULTS

The quality of the reconstructed images is validated through Root Mean Square Error (RMSE) and Peak Signal-to-Noise Ratio (PSNR). The results show that the proposed method outperforms the standard CS reconstructions in our experiments with an improvement of 54.8% in RMSE and 14.3% in terms of PSNR. Moreover, the Gaussian random sub-sampling-based image reconstruction results are better than the Cartesian sub-sampling-based reconstruction results.

CONCLUSION

The results show that the proposed method yields a good sparse signal approximation and superior convergence behavior, which implies a promising technique for the reconstruction of cardiac MR images as compared to the conventional CS algorithm.

Neutrophil-Lymphocyte Ratio and Absolute Lymphocyte Count as Prognostic Markers in Patients Treated with Curative-intent Radiotherapy for Non-small Cell Lung Cancer

AIMS

The neutrophil-lymphocyte ratio (NLR) and the absolute lymphocyte count (ALC) have been proposed as prognostic markers in non-small cell lung cancer (NSCLC). The objective of this study was to examine the association of NLR/ALC before and after curative-intent radiotherapy for NSCLC on disease recurrence and overall survival.

MATERIALS AND METHODS

A retrospective study of consecutive patients who underwent curative-intent radiotherapy for NSCLC across nine sites in the UK from 1 October 2014 to 1 October 2016. A multivariate analysis was carried out to assess the ability of pre-treatment NLR/ALC, post-treatment NLR/ALC and change in NLR/ALC, adjusted for confounding factors using the Cox proportional hazards model, to predict disease recurrence and overall survival within 2 years of treatment.

RESULTS

In total, 425 patients were identified with complete blood parameter values. None of the NLR/ALC parameters were independent predictors of disease recurrence. Higher pre-NLR, post-NLR and change in NLR plus lower post-ALC were all independent predictors of worse survival. Receiver operator curve analysis found a pre-NLR > 2.5 (odds ratio 1.71, 95% confidence interval 1.06-2.79, P < 0.05), a post-NLR > 5.5 (odds ratio 2.36, 95% confidence interval 1.49-3.76, P < 0.001), a change in NLR >3.6 (odds ratio 2.41, 95% confidence interval 1.5-3.91, P < 0.001) and a post-ALC < 0.8 (odds ratio 2.86, 95% confidence interval 1.76-4.69, P < 0.001) optimally predicted poor overall survival on both univariate and multivariate analysis when adjusted for confounding factors. Median overall survival for the high-versus low-risk groups were: pre-NLR 770 versus 1009 days (P = 0.34), post-NLR 596 versus 1287 days (P ≤ 0.001), change in NLR 553 versus 1214 days (P ≤ 0.001) and post-ALC 594 versus 1287 days (P ≤ 0.001).

CONCLUSION

NLR and ALC, surrogate markers for systemic inflammation, have prognostic value in NSCLC patients treated with curative-intent radiotherapy. These simple and readily available parameters may have a future role in risk stratification post-treatment to inform the intensity of surveillance protocols.

952 In-Patient Trauma Surgery in COVID-19 Positive Patients Carries A Significantly Higher Mortality Risk When Compared to In-Patient Covid-19 Negative Patients and Day Case Trauma Patients

Introduction

Covid-19 caused many service changes, yet Trauma surgery continued throughout. We compare mortality rates from In-Patient (IP) and Day Case (DC) trauma patients and compare the mortality rates of patients who tested positive or negative for Covid-19.

Method

We reviewed all trauma admissions that underwent surgical intervention in both our IP and DC services during 31 days from March 23^rd 2020. We recorded their sex, age, operation, Covid-19 symptoms, Covid-19 test results and mortality. The findings were compared between the groups.

Results

In total 127 patients underwent surgery (66 IP; 61 DC). There were 6 deaths (9.1%) within the IP group and 0 deaths in the DC group (p = 0.006). In the IP group 8 patients (12.1%) tested positive for Covid-19 of which 4 died (50%) compared to the remaining 58 patients (87.9%) of which 2 (3.4%) died (p < 0.001). A higher mortality rate was observed in patients with symptoms but a negative Covid-19 test (6.7%) than patients in whom a test was never indicated (2.3%).

Conclusion

Covid-19 positive patients requiring in-patient admission for trauma surgery have a significantly higher mortality rate than both in-patient admissions that were Covid-19 negative or asymptomatic and patients that were treated with Day Case Trauma surgery.

890 Predictive Factors for Mortality Following Trauma & Orthopaedic Surgery in The Covid-19 Pandemic. The Manchester Equation

Introduction

Covid-19 caused many service changes including limitations on operations due to potential increased mortality risk to patients. We report our findings from Trauma & Orthopaedic (T&O) surgical mortality through this period and the effectiveness of using a scoring system (The Manchester Equation) to predict likelihood of mortality.

Method

We reviewed all T&O admissions that underwent surgical intervention during the height of the pandemic. We recorded numerous factors for each patient including mortality and Covid status. From this we created a scoring system which is the product of Covid status, Anaesthetic type, Medical co-morbidities and other medical factors and ASA Score. We then analysed the findings to determine whether the score could be predictive of mortality rate.

Results

Of 123 patients undergoing surgery 6 deaths were observed (mean score of 51.3) compared to 117 patients surviving (mean score 31.9), p = 0.001. A score of less than 32 carried a 0% chance of death whereas a score of 32 or more resulted in a 14.6% mortality rate (p = 0.01).

Conclusion

The Manchester Equation can be used to help predict the mortality rate of T&O surgery in the presence of Covid-19 and may be useful for clinical decision making and consent purposes.

Predicting the Risk of Disease Recurrence and Death Following Curative-intent Radiotherapy for Non-small Cell Lung Cancer: The Development and Validation of Two Scoring Systems From a Large Multicentre UK Cohort

AIMS

There is a paucity of evidence on which to produce recommendations on neither the clinical nor the imaging follow-up of lung cancer patients after curative-intent radiotherapy. In the 2019 National Institute for Health and Care Excellence lung cancer guidelines, further research into risk-stratification models to inform follow-up protocols was recommended.

MATERIALS AND METHODS

A retrospective study of consecutive patients undergoing curative-intent radiotherapy for non-small cell lung cancer from 1 October 2014 to 1 October 2016 across nine UK trusts was carried out. Twenty-two demographic, clinical and treatment-related variables were collected and multivariable logistic regression was used to develop and validate two risk-stratification models to determine the risk of disease recurrence and death.

RESULTS

In total, 898 patients were included in the study. The mean age was 72 years, 63% (562/898) had a good performance status (0-1) and 43% (388/898), 15% (134/898) and 42% (376/898) were clinical stage I, II and III, respectively. Thirty-six per cent (322/898) suffered disease recurrence and 41% (369/898) died in the first 2 years after radiotherapy. The ASSENT score (age, performance status, smoking status, staging endobronchial ultrasound, N-stage, T-stage) was developed, which stratifies the risk for disease recurrence within 2 years, with an area under the receiver operating characteristic curve (AUROC) for the total score of 0.712 (0.671-0.753) and 0.72 (0.65-0.789) in the derivation and validation sets, respectively. The STEPS score (sex, performance status, staging endobronchial ultrasound, T-stage, N-stage) was developed, which stratifies the risk of death within 2 years, with an AUROC for the total score of 0.625 (0.581-0.669) and 0.607 (0.53-0.684) in the derivation and validation sets, respectively.

CONCLUSIONS

These validated risk-stratification models could be used to inform follow-up protocols after curative-intent radiotherapy for lung cancer. The modest performance highlights the need for more advanced risk prediction tools.

0936 Cardiometabolic Disorders are Independently Associated with Excessive Daytime Sleepiness in Young Adults

Introduction

Cardiometabolic risk factors (CMR), including obesity, hypertension, diabetes and hypercholesterolemia, have been associated with sleep apnea and insufficient sleep, both of which can lead to excessive daytime sleepiness (EDS). We hypothesized that CMR are associated with EDS in young adults independent of sleep apnea, sleep duration and mental health disorders (MHD).

Methods

The Penn State Child Cohort is a population-based longitudinal sample of 700 children (8.7±1.7y), of whom 421 were followed-up 8.3 years later during adolescence (17.0±2.3y) and 425 another 7.0 years later during young adulthood (24.4±2.6y). Subjects underwent a 9-h in-lab polysomnography in childhood and adolescence and parent- or self-reported standardized surveys at all time points. Self-reports in young adulthood and in-lab measurements in childhood were used to ascertain CMR and sleep apnea. Parent-reports in childhood and self-reports in young adulthood were used to ascertain the presence of MHD and EDS. Logistic regression models adjusted for age, race, sex, snoring/observed apneas, insomnia symptoms, and sleep duration in young adulthood as well as mean arterial blood pressure, body mass index percentile and apnea/hypopnea index in childhood.

Results

CMR (OR=2.71, 95%CI=1.69-4.36) and MHD (OR=4.61, 95%CI=2.79-7.62) were associated with EDS in univariate models. After adjusting for covariates in childhood and young adulthood, CMR and MHD remained independently associated with EDS (OR=2.32, 95%CI=1.29-4.16 and OR=2.78, 95%CI=1.59-4.87, respectively).

Conclusion

EDS in young adults with CMR or MHD does not solely arise from sleep apnea, insufficient sleep or other sleep disturbances. EDS may be the result of central pathophysiologic mechanisms or the functional impairment associated with cardiovascular, metabolic and mental health disorders. These data further support that youth with these disorders should be screened for EDS and appropriately managed.

Support

National Institutes of Health (R01HL136587, R01HL97165, R01HL63772, UL1TR000127)

Effects of pioglitazone on ventricular myocyte shortening and Ca(2+) transport in the Goto-Kakizaki type 2 diabetic rat

Pioglitazone (PIO) is a thiazolidindione antidiabetic agent which improves insulin sensitivity and reduces blood glucose in experimental animals and treated patients. At the cellular level the actions of PIO in diabetic heart are poorly understood. A previous study has demonstrated shortened action potential duration and inhibition of a variety of transmembrane currents including L-type Ca(2+) current in normal canine ventricular myocytes. The effects of PIO on shortening and calcium transport in ventricular myocytes from the Goto-Kakizaki (GK) type 2 diabetic rat have been investigated. 10 min exposure to PIO (0.1-10 microM) reduced the amplitude of shortening to similar extents in ventricular myocytes from GK and control rats. 1 microM PIO reduced the amplitude of the Ca(2+) transients to similar extents in ventricular myocytes from GK and control rats. Caffeine-induced Ca(2+) release from the sarcoplasmic reticulum and recovery of Ca(2+) transients following application of caffeine and myofilament sensitivity to Ca(2+) were not significantly altered in ventricular myocytes from GK and control rats. Amplitude of L-type Ca(2+) current was not significantly decreased in myocytes from GK compared to control rats and by PIO treatment. The negative inotropic effects of PIO may be attributed to a reduction in the amplitude of the Ca(2+) transient however, the mechanisms remain to be resolved.

Heparin-enhanced ADP-induced platelet aggregation in patients undergoing cardiopulmonary bypass surgery

Heparin has been shown to enhance ADP-induced platelet aggregation in patients undergoing cardiopulmonary bypass surgery. This effect appears to be maximal throughout the initial 30 minutes of systemic heparinization and once reached is maintained throughout the bypass procedure. The prebypass state is regained following heparin reversal by protamine sulphate. It is possible that this effect of heparin on platelet function may contribute towards some of the platelet microembolization phenomena seen in patients following cardiopulmonary bypass surgery.

Paediatric day case tonsillectomy: a safe, feasible and an economical way to treat patients – Yorkhill experience

Introduction

Day case surgery is widely encouraged as it has many benefits. In this study, we evaluate the feasibility of paediatric tonsillectomies as day case surgery procedures in a tertiary paediatric centre.

Methods

The outcome of paediatric tonsillectomy performed as day case procedures was studied for four months. We recorded complication rates in comparison to the standard in-patient practice.

Results

23 paediatric patients were included in this study. The age of the patients ranged from four to 11 years, with mean age of 6.5. No patients suffered post-operative complications within the first 24 h. Two patients were re-admitted due to a post-operative complication (8.6%) and one patient for a non-operative cause (4.3%) beyond the initial 24 h.

Conclusion

Paediatric Day Case Paediatric Tonsillectomy is a safe, feasible and an economical way to manage patients. It should be practised as a day case where appropriate and when criteria are met.

Comparative study of titanium(IV)-based exchangers in aqueous and mixed solvent systems

The antimonate, arsenate, tungstate, molybdate and selenite of titanium have been synthesized. Their composition and chemical and thermal stability have been determined. Effects of pH and temperature on ion-exchange capacity have been studied. Titanium antimonate was found to be the most stable. The utility of these ion-exchangers for analytical separations was examined by determining the distribution coefficients for 26 metal ions in some aqueous, non-aqueous and mixed solvent systems. Quantitative separations of HgCd, PbCu and PbZn have been achieved on titanium tungstate columns, and LaBa mixtures have been separated on a titanium arsenate column.

Probing atomic structure in magnetic core/shell nanoparticles using synchrotron radiation

Core/shell Fe/Cu and Fe/Au nanoparticles were prepared directly by deposition from the gas phase. A detailed study of the atomic structure in both the cores and shells of the nanoparticles was undertaken by means of extended absorption fine structure (EXAFS) measurements. For Fe/Cu nanoparticles, a Cu shell ∼ 20 monolayers thick appears similar in structure to bulk Cu and is sufficient to cause the structure in the Fe core to switch from body centred cubic (bcc; as in bulk Fe) to face centred cubic. This is not the case for thinner Cu shells, 1-2 monolayers in thickness, in which there is a considerable contraction in nearest-neighbour interatomic distance as the shell structure changes to bcc. In Fe/Au nanoparticles, the crystal structure in the Fe core remains bcc for all Au thicknesses although there is some stretching of the lattice. In thin Au shells ∼ 2 monolayers thick, there is strong contraction in interatomic distances. There does not appear to be significant alloying at the Fe/Au interface.

Morphology of sighs and their role in the control of breathing in preterm infants, term infants and adults

BACKGROUND

Although there is evidence that sighs are important to restore lung volume, the factors responsible for inducing a sigh and the effects of sighs on the stability of the respiratory system remain unclear.

OBJECTIVE

To compare newborn with adult sigh morphology in order to better understand the physiological mechanisms that induce sighs and the role sighs play on the control of breathing in infants.

DESIGN/METHODS

We measured respiratory variables during control, the pre-sigh, the sigh, and the post-sigh period during quiet and REM sleep in 10 preterm infants, 10 term infants and 10 adults using a flow-through system.

RESULTS

No significant differences were observed in any of the respiratory variables between the pre-sigh and the control breaths in any of the subjects in any of the two sleep states, suggesting that indices of respiratory drive are not predictive of an impending sigh. Sighs were relatively larger in infants than in adults and had a characteristic biphasic inspiratory flow observed almost exclusively in infants. While post-sigh ventilation was usually increased in adults, it was usually decreased in infants due to the presence of apneas.

CONCLUSIONS

The established indexes of respiratory drive are not predictive of an impeding sigh. When compared with control breaths, sighs are much larger in preterm and term infants than in adults. These big augmented breaths in infants are often followed by apnea and hypoventilation likely secondary to the increased activity of the peripheral chemoreceptors present in neonates.