Analysis of Anxiety, Depression and Fear of Progression at 12 Months Post-Cytoreductive Surgery in the SOCQER-2 (Surgery in Ovarian Cancer-Quality of Life Evaluation Research) Prospective, International, Multicentre Study

Patients with ovarian cancer (OC) often experience anxiety, depression and fear of progression (FOP); however, it is unclear whether surgical complexity has a role to play. We investigated the prevalence of anxiety, depression and FOP at 12 months post-cytoreductive surgery and investigated associations with surgical complexity, patient (age, ethnicity, performance status, BMI) and tumour (stage, disease load) factors. One hundred and forty-one patients with FIGO Stage III-IV OC, who did not have disease progression at 12 months post-surgery, completed the Hospital Anxiety and Depression Scale and FOP short-form questionnaire. Patients underwent surgery with low (40.4%), intermediate (31.2%) and high (28.4%) surgical complexity scores. At 12 months post-surgery, 99 of 141 (70%) patients with advanced OC undergoing surgery experienced clinically significant anxiety, 21 of 141 (14.9%) patients experienced moderate to severe depression and 37 of 140 (26.4%) experienced dysfunctional FOP. No associations were identified between the three different surgical complexity groups with regards to anxiety, depression or FOP scores. Unsurprisingly, given the natural history of the disease, most patients with OC suffer from anxiety, depression and fear of progression after completion of first-line cancer treatment. Surgical complexity at the time of surgery is not associated with a deleterious impact on anxiety, depression or FOP for patients with OC. Patients with OC experience a profound mental health impact and should be offered mental health support throughout their cancer journey.

A single blinded, phase IV, adaptive randomised control trial to evaluate the safety of coadministration of seasonal influenza and COVID-19 vaccines (The FluVID study)

OBJECTIVES

We evaluated the frequency of moderate and severe adverse events following coadministration of seasonal influenza vaccine (SIV) versus placebo with COVID-19 vaccines among adults to support practice guidelines.

METHODS

FluVID is a participant-blinded, phase IV, randomised control trial. On the same day as the participant's scheduled COVID-19 vaccine, participants were randomised to receive SIV or saline placebo; those assigned placebo at visit one then received SIV a week later, and vice versa. Self-reported adverse events were collected daily for seven days following each visit. The primary endpoint was any solicited adverse event of at least moderate severity occurring up to seven days following receipt of SIV or placebo. This was modelled using a Bayesian logistic regression model. Analyses were performed by COVID-19 vaccine type and dose number.

RESULTS

Overall, 248 participants were enrolled; of these, 195 had received BNT162b2 and 53 had received mRNA1273 COVID-19 vaccines according to national guidelines. After randomisation, 119 were assigned to receive SIV and 129 were assigned to receive placebo at visit one. Adverse events were most frequently reported as mild (grade 1) in nature. Among 142 BNT162b2 booster dose one and 43 BNT162b2 booster dose two recipients, the posterior median risk difference for moderate/severe adverse events following SIV versus placebo was 13% (95% credible interval [CrI] -0.03 to 0.27) and 13% (95%CrI -0.37 to 0.12), respectively. Among 18 mRNA1273 booster dose one and 35 mRNA1273 booster dose two recipients, the posterior median risk difference of moderate/severe adverse events following influenza vaccine versus placebo was 6% (95%CrI -0.29 to 0.41) and -4% (95%CrI -0.30 to 0.23), respectively.

CONCLUSION

Adverse events following SIV and COVID-19 co-administration were generally mild and occurred with similar frequency to events following COVID-19 vaccine alone. We found no evidence to justify routine separation of SIV and COVID-19 vaccine doses.

CLINICAL TRIAL REGISTRATION

ACTRN12621001063808.

MDT practice determines treatment pathway for patients with advanced ovarian cancer: A multi-centre observational study

OBJECTIVE

To investigate decision making for patients with advanced ovarian cancer as a possible explanation of geographical variation in treatment patterns.

METHODS

We carried out a multi-centre observational study in multidisciplinary teams meetings for five major UK cancer centres. All patients presenting to five cancer centres with advanced ovarian cancer over a six-week period. The GO-MDT-MODe tool was used to provide a measure of participation and quality of case discussion for all cases of advanced ovarian cancer. MDT scores were correlated with surgical data extracted from national audit data. Data were recorded for overall MDT performance.

RESULTS

A total of 870 case discussions, including 145 cases of advanced ovarian cancer, were observed. MDTs varied in structure, format and time allocation between centres. Cluster analysis showed significant variation in quality and participation of discussion between centres (p < 0.0025) and this correlated with the proportion of patients in the wider cancer alliance undergoing surgery.

CONCLUSIONS

We have shown that at least part of the variation in practice seen in the UK correlates with different behaviours within MDTs. Increasing time for discussion and encouraging participation from all staff groups may increase proportions of patients undergoing optimal treatment regimens.

Global uncertainty in the diagnosis of neurological complications of SARS-CoV-2 infection by both neurologists and non-neurologists: An international inter-observer variability study

INTRODUCTION

Uniform case definitions are required to ensure harmonised reporting of neurological syndromes associated with SARS-CoV-2. Moreover, it is unclear how clinicians perceive the relative importance of SARS-CoV-2 in neurological syndromes, which risks under- or over-reporting.

METHODS

We invited clinicians through global networks, including the World Federation of Neurology, to assess ten anonymised vignettes of SARS-CoV-2 neurological syndromes. Using standardised case definitions, clinicians assigned a diagnosis and ranked association with SARS-CoV-2. We compared diagnostic accuracy and assigned association ranks between different settings and specialties and calculated inter-rater agreement for case definitions as "poor" (κ ≤ 0.4), "moderate" or "good" (κ > 0.6).

RESULTS

1265 diagnoses were assigned by 146 participants from 45 countries on six continents. The highest correct proportion were cerebral venous sinus thrombosis (CVST, 95.8%), Guillain-Barré syndrome (GBS, 92.4%) and headache (91.6%) and the lowest encephalitis (72.8%), psychosis (53.8%) and encephalopathy (43.2%). Diagnostic accuracy was similar between neurologists and non-neurologists (median score 8 vs. 7/10, p = 0.1). Good inter-rater agreement was observed for five diagnoses: cranial neuropathy, headache, myelitis, CVST, and GBS and poor agreement for encephalopathy. In 13% of vignettes, clinicians incorrectly assigned lowest association ranks, regardless of setting and specialty.

CONCLUSION

The case definitions can help with reporting of neurological complications of SARS-CoV-2, also in settings with few neurologists. However, encephalopathy, encephalitis, and psychosis were often misdiagnosed, and clinicians underestimated the association with SARS-CoV-2. Future work should refine the case definitions and provide training if global reporting of neurological syndromes associated with SARS-CoV-2 is to be robust.

Impact of Multiple COVID-19 Waves on Gynaecological Cancer Services in the UK

BACKGROUND

This study aimed to assess the impact of multiple COVID-19 waves on UK gynaecological-oncology services.

METHODS

An online survey was distributed to all UK-British-Gynaecological-Cancer-Society members during three COVID-19 waves from 2020 to2022.

RESULTS

In total, 51 hospitals (including 32 cancer centres) responded to Survey 1, 42 hospitals (29 centres) to Survey 2, and 39 hospitals (30 centres) to Survey 3. During the first wave, urgent referrals reportedly fell by a median of 50% (IQR = 25-70%). In total, 49% hospitals reported reduced staffing, and the greatest was noted for trainee doctors, by a median of 40%. Theatre capacity was reduced by a median of 40%. A median of 30% of planned operations was postponed. Multidisciplinary meetings were completely virtual in 39% and mixed in 65% of the total. A median of 75% of outpatient consultations were remote. By the second wave, fewer hospitals reported staffing reductions, and there was a return to pre-pandemic urgent referrals and multidisciplinary workloads. Theatre capacity was reduced by a median of 10%, with 5% of operations postponed. The third wave demonstrated worsening staff reductions similar to Wave 1, primarily from sickness. Pre-pandemic levels of urgent referrals/workload continued, with little reduction in surgical capacity.

CONCLUSION

COVID-19 led to a significant disruption of gynaecological-cancer care across the UK, including reduced staffing, urgent referrals, theatre capacity, and working practice changes. Whilst disruption eased and referrals/workloads returned to normal, significant staff shortages remained in 2022, highlighting persistent capacity constraints.

Therapies in Cervical Cancer-Editorial

George Papanikolaou is famously quoted as saying "the first observation of cancer cells in the smear of the uterine cervix gave me one of the greatest thrills I ever experienced during my scientific career" [...].

Climate risk assessment needs urgent improvement

Climate risk assessments are a key tool in planning for climate change impacts. This commentary examines the current underlying problems with them and puts forward a framework to provide solutions to improve their effectiveness.

Effects of heart failure and diabetes on invasive biomarkers of skeletal muscle wasting

Funding Acknowledgements

Type of funding sources: None.

Background

Muscle wasting is common in patients with diabetes mellitus (DM) and chronic heart failure (HF), which exacerbates cachexia and poor quality of life. However, a gap in clinical translation remains as the mechanisms underlying muscle wasting in DM and HF remain poorly validated, with most evidence assumed from experimental small-animal models.

Purpose

Validate if markers of muscle wasting (e.g., autophagy, proteolysis, myogenesis) were correlated to muscle phenotype and clinical indices in humans with DM and HF.

Method

Male patients with DM (n=4), HF (n=4; NYHA=2), DMHF (n=7; NYHA=2) were included. DM was classified as a HbA1c level ≥48mmol/mol and HF classified as a left ventricular ejection fraction (LVEF) ≤40%, with patients on optimised medication. Muscle biopsies of pectoralis major were excised during routine pacemaker surgery and frozen at -80°C for both histological and gene expression analysis. Muscle samples were sectioned, stained, and imaged for fibre cross-sectional area and fibre type. RT-PCR gene expression was conducted for markers of muscle regeneration (myod, myogenin), protein degradation (myostatin and autophagy-related LC3B, ATG7, CTSL), and anabolic signalling (IGF-1). Statistical analysis included ANOVAs and correlation analysis to identify relationships between variables. Values of p&lt;0.05 were accepted as significant.

Results

Groups (DM, HF, DMHF) were not different (P&gt;0.05) in relation to age (79±9, 72±8, 72±10 years) or BMI (24.5±3.6, 28.5±4.2, 29.5±6.0) respectively. Fibre size or fibre type were not different (P&gt;0.05) between groups. In line with this, gene expression for markers of myogenesis and anabolism as well as myostatin were not different (P&gt;0.05) between groups, but a trend in downregulation of the proteolytic autophagy-related genes (LC3B, ATG7, CTSL) in DMHF vs DM or HF was found on average by 21, 36, and 30% respectively. Autophagy-related genes LC3B, ATG7, CTSL were positively correlated (P&lt;0.05) to type IIa fibre numerical density (R=0.82, 0.86, 0.89) and LVEF (R=0.85, 0.92, 0.83), respectively.

Conclusion

Our findings indicate that gene expression of autophagy could represent a robust marker of muscle wasting and cardiac dysfunction in humans with DM and HF. Muscle biopsies from patients with DM and HF identified the proteolytic system of autophagy, important for cellular homeostasis, may be inhibited and this was correlated to fibre phenotype and LVEF. However, the process of muscle wasting in DM and HF within the clinical setting may not necessarily reflect those reported in animal models given various other markers were not changed.

Climate justice is central to addressing the climate emergency’s psychological consequences in the Global South: a narrative review

The United Nations has signalled a ‘code red’, marking climate change as an existential threat for humanity. The world is rapidly warming, and the consequences of climate change include an increase and intensification in flooding, droughts, wildfires, and other traumatic exposures. Although countries in the Global South have contributed least to global warming, they are the most vulnerable owing to historical inequities. The concept of ‘climate justice’ recognises that historical racial discrimination, class disenfranchisement, political misrecognition, and other social injustices make surviving climate change and thriving within it more challenging. This narrative review considers the psychological consequences of the climate emergency through a climate justice lens. The article discusses the unequal exposures to psychological adversities, socio-historical barriers to adaptations and, finally, institutional betrayal that complicates the experience of psychological distress. The review concludes by pragmatically discussing how psychology could support climate justice ends.

Quality of life from cytoreductive surgery in advanced Ovarian cancer: investigating association with disease burden and surgical complexity in the international, prospective, SOCQER2 cohort study

OBJECTIVE

To investigate quality of life (QoL) and association with surgical complexity and disease burden after surgical resection for advanced ovarian cancer in centres with variation in surgical approach DESIGN: Prospective multicentre observational study SETTING: United Kingdom, Kolkata, India, and Melbourne, Australia gynaecological cancer surgery centres.

PARTICIPANTS

Patients undergoing surgical resection for late stage ovarian cancer. Exposure Low, intermediate or high Surgical Complexity Score (SCS) surgery MAIN OUTCOMES AND MEASURES: Primary: EORTC-QLQ-C30 Global score change. Secondary: EORTC OV28, progression free survival.

RESULTS

Patients' pre-operative disease burden and SCS varied between centres, confirming differences in surgical ethos. QoL response rates were 90% up to 18 months. Mean change from the pre-surgical baseline in the EORTC QLQ-C30 was 3.4 (SD 1.8, n=88) in the low, 4.0 (SD 2.1, n=55) in the intermediate and 4.3 (SD 2.1, n=52) in the high SCS group after 6 weeks (p=0.048) and 4.3 (SD 2.1, n=51), 5.1 (SD 2.2, n=41) and 5.1 (SD 2.2, n=35) respectively after 12 months (p=0.133). In a repeated measures model, there were no clinically or statistically meaningful differences in EORTC QLQ-C30 global scores between the three SCS groups, p= 0.840 but there was a small statistically significant improvement in all groups over time (p<0.001). The high SCS group experienced small to moderate decreases in physical (p=0.004), role (p=0.016) and emotional (p=0.001) function at 6 weeks post-surgery which resolved by 6-12 months.

CONCLUSIONS AND RELEVANCE

Global QoL of patients undergoing low, intermediate, and high SCS surgery improved at 12 months post operation and was no worse in patients undergoing extensive surgery.

Investigation of Autosomal Genetic Sex Differences in Parkinson's Disease

OBJECTIVE

Parkinson's disease (PD) is a complex neurodegenerative disorder. Men are on average ~ 1.5 times more likely to develop PD compared to women with European ancestry. Over the years, genomewide association studies (GWAS) have identified numerous genetic risk factors for PD, however, it is unclear whether genetics contribute to disease etiology in a sex-specific manner.

METHODS

In an effort to study sex-specific genetic factors associated with PD, we explored 2 large genetic datasets from the International Parkinson's Disease Genomics Consortium and the UK Biobank consisting of 13,020 male PD cases, 7,936 paternal proxy cases, 89,660 male controls, 7,947 female PD cases, 5,473 maternal proxy cases, and 90,662 female controls. We performed GWAS meta-analyses to identify distinct patterns of genetic risk contributing to disease in male versus female PD cases.

RESULTS

In total, 19 genomewide significant regions were identified and no sex-specific effects were observed. A high genetic correlation between the male and female PD GWAS were identified (rg = 0.877) and heritability estimates were identical between male and female PD cases (~ 20%).

INTERPRETATION

We did not detect any significant genetic differences between male or female PD cases. Our study does not support the notion that common genetic variation on the autosomes could explain the difference in prevalence of PD between males and females cases at least when considering the current sample size under study. Further studies are warranted to investigate the genetic architecture of PD explained by X and Y chromosomes and further evaluate environmental effects that could potentially contribute to PD etiology in male versus female patients. ANN NEUROL 2021;90:41-48.

Divergent transcriptomic profiles in skeletal muscle of diabetics with and without heart failure

Funding Acknowledgements

Type of funding sources: None.

Background

Patients with type 2 diabetes mellitus (DM) that have coexistent heart failure (HF) have exacerbated symptoms and prognosis, however beside cardiac dysfunction the mechanisms governing these features are incompletely understood. Evidence indicates abnormalities in the periphery could contribute to this worse clinical phenotype, including a role for skeletal muscle whereby disturbances in the transcriptome could disrupt muscle homeostasis/repair to offer a novel therapeutic approach.

Purpose

Is the skeletal muscle transcriptome distinguishable between DM patients with and without HF?

Methods

DM patients without (n = 11) or with HF with reduced left ventricular ejection fraction (LVEF) (n = 16) were included. Muscle biopsies were collected from the pectoralis major during pacemaker implantation. Following RNA extraction and cDNA synthesis, non-bias RNA sequencing (RNAseq) was performed (Cambridge Genomic Services, UK) followed by targeted RT-PCR gene expression of relevant targets. DESeq2 identified differentially expressed genes (DEGs) with a false discovery rate (p &lt; 0.05). Gene enrichment analysis was performed with clusterProfiler v3.16.0 to interrogate the gene ontology database, while pathway analysis was conducted using ReactomePA v1.32.0 to interrogate the Reactome database, using an adjusted p value. Values of p &lt; 0.05 were accepted as significant.

Results

Groups were not different (p &gt; 0.05) for age (74 ± 11 vs. 66 ± 10 years), BMI (31 ± 7 vs 29 ± 6), sex (n = 2 females per group), or HbA1c (56 ± 10 vs. 57 ± 8 mmol/mol), although LVEF was lower in the group with HF (27 ± 8 vs. 54 ± 2%; p &lt; 0.05).  Of the 19,544 genes analysed, RNAseq identified 53 DEGs between DM patients with and without HF, with several relevant targets related to myofiber homeostasis such as autophagy (RUBCN), protein synthesis (DGKζ), and inflammation/apoptosis (TLE1). Follow-up RT-PCR analysis confirmed a trend towards upregulation of the autophagy-related machinery p62 (p = 0.043) and BNIP3 (p = 0.085) in the HF group, but not ubiquitin-proteasome (MuRF1, MAFbx; p &gt; 0.05). Gene-enrichment analysis of DEGs identified 7 overrepresented terms (P &lt; 0.05), including lipid metabolism/signalling alongside epigenetic modifications related to histone deacetylases (HDAC6/10). Furthermore, pathway analysis identified 4 terms (p &lt; 0.05) related to NOTCH signalling and phosphatidyl inositol-bisphosphate (PIP2) hydrolysis thus indicating alterations to muscle repair and lipid signalling respectively.

Conclusion(s): This study confirms that DM patients with and without HF demonstrate distinct skeletal muscle transcriptome profiles. Key differences related to skeletal muscle myogenesis, autophagy, epigenetic regulation, and lipid signalling were identified that could form part of important therapeutic targets. Whether these underlying muscle transcriptome differences contribute to poorer clinical outcomes in DM patients with HF remains to be determined.

Specialist oncological surgery for removal of the ovaries and fallopian tubes in BRCA1 and BRCA2 pathogenic variant carriers may reduce primary peritoneal cancer risk to very low levels

Risk‐reducing bilateral salpingo‐oophorectomy (RRBSO) is highly effective for the prevention of high‐grade serous ovarian cancer (HGSOC) in BRCA1/2 pathogenic variant carriers (PVCs), but does not completely eliminate future risk of primary peritoneal cancer (PPC). The requirement to completely remove fallopian tubes at RRBSO and carefully exclude occult cancer/serous tubal intraepithelial carcinoma (STIC) lesions may not have been appreciated historically. We calculated rates of HGSOC and PPC in confirmed BRCA1/2 PVCs registered on the regional database in those who did (cases) and did not (controls) undergo RRBSO after genetic testing. Expected annual rates of ovarian/peritoneal cancer were 1% for BRCA1 ≥ 35 years and 0.5% for BRCA2 ≥ 45 years. Follow‐up before 35/45 years was “risk free” and lead time excluded RRBSO <35 years and <45 years for BRCA1 and BRCA2, respectively. Women were followed from personal mutation report (controls) or RRBSO (cases) to death, ovarian/peritoneal cancer or last follow‐up, whichever was sooner. In total, 891 cases (BRCA1 = 468, BRCA2 = 423) and 1302 controls had follow‐up ≥35 years (BRCA1 = 736) and ≥45 years (BRCA2 = 566), respectively, over a total of 7261.1 risk eligible years (mean = 8.15 years). Twenty‐one occult ovarian cancers were found at RRBSO (2.4%), 16 at stage 1. Post RRBSO, 56.97 ovarian/peritoneal cancers were expected but only 3 were observed (HR = 0.053; 95% CI = 0.013‐0.14), with combined Kaplan‐Meier analysis HR = 0.029 (95% CI = 0.009‐0.100, P < .001). Risk reduction was greater in specialist (HR = 0.03; 95% CI = 0.001‐0.13) compared to non‐specialist centres (HR = 0.11; 95% CI = 0.02‐0.37) (P = .07). In controls, 23.35 ovarian/peritoneal cancers were expected with 32 observed (HR = 1.37; 95% CI = 0.95‐1.91). RRBSO <35/<45 years reduces the risk of ovarian/peritoneal cancer by 95% in BRCA1/2 PVCs and may be greater in specialist centres.

What's new?

Women who carry genetic variants in BRCA1/2 that are linked to high‐grade serous ovarian cancer are advised to undergo risk‐reducing prophylactic bilateral salpingo‐oophorectomy (RRBSO). RRBSO, however, is associated with a significant residual risk of primary peritoneal cancer (PPC). Here, the rate of PPC following prophylactic surgery for high‐grade serous ovarian cancer was investigated among 2,193 BRCA1/2 mutation carriers who had undergone RRBSO. Estimates indicate that prophylactic surgery reduced the overall risk of PPC by 95 percent, a far greater reduction than previously described. Residual risk was lowest when RRBSO was carried out at specialist centers compared to non‐specialist centers.

Loss-of-Function Variants in HOPS Complex Genes VPS16 and VPS41 Cause Early Onset Dystonia Associated with Lysosomal Abnormalities

OBJECTIVES

The majority of people with suspected genetic dystonia remain undiagnosed after maximal investigation, implying that a number of causative genes have not yet been recognized. We aimed to investigate this paucity of diagnoses.

METHODS

We undertook weighted burden analysis of whole-exome sequencing (WES) data from 138 individuals with unresolved generalized dystonia of suspected genetic etiology, followed by additional case-finding from international databases, first for the gene implicated by the burden analysis (VPS16), and then for other functionally related genes. Electron microscopy was performed on patient-derived cells.

RESULTS

Analysis revealed a significant burden for VPS16 (Fisher's exact test p value, 6.9 × 10⁹ ). VPS16 encodes a subunit of the homotypic fusion and vacuole protein sorting (HOPS) complex, which plays a key role in autophagosome-lysosome fusion. A total of 18 individuals harboring heterozygous loss-of-function VPS16 variants, and one with a microdeletion, were identified. These individuals experienced early onset progressive dystonia with predominant cervical, bulbar, orofacial, and upper limb involvement. Some patients had a more complex phenotype with additional neuropsychiatric and/or developmental comorbidities. We also identified biallelic loss-of-function variants in VPS41, another HOPS-complex encoding gene, in an individual with infantile-onset generalized dystonia. Electron microscopy of patient-derived lymphocytes and fibroblasts from both patients with VPS16 and VPS41 showed vacuolar abnormalities suggestive of impaired lysosomal function.

INTERPRETATION

Our study strongly supports a role for HOPS complex dysfunction in the pathogenesis of dystonia, although variants in different subunits display different phenotypic and inheritance characteristics. ANN NEUROL 2020;88:867-877.

Genetic modifiers of risk and age at onset in GBA associated Parkinson's disease and Lewy body dementia

Parkinson's disease is a genetically complex disorder. Multiple genes have been shown to contribute to the risk of Parkinson's disease, and currently 90 independent risk variants have been identified by genome-wide association studies. Thus far, a number of genes (including SNCA, LRRK2, and GBA) have been shown to contain variability across a spectrum of frequency and effect, from rare, highly penetrant variants to common risk alleles with small effect sizes. Variants in GBA, encoding the enzyme glucocerebrosidase, are associated with Lewy body diseases such as Parkinson's disease and Lewy body dementia. These variants, which reduce or abolish enzymatic activity, confer a spectrum of disease risk, from 1.4- to >10-fold. An outstanding question in the field is what other genetic factors that influence GBA-associated risk for disease, and whether these overlap with known Parkinson's disease risk variants. Using multiple, large case-control datasets, totalling 217 165 individuals (22 757 Parkinson's disease cases, 13 431 Parkinson's disease proxy cases, 622 Lewy body dementia cases and 180 355 controls), we identified 1691 Parkinson's disease cases, 81 Lewy body dementia cases, 711 proxy cases and 7624 controls with a GBA variant (p.E326K, p.T369M or p.N370S). We performed a genome-wide association study and analysed the most recent Parkinson's disease-associated genetic risk score to detect genetic influences on GBA risk and age at onset. We attempted to replicate our findings in two independent datasets, including the personal genetics company 23andMe, Inc. and whole-genome sequencing data. Our analysis showed that the overall Parkinson's disease genetic risk score modifies risk for disease and decreases age at onset in carriers of GBA variants. Notably, this effect was consistent across all tested GBA risk variants. Dissecting this signal demonstrated that variants in close proximity to SNCA and CTSB (encoding cathepsin B) are the most significant contributors. Risk variants in the CTSB locus were identified to decrease mRNA expression of CTSB. Additional analyses suggest a possible genetic interaction between GBA and CTSB and GBA p.N370S induced pluripotent cell-derived neurons were shown to have decreased cathepsin B expression compared to controls. These data provide a genetic basis for modification of GBA-associated Parkinson's disease risk and age at onset, although the total contribution of common genetics variants is not large. We further demonstrate that common variability at genes implicated in lysosomal function exerts the largest effect on GBA associated risk for disease. Further, these results have implications for selection of GBA carriers for therapeutic interventions.

Risk factors for Cesarean delivery in pregnancy with small-for-gestational-age fetus undergoing induction of labor

OBJECTIVES

To identify risk factors for Cesarean delivery and non-reassuring fetal heart tracing (NRFHT) in pregnancies with a small-for-gestational-age (SGA) fetus undergoing induction of labor and to design and validate a prediction model, combining antenatal and intrapartum variables known at the time of labor induction, to identify pregnancies at increased risk of Cesarean delivery.

METHODS

This was a retrospective cohort study of non-anomalous, singleton gestations with a SGA fetus that underwent induction of labor, delivered in a single tertiary referral center between January 2011 and December 2016. SGA was defined as estimated fetal weight (EFW) < 10^th percentile. The primary outcome was to identify risk factors associated with Cesarean delivery. The secondary outcome was to identify risk factors associated with NRFHT. Univariate and multivariate analyses were used to determine which clinical characteristics, available at the time of admission, had the strongest association with Cesarean delivery and NRFHT during labor induction. The predictive value of the final models was assessed by the area under the receiver-operating-characteristics curve (AUC). Sensitivity and specificity of the models were also assessed. Internal validation of the models was performed using 10 000 bootstrap replicates of the original cohort. The adequacy of the models was evaluated using the Hosmer-Lemeshow goodness-of-fit test.

RESULTS

A total of 594 pregnancies were included. Cesarean delivery was performed in 243 (40.9%) pregnancies. Significant risk factors associated with Cesarean delivery, and included in the final model, were maternal age, gestational age at delivery and initial method of labor induction. The bootstrap estimate of the AUC of the final prediction model for Cesarean delivery was 0.82 (95% CI, 0.78-0.86). The model had sensitivity of 64.2%, specificity of 86.9%, positive likelihood ratio (LR) of 4.9 and negative LR of 0.41. The model had good fit (P = 0.617). NRFHT complicated 117 (19.7%) pregnancies. Significant risk factors for NRFHT included EFW < 5^th percentile, abnormal umbilical artery Doppler studies (pulsatility index > 95^th percentile or absent/reversed end-diastolic flow) and gestational age at delivery. The final prediction model for NRFHT had an AUC of 0.69 (95% CI, 0.63-0.75) and specificity of 97.0%.

CONCLUSION

We identified several significant risk factors for Cesarean delivery and NRFHT among SGA pregnancies undergoing induction of labor. Clinicians may use these risk factors to guide patient counseling and to help anticipate the potential need for operative delivery. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Integrating suitability for teaching into an electronic health record - A novel and versatile tool for medical education

This article was migrated. The article was marked as recommended. The educational literature has noted the implications of electronic health records (EHR) for patient care and discussed various implications for the learner-teacher relationship but it has so far not viewed EHR as an educational tool. We wondered whether we could use EHR to facilitate undergraduate medical students' exposure to hospital in-patients with an interesting history or findings on clinical examination. As clinicians, we encounter such patients on a regular basis during ward rounds and referrals but students are often absent during these encounters, leading to a loss of learning opportunities. Our aim was therefore to harness the EHR and create an electronic "flag" that would, following consent, document suitable inpatients and thus maximise the students' exposure to patients who present learning opportunities. With help from our IT department we developed a simple add on to our existing EHR that allows any clinician to electronically highlight and document such patients during inpatient encounters. A member of the educational faculty can, whenever required, interrogate the EHR for the presence of inpatients with interesting findings on examination in the hospital and facilitate contact with our medical students. We report details of our approach, describe early experience and potential pitfalls and suggest future applications.

Integrating suitability for teaching into an electronic health record - A novel and versatile tool for medical education

This article was migrated. The article was not marked as recommended. The educational literature has noted the implications of electronic health records (EHR) for patient care and discussed various implications for the learner-teacher relationship but it has so far not viewed EHR as an educational tool. We wondered whether one could use EHR to facilitate undergraduate medical students' exposure to hospital in-patients with an interesting history or findings on clinical examination. As clinicians, we encounter such patients on a regular basis during ward rounds and referrals but students are often absent during these encounters, leading to a loss of learning opportunities. Our aim was therefore to harness the EHR and create an electronic "flag" that would, following verbal consent, document suitable inpatients and thus maximise the students' exposure to interesting findings on clinical examination. With help from our IT department we developed a simple add on to our existing EHR that allows any clinician to electronically highlight and document such patients during inpatient encounters. A member of the educational faculty can, whenever required, interrogate the EHR for the presence of inpatients with interesting findings on examination in the hospital and facilitate contact with our medical students. We report details of our approach, describe early experience and potential pitfalls and suggest future applications.

Mitofusin-mediated ER stress triggers neurodegeneration in pink1/parkin models of Parkinson's disease

Mutations in PINK1 and PARKIN cause early-onset Parkinson's disease (PD), thought to be due to mitochondrial toxicity. Here, we show that in Drosophila pink1 and parkin mutants, defective mitochondria also give rise to endoplasmic reticulum (ER) stress signalling, specifically to the activation of the protein kinase R-like endoplasmic reticulum kinase (PERK) branch of the unfolded protein response (UPR). We show that enhanced ER stress signalling in pink1 and parkin mutants is mediated by mitofusin bridges, which occur between defective mitochondria and the ER. Reducing mitofusin contacts with the ER is neuroprotective, through suppression of PERK signalling, while mitochondrial dysfunction remains unchanged. Further, both genetic inhibition of dPerk-dependent ER stress signalling and pharmacological inhibition using the PERK inhibitor GSK2606414 were neuroprotective in both pink1 and parkin mutants. We conclude that activation of ER stress by defective mitochondria is neurotoxic in pink1 and parkin flies and that the reduction of this signalling is neuroprotective, independently of defective mitochondria. A video abstract for this article is available online in the supplementary information

Comparing hospital and telephone follow-up for patients treated for stage-I endometrial cancer (ENDCAT trial): a randomised, multicentre, non-inferiority trial

OBJECTIVE

To evaluate the effectiveness of nurse-led telephone follow-up (TFU) for patients with stage-I endometrial cancer.

DESIGN

Multicentre, randomised, non-inferiority trial.

SETTING

Five centres in the North West of England.

SAMPLE

A cohort of 259 women treated for stage-I endometrial cancer attending hospital outpatient clinics for routine follow-up.

METHODS

Participants were randomly allocated to receive traditional hospital based follow-up (HFU) or nurse-led TFU.

MAIN OUTCOME MEASURES

Primary outcomes were psychological morbidity (State Trait Anxiety Inventory, STAI-S) and patient satisfaction with the information provided. Secondary outcomes included patient satisfaction with service, quality of life, and time to detection of recurrence.

RESULTS

The STAI-S scores post-randomisation were similar between groups [mean (SD): TFU 33.0 (11.0); HFU 35.5 (13.0)]. The estimated between-group difference in STAI-S was 0.7 (95% confidence interval, 95% CI -1.9 to 3.3); the confidence interval lies above the non-inferiority limit (-3.5), indicating the non-inferiority of TFU. There was no significant difference between groups in reported satisfaction with information (odds ratio, OR 0.9; 95% CI 0.4-2.1; P = 0.83). Women in the HFU group were more likely to report being kept waiting for their appointment (P = 0.001), that they did not need any information (P = 0.003), and were less likely to report that the nurse knew about their particular case and situation (P = 0.005).

CONCLUSIONS

The TFU provides an effective alternative to HFU for patients with stage-I endometrial cancer, with no reported physical or psychological detriment. Patient satisfaction with information was high, with similar levels between groups.

TWEETABLE ABSTRACT

ENDCAT trial shows effectiveness of nurse-led telephone follow-up for patients with stage-I endometrial cancer.

Pertussis vaccination coverage among Australian women prior to childbirth in the cocooning era: a two-hospital, cross-sectional survey, 2010 to 2013

BACKGROUND

Recent pertussis epidemics have triggered implementation of cocooning, involving caregiver vaccination to indirectly protecting susceptible infants.

AIM

To determine patient, provider and setting factors associated with maternal pertussis booster vaccination (dTpa) within 5-10 years before childbirth.

MATERIALS AND METHODS

Cross-sectional survey using Health Belief Model constructs among postpartum women in a tertiary referral centre and a private hospital in Sydney, Australia.

RESULTS

Pertussis vaccination was current among 33.7% of the 2483 new mothers (0.5% vaccinated during pregnancy). Women were more likely to be vaccinated if they had heard of 'whooping cough' from a health professional (OR: 2.59, P < 0.001, 95% CI: 1.70-3.95), were recommended the vaccine (OR: 2.48, P < 0.00, 95% CI: 1.55-4.00), perceived pertussis as 'severe' for adults (OR: 1.21, p0.009, 95% CI: 1.05-1.39) and 'common' within their community (OR: 1.38, P < 0.001, 95% CI: 1.18-1.61). They more often agreed that it was their parental responsibility to be vaccinated (OR: 1.61, P = 0.002, 95% CI: 1.19-2.18), and this would help prevent their baby from contracting pertussis (OR: 1.22, P = 0.046, 95% CI: 1.00-1.47). Vaccinated women were less likely to report vaccination barriers: time constraints (OR: 0.75, P < 0.001, 95% CI: 0.66-0.85) and having safety concerns (OR: 0.80, P < 0.001, 95% CI: 0.69-0.92). Additionally, their partners reported three times higher uptake (76% vs 49%; P < 0.001; 95% CI: 2.66-3.85).

CONCLUSIONS

Current pertussis vaccination in only one in every three postpartum participants may indicate insufficient coverage to protect newborns. Practitioners are instrumental in raising awareness and addressing vaccine concerns. Integrating vaccination into routine obstetric care, whether antenatally or postnatally, may minimise barriers.

Systematic review of fever, febrile convulsions and serious adverse events following administration of inactivated trivalent influenza vaccines in children

In 2010, increased febrile convulsions (FC) occurred after administration of inactivated trivalent influenza vaccine (TIV) in Australia. We systematically reviewed the rates of fever, FC and serious adverse events (SAEs) after TIV, focussing on published and unpublished clinical trial data from 2005 to 2012, and performed meta-analysis of fever rates. From 4,372 records in electronic databases, 18 randomised controlled trials (RCTs), 14 non-randomised clinical trials, six observational studies and 12 registered trials (five RCTs and seven non-randomised) were identified. In published RCTs, fever ≥ 38 °C rates after first dose of non-adjuvanted TIV were 6.7% and 6.9% for children aged 6–35 months and ≥ 3 years, respectively. Analysis of RCTs by vaccine manufacturer showed pooled fever estimates up to 5.1% with Sanofi or GlaxoSmithKline vaccines; bioCSL vaccines were used in two non-randomised clinical trials and one unpublished RCT and were associated with fever in 22.5–37.1% for children aged 6–35 months. In RCTs, FCs occurred at a rate of 1.1 per 1,000 vaccinated children. While most TIVs induced acceptably low fever rates, bioCSL influenza vaccines were associated with much higher rates of fever in young children. Future standardised study methodology and access to individual level data would be illuminating.

NeuroX, a fast and efficient genotyping platform for investigation of neurodegenerative diseases

Our objective was to design a genotyping platform that would allow rapid genetic characterization of samples in the context of genetic mutations and risk factors associated with common neurodegenerative diseases. The platform needed to be relatively affordable, rapid to deploy, and use a common and accessible technology. Central to this project, we wanted to make the content of the platform open to any investigator without restriction. In designing this array we prioritized a number of types of genetic variability for inclusion, such as known risk alleles, disease-causing mutations, putative risk alleles, and other functionally important variants. The array was primarily designed to allow rapid screening of samples for disease-causing mutations and large population studies of risk factors. Notably, an explicit aim was to make this array widely available to facilitate data sharing across and within diseases. The resulting array, NeuroX, is a remarkably cost and time effective solution for high-quality genotyping. NeuroX comprises a backbone of standard Illumina exome content of approximately 240,000 variants, and over 24,000 custom content variants focusing on neurologic diseases. Data are generated at approximately $50-$60 per sample using a 12-sample format chip and regular Infinium infrastructure; thus, genotyping is rapid and accessible to many investigators. Here, we describe the design of NeuroX, discuss the utility of NeuroX in the analyses of rare and common risk variants, and present quality control metrics and a brief primer for the analysis of NeuroX derived data.

Predictors of complications in gynaecological oncological surgery: a prospective multicentre study (UKGOSOC-UK gynaecological oncology surgical outcomes and complications)

BACKGROUND

There are limited data on surgical outcomes in gynaecological oncology. We report on predictors of complications in a multicentre prospective study.

METHODS

Data on surgical procedures and resulting complications were contemporaneously recorded on consented patients in 10 participating UK gynaecological cancer centres. Patients were sent follow-up letters to capture any further complications. Post-operative (Post-op) complications were graded (I-V) in increasing severity using the Clavien-Dindo system. Grade I complications were excluded from the analysis. Univariable and multivariable regression was used to identify predictors of complications using all surgery for intra-operative (Intra-op) and only those with both hospital and patient-reported data for Post-op complications.

RESULTS

Prospective data were available on 2948 major operations undertaken between April 2010 and February 2012. Median age was 62 years, with 35% obese and 20.4% ASA grade ⩾3. Consultant gynaecological oncologists performed 74.3% of operations. Intra-op complications were reported in 139 of 2948 and Grade II-V Post-op complications in 379 of 1462 surgeries. The predictors of risk were different for Intra-op and Post-op complications. For Intra-op complications, previous abdominal surgery, metabolic/endocrine disorders (excluding diabetes), surgical complexity and final diagnosis were significant in univariable and multivariable regression (P<0.05), with diabetes only in multivariable regression (P=0.006). For Post-op complications, age, comorbidity status, diabetes, surgical approach, duration of surgery, and final diagnosis were significant in both univariable and multivariable regression (P<0.05).

CONCLUSIONS

This multicentre prospective audit benchmarks the considerable morbidity associated with gynaecological oncology surgery. There are significant patient and surgical factors that influence this risk.

Analysis of genome-wide association studies of Alzheimer disease and of Parkinson disease to determine if these 2 diseases share a common genetic risk

IMPORTANCE

Despite Alzheimer disease (AD) and Parkinson disease (PD) being clinically distinct entities, there is a possibility of a pathological overlap, with some genome-wide association (GWA) studies suggesting that the 2 diseases represent a biological continuum. The application of GWA studies to idiopathic forms of AD and PD have identified a number of loci that contain genetic variants that increase the risk of these disorders.

OBJECTIVE

To assess the genetic overlap between PD and AD by testing for the presence of potentially pleiotropic loci in 2 recent GWA studies of PD and AD.

DESIGN

Combined GWA analysis.

SETTING

Data sets from the United Kingdom, Germany, France, and the United States.

PARTICIPANTS

Thousands of patients with AD or PD and their controls.

MAIN OUTCOMES AND MEASURES

Meta-analysis of GWA studies of AD and PD.

METHODS

To identify evidence for potentially pleiotropic alleles that increased the risk for both PD and AD, we performed a combined PD-AD meta-analysis and compared the results with those obtained in the primary GWA studies.We also tested for a net effect of potentially polygenic alleles that were shared by both disorders by performing a polygenic score analysis. Finally, we also performed a gene-based association analysis that was aimed at detecting genes that harbor multiple disease-causing single-nucleotide polymorphisms, some of which confer a risk of PD and some a risk of AD.

RESULTS

Detailed interrogation of the single-nucleotide polymorphism, polygenic, and gene-based analyses resulted in no significant evidence that supported the presence of loci that increase the risk of both PD and AD.

CONCLUSIONS AND RELEVANCE

Our findings therefore imply that loci that increase the risk of both PD and AD are not widespread and that the pathological overlap could instead be “downstream” of the primary susceptibility genes that increase the risk of each disease.

Genetic comorbidities in Parkinson's disease

Parkinson's disease (PD) has a number of known genetic risk factors. Clinical and epidemiological studies have suggested the existence of intermediate factors that may be associated with additional risk of PD. We construct genetic risk profiles for additional epidemiological and clinical factors using known genome-wide association studies (GWAS) loci related to these specific phenotypes to estimate genetic comorbidity in a systematic review. We identify genetic risk profiles based on GWAS variants associated with schizophrenia and Crohn's disease as significantly associated with risk of PD. Conditional analyses adjusting for SNPs near loci associated with PD and schizophrenia or PD and Crohn's disease suggest that spatially overlapping loci associated with schizophrenia and PD account for most of the shared comorbidity, while variation outside of known proximal loci shared by PD and Crohn's disease accounts for their shared genetic comorbidity. We examine brain methylation and expression signatures proximal to schizophrenia and Crohn's disease loci to infer functional changes in the brain associated with the variants contributing to genetic comorbidity. We compare our results with a systematic review of epidemiological literature, while the findings are dissimilar to a degree; marginal genetic associations corroborate the directionality of associations across genetic and epidemiological data. We show a strong genetically defined level of comorbidity between PD and Crohn's disease as well as between PD and schizophrenia, with likely functional consequences of associated variants occurring in brain.

Patient-reporting improves estimates of postoperative complication rates: a prospective cohort study in gynaecological oncology

Background:

Most studies use hospital data to calculate postoperative complication rates (PCRs). We report on improving PCR estimates through use of patient-reporting.

Methods:

A prospective cohort study of major surgery performed at 10 UK gynaecological cancer centres was undertaken. Hospitals entered the data contemporaneously into an online database. Patients were sent follow-up letters to capture postoperative complications. Grade II–V (Clavien–Dindo classification) patient-reported postoperative complications were verified from hospital records. Postoperative complication rate was defined as the proportion of surgeries with a Grade II–V postoperative complication.

Results:

Patient replies were received for 1462 (68%) of 2152 surgeries undertaken between April 2010 and February 2012. Overall, 452 Grade II–V (402 II, 50 III–V) complications were reported in 379 of the 1462 surgeries. This included 172 surgeries with 200 hospital-reported complications and 231 with 280 patient-reported complications. All (100% concordance) 36 Grade III–V and 158 of 280 (56.4% concordance) Grade II patient-reported complications were verified on hospital case-note review. The PCR using hospital-reported data was 11.8% (172 out of 1462; 95% CI 11–14), patient-reported was 15.8% (231 out of 1462; 95% CI 14–17.8), hospital and verified patient-reported was 19.4% (283 out of 1462; 95% CI 17.4–21.4) and all data were 25.9% (379 out of 1462; 95% CI 24–28). After excluding Grade II complications, the hospital and patient verified Grade III–V PCR was 3.3% (48 out of 1462; 95% CI 2.5–4.3).

Conclusion:

This is the first prospective study of postoperative complications we are aware of in gynaecological oncology to include the patient-reported data. Patient-reporting is invaluable for obtaining complete information on postoperative complications. Primary care case-note review is likely to improve verification rates of patient-reported Grade II complications.

The involvement of parents in healthcare decisions where adult children are at risk of lacking decision-making capacity: a qualitative study of treatment decisions in epilepsy

BACKGROUND

Patients with intellectual disabilities (ID) receive health care by proxy. It is family members and/or paid support staff who must recognise health problems, communicate with clinicians, and report the benefits, if any, of a particular treatment. At the same time international and national statutes protect and promote the right of people with disabilities to access the highest attainable standards of health on the basis of free and informed consent.

METHODS

To consider the role of parent-proxies in the management of epilepsy in adult children with ID who are at risk of lacking capacity to make decisions about their health care we interviewed 21 mothers.

FINDINGS

These mothers are not pursuing changes in treatment that might improve their son or daughter's epilepsy, nor are they willing to countenance changes in treatment. Clinicians concerned to build and sustain therapeutic alliances with these mothers, our evidence suggests, may well avoid going against their wishes.

DISCUSSION

Our research highlights the interactional contingencies of a hitherto neglected three-way clinical relationship comprising parent-proxy, an adult at risk of lacking decision-making capacity, and a treating clinician. This is a relationship, our findings suggest, where little importance is attached to either patient consent, or involvement in treatment decisions.

Female human papillomavirus (HPV) vaccination: global uptake and the impact of attitudes

Human papillomavirus (HPV) is the causative agent in cervical cancer and has been implicated in a range of other malignancies. Preventative vaccines are now internationally available and provide high levels of protection from common viral strains. The introduction of a comprehensive vaccination programme (except 'program' in computers) could prevent over 60% of current cervical cancer cases, but this is dependent on such programmes achieving a high level of coverage. In this review, we summarise the current trends in female HPV vaccination coverage throughout the world, and place it in the context of available research on attitudes towards vaccination amongst the public and health professionals. Where countries have the resources for mass vaccination programmes, uptake has varied. School-based opt-out programmes consistently achieve highest coverage, whilst countries and regions without systematic vaccination schemes have low coverage. In all countries, the success of vaccination programmes is dependent on the support of the public and healthcare professionals. Whilst public acceptance is dependent on multiple factors, it has repeatedly been shown that recommendation by a health professional, particularly clinicians, is key to vaccine uptake. Worryingly, it appears that a proportion of clinicians still have significant reservations about promoting vaccination, particularly for younger age groups. A commitment now, to fully educating both the public and clinicians, has the potential to make a dramatic future impact.