A phase 1/2 study of pepinemab in children, adolescents, or young adults with recurrent or refractory solid tumors: A children's oncology group consortium report (ADVL1614)

PURPOSE

Pepinemab, a humanized IgG4 monoclonal antibody, targets the SEMA4D (CD100) antigen to inhibit binding to its high-affinity receptors (plexin B1/PLXNB1, plexin B2/PLXNB2) and low-affinity receptor (CD72). SEMA4D blockade leads to increased cytotoxic T-cell infiltration, delayed tumor growth, and durable tumor rejection in murine tumor models. Pepinemab was well tolerated and improved T cell infiltration in clinical studies in adults with refractory tumors. SEMA4D was identified as a strong candidate proto-oncogene in a model of osteosarcoma. Based on these preclinical and clinical data, we conducted a phase 1/2 study to determine the recommended phase 2 dose (RP2D), pharmacokinetics, pharmacodynamics, and immunogenicity, of pepinemab in pediatric patients with recurrent/refractory solid tumors, and activity in osteosarcoma.

EXPERIMENTAL DESIGN

Pepinemab was administered intravenously on Days 1 and 15 of a 28-day cycle at 20 mg/kg, the adult RP2D. Part A (phase 1) used a Rolling 6 design; Part B (phase 2) used a Simon 2-stage design in patients with osteosarcoma. Pharmacokinetics and target saturation were evaluated in peripheral blood.

RESULTS

Pepinemab (20 mg/kg) was well tolerated and no dose-limiting toxicities were observed during Part A. There were no objective responses. Two patients with osteosarcoma achieved disease control and prolonged stable disease. Pepinemab pharmacokinetics were similar to adults.

CONCLUSIONS

Pepinemab (20 mg/kg) is safe, well tolerated and resulted in adequate and sustained target saturation in pediatric patients. Encouraging disease control in two patients with osteosarcoma warrants further investigation with novel combination strategies to modulate the tumor microenvironment and antitumor immune response.

CLINICAL TRIAL REGISTRY

This trial is registered as NCT03320330 at Clinicaltrials.gov.

DISCLAIMER

The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

An updated survey of freshwater fishes within Letchworth State Park and surrounding area's of the Genesee River

The goal of this study was to gather information about freshwater fishes in Letchworth State Park (42.615275° N, -77.992825° W), a portion of New York State-owned land located in the Genesee River Watershed that lacks known data about its fish diversity. Fish collection took place between 2017 and 2019 in the Genesse River upstream and downstream of the falls using electrofishing, gill, hoop, and seine netting. This was the first attempt at a comprehensive survey of this portion of the river, which allowed for a baseline to be established regarding fish biodiversity in the region. The updated total number of species found in this portion of the Genesee River was 25, 22 of which were newly identified downstream of the falls in Letchworth State Park. We encourage further collection and continuation of this survey with consistent sampling techniques to raise awareness about the importance of freshwater fish diversity in stream ecosystems across the globe.

Concerted adoption as an emerging strategy for digital transformation of healthcare-lessons from Australia, Canada, and England

OBJECTIVES

With an increasing focus on the digitalization of health and care settings, there is significant scope to learn from international approaches to promote concerted adoption of electronic health records.

MATERIALS AND METHODS

We review three large-scale initiatives from Australia, Canada, and England, and extract common lessons for future health and social care transformation strategy.

RESULTS

We discuss how, despite differences in contexts, concerted adoption enables sharing of experience and learning to streamline the digital transformation of health and care.

DISCUSSION AND CONCLUSION

Concerted adoption can be accelerated through building communities of expertise and partnerships promoting knowledge transfer and circulation of expertise; commonalities in geographical and cultural contexts; and commonalities in technological systems.

Peritoneal malignancy in the global COVID-19 pandemic: experience of recovery and restoration in a high-volume centre through NHS and independent sector collaboration

INTRODUCTION

Treatment of peritoneal malignancy with cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) requires substantial critical care, theatre and nursing resources. The COVID-19 pandemic caused challenges in providing a high volume, tertiary referral service.

METHODS

We reviewed data on referrals and operations performed in a tertiary referral centre in both NHS and independent sector settings. The impact of COVID-19 on activity was assessed using 2019 as a benchmark.

RESULTS

New patient referrals were similar, with 891 in 2019 compared with 833 in 2020. Delivery of CRS and HIPEC operations were initially impacted by COVID-19. NHS and independent sector collaboration facilitated recovery, with 284 patients treated in 2020 compared with 280 in 2019.

CONCLUSIONS

Close collaboration and structural organisation between the clinical and management teams in the NHS and independent sectors facilitated recovery and restoration of a complex tertiary referral service for peritoneal malignancy during the COVID pandemic.

Amplitude Analysis of the B^{0}→K^{*0}μ^{+}μ^{-} Decay

An amplitude analysis of the B^{0}→K^{*0}μ^{+}μ^{-} decay is presented using a dataset corresponding to an integrated luminosity of 4.7  fb^{-1} of pp collision data collected with the LHCb experiment. For the first time, the coefficients associated to short-distance physics effects, sensitive to processes beyond the standard model, are extracted directly from the data through a q^{2}-unbinned amplitude analysis, where q^{2} is the μ^{+}μ^{-} invariant mass squared. Long-distance contributions, which originate from nonfactorizable QCD processes, are systematically investigated, and the most accurate assessment to date of their impact on the physical observables is obtained. The pattern of measured corrections to the short-distance couplings is found to be consistent with previous analyses of b- to s-quark transitions, with the largest discrepancy from the standard model predictions found to be at the level of 1.8 standard deviations. The global significance of the observed differences in the decay is 1.4 standard deviations.

Fraction of χ_{c} Decays in Prompt J/ψ Production Measured in pPb Collisions at sqrt[s_{NN}]=8.16 TeV

The fraction of χ_{c1} and χ_{c2} decays in the prompt J/ψ yield, F_{χ_{c}→J/ψ}=σ_{χ_{c}→J/ψ}/σ_{J/ψ}, is measured by the LHCb detector in pPb collisions at sqrt[s_{NN}]=8.16  TeV. The study covers the forward (1.5 Collapse

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Observation of Cabibbo-Suppressed Two-Body Hadronic Decays and Precision Mass Measurement of the Ω_{c}^{0} Baryon

The first observation of the singly Cabibbo-suppressed Ω_{c}^{0}→Ω^{-}K^{+} and Ω_{c}^{0}→Ξ^{-}π^{+} decays is reported, using proton-proton collision data at a center-of-mass energy of 13 TeV, corresponding to an integrated luminosity of 5.4  fb^{-1}, collected with the LHCb detector between 2016 and 2018. The branching fraction ratios are measured to be B(Ω_{c}^{0}→Ω^{-}K^{+})/B(Ω_{c}^{0}→Ω^{-}π^{+})=[6.08±0.51(stat)±0.40(syst)]%,B(Ω_{c}^{0}→Ξ^{-}π^{+})/B(Ω_{c}^{0}→Ω^{-}π^{+})=[15.81±0.87(stat)±0.44(syst)±0.16(ext)]%. In addition, using the Ω_{c}^{0}→Ω^{-}π^{+} decay channel, the Ω_{c}^{0} baryon mass is measured to be M(Ω_{c}^{0})=2695.28±0.07(stat)±0.27(syst)±0.30(ext)  MeV, improving the precision of the previous world average by a factor of 4.

Enhanced Production of Λ_{b}^{0} Baryons in High-Multiplicity pp Collisions at sqrt[s]=13 TeV

The production rate of Λ_{b}^{0} baryons relative to B^{0} mesons in pp collisions at a center-of-mass energy sqrt[s]=13  TeV is measured by the LHCb experiment. The ratio of Λ_{b}^{0} to B^{0} production cross sections shows a significant dependence on both the transverse momentum and the measured charged-particle multiplicity. At low multiplicity, the ratio measured at LHCb is consistent with the value measured in e^{+}e^{-} collisions, and increases by a factor of ∼2 with increasing multiplicity. At relatively low transverse momentum, the ratio of Λ_{b}^{0} to B^{0} cross sections is higher than what is measured in e^{+}e^{-} collisions, but converges with the e^{+}e^{-} ratio as the momentum increases. These results imply that the evolution of heavy b quarks into final-state hadrons is influenced by the density of the hadronic environment produced in the collision. Comparisons with several models and implications for the mechanisms enforcing quark confinement are discussed.

Improved Measurement of CP Violation Parameters in B_{s}^{0}→J/ψK^{+}K^{-} Decays in the Vicinity of the ϕ(1020) Resonance

The decay-time-dependent CP asymmetry in B_{s}^{0}→J/ψ(→μ^{+}μ^{-})K^{+}K^{-} decays is measured using proton-proton collision data, corresponding to an integrated luminosity of 6  fb^{-1}, collected with the LHCb detector at a center-of-mass energy of 13 TeV. Using a sample of approximately 349 000 B_{s}^{0} signal decays with an invariant K^{+}K^{-} mass in the vicinity of the ϕ(1020) resonance, the CP-violating phase ϕ_{s} is measured, along with the difference in decay widths of the light and heavy mass eigenstates of the B_{s}^{0}-B[over ¯]_{s}^{0} system, ΔΓ_{s}, and the difference of the average B_{s}^{0} and B^{0} meson decay widths, Γ_{s}-Γ_{d}. The values obtained are ϕ_{s}=-0.039±0.022±0.006  rad, ΔΓ_{s}=0.0845±0.0044±0.0024  ps^{-1}, and Γ_{s}-Γ_{d}=-0.0056_{-0.0015}^{+0.0013}±0.0014  ps^{-1}, where the first uncertainty is statistical and the second systematic. These are the most precise single measurements to date and are consistent with expectations based on the Standard Model and with the previous LHCb analyses of this decay. These results are combined with previous independent LHCb measurements. The phase ϕ_{s} is also measured independently for each polarization state of the K^{+}K^{-} system and shows no evidence for polarization dependence.

Measurement of CP Violation in B^{0}→ψ(→ℓ^{+}ℓ^{-})K_{S}^{0}(→π^{+}π^{-}) Decays

A measurement of time-dependent CP violation in the decays of B^{0} and B[over ¯]^{0} mesons to the final states J/ψ(→μ^{+}μ^{-})K_{S}^{0}, ψ(2S)(→μ^{+}μ^{-})K_{S}^{0} and J/ψ(→e^{+}e^{-})K_{S}^{0} with K_{S}^{0}→π^{+}π^{-} is presented. The data correspond to an integrated luminosity of 6  fb^{-1} collected at a center-of-mass energy of sqrt[s]=13  TeV with the LHCb detector. The CP-violation parameters are measured to be S_{ψK_{S}^{0}}=0.717±0.013(stat)±0.008(syst) and C_{ψK_{S}^{0}}=0.008±0.012(stat)±0.003(syst). This measurement of S_{ψK_{S}^{0}} represents the most precise single measurement of the CKM angle β to date and is more precise than the current world average. In addition, measurements of the CP-violation parameters of the individual channels are reported and a combination with the LHCb Run 1 measurements is performed.

Early experiences of integrating an artificial intelligence-based diagnostic decision support system into radiology settings: a qualitative study

OBJECTIVES

Artificial intelligence (AI)-based clinical decision support systems to aid diagnosis are increasingly being developed and implemented but with limited understanding of how such systems integrate with existing clinical work and organizational practices. We explored the early experiences of stakeholders using an AI-based imaging software tool Veye Lung Nodules (VLN) aiding the detection, classification, and measurement of pulmonary nodules in computed tomography scans of the chest.

MATERIALS AND METHODS

We performed semistructured interviews and observations across early adopter deployment sites with clinicians, strategic decision-makers, suppliers, patients with long-term chest conditions, and academics with expertise in the use of diagnostic AI in radiology settings. We coded the data using the Technology, People, Organizations, and Macroenvironmental factors framework.

RESULTS

We conducted 39 interviews. Clinicians reported VLN to be easy to use with little disruption to the workflow. There were differences in patterns of use between experts and novice users with experts critically evaluating system recommendations and actively compensating for system limitations to achieve more reliable performance. Patients also viewed the tool positively. There were contextual variations in tool performance and use between different hospital sites and different use cases. Implementation challenges included integration with existing information systems, data protection, and perceived issues surrounding wider and sustained adoption, including procurement costs.

DISCUSSION

Tool performance was variable, affected by integration into workflows and divisions of labor and knowledge, as well as technical configuration and infrastructure.

CONCLUSION

The socio-organizational factors affecting performance of diagnostic AI are under-researched and require attention and further research.

Evaluation of variable new antigen receptors (vNARs) as a novel cathepsin S (CTSS) targeting strategy

Aberrant activity of the cysteine protease Cathepsin S (CTSS) has been implicated across a wide range of pathologies. Notably in cancer, CTSS has been shown to promote tumour progression, primarily through facilitating invasion and migration of tumour cells and augmenting angiogenesis. Whilst an attractive therapeutic target, more efficacious CTSS inhibitors are required. Here, we investigated the potential application of Variable New Antigen Receptors (vNARs) as a novel inhibitory strategy. A panel of potential vNAR binders were identified following a phage display panning process against human recombinant proCTSS. These were subsequently expressed, purified and binding affinity confirmed by ELISA and SPR based approaches. Selected lead clones were taken forward and were shown to inhibit CTSS activity in recombinant enzyme activity assays. Further assessment demonstrated that our lead clones functioned by a novel inhibitory mechanism, by preventing the activation of proCTSS to the mature enzyme. Moreover, using an intrabody approach, we exhibited the ability to express these clones intracellularly and inhibit CTSS activity whilst lead clones were also noted to impede cell invasion in a tumour cell invasion assay. Collectively, these findings illustrate a novel mechanistic approach for inhibiting CTSS activity, with anti-CTSS vNAR clones possessing therapeutic potential in combating deleterious CTSS activity. Furthermore, this study exemplifies the potential of vNARs in targeting intracellular proteins, opening a range of previously "undruggable" targets for biologic-based therapy.

Evaluation of Digitalisation in Healthcare and the Quantification of the "Unmeasurable"

Evaluating healthcare digitalisation, where technology implementation and adoption transforms existing socio-organisational processes, presents various challenges for outcome assessments. Populations are diverse, interventions are complex and evolving over time, meaningful comparisons are difficult as outcomes vary between settings, and outcomes take a long time to materialise and stabilise. Digitalisation may also have unanticipated impacts. We here discuss the limitations of evaluating the digitalisation of healthcare, and describe how qualitative and quantitative approaches can complement each other to facilitate investment and implementation decisions. In doing so, we argue how existing approaches have focused on measuring what is easily measurable and elevating poorly chosen values to inform investment decisions. Limited attention has been paid to understanding processes that are not easily measured even though these can have significant implications for contextual transferability, sustainability and scale-up of interventions. We use what is commonly known as the McNamara Fallacy to structure our discussions. We conclude with recommendations on how we envisage the development of mixed methods approaches going forward in order to address shortcomings.

Contaminated sediment in the Detroit River provokes acclimated responses in wild brown bullhead (Ameiurus nebulosus) populations

In a previous study, adaptive responses to a single polycyclic aromatic hydrocarbon (PAH), benzo[a]pyrene (BaP), were identified in brown bullhead (Ameiurus nebulosus) captured from contaminated sites across the Great Lakes. The tumor suppressor p53 and phase I toxin metabolizing CYP1A genes showed a elevated and refractory response, respectively, up to the F1 generation (Williams and Hubberstey, 2014). As an extension to the first study, bullhead were exposed to sediment collected from sites along the Detroit River to see if these adaptive responses are attainable when fish from a contaminated site are exposed to a mixture of contaminants, instead of a single compound. p53 and CYP1A proteins were measured again with the addition of phase II glutathione-s-transferase (GST) activity in the present study. Three treatment groups were measured: acute (treated immediately), cleared (depurated for three months and subsequent treatment), and farm raised F1 offspring. All three treatment groups were exposed to clean and contaminated sediment for 24 and 96 h. Acute fish from contaminated sites exposed to contaminated sediment revealed an initial elevated p53 response that did not persist in fish after long-term contaminated sediment exposure. Acute fish from contaminated sites exposed to contaminated sediment revealed refractory CYP1A expression, which disappeared in cleared fish and whose F1 response overlapped with clean site F1 offspring. Decreasing GST activity was evident in both clean and contaminated fish over time, and only clean site fish responded to long-term contaminated sediment deliberately with increasing GST activity. Because p53 and CYP1A gene expression and GST activity responses did not overlap between contaminated fish treatment groups, our study suggests that contaminated fish have acclimated to the contaminants present in their environments and no evidence of adaptation could be detected within these biomarkers.

Observation of New Baryons in the Ξ_{b}^{-}π^{+}π^{-} and Ξ_{b}^{0}π^{+}π^{-} Systems

The first observation and study of two new baryonic structures in the final state Ξ_{b}^{0}π^{+}π^{-} and the confirmation of the Ξ_{b}(6100)^{-} state in the Ξ_{b}^{-}π^{+}π^{-} decay mode are reported using proton-proton collision data collected by the LHCb experiment, corresponding to an integrated luminosity of 9  fb^{-1}. In addition, the properties of the known Ξ_{b}^{*0}, Ξ_{b}^{'-} and Ξ_{b}^{*-} resonances are measured with improved precision. The new decay mode of the Ξ_{b}^{0} baryon to the Ξ_{c}^{+} π^{-} π^{+} π^{-} final state is observed and exploited for the first time in these measurements.

Precision Measurement of CP Violation in the Penguin-Mediated Decay B_{s}^{0}→ϕϕ

A flavor-tagged time-dependent angular analysis of the decay B_{s}^{0}→ϕϕ is performed using pp collision data collected by the LHCb experiment at the center-of-mass energy of 13 TeV, corresponding to an integrated luminosity of 6  fb^{-1}. The CP-violating phase and direct CP-violation parameter are measured to be ϕ_{s}^{ss[over ¯]s}=-0.042±0.075±0.009  rad and |λ|=1.004±0.030±0.009, respectively, assuming the same values for all polarization states of the ϕϕ system. In these results, the first uncertainties are statistical and the second systematic. These parameters are also determined separately for each polarization state, showing no evidence for polarization dependence. The results are combined with previous LHCb measurements using pp collisions at center-of-mass energies of 7 and 8 TeV, yielding ϕ_{s}^{ss[over ¯]s}=-0.074±0.069  rad and |λ|=1.009±0.030. This is the most precise study of time-dependent CP violation in a penguin-dominated B meson decay. The results are consistent with CP symmetry and with the standard model predictions.

Early Experiences of Integrating an Artificial Intelligence-Based Diagnostic Decision Support System into Radiology Settings: A Qualitative Study

BACKGROUND

Artificial Intelligence (AI) based clinical decision support systems to aid diagnosis are increasingly being developed and implemented but with limited understanding of how such systems integrate with existing clinical work and organizational practices. We explored the early experiences of stakeholders using an AI-based e-learning imaging software tool Veye Lung Nodules (VLN) aiding the detection, classification, and measurement of pulmonary nodules in computed tomography scans of the chest. We performed semi-structured interviews and observations across early adopter deployment sites with clinicians, strategic decision-makers, suppliers, patients with long-term chest conditions, and academics with expertise in the use of diagnostic AI in radiology settings. We coded the data using the Technology, People, Organizations and Macro-environmental factors framework (TPOM). We conducted 39 interviews. Clinicians reported VLN to be easy to use with little disruption to the workflow. There were differences in patterns of use between experts and novice users with experts critically evaluating system recommendations and actively compensating for system limitations to achieve more reliable performance. Patients also viewed the tool positively. There were contextual variations in tool performance and use between different hospital sites and different use cases. Implementation challenges included integration with existing information systems, data protection, and perceived issues surrounding wider and sustained adoption, including procurement costs. Tool performance was variable, affected by integration into workflows and divisions of labor and knowledge, as well as technical configuration and infrastructure. These under-researched factors require attention and further research.

Measurement of the Λ_{b}^{0}→Λ(1520)μ^{+}μ^{-} Differential Branching Fraction

The branching fraction of the rare decay Λ_{b}^{0}→Λ(1520)μ^{+}μ^{-} is measured for the first time, in the squared dimuon mass intervals q^{2}, excluding the J/ψ and ψ(2S) regions. The data sample analyzed was collected by the LHCb experiment at center-of-mass energies of 7, 8, and 13 TeV, corresponding to a total integrated luminosity of 9  fb^{-1}. The result in the highest q^{2} interval, q^{2}>15.0  GeV^{2}/c^{4}, where theoretical predictions have the smallest model dependence, agrees with the predictions.

Optimising ePrescribing in hospitals through the interoperability of systems and processes: a qualitative study in the UK, US, Norway and the Netherlands

BACKGROUND

Investment in the implementation of hospital ePrescribing systems has been a priority in many economically-developed countries in order to modernise the delivery of healthcare. However, maximum gains in the safety, quality and efficiency of care are unlikely to be fully realised unless ePrescribing systems are further optimised in a local context. Typical barriers to optimal use are often encountered in relation to a lack of systemic capacity and preparedness to meet various levels of interoperability requirements, including at the data, systems and services levels. This lack of systemic interoperability may in turn limit the opportunities and benefits potentially arising from implementing novel digital heath systems.

METHODS

We undertook n = 54 qualitative interviews with key stakeholders at nine digitally advanced hospital sites across the UK, US, Norway and the Netherlands. We included hospitals featuring 'standalone, best of breed' systems, which were interfaced locally, and multi-component and integrated electronic health record enterprise systems. We analysed the data inductively, looking at strategies and constraints for ePrescribing interoperability within and beyond hospital systems.

RESULTS

Our thematic analysis identified 4 main drivers for increasing ePrescribing systems interoperability: (1) improving patient safety (2) improving integration & continuity of care (3) optimising care pathways and providing tailored decision support to meet local and contextualised care priorities and (4) to enable full patient care services interoperability in a variety of settings and contexts. These 4 interoperability dimensions were not always pursued equally at each implementation site, and these were often dependent on the specific national, policy, organisational or technical contexts of the ePrescribing implementations. Safety and efficiency objectives drove optimisation targeted at infrastructure and governance at all levels. Constraints to interoperability came from factors such as legacy systems, but barriers to interoperability of processes came from system capability, hospital policy and staff culture.

CONCLUSIONS

Achieving interoperability is key in making ePrescribing systems both safe and useable. Data resources exist at macro, meso and micro levels, as do the governance interventions necessary to achieve system interoperability. Strategic objectives, most notably improved safety, often motivated hospitals to push for evolution across the entire data architecture of which they formed a part. However, hospitals negotiated this terrain with varying degrees of centralised coordination. Hospitals were heavily reliant on staff buy-in to ensure that systems interoperability was built upon to achieve effective data sharing and use. Positive outcomes were founded on a culture of agreement about the usefulness of access by stakeholders, including prescribers, policymakers, vendors and lab technicians, which was reflected in an alignment of governance goals with system design.

The need to strengthen the evaluation of the impact of Artificial Intelligence-based decision support systems on healthcare provision

Despite the renewed interest in Artificial Intelligence-based clinical decision support systems (AI-CDS), there is still a lack of empirical evidence supporting their effectiveness. This underscores the need for rigorous and continuous evaluation and monitoring of processes and outcomes associated with the introduction of health information technology. We illustrate how the emergence of AI-CDS has helped to bring to the fore the critical importance of evaluation principles and action regarding all health information technology applications, as these hitherto have received limited attention. Key aspects include assessment of design, implementation and adoption contexts; ensuring systems support and optimise human performance (which in turn requires understanding clinical and system logics); and ensuring that design of systems prioritises ethics, equity, effectiveness, and outcomes. Going forward, information technology strategy, implementation and assessment need to actively incorporate these dimensions. International policy makers, regulators and strategic decision makers in implementing organisations therefore need to be cognisant of these aspects and incorporate them in decision-making and in prioritising investment. In particular, the emphasis needs to be on stronger and more evidence-based evaluation surrounding system limitations and risks as well as optimisation of outcomes, whilst ensuring learning and contextual review. Otherwise, there is a risk that applications will be sub-optimally embodied in health systems with unintended consequences and without yielding intended benefits.

Fair and equitable AI in biomedical research and healthcare: Social science perspectives

Artificial intelligence (AI) offers opportunities but also challenges for biomedical research and healthcare. This position paper shares the results of the international conference "Fair medicine and AI" (online 3-5 March 2021). Scholars from science and technology studies (STS), gender studies, and ethics of science and technology formulated opportunities, challenges, and research and development desiderata for AI in healthcare. AI systems and solutions, which are being rapidly developed and applied, may have undesirable and unintended consequences including the risk of perpetuating health inequalities for marginalized groups. Socially robust development and implications of AI in healthcare require urgent investigation. There is a particular dearth of studies in human-AI interaction and how this may best be configured to dependably deliver safe, effective and equitable healthcare. To address these challenges, we need to establish diverse and interdisciplinary teams equipped to develop and apply medical AI in a fair, accountable and transparent manner. We formulate the importance of including social science perspectives in the development of intersectionally beneficent and equitable AI for biomedical research and healthcare, in part by strengthening AI health evaluation.

Observation of New Ω_{c}^{0} States Decaying to the Ξ_{c}^{+}K^{-} Final State

Two new excited states, Ω_{c}(3185)^{0} and Ω_{c}(3327)^{0}, are observed in the Ξ_{c}^{+}K^{-} invariant-mass spectrum using proton-proton collision data collected by the LHCb experiment, corresponding to an integrated luminosity of 9  fb^{-1}. Five previously observed excited Ω_{c}^{0} states are confirmed, namely Ω_{c}(3000)^{0}, Ω_{c}(3050)^{0}, Ω_{c}(3065)^{0}, Ω_{c}(3090)^{0}, and Ω_{c}(3119)^{0}. The masses and widths of these seven states are measured with the highest precision to date.

Evidence of a J/ψK_{S}^{0} Structure in B^{0}→J/ψϕK_{S}^{0} Decays

An amplitude analysis of B^{0}→J/ψϕK_{S}^{0} decays is performed using proton-proton collision data, corresponding to an integrated luminosity of 9  fb^{-1}, collected with the LHCb detector at center-of-mass energies of 7, 8, and 13 TeV. Evidence with a significance of 4.0 standard deviations of a structure in the J/ψK_{S}^{0} system, named T_{ψs1}^{θ}(4000)^{0}, is seen, with its mass and width measured to be 3991_{-10}^{+12} _{-17}^{+9}  MeV/c^{2} and 105_{-25}^{+29} _{-23}^{+17}  MeV, respectively, where the first uncertainty is statistical and the second systematic. The T_{ψs1}^{θ}(4000)^{0} state is likely to be the isospin partner of the T_{ψs1}^{θ}(4000)^{+} state, previously observed in the J/ψK^{+} system of the B^{+}→J/ψϕK^{+} decay. When isospin symmetry for the charged and neutral T_{ψs1}^{θ}(4000) states is assumed, the signal significance increases to 5.4 standard deviations.

Measurement of the Ratios of Branching Fractions R(D^{*}) and R(D^{0})

The ratios of branching fractions R(D^{*})≡B(B[over ¯]→D^{*}τ^{-}ν[over ¯]_{τ})/B(B[over ¯]→D^{*}μ^{-}ν[over ¯]_{μ}) and R(D^{0})≡B(B^{-}→D^{0}τ^{-}ν[over ¯]_{τ})/B(B^{-}→D^{0}μ^{-}ν[over ¯]_{μ}) are measured, assuming isospin symmetry, using a sample of proton-proton collision data corresponding to 3.0  fb^{-1} of integrated luminosity recorded by the LHCb experiment during 2011 and 2012. The tau lepton is identified in the decay mode τ^{-}→μ^{-}ν_{τ}ν[over ¯]_{μ}. The measured values are R(D^{*})=0.281±0.018±0.024 and R(D^{0})=0.441±0.060±0.066, where the first uncertainty is statistical and the second is systematic. The correlation between these measurements is ρ=-0.43. The results are consistent with the current average of these quantities and are at a combined 1.9 standard deviations from the predictions based on lepton flavor universality in the standard model.

Measurement of the Prompt D^{0} Nuclear Modification Factor in p-Pb Collisions at sqrt[s_{NN}]=8.16 TeV

The production of prompt D^{0} mesons in proton-lead collisions in both the forward and backward rapidity regions at a center-of-mass energy per nucleon pair of sqrt[s_{NN}]=8.16  TeV is measured by the LHCb experiment. The nuclear modification factor of prompt D^{0} mesons is determined as a function of the transverse momentum p_{T}, and the rapidity in the nucleon-nucleon center-of-mass frame y^{*}. In the forward rapidity region, significantly suppressed production with respect to pp collisions is measured, which provides significant constraints on models of nuclear parton distributions and hadron production down to the very low Bjorken-x region of ∼10^{-5}. In the backward rapidity region, a suppression with a significance of 2.0-3.8 standard deviations compared to parton distribution functions in a nuclear environment expectations is found in the kinematic region of p_{T}>6  GeV/c and -3.25 Collapse

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Better safe than so ray: national survey of radiation protection amongst interventional radiology trainees in the United Kingdom

OBJECTIVE

To establish the provision and use of radiation personal protective equipment (PPE) and dosimetry amongst UK interventional radiology (IR) trainees and highlight areas of improvement in order to enhance the radiation safety.

METHODS

A survey questionnaire was designed by members of the British Society of Interventional Radiology (BSIR) trainee committee via survey monkey and distributed to UK IR trainees via the BSIR membership mailing list, local representatives and Twitter. The survey was open from 04/01/2021 to 20/02/2021. Only IR trainees in years ST4 and above were included.

RESULTS

Of the 73 respondents, 62 qualified for analysis. Respondents (81% male) spent a median of 5.5 sessions (half day list) per week in the angiography suite and 58% (n=36) had difficulty finding appropriately sized lead aprons at least once a week. Overall 53% (n=33) had concerns about their radiation PPE. Furthermore 56% of trainees (n=35) experienced back pain among other symptoms attributed to wearing the lead aprons available to them. 77% (n=48) regularly wore lead glasses. For trainees requiring prescription glasses (n=22) overfit goggles were provided however 17 (77%) of these trainees felt the goggles compromised their ability to perform the procedure. Eye and finger dosimeters were used by 50% and 52% of respondents respectively. Compliance with body dosimetry was 99%.

CONCLUSION

Provision of radiation PPE and dose monitoring for IR trainees is suboptimal, particularly access to adequate eye protection or suitably fitting leads. Based on the findings of this survey, recommendations have been made to promote the safety and radiation awareness of IR trainees.

ADVANCES IN KNOWLEDGE

Radiation protection practices for IR trainees nationally are poor. Provision of suitable eye protection and well fitting lead body protection is low.

Measurement of the Time-Integrated CP Asymmetry in D^{0}→K^{-}K^{+} Decays

The time-integrated CP asymmetry in the Cabibbo-suppressed decay D^{0}→K^{-}K^{+} is measured using proton-proton collision data, corresponding to an integrated luminosity of 5.7  fb^{-1} collected at a center-of-mass energy of 13 TeV with the LHCb detector. The D^{0} mesons are required to originate from promptly produced D^{*+}→D^{0}π^{+} decays, and the charge of the companion pion is used to determine the flavor of the charm meson at production. The time-integrated CP asymmetry is measured to be A_{CP}(K^{-}K^{+})=[6.8±5.4±1.6]×10^{-4} where the first uncertainty is statistical and the second systematic. The direct CP asymmetries in D^{0}→K^{-}K^{+} and D^{0}→π^{-}π^{+} decays, a_{K^{-}K^{+}}^{d} and a_{π^{-}π^{+}}^{d}, are derived by combining A_{CP}(K^{-}K^{+}) with the time-integrated CP asymmetry difference, ΔA_{CP}=A_{CP}(K^{-}K^{+})-A_{CP}(π^{-}π^{+}), and other inputs, giving a_{K^{-}K^{+}}^{d}=(7.7±5.7)×10^{-4},a_{π^{-}π^{+}}^{d}=(23.2±6.1)×10^{-4},with a correlation coefficient corresponding to ρ=0.88. The compatibility of these results with CP symmetry is 1.4 and 3.8 standard deviations for D^{0}→K^{-}K^{+} and D^{0}→π^{-}π^{+} decays, respectively. This is the first evidence for direct CP violation in a specific D^{0} decay.

Evaluating the cost implications of integrating SARS-CoV-2 genome sequencing for infection prevention and control investigation of nosocomial transmission within hospitals

BACKGROUND

The COG-UK hospital-onset COVID-19 infection (HOCI) trial evaluated the impact of SARS-CoV-2 whole-genome sequencing (WGS) on acute infection, prevention, and control (IPC) investigation of nosocomial transmission within hospitals.

AIM

To estimate the cost implications of using the information from the sequencing reporting tool (SRT), used to determine likelihood of nosocomial infection in IPC practice.

METHODS

A micro-costing approach for SARS-CoV-2 WGS was conducted. Data on IPC management resource use and costs were collected from interviews with IPC teams from 14 participating sites and used to assign cost estimates for IPC activities as collected in the trial. Activities included IPC-specific actions following a suspicion of healthcare-associated infection (HAI) or outbreak, as well as changes to practice following the return of data via SRT.

FINDINGS

The mean per-sample costs of SARS-CoV-2 sequencing were estimated at £77.10 for rapid and £66.94 for longer turnaround phases. Over the three-month interventional phases, the total management costs of IPC-defined HAIs and outbreak events across the sites were estimated at £225,070 and £416,447, respectively. The main cost drivers were bed-days lost due to ward closures because of outbreaks, followed by outbreak meetings and bed-days lost due to cohorting contacts. Actioning SRTs, the cost of HAIs increased by £5,178 due to unidentified cases and the cost of outbreaks decreased by £11,246 as SRTs excluded hospital outbreaks.

CONCLUSION

Although SARS-CoV-2 WGS adds to the total IPC management cost, additional information provided could balance out the additional cost, depending on identified design improvements and effective deployment.

Measurement of the Branching Fractions B(B^{0}→pp[over ¯]pp[over ¯]) and B(B_{s}^{0}→pp[over ¯]pp[over ¯])

Searches for the rare hadronic decays B^{0}→pp[over ¯]pp[over ¯] and B_{s}^{0}→pp[over ¯]pp[over ¯] are performed using proton-proton collision data recorded by the LHCb experiment and corresponding to an integrated luminosity of 9  fb^{-1}. Significances of 9.3σ and 4.0σ, including statistical and systematic uncertainties, are obtained for the B^{0}→pp[over ¯]pp[over ¯] and B_{s}^{0}→pp[over ¯]pp[over ¯] signals, respectively. The branching fractions are measured relative to the topologically similar normalization decays B^{0}→J/ψ(→pp[over ¯])K^{*0}(→K^{+}π^{-}) and B_{s}^{0}→J/ψ(→pp[over ¯])⁢ϕ(→K^{+}K^{-}). The branching fractions are measured to be B(B^{0}→pp[over ¯]pp[over ¯])=(2.2±0.4±0.1±0.1)×10^{-8} and B(B_{s}^{0}→pp[over ¯]pp[over ¯])=(2.3±1.0±0.2±0.1)×10^{-8}. In these measurements, the first uncertainty is statistical, the second is systematic, and the third one is due to the external branching fraction of the normalization channel.

Observation of a Resonant Structure near the D_{s}^{+}D_{s}^{-} Threshold in the B^{+}→D_{s}^{+}D_{s}^{-}K^{+} Decay

An amplitude analysis of the B^{+}→D_{s}^{+}D_{s}^{-}K^{+} decay is carried out to study for the first time its intermediate resonant contributions, using proton-proton collision data collected with the LHCb detector at center-of-mass energies of 7, 8, and 13 TeV. A near-threshold peaking structure, referred to as X(3960), is observed in the D_{s}^{+}D_{s}^{-} invariant-mass spectrum with significance greater than 12 standard deviations. The mass, width, and the quantum numbers of the structure are measured to be 3956±5±10  MeV, 43±13±8  MeV, and J^{PC}=0^{++}, respectively, where the first uncertainties are statistical and the second systematic. The properties of the new structure are consistent with recent theoretical predictions for a state composed of cc[over ¯]ss[over ¯] quarks. Evidence for an additional structure is found around 4140 MeV in the D_{s}^{+}D_{s}^{-} invariant mass, which might be caused either by a new resonance with the 0^{++} assignment or by a J/ψϕ↔D_{s}^{+}D_{s}^{-} coupled-channel effect.

Test of Lepton Universality in b→sℓ^{+}ℓ^{-} Decays

The first simultaneous test of muon-electron universality using B^{+}→K^{+}ℓ^{+}ℓ^{-} and B^{0}→K^{*0}ℓ^{+}ℓ^{-} decays is performed, in two ranges of the dilepton invariant-mass squared, q^{2}. The analysis uses beauty mesons produced in proton-proton collisions collected with the LHCb detector between 2011 and 2018, corresponding to an integrated luminosity of 9  fb^{-1}. Each of the four lepton universality measurements reported is either the first in the given q^{2} interval or supersedes previous LHCb measurements. The results are compatible with the predictions of the Standard Model.

The Impact of Pre-Operative Anaemia on One Year Amputation Free Survival and Re-Admissions in Patients Undergoing Vascular Surgery for Peripheral Arterial Disease: a National Vascular Registry Study

OBJECTIVE

Anaemia is common among patients undergoing surgery, but its association with post-operative outcomes in patients with peripheral arterial disease (PAD) is unclear. The aim of this observational population based study was to examine the association between pre-operative anaemia and one year outcomes after surgical revascularisation for PAD.

METHODS

This study used data from the National Vascular Registry, linked with an administrative database (Hospital Episode Statistics), to identify patients who underwent open surgical lower limb revascularisation for PAD in English NHS hospitals between January 2016 and December 2019. The primary outcome was one year amputation free survival. Secondary outcomes were one year re-admission rate, 30 day re-intervention rate, 30 day ipsilateral major amputation rate and 30 day death. Flexible parametric survival analysis and generalised linear regression were performed to assess the effect of anaemia on one year outcomes.

RESULTS

The analysis included 13 641 patients, 57.9% of whom had no anaemia, 23.8% mild, and 18.3% moderate or severe anaemia. At one year follow up, 80.6% of patients were alive and amputation free. The risk of one year amputation or death was elevated in patients with mild anaemia (adjusted HR 1.3; 95% CI 1.15 - 1.41) and moderate or severe anaemia (aHR 1.5; 1.33 - 1.67). Patients with moderate or severe anaemia experienced more re-admissions over one year (adjusted IRR 1.31; 1.26 - 1.37) and had higher odds of 30 day re-interventions (aOR 1.22; 1.04 - 1.45), 30 day ipsilateral major amputation (aOR 1.53; 1.17 - 2.01), and 30 day death (aOR 1.39; 1.03 - 1.88) compared with patients with no anaemia.

CONCLUSION

Pre-operative anaemia is associated with lower one year amputation free survival and higher one year re-admission rates following surgical revascularisation in patients with PAD. Research is required to evaluate whether interventions to correct anaemia improve outcomes after lower limb revascularisation.

First Observation of a Doubly Charged Tetraquark and Its Neutral Partner

A combined amplitude analysis is performed for the decays B^{0}→D[over ¯]^{0}D_{s}^{+}π^{-} and B^{+}→D^{-}D_{s}^{+}π^{+}, which are related by isospin symmetry. The analysis is based on data collected by the LHCb detector in proton-proton collisions at center-of-mass energies of 7, 8, and 13 TeV. The full data sample corresponds to an integrated luminosity of 9  fb^{-1}. Two new resonant states with masses of 2.908±0.011±0.020  GeV and widths of 0.136±0.023±0.013  GeV are observed, which decay to D_{s}^{+}π^{+} and D_{s}^{+}π^{-} respectively. The former state indicates the first observation of a doubly charged open-charm tetraquark state with minimal quark content [cs[over ¯]ud[over ¯]], and the latter state is a neutral tetraquark composed of [cs[over ¯]u[over ¯]d] quarks. Both states are found to have spin-parity of 0^{+}, and their resonant parameters are consistent with each other, which suggests that they belong to an isospin triplet.

Search for Rare Decays of D^{0} Mesons into Two Muons

A search for the very rare D^{0}→μ^{+}μ^{-} decay is performed using data collected by the LHCb experiment in proton-proton collisions at sqrt[s]=7, 8, and 13 TeV, corresponding to an integrated luminosity of 9  fb^{-1}. The search is optimized for D^{0} mesons from D^{*+}→D^{0}π^{+} decays but is also sensitive to D^{0} mesons from other sources. No evidence for an excess of events over the expected background is observed. An upper limit on the branching fraction of this decay is set at B(D^{0}→μ^{+}μ^{-})<3.1×10^{-9} at a 90% C.L. This represents the world's most stringent limit, constraining models of physics beyond the standard model.

Observation of a J/ψΛ Resonance Consistent with a Strange Pentaquark Candidate in B^{-}→J/ψΛp[over ¯] Decays

An amplitude analysis of B^{-}→J/ψΛp[over ¯] decays is performed using 4400 signal candidates selected on a data sample of pp collisions recorded at center-of-mass energies of 7, 8, and 13 TeV with the LHCb detector, corresponding to an integrated luminosity of 9  fb^{-1}. A narrow resonance in the J/ψΛ system, consistent with a pentaquark candidate with strangeness, is observed with high significance. The mass and the width of this new state are measured to be 4338.2±0.7±0.4  MeV and 7.0±1.2±1.3  MeV, where the first uncertainty is statistical and the second systematic. The spin is determined to be 1/2 and negative parity is preferred. Because of the small Q-value of the reaction, the most precise single measurement of the B^{-} mass to date, 5279.44±0.05±0.07  MeV, is obtained.

First Measurement of Hard Exclusive π^{-}Δ^{++} Electroproduction Beam-Spin Asymmetries off the Proton

The polarized cross-section ratio σ_{LT^{'}}/σ_{0} from hard exclusive π^{-}Δ^{++} electroproduction off an unpolarized hydrogen target has been extracted based on beam-spin asymmetry measurements using a 10.2  GeV/10.6  GeV incident electron beam and the CLAS12 spectrometer at Jefferson Lab. The study, which provides the first observation of this channel in the deep-inelastic regime, focuses on very forward-pion kinematics in the valence regime, and photon virtualities ranging from 1.5  GeV^{2} up to 7  GeV^{2}. The reaction provides a novel access to the d-quark content of the nucleon and to p→Δ^{++} transition generalized parton distributions. A comparison to existing results for hard exclusive π^{+}n and π^{0}p electroproduction is provided, which shows a clear impact of the excitation mechanism, encoded in transition generalized parton distributions, on the asymmetry.

Reducing radiation exposure and cancer risk for children with scoliosis: EOS the new gold standard

PURPOSE

Children are exposed to significant radiation doses during the investigation and treatment phases of scoliosis. EOS is a new form of low-dose radiation scan which also yields great image quality. However, currently its use is discouraged in the UK due to higher costs. We aimed to quantify the additional radiation dose and cancer risk.

METHODS

We retrospectively reviewed all paediatric cases who received both standing whole spine roentgenograms and EOS scans as part of their investigations for scoliosis during a six-month period. We compared the radiation doses between the two modalities and estimated the additional mean lifetime cancer risk per study.

RESULTS

We identified 206 children (mean age 14.4) who met the criteria of having both scans. Dose area products (dGycm2) were converted to estimated effective doses (mSv). The total mean doses were 0.68 mSv (PA 0.49 + Lat 0.19) for plain films, and 0.13 mSv (PA 0.08 + Lat 0.04) for EOS scans (p < 0.001). Additional lifetime cancer risk of a plain film was 543% greater than EOS for both sexes (1/10727 versus 1/5827 in males, 1/34483 versus 1/6350 in females).

CONCLUSION

There is approximately 5.4-fold increase in risk of cancer for both boys and girls with roentgenograms over EOS, with girls being the most impacted. This carries a significant impact when considering the need for repeat imaging on additional lifetime malignancy risk in children. In our opinion, EOS dual planar scanning is the new gold standard when X-ray of the whole spine is required.

LEVEL OF EVIDENCE

III.

First CLAS12 Measurement of Deeply Virtual Compton Scattering Beam-Spin Asymmetries in the Extended Valence Region

Deeply virtual Compton scattering (DVCS) allows one to probe generalized parton distributions describing the 3D structure of the nucleon. We report the first measurement of the DVCS beam-spin asymmetry using the CLAS12 spectrometer with a 10.2 and 10.6 GeV electron beam scattering from unpolarized protons. The results greatly extend the Q^{2} and Bjorken-x phase space beyond the existing data in the valence region and provide 1600 new data points measured with unprecedented statistical uncertainty, setting new, tight constraints for future phenomenological studies.

Optometrists' Perspectives Regarding Artificial Intelligence Aids and Contributing Retinal Images to a Repository: Web-Based Interview Study

BACKGROUND

A repository of retinal images for research is being established in Scotland. It will permit researchers to validate, tune, and refine artificial intelligence (AI) decision-support algorithms to accelerate safe deployment in Scottish optometry and beyond. Research demonstrates the potential of AI systems in optometry and ophthalmology, though they are not yet widely adopted.

OBJECTIVE

In this study, 18 optometrists were interviewed to (1) identify their expectations and concerns about the national image research repository and their use of AI decision support and (2) gather their suggestions for improving eye health care. The goal was to clarify attitudes among optometrists delivering primary eye care with respect to contributing their patients' images and to using AI assistance. These attitudes are less well studied in primary care contexts. Five ophthalmologists were interviewed to discover their interactions with optometrists.

METHODS

Between March and August 2021, 23 semistructured interviews were conducted online lasting for 30-60 minutes. Transcribed and pseudonymized recordings were analyzed using thematic analysis.

RESULTS

All optometrists supported contributing retinal images to form an extensive and long-running research repository. Our main findings are summarized as follows. Optometrists were willing to share images of their patients' eyes but expressed concern about technical difficulties, lack of standardization, and the effort involved. Those interviewed thought that sharing digital images would improve collaboration between optometrists and ophthalmologists, for example, during referral to secondary health care. Optometrists welcomed an expanded primary care role in diagnosis and management of diseases by exploiting new technologies and anticipated significant health benefits. Optometrists welcomed AI assistance but insisted that it should not reduce their role and responsibilities.

CONCLUSIONS

Our investigation focusing on optometrists is novel because most similar studies on AI assistance were performed in hospital settings. Our findings are consistent with those of studies with professionals in ophthalmology and other medical disciplines: showing near universal willingness to use AI to improve health care, alongside concerns over training, costs, responsibilities, skill retention, data sharing, and disruptions to professional practices. Our study on optometrists' willingness to contribute images to a research repository introduces a new aspect; they hope that a digital image sharing infrastructure will facilitate service integration.

Development and evaluation of a novel educational program for providers on the use of polygenic risk scores

PURPOSE

This study aimed to develop an online educational program for using PRS for breast and ovarian cancer risk-assessments and evaluate the impact on genetic healthcare providers' (GHP) attitudes, confidence, knowledge, and preparedness.

METHODS

The educational program comprised of an online module covering theoretical aspects of PRS, and a facilitated virtual workshop with pre-recorded roleplays and case discussions. Data were collected in pre-and post-education surveys. Eligible participants were GHPs working in Australian familial cancer clinics registered to recruit patients for a breast and ovarian cancer PRS clinical trial (n=12).

RESULTS

124 GHPs completed the PRS education, of whom 80 (64%) and 67 (41%) completed the pre-and post-education surveys, respectively. Pre-education, GHPs reported limited experience, confidence and preparedness using PRS, but recognized its potential benefits. Post-education GHPs indicated improved attitudes (p=<0.001), confidence (p=<0.001), knowledge (p=<0.001), and preparedness (p=<0.001) to use PRS. Most GHPs felt the program entirely met their learning needs (73%) and was completely relevant to their clinical practice (88%). GHPs identified PRS implementation barriers, including limited funding models, diversity issues, and need for clinical guidelines.

CONCLUSIONS

Our education program improved GHP attitudes, confidence, knowledge, and preparedness for using PRS/personalized risk and provides a framework for development of future programs.

Risk for Infection in Humans after Exposure to Birds Infected with Highly Pathogenic Avian Influenza A(H5N1) Virus, United States, 2022

During February 7─September 3, 2022, a total of 39 states experienced outbreaks of highly pathogenic avian influenza A(H5N1) virus in birds from commercial poultry farms and backyard flocks. Among persons exposed to infected birds, highly pathogenic avian influenza A(H5) viral RNA was detected in 1 respiratory specimen from 1 person.

Learning From Experience and Finding the Right Balance in the Governance of Artificial Intelligence and Digital Health Technologies

Artificial intelligence (AI) and machine learning medical tools have the potential to be transformative in care delivery; however, this change will only be realized if accompanied by effective governance that ensures patient safety and public trust. Recent digital health initiatives have called for tighter governance of digital health. A correct balance must be found between ensuring product safety and performance while also enabling the innovation needed to deliver better approaches for patients and affordable efficient health care for society. This requires innovative, fit-for-purpose approaches to regulation. Digital health technologies, particularly AI-based tools, pose specific challenges to the development and implementation of functional regulation. The approaches of regulatory science and "better regulation" have a critical role in developing and evaluating solutions to these problems and ensuring effective implementation. We describe the divergent approaches of the European Union and the United States in the implementation of new regulatory approaches in digital health, and we consider the United Kingdom as a third example, which is in a unique position of developing a new post-Brexit regulatory framework.

First Measurement of Λ Electroproduction off Nuclei in the Current and Target Fragmentation Regions

We report results of Λ hyperon production in semi-inclusive deep-inelastic scattering off deuterium, carbon, iron, and lead targets obtained with the CLAS detector and the Continuous Electron Beam Accelerator Facility 5.014 GeV electron beam. These results represent the first measurements of the Λ multiplicity ratio and transverse momentum broadening as a function of the energy fraction (z) in the current and target fragmentation regions. The multiplicity ratio exhibits a strong suppression at high z and an enhancement at low z. The measured transverse momentum broadening is an order of magnitude greater than that seen for light mesons. This indicates that the propagating entity interacts very strongly with the nuclear medium, which suggests that propagation of diquark configurations in the nuclear medium takes place at least part of the time, even at high z. The trends of these results are qualitatively described by the Giessen Boltzmann-Uehling-Uhlenbeck transport model, particularly for the multiplicity ratios. These observations will potentially open a new era of studies of the structure of the nucleon as well as of strange baryons.

Outcomes of Surgery for Patients with Peripheral Arterial Disease During the COVID-19 Pandemic in the United Kingdom: A Population Based Study

OBJECTIVE

There is limited information on changes in the patterns of care and outcomes for patients who had vascular procedures after the first wave of the COVID-19 pandemic. The aim of this population based study was to examine the patterns of care and outcomes for vascular lower limb procedures in the UK during the COVID-19 pandemic.

METHODS

Lower limb revascularisations and major amputations performed from January 2019 to April 2021 in the UK and entered in the National Vascular Registry were included in the study. The primary outcome was in hospital post-operative mortality and secondary outcomes were complications and re-interventions. The study was divided into Pre-pandemic (1 January 2019 - 29 February 2020), Wave 1 (1 March - 30 June 2020), Respite (1 July - 31 October 2020), Wave 2/3 (1 November 2020 - 30 April 2021).

RESULTS

The study included 36 938 procedures (7 245 major amputations, 16 712 endovascular, 12 981 open revascularisations), with 15 501 procedures after March 2020, a 27.7% reduction compared with pre-pandemic. The proportion of open surgical procedures performed under general anaesthetic was lower in Wave 1 and after compared with pre-pandemic (76.7% vs. 81.9%, p < .001). Only 4.6% of patients in the cohort had SARS-CoV-2 infection (n = 708), but their in hospital post-operative mortality was 25.0% (n = 177), six times higher than patients without SARS-CoV-2 (adjusted odds ratio 5.88; 95% CI 4.80 - 7.21, p < .001). The in hospital mortality rate was higher during the pandemic than pre-pandemic after elective open and endovascular revascularisation (respectively 1.6% vs. 1.1%, p = .033, and 0.9% vs. 0.5%, p = .005) and major amputations (10.4% during Wave 2/3 vs. 7.7% pre-pandemic, p = .022).

CONCLUSION

There was excess post-operative mortality for patients undergoing lower limb vascular procedures during the pandemic, which was associated with SARS-CoV-2 infections. Further research should be conducted on long-term outcomes of patients operated on during the COVID-19 pandemic period.

A complex ePrescribing-based Anti-Microbial Stewardship (ePAMS+) intervention for hospitals combining technological and behavioural components: protocol for a feasibility trial

BACKGROUND

Antimicrobial resistance is a leading global public health threat, with inappropriate use of antimicrobials in healthcare contributing to its development. Given this urgent need, we developed a complex ePrescribing-based Anti-Microbial Stewardship intervention (ePAMS+).

METHODS

ePAMS+ includes educational and organisational behavioural elements, plus guideline-based clinical decision support to aid optimal antimicrobial use in hospital inpatients. ePAMS+ particularly focuses on prompt initiation of antimicrobials, followed by early review once test results are available to facilitate informed decision-making on stopping or switching where appropriate. A mixed-methods feasibility trial of ePAMS+ will take place in two NHS acute hospital care organisations. Qualitative staff interviews and observation of practice will respectively gather staff views on the technical component of ePAMS+ and information on their use of ePAMS+ in routine work. Focus groups will elicit staff and patient views on ePAMS+; one-to-one interviews will discuss antimicrobial stewardship with staff and will record patient experiences of receiving antibiotics and their thoughts on inappropriate prescribing. Qualitative data will be analysed thematically. Fidelity Index development will enable enactment of ePAMS+ to be measured objectively in a subsequent trial assessing the effectiveness of ePAMS+. Quantitative data collection will determine the feasibility of extracting data and deriving key summaries of antimicrobial prescribing; we will quantify variability in the primary outcome, number of antibiotic defined daily doses, to inform the future larger-scale trial design.

DISCUSSION

This trial is essential to determine the feasibility of implementing the ePAMS+ intervention and measuring relevant outcomes, prior to evaluating its clinical and cost-effectiveness in a full scale hybrid cluster-randomised stepped-wedge clinical trial. Findings will be shared with study sites and with qualitative research participants and will be published in peer-reviewed journals and presented at academic conferences.

TRIAL REGISTRATION

The qualitative and Fidelity Index research were approved by the Health and Research Authority and the North of Scotland Research Ethics Service (ref: 19/NS/0174). The feasibility trial and quantitative analysis (protocol v1.0, 15 December 2021) were approved by the London South East Research Ethics Committee (ref: 22/LO/0204) and registered with ISRCTN ( ISRCTN 13429325 ) on 24 March 2022.

Socio-Organizational Dimensions: The Key to Advancing the Shared Care Record Agenda in Health and Social Care

Integrating health and social care delivery with the help of digital technologies is a grand challenge. We argue that previous attempts have largely failed to achieve their objectives because implementers and decision makers disregard the complex socio-organizational dimensions of change associated with initiatives. These include structural and organizational complexity inhibiting the development of shared care pathways; professional jurisdictions, interests, and expertise; and existing data and governance structures. We provide an overview of those dimensions that can inform strategic decisions going forward, thereby contributing to the chances of success of shared care initiatives.

Factors affecting turnaround time of SARS-CoV-2 sequencing for inpatient infection prevention and control decision making: analysis of data from the COG-UK HOCI study

BACKGROUND

Barriers to rapid return of sequencing results can affect the utility of sequence data for infection prevention and control decisions.

AIM

To undertake a mixed-methods analysis to identify challenges that sites faced in achieving a rapid turnaround time (TAT) in the COVID-19 Genomics UK Hospital-Onset COVID-19 Infection (COG-UK HOCI) study.

METHODS

For the quantitative analysis, timepoints relating to different stages of the sequencing process were extracted from both the COG-UK HOCI study dataset and surveys of study sites. Qualitative data relating to the barriers and facilitators to achieving rapid TATs were included from thematic analysis.

FINDINGS

The overall TAT, from sample collection to receipt of sequence report by infection control teams, varied between sites (median 5.1 days, range 3.0-29.0 days). Most variation was seen between reporting of a positive COVID-19 polymerase chain reaction (PCR) result to sequence report generation (median 4.0 days, range 2.3-27.0 days). On deeper analysis, most of this variability was accounted for by differences in the delay between the COVID-19 PCR result and arrival of the sample at the sequencing laboratory (median 20.8 h, range 16.0-88.7 h). Qualitative analyses suggest that closer proximity of sequencing laboratories to diagnostic laboratories, increased staff flexibility and regular transport times facilitated a shorter TAT.

CONCLUSION

Integration of pathogen sequencing into diagnostic laboratories may help to improve sequencing TAT to allow sequence data to be of tangible value to infection control practice. Adding a quality control step upstream to increase capacity further down the workflow may also optimize TAT if lower quality samples are removed at an earlier stage.

Evaluation of the ICD-10 system in coding revascularisation procedures in patients with peripheral arterial disease in England: A retrospective cohort study using national administrative and clinical databases

BACKGROUND

Many studies evaluating care in hospitals in England use the Hospital Episode Statistics (HES) administrative database. The aim of this study was to explore whether the International Classification of Diseases 10th Revision (ICD-10) system used by HES supported the evaluation of care received by patients with peripheral arterial disease (PAD) who had revascularisation.

METHODS

This retrospective cohort study used records on patients who had revascularisation for PAD between 1st January 2017 and 31st December 2019 in England, collected prospectively in the National Vascular Registry (NVR) and linked to HES. Patients were excluded if their NVR record did not have a match in HES, due to lack of consent or different admission and procedure dates. Agreement between different presentations of PAD recorded in the NVR and the ICD-10 diagnostic codes recorded in HES was evaluated using the unweighted Kappa statistic and sensitivity and specificity. Agreement between the NVR and HES was also assessed for gender, age, comorbidities, mode of admission, and procedure type and side.

FINDINGS

In total, 20,603 patients who had 24,621 admissions were included in the study. Agreement between NVR and HES on patient gender (Kappa = 0.98), age (Kappa = 0.98), mode of admission (Kappa = 0.80), and procedure type and side (Kappa = 0.92 and 0.87, respectively) was excellent. When all diagnostic fields in HES were explored, substantial agreement was observed for chronic ischaemia with tissue loss (Kappa = 0.63), but it was lower for chronic ischaemia without tissue loss (Kappa = 0.32) and acute limb ischaemia (Kappa = 0.15). Agreement on comorbidities was mixed; excellent for diabetes (Kappa = 0.82), moderate for chronic lung disease (Kappa = 0.56), chronic kidney disease (Kappa = 0.56), and ischaemic heart disease (Kappa = 0.45) and fair for chronic heart failure (Kappa = 0.35).

INTERPRETATION

The diagnostic ICD-10 codes currently used in HES cannot accurately differentiate between stages of PAD. Therefore, studies using HES to examine patterns of care and outcomes for patients with PAD are likely to suffer from misclassification bias. Adopting an extended ICD-10 system or the ICD-11 version released to the World Health Organisation member states in 2022, may overcome this problem.

FUNDING

Healthcare Quality Improvement Partnership (HQIP).

1743. Antimicrobial and Diagnostic Stewardship Targeting Urinary Tract Infections in the Emergency Department: A Pharmacist-driven Quality Improvement Project at a Tertiary Military Treatment Facility

Background

With the increasing interest in ambulatory stewardship, we designed a quality improvement project to enhance guideline concordant antimicrobial and diagnostic stewardship practices targeting urinary tract infections (UTI) in the ED of a Military Treatment Facility. Between two data collection phases (P1, P2), we provided education on national guidelines, local protocols and antibiograms, modified order-sets, and implemented enhancements targeting urine collection. The primary outcome was a change in guideline-concordant practices between P1 and P2.

Methods

This prospective pharmacist-driven study had two 3-month data collection periods including ED encounters that resulted in a urinalysis (UA), urine culture (UCx) and antibiotics for UTI upon discharge. We collected data on participant demographics, clinical course and therapy details via chart review. Culture callback and corresponding interventions were made within 72 hours. Based on P1 results, we broadened our scope in P2 to include a diagnostic stewardship arm (Figure 1). This project was IRB approved under a non-research determination.

Results

There were no significant changes in guideline-concordant prescribing or diagnostic practices between P1 and P2 (Figure 2). Inappropriate antibiotic selection was primarily due to use of cephalosporins and FQs as first line agents (Table 1). The primary pharmacy intervention was discontinuation of therapy (P1 29.1%, P2 39.8%). One-third of patients receiving antibiotics were asymptomatic, a majority of which had a positive UA (P1 68.4%, P2 73.3%). There was a high rate of UCx contamination which improved in P3 but did not reach statistical significance (P1 25.6%, P2 17.2%, p=0.19). Across all P2 encounters, 51.4% of UCx were deemed inappropriate.

Conclusion

Significant guideline-discordant prescribing persisted despite interventions. An overreliance on UA findings results in treatment of asymptomatic bacteriuria. Education and order-set modification alone are insufficient for a lasting impact on prescribing practices especially where there is a high rate of provider turnover. An EMR with embedded clinical and alert-based decision support capabilities are likely to make a sustained impact in curbing inappropriate treatment of asymptomatic bacteriuria.

Disclosures

All Authors: No reported disclosures.