Concept analysis of 'Facilitating a transformative radiation protection environment'

INTRODUCTION

Suboptimal radiation protection evidenced in literature necessitated the development of a theory to optimise radiation protection. To develop a theory, concept analysis of the central concept guiding the theory is required to provide explicit theoretical and operational definitions. This article presents the concept analysis of the central concept of 'facilitating a transformative radiation protection environment' used to develop a theory to optimise radiation protection.

METHODS

The study used Walker and Avant's concept analysis process of selecting a concept, determining the aims and purpose of analysis, identifying all uses of the concept, and determining the defining attributes by identifying a model case, a borderline case and a contrary case.

RESULTS

The central concept was dissected into the individual concepts of facilitating, transformative, radiation, protection, and environment to enhance the definition and conceptual meaning of the central concept. The essential and related attributes of the individual concepts informed the summative definition of the central concept, and a model, borderline and contrary case contributed to the conceptual meaning.

CONCLUSION

The summative definition of the central concept of "facilitating a transformative radiation protection environment" was determined to be through the essential attributes of help, process, change, X-rays, keeping safe considering the benefits versus risks of ionising radiation exposure and the total internal, external context within which persons exist and the related attributes.

IMPLICATIONS FOR PRACTICE

Explored extensively in nursing literature, concept analyses in radiography are limited. Therefore, this article articulates the process of concept analysis and its use in radiography. Concept analysis provides a systematic process to analyse concepts often assumed to be understood, highlighting its importance in radiography literature and to educational praxis.

Is prone positioning a valid intervention for ARDS in the deployed intensive care unit?

Prone positioning is an intervention used for patients with acute respiratory distress syndrome (ARDS) whose hypoxia is worsening despite conventional treatment. Previously used infrequently, it became an important treatment escalation strategy for hypoxia during the COVID-19 pandemic. Current evidence for prone positioning suggests increased survivability in intubated patients with moderate to severe ARDS who are prone for >12 hours a day. As a relatively low-cost, low-tech intervention with a growing evidence base, the viability of prone positioning in the deployed land environment is considered in this article. The practical technique of prone positioning is easy to teach to healthcare staff experienced in manual handling. However, it requires significant resources, in particular staff numbers, and time to execute and maintain, and necessitates a pressure-minimising mattress. Additionally, staff are placed at increased risk of musculoskeletal injuries and potential exposure to aerosolised microbes if there is a disconnection of the breathing system. We conclude that in the deployed 2/1/2/12 facility (or larger), with access to higher staff numbers and high-specification mattresses, prone positioning is a valid escalation technique for intubated hypoxic patients with ARDS. However, in smaller facilities where resources are constrained, its implementation is unlikely to be achievable.

A dynamical measure of the black hole mass in a quasar 11 billion years ago

Tight relationships exist in the local Universe between the central stellar properties of galaxies and the mass of their supermassive black hole (SMBH)1-3. These suggest that galaxies and black holes co-evolve, with the main regulation mechanism being energetic feedback from accretion onto the black hole during its quasar phase4-6. A crucial question is how the relationship between black holes and galaxies evolves with time; a key epoch to examine this relationship is at the peaks of star formation and black hole growth 8-12 billion years ago (redshifts 1-3)7. Here we report a dynamical measurement of the mass of the black hole in a luminous quasar at a redshift of 2, with a look back in time of 11 billion years, by spatially resolving the broad-line region (BLR). We detect a 40-μas (0.31-pc) spatial offset between the red and blue photocentres of the Hα line that traces the velocity gradient of a rotating BLR. The flux and differential phase spectra are well reproduced by a thick, moderately inclined disk of gas clouds within the sphere of influence of a central black hole with a mass of 3.2 × 108 solar masses. Molecular gas data reveal a dynamical mass for the host galaxy of 6 × 1011 solar masses, which indicates an undermassive black hole accreting at a super-Eddington rate. This suggests a host galaxy that grew faster than the SMBH, indicating a delay between galaxy and black hole formation for some systems.

Infection prevention and control in CT Part 1: An Australian study of roles, responsibilities and practices

INTRODUCTION

The computed tomography (CT) suite presents Infection Prevention and Control (IPC) risks for staff and patients. This is the first of a two-part series on IPC in the CT setting and reports on Australian baseline data related to intravenous contrast media administration and the use of power injectors in the CT suite, including knowledge sources related to the delivery of contrast media. The second part provides insights into CT staff's perceptions of high-risk scenarios for non-adherence to standard or transmission-based precautions.

METHODS

The study employed an online survey design, directed at radiographers and radiology nurses working in Australia. The survey included questions relating to CT workplace staffing and equipment, contrast media use and occupational roles, and knowledge sources used for infection control and contrast injectors.

RESULTS

Overall, 160 study participants completed the survey (radiographers: n = 138, 86.3%; nurses: n = 22, 13.7%). Differences were identified between public and private practice. Public hospitals completed more contrast-enhanced scans, and with dual injecting systems, operated and cleaned by radiographers and nurses. Private clinics generally used single-system, power injectors. Radiographers and nurses relied heavily on their colleagues and product guidelines for IPC information. IPC teams were uncommon in private clinics, very common in public departments and 50% of respondents had undertaken IPC training in the last 12 months.

CONCLUSION

Insights into use and duties of professionals delivering intravenous contrast media administration using power injectors in the CT suite will help to inform decision-making processes on IPC education strategies and map risk.

IMPLICATION FOR PRACTICE

Future research should focus on how radiology workers in CT perceive IPC risk and/or might vary from best practice, which has direct clinical implications for safety if contamination, or incorrect information is routinely applied.

Infection prevention and control in CT Part 2: Radiographers' and radiology nurses' perceptions of high-risk scenarios contributing to non-adherence to IPC protocols

INTRODUCTION

Adherence to standard and transmission-based precautions in the computed tomography (CT) setting is central to effective infection prevention and control (IPC), yet there is limited evidence about medical imaging (MI) professionals' self-reported predictors of IPC breaches. This is the second of a two-part series on IPC in the CT setting. Part 1 reported on Australian baseline data relating to intravenous contrast media administration and power injectors. Part 2 presents Australian radiographers' and radiology nurses' perceptions of clinical situations that reduce adherence to standard and transmission-based precautions in CT.

METHODS

A self-administered survey was distributed to Australian radiographers and radiology nurses working in CT. Responses to an open-ended question "If I was to not adhere to the standard and transmission-based precautions in the CT department, it is most likely when …" was analysed using inductive coding for themes, followed by deductive analysis mapped to the Systems Engineering Initiative for Patient Safety (SEIPS) model.

RESULTS

Study participants (n = 136) were radiographers (n = 119; 87.5%) and nurses (n = 17; 12.5%). 'Four themes were derived from the inductive analysis: (1) high-risk working conditions, (2) compliance with good practice, (3) attitudes and practice, and (4) quality of communication. Deductive analysis, using the SEIPS domains revealed that predominant issues related to 'Tasks' (43.7%) and 'Organisation' (30.6%) followed by issues related to 'Person' (16.9%), 'Tools and technology' (6.9%) and 'Environment' (1.9%).

CONCLUSION

Multi-faceted pressures on radiology staff may compromise adherence to standard and transmission-based precautions in CT. Task difficulty, time pressures whilst undertaking tasks, and reduced staffing could lead to lower adherence to standard and transmission-based precautions.

IMPLICATIONS FOR PRACTICE

Future studies that focus on evaluation of 'Tasks' and 'Organisation' domains of the SEIPS model may provide further insights to non-adherence behaviours in MI.

The Blunt Liver and Spleen Trauma (BLAST) audit: national survey and prospective audit of children with blunt liver and spleen trauma in major trauma centres

PURPOSE

To compare the reported and observed management of UK children with blunt liver or spleen injury (BLSI) to the American Pediatric Surgical Association (APSA) 2019 BLSI guidance.

METHODS

UK Paediatric Major Trauma Centres (pMTCs) undertook 1 year of prospective data collection on children admitted to or discussed with those centres with BLSI and an online questionnaire was distributed to all consultants who care for children with BLSI in those centres.

RESULTS

All 21/21 (100%) pMTCs participated; 131 patients were included and 100/152 (65%) consultants responded to the survey. ICU care was reported and observed to be primarily determined using haemodynamic status or concomitant injuries rather than injury grade, in accordance with APSA guidance. Bed rest was reported to be determined by grade of injury by 63% of survey respondents and observed in a similar proportion of patients. Contrary to APSA guidance, follow-up radiological assessment of the injured spleen or liver was undertaken in 44% of patients before discharge and 32% after discharge, the majority of whom were asymptomatic.

CONCLUSIONS

UK management of BLSI differs from many aspects of APSA guidance. A shift towards using clinical features to determine ICU admission and readiness for discharge is demonstrated, in line with a strong evidence base. However, routine bed rest and re-imaging after BLSI is common, contrary to APSA guidance. This disparity may exist due to concern that evidence around the incidence, presentation and natural history of complications after conservatively managed BLSI, particularly bleeding from pseudoaneurysms, is weak.

Radiographers' organisational commitment and occupational stress: First Covid-19 wave

INTRODUCTION

Radiographers, like many health professionals, are in a high-risk group for succumbing to workplace demands beyond their ability to cope, particularly in the context of the COVID-19 pandemic resulting in occupational stress. Occupational stress has been linked to poor organisational commitment. Therefore, the purpose of this research was to evaluate radiographers' organisational commitment and occupational stress after the first wave of the COVID-19 pandemic.

METHODS

A mixed method approach entailed data collected from purposively sampled Australian radiographers working during the first COVID-19 wave. The quantitative phase used an online commitment questionnaire, and 21 semi-structured individual virtual interviews were conducted in the qualitative phase. Data interpretation and analysis used statistical and thematic approaches.

RESULTS

The quantitative data revealed a higher level of continuance than affective and normative commitment. Whereas the qualitative findings showed participants high levels of affective commitment to their occupation and, together with leadership support, working collectively towards a positive outcome.

CONCLUSION

Despite the variety of occupational stressors that arose during the COVID-19 crisis, Australian radiographers enjoy a high level of occupational and organisational commitment.

IMPLICATIONS FOR PRACTICE

Radiographers' organisational commitment represents their emotional and psychological attachment to their workplace, and radiographers experiencing occupational stress represent high levels of psychosomatic distress and burnout. Therefore, considering radiographers' organisational commitment and occupational stress is essential in the delivery of services, quality of patient care and radiographers well-being.

Towards virtual histology with X-ray grating interferometry

Breast cancer is the most common type of cancer worldwide. Diagnosing breast cancer relies on clinical examination, imaging and biopsy. A core-needle biopsy enables a morphological and biochemical characterization of the cancer and is considered the gold standard for breast cancer diagnosis. A histopathological examination uses high-resolution microscopes with outstanding contrast in the 2D plane, but the spatial resolution in the third, Z-direction, is reduced. In the present paper, we propose two high-resolution table-top systems for phase-contrast X-ray tomography of soft-tissue samples. The first system implements a classical Talbot-Lau interferometer and allows to perform ex-vivo imaging of human breast samples with a voxel size of 5.57 μm. The second system with a comparable voxel size relies on a Sigray MAAST X-ray source with structured anode. For the first time, we demonstrate the applicability of the latter to perform X-ray imaging of human breast specimens with ductal carcinoma in-situ. We assessed image quality of both setups and compared it to histology. We showed that both setups made it possible to target internal features of breast specimens with better resolution and contrast than previously achieved, demonstrating that grating-based phase-contrast X-ray CT could be a complementary tool for clinical histopathology.

Rehabilitation post-COVID-19: cross-sectional observations using the Stanford Hall remote assessment tool

INTRODUCTION

The multisystem COVID-19 can cause prolonged symptoms requiring rehabilitation. This study describes the creation of a remote COVID-19 rehabilitation assessment tool to allow timely triage, assessment and management. It hypotheses those with post-COVID-19 syndrome, potentially without laboratory confirmation and irrespective of initial disease severity, will have significant rehabilitation needs.

METHODS

Cross-sectional study of consecutive patients referred by general practitioners (April-November 2020). Primary outcomes were presence/absence of anticipated sequelae. Binary logistic regression was used to test association between acute presentation and post-COVID-19 symptomatology.

RESULTS

155 patients (n=127 men, n=28 women, median age 39 years, median 13 weeks post-illness) were assessed using the tool. Acute symptoms were most commonly shortness of breath (SOB) (74.2%), fever (73.5%), fatigue (70.3%) and cough (64.5%); and post-acutely, SOB (76.7%), fatigue (70.3%), cough (57.4%) and anxiety/mood disturbance (39.4%). Individuals with a confirmed diagnosis of COVID-19 were 69% and 63% less likely to have anxiety/mood disturbance and pain, respectively, at 3 months.

CONCLUSIONS

Rehabilitation assessment should be offered to all patients suffering post-COVID-19 symptoms, not only those with laboratory confirmation and considered independently from acute illness severity. This tool offers a structure for a remote assessment. Post-COVID-19 programmes should include SOB, fatigue and mood disturbance management.

Australian student radiographers' experiences and perspectives in general paediatric medical imaging examinations

INTRODUCTION

Paediatric patients differ from adult patients with respect to anatomy, examination factors, behaviour, and intellectual development, requiring dedicated specialised knowledge and expertise. In the absence of a formal dedicated paediatric medical imaging subspecialty, this study undertook to understand student radiographers' experiences and perspectives on paediatric medical imaging.

METHODS

The study entailed a descriptive cross-sectional survey design entailed a 51-item closed and open-ended response questionnaire using a total sampling method. Data were collected from both under- and postgraduate student radiographers who undertook clinical placement. Data interpretation and analysis involved statistical analysis of close-ended questions and thematic analysis of open-ended questions.

RESULTS

The overall response rate was 70%. Most participants acknowledged the importance of dedicated paediatric content as well as the theory content covered. The shortcoming in pre-placement practical component was overcome through varied approaches like observations and attempting through supervision whilst experiencing uncertainty, anxiety and felt unfair to risk the patient. As reported in literature like their qualified counterparts expressed similar challenges in technique adaptation, styles of interactions in gaining cooperation from both the children and parents. They also felt paediatric content and the practicals should be embedded throughout the course offering to not compromise the day-to-day service delivery.

CONCLUSIONS

The study findings iterate the importance paediatric imaging in the service delivery context. The importance of undertaking these examinations reliant on experiential learning is insufficient to bridge the gap of preparation prior to placement.

IMPLICATIONS FOR PRACTICE

Collaborative academic and clinical radiography education will ensure that radiography students' dedicated specialised paediatric imaging knowledge and experience are enhanced.

Diagnostic radiography students' perspectives on cultural competence and safety

INTRODUCTION

Cultural competency and safety are essential components to consider in the provision of person-centred equitable healthcare. Therefore, student radiographers' learning should include the necessary knowledge, skill sets and competence to recognise the patient's unique characteristics to enable culturally competent and safe medical imaging services. Therefore, this study explored undergraduate and postgraduate diagnostic radiography students' perspectives on cultural competency and safety.

METHODS

A qualitative phenomenological design with a hermeneutic phenomenological approach was followed to explore student perspectives. Student radiographers (second and third-year undergraduate and first and second-year postgraduate) from the study site were purposively and conveniently recruited to participate in focus group interviews. Fifteen focus group interviews were conducted, recorded and transcribed verbatim before undergoing thematic analysis.

RESULTS

Thematic analysis identified two themes. Theme one centred around the cultural competence and safety learnt by student radiographers at university and the second theme cultural competence and safety learnt in workplace learning.

CONCLUSION

This study demonstrated the importance of cultural competence and safe practice in examining patients of different cultures. It highlights the importance of creating awareness among students of their own abilities and capabilities of cultural sensitivity and safe practice as part of their learning. Future health professionals should be empowered to address and respond to patients' unique needs in a competent, safe and professional manner to reduce health disparities.

IMPLICATIONS FOR PRACTICE

Cultural competence and safety are integral to person-centred care. Including these concepts in radiography education is therefore vital to ensure optimal patient outcomes.

The metabolic health of young men conceived using intracytoplasmic sperm injection

STUDY QUESTION

Is the metabolic health of men conceived using ICSI different to that of IVF and spontaneously conceived (SC) men?

SUMMARY ANSWER

ICSI-conceived men aged 18-24 years, compared with SC controls, showed differences in some metabolic parameters including higher resting diastolic blood pressure (BP) and homeostasis model assessment for insulin resistance (HOMA-IR) scores, although the metabolic parameters of ICSI- and IVF-conceived singleton men were more comparable.

WHAT IS KNOWN ALREADY

Some studies suggest that IVF-conceived offspring may have poorer cardiovascular and metabolic profiles than SC children. Few studies have examined the metabolic health of ICSI-conceived offspring.

STUDY DESIGN, SIZE, DURATION

This cohort study compared the metabolic health of ICSI-conceived men to IVF-conceived and SC controls who were derived from prior cohorts. Participants included 121 ICSI-conceived men (including 100 singletons), 74 IVF-conceived controls (all singletons) and 688 SC controls (including 662 singletons).

PARTICIPANTS/MATERIALS, SETTING, METHODS

Resting systolic and diastolic BP (measured using an automated sphygmomanometer), height, weight, BMI, body surface area and fasting serum metabolic markers including fasting insulin, glucose, total cholesterol, high-density lipoprotein cholesterol (HDLC), low-density lipoprotein cholesterol, triglycerides, highly sensitive C-reactive protein (hsCRP) and HOMA-IR were compared between groups. Data were analysed using multivariable linear regression adjusted for various covariates including age and education level.

MAIN RESULTS AND THE ROLE OF CHANCE

After adjusting for covariates, compared to 688 SC controls, 121 ICSI-conceived men had higher diastolic BP (β 4.9, 95% CI 1.1-8.7), lower fasting glucose (β -0.7, 95% CI -0.9 to -0.5), higher fasting insulin (ratio 2.2, 95% CI 1.6-3.0), higher HOMA-IR (ratio 1.9, 95% CI 1.4-2.6), higher HDLC (β 0.2, 95% CI 0.07-0.3) and lower hsCRP (ratio 0.4, 95% CI 0.2-0.7) levels. Compared to 74 IVF-conceived singletons, only glucose differed in the ICSI-conceived singleton men (β -0.4, 95% CI -0.7 to -0.1). No differences were seen in the paternal infertility subgroups.

LIMITATIONS, REASONS FOR CAUTION

The recruitment rate of ICSI-conceived men in this study was low and potential for recruitment bias exists. The ICSI-conceived men, the IVF-conceived men and SC controls were from different cohorts with different birth years and different geographical locations. Assessment of study groups and controls was not contemporaneous, and the measurements differed for some outcomes (BP, insulin, glucose, lipids and hsCRP).

WIDER IMPLICATIONS OF THE FINDINGS

These observations require confirmation in a larger study with a focus on potential mechanisms. Further efforts to identify whether health differences are due to parental characteristics and/or factors related to the ICSI procedure are also necessary.

STUDY FUNDING/COMPETING INTEREST(S)

This study was funded by an Australian National Health and Medical Research Council Partnership Grant (NHMRC APP1140706) and was partially funded by the Monash IVF Research and Education Foundation. S.R.C. was supported through an Australian Government Research Training Program Scholarship. R.J.H. is supported by an NHMRC project grant (634457), and J.H. and R.I.M. have been supported by the NHMRC as Senior and Principal Research Fellows respectively (J.H. fellowship number: 1021252; R.I.M. fellowship number: 1022327). L.R. is a minority shareholder and the Group Medical Director for Monash IVF Group, and reports personal fees from Monash IVF Group and Ferring Australia, honoraria from Ferring Australia and travel fees from Merck Serono and MSD and Guerbet; R.J.H. is the Medical Director of Fertility Specialists of Western Australia and has equity in Western IVF; R.I.M. is a consultant for and shareholder of Monash IVF Group and S.R.C. reports personal fees from Besins Healthcare and nonfinancial support from Merck outside of the submitted work. The remaining authors have no conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

N/A.

Imaging Breast Microcalcifications Using Dark-Field Signal in Propagation-Based Phase-Contrast Tomography

Breast microcalcifications are an important primary radiological indicator of breast cancer. However, microcalcification classification and diagnosis may be still challenging for radiologists due to limitations of the standard 2D mammography technique, including spatial and contrast resolution. In this study, we propose an approach to improve the detection of microcalcifications in propagation-based phase-contrast X-ray computed tomography of breast tissues. Five fresh mastectomies containing microcalcifications were scanned at different X-ray energies and radiation doses using synchrotron radiation. Both bright-field (i.e. conventional phase-retrieved images) and dark-field images were extracted from the same data sets using different image processing methods. A quantitative analysis was performed in terms of visibility and contrast-to-noise ratio of microcalcifications. The results show that while the signal-to-noise and the contrast-to-noise ratios are lower, the visibility of the microcalcifications is more than two times higher in the dark-field images compared to the bright-field images. Dark-field images have also provided more accurate information about the size and shape of the microcalcifications.

Radiographers' experiences and perspectives of forensic imaging in Australia: A qualitative study

INTRODUCTION

Forensic imaging plays a pivotal role regarding medico-legal issues by investigating the cause(s) of injuries to living or deceased individuals. There is currently a gap in the literature on forensic imaging due to limited national and international guidelines, protocols and scope of duties and responsibilities of radiographers undertaking forensic imaging. Thus, this study aimed to investigate the gap by exploring the experiences and perspectives of radiographers on forensic imaging in Australia.

METHODS

A qualitative approach collected data from fifteen purposively sampled qualified Australian radiographers through individual in-depth interviews. The verbatim transcribed data were thematically analysed.

RESULTS

Two themes were identified: 1) Radiographers' experiences of forensic imaging; 2) Radiographers' perceptions of forensic imaging within the job scope of a qualified radiographer.

CONCLUSIONS

Participants' experiences of forensic imaging ranged from anxiety to a positive experience, and others posed ethical and situational dilemmas heightened by the lack of dedicated forensic imaging protocols. While some radiographers expressed that every radiographer should conduct forensic imaging, others felt it was not mandatory.

IMPLICATIONS FOR PRACTICE

Radiographers' shared subjective experiences, thoughts and feelings provided insight into forensic imaging and the need for more significant support from educational and governing bodies.

P-083 The incidence of sperm DNA damage in men with chronic reproductive health issues

Study question

What is the incidence of sperm DNA damage in men attending tertiary (urological) healthcare with long histories of infertility?

Summary answer

The majority of these men (95%), all with normal semen analyses had high levels of sperm DNA damage.

What is known already

Conventional semen analysis assesses sperm concentration, motility, and morphology but with a high degree of biological variability. Around 25% of men are given a diagnosis of unexplained infertility by normal semen analysis. The World Health Organisation (WHO) stated in 2021 that ‘clinically there is a growing awareness that chromosomal anomalies and gene mutations underlie a diverse spectrum of male infertility,’ so now recommends that sperm DNA is determined as an extended analysis. Sperm DNA damage occurs more often in infertile men and DNA damage is associated with recurrent pregnancy loss and decreased live birth rates following fertility treatment.

Study design, size, duration

A retrospective study of men attending a tertiary centre with productive failure had been offered a standard semen analysis and sperm DNA fragmentation using SpermComet technology.

Participants/materials, setting, methods

Results from 148 men tested between April 2017 and September 2021 were recruited from a tertiary urological database in the UK. Alongside a semen analysis, they also had a sperm DNA fragmentation test.

Sperm DNA quality for the participants was assessed and reported as average, low and high DNA damage as a percentage compared with clinical thresholds used by Examen from their sperm data bank of 74 fertile sperm donors with recently achieved clinical pregnancies.

Main results and the role of chance

The average comet score was 37.8% +/-0.5, low comet score was 35.3% +/- 1.5 and high comet score was 20.2% +/-1.2. These values were all significantly outside ( p < 0.001, Mann Whitney test)) fertile parameters.

95% of these men presenting for infertility investigations had a significantly raised DNA damage across their semen sample with low proportions of healthy sperm and high levels of sperm with genomic damage.

Limitations, reasons for caution

Retrospective design, small sample size, lack of randomisation and low power analysis.

Wider implications of the findings

Sperm DNA damage was found in most of these men who, over years of investigation hadn't been offered tests other than semen analysis or therapy to improve their sperm quality. Thus, this tool could be a useful adjunct to semen analysis to guide the men to reproductive health.

Trial registration number

not applicable

P-099 The effect of sperm DNA quality on blastocyst and euploid rates

Study question

Do sperm DNA quality measurements influence the blastocyst rate and/or euploid rates?

Summary answer

Sperm DNA fragmentation has a negative influence on the rate of blastulation. It does not impact on euploidy rates assessed by pre-implantation genetic testing (PGT-A).

What is known already

Some studies show that sperm DNA has no influence on embryo development and that its negative influence begins following implantation. Other studies show that every step of the fertility process from fertilization onwards is impacted by the male gamete as well as the female gamete. To date, data has been confounded by different sperm DNA tests and different clinical practices and parameters measured.

Study design, size, duration

This was a retrospective study using the sensitive Comet assay to analyse whether it’s three sperm DNA fragmentation scores influence embryo development or euploidy.

Participants/materials, setting, methods

Data from 110 cycles of intracytoplasmic sperm injection (ICSI) where the blastocyst rate (number of blastocysts/number of mature oocytes injected) was obtained from the patient database of a UK single centre. Inclusion criteria: Only outcomes from the first assisted reproductive cycle after a Comet assay had been performed were included. Included cycles were within one year of the test.

Main results and the role of chance

Blastocysts were ranked in 4 groups- 0.25-0.49, 0.5-0.74, 0.75-1.00. Three Comet scores were analysed: Average Comet Score (damage across the semen sample; ACS), Low Comet Score (proportion of sperm with good DNA; LCS) and High Comet Score ( proportion of sperm with high DNA damage; HCS). Clinical thresholds were calculated by comparison with fertile donor sperm. High ACS and LCS and low HCS were all associated with higher blastocyst rates (ANOVA, p = 0.013; Kruskal Wallis, p = 0.027, Post Hoc pairwise comparisons between blastocyst groups (p = 0.016-0.024). No relationship was found between euploid rate (number of euploid embryos/total embryo number) and sperm DNA damage p = 0.761).

Limitations, reasons for caution

Retrospective design requiring more data to clarify these associations coupled with the lack of randomisation and low power analysis.

Wider implications of the findings

This study reports the negative impact of sperm DNA fragmentation on blastocyst formation rates. Male partner diagnostic assessments such as sperm DNA quality testing are useful adjuncts to semen analysis. Further research to determine if there is a relationship between sperm DNA damage and euploid embryo outcomes is ongoing.

Trial registration number

IRB-001C06-01-22

P-033 A third of men with normospermia attending for initial fertility assessment could have DNA damage

Study question

What is the incidence of sperm DNA damage in men with normal semen analyses attending for initial fertility investigation?

Summary answer

Half of men (54%) attending for infertilty investigation had a normal semen analysis of which a third (32%) of these had abnormal sperm DNA.

What is known already

Conventional semen analysis assesses sperm concentration, motility, and morphology but with a high degree of biological variability. Around 25% of men are given a diagnosis of unexplained infertility by normal semen analysis. The World Health Organisation (WHO) stated in 2021 that ‘clinically there is a growing awareness that chromosomal anomalies and gene mutations underlie a diverse spectrum of male infertility,’ so now recommends that sperm DNA is determined as an extended analysis. Sperm DNA damage occurs more often in infertile men and DNA damage is associated with recurrent pregnancy loss and decreased live birth rates following fertility treatment.

Study design, size, duration

A prospective cohort study of men attending a secondary fertility clinic were offered a standard semen analysis plus sperm DNA fragmentation using SpermComet technology. UK IRAS ethical approval was obtained. Men attending were given a patient information leaflet at their first appointment. The study duration was 6 months. In total, 142 men were recruited out of a possible maximum of 409 attendees.

Participants/materials, setting, methods

Participants included men who had been referred as a couple to a secondary level infertility clinic for an initial assessment. Information leaflets were either posted to them prior to their first appointment or given to them at the initial nurse-led consultation. Those who subsequently contacted our research team re-attended for a sperm analysis and an aliquot was cryopreserved and sent in weekly batches to Examen (Northern Ireland) for SpermComet DNA fragmentation assessment.

Main results and the role of chance

Between May and November 2021, there were 409 attendees of whom 142 consented to the study.

Sperm DNA quality for the participants was assessed and reported as average, low and high DNA damage as a percentage compared with clinical thresholds used by Examen from their sperm bank of 63 fertile sperm donors who had recently achieved clinical pregnancies.

Of the 142 recruited, 77 men (54%) attending for initial investigations had normospermia assessed against the WHO criteria, so were initially classified as unexplained. Of these, 25 (32%) had abnormal sperm DNA values. The average comet score was 39.7% +/-1.3, low comet score was 37.8% +/- 4.4 and high comet score was 17.0% +/-2.0. These values were all significantly outside ( p < 0.001) of the fertile parameters from 63 fertile donors used by Examen (fertile range: average <26%%, low >74% and high <4%).

Our results suggest that up to a third of men reported to have normospermia will have DNA damaged sperm. This is important to consider before labelling a couple as 'unexplained'. Knowing the male's sperm DNA fragmentation assessment would allow for further discussion and exploration of lifestyle and dietary advice.

Limitations, reasons for caution

During the study period, not all attendees agreed to participate as it required an additional hospital visit. In this single site study, men have not yet been followed up for future fertility outcome such as natural conception and need or success of assisted conception.

Wider implications of the findings

Sperm DNA damage was found in a third of men who would previously have been classified as fertile and offered no further investigations or treatment to improve their sperm quality. Thus, this tool could be a useful adjunct to semen analysis to guide these couples’ future treatment pathways.

Trial registration number

not applicable

O-295 Passive sperm sorting does not select for sperm with lower DNA fragmentation levels compared to density gradient centrifugation in split samples

Study question

Does the passive sperm separation device, Zymot, select sperm with lower DNA fragmentation levels compared to Density Gradient Centrifugation (DGC)?

Summary answer

The sperm separation device Zymot did not select sperm with lower DNA fragmentation levels compared to sperm selected by DGC or the neat sample.

What is known already

Previous studies have shown that sperm with high DNA fragmentation levels result in lower fertilisation rates, impaired embryo development, lower pregnancy rates and increases the risk of miscarriage. Currently, prior to fertility treatment, the method of choice for sperm selection is using DGC, which involves the centrifugation of sperm. Therefore, there is a clinical need for a sperm selection method that avoids centrifugation, while mimicking the natural process of sperm selection in the female reproductive tract and selects sperm with intact DNA.

Study design, size, duration

This blinded controlled study included 29 patients from which semen samples were obtained between May 2021- January 2022 at ReproMed fertility clinic (Dublin, Ireland). Ejaculates were split and processed using either DGC, passive separation device (Zymot; 850 uL) or unprocessed (neat; control) and assessed for sperm quality in terms of motility (progressive, non-progressive and immotile), morphology and DNA fragmentation (assessed using the COMET assay). Two hundred sperm were assessed for each analysis.

Participants/materials, setting, methods

Motility and morphology were assessed using microscopy techniques as per WHO guidelines. DNA fragmentation was assessed using the COMET assay and each sample was given an Average COMET score (ACS), Low COMET score (LCS) and High COMET score (HCS). All data were checked for normality of distribution following which they were analysed using analysis of variance (ANOVA) with Bonferroni post-hoc tests. All values presented are mean ± standard error of the mean.

Main results and the role of chance

Sperm sorted by the Zymot device had higher progressive motility (78.7 + 3.42%) than both the neat (53.3 + 3.40%) and DGC (51.8 + 3.74%%) samples (P < 0.001). Sperm selected by DGC had a greater percentage of sperm with non-progressive motility (16.0 + 2.02%) compared to the neat sample (8.6 + 1.11%) and the Zymot device (9.9 + 1.60%). The overall percentage of normal morphology in the neat sample was 4.3 + 0.16% and there was no effect of sperm selection method on the percentage of sperm with normal morphology (P > 0.05). The ACS in the neat sample was 32.5 + 1.48% and neither DGC (28.2 + 1.45%) or Zymot (29.1 + 1.50%) improved this (P > 0.05). In line with this, neither LCS nor HCS differed between the treatments (P > 0.05).

Limitations, reasons for caution

A higher number of patient samples are needed to validate the efficacy of the Zymot sperm separation device on DNA fragmentation levels. Also, targeting patients with higher DNA fragmentation in the neat sample may yield greater benefits.

Wider implications of the findings

The results of this study indicate that the passive sperm selection device, Zymot, selects more motile sperm but does not select sperm with intact DNA. There is a need for a non-cell destructive method to select sperm with intact DNA to improve the outcomes for couples undergoing fertility treatment.

Trial registration number

Not Applicable

Hypofractionation in Hepatocellular Carcinoma - The Effect of Fractionation Size

The use of stereotactic body radiotherapy (SBRT) in hepatocellular carcinoma (HCC) has increased over the years. Several prospective studies have demonstrated its safety and efficacy, and randomised trials are underway. The advancement in technology has enabled the transition from three-dimensional conformal radiotherapy to highly focused SBRT. Liver damage is the primary limiting toxicity with radiation, with the incidence of grade 3 varying from 0 to 30%. The reported radiotherapy fractionation schedule for HCC, and in practice use, ranges from one to 10 fractions, based on clinician preference and technology available, tumour location and tumour size. This review summarises the safety and efficacy of various SBRT fractionation schedules for HCC.

1612 Unconscious Gender Bias from Patients: Are Female and Male Doctors Perceived Differently?

Introduction

While the need for gender equality has been well recognised within the medical profession, attitudes of patients towards doctors of different genders has not been addressed. We aim to identify whether gender biases exist within the minds of patients we treat and how we can address this.

Method

A survey was disseminated through social media platforms and work communication groups. Data was collected on gender, ethnicity, frequency of being mistaken for different members of the healthcare team and frequency of being asked to perform non-medical tasks. A free text option was available for respondents to elaborate on the context and how this made them feel.

Results

88 doctors (26 male, 62 female) responded. 65% (40) of females have had their roles misidentified at least once a week, compared to 0%(0) of males. 75% (46) of women reported negative emotions associated with being mistaken in their role, 25% (15) were neutral, none were positive. 62% (38) of female doctor’s report being asked to perform non-medical tasks at least once a week compared to 31% (8) of male doctors.

Conclusions

There is a clear disparity in how patients perceive male and female roles in medicine, with females being less likely to be identified as a doctor and twice as likely to be asked to perform non-medical tasks. As well as being potentially disruptive to their role, responses suggest that this impacts negatively on the confidence of these respondents. Further exploration of this subject, the impacts and remedies will be required in future.

Financial Incentives for Preventing Postpartum return to Smoking (FIPPS): study protocol for a three-arm randomised controlled trial

Background

Financial incentives are an effective way of helping women to stop smoking during pregnancy. Unfortunately, most women who stop smoking at this time return to smoking within 12 months of the infant’s birth. There is no evidence for interventions that are effective at preventing postpartum smoking relapse. Financial incentives provided after the birth may help women to sustain cessation. This randomised controlled trial will assess the effectiveness and cost-effectiveness of financial incentives to help women who are abstinent from smoking at end-of-pregnancy to avoid return to smoking up to 12 months postpartum.

Methods

This is a UK-based, multi-centre, three-arm, superiority, parallel group, individually randomised controlled trial, with 1:1:1 allocation. It will compare the effectiveness of two financial incentive interventions with each other (one intervention for up to 3 months postpartum offering up to £120 of incentives (£60 for the participant and £60 for a significant other support); the other for up to 12 months postpartum with up to £300 of incentives (£240 for the participant and £60 for a significant other support) and with a no incentives/usual care control group. Eligible women will be between 34 weeks gestation and 2 weeks postpartum, abstinent from smoking for at least 4 weeks, have an expired carbon monoxide (CO) reading < 4 parts per million (ppm), aged at least 16 years, intend remaining abstinent from smoking after the birth and able to speak and read English.

The primary outcome is self-reported, lapse-free, smoking abstinence from the last quit attempt in pregnancy until 12 months postpartum, biochemically validated by expired CO and/or salivary cotinine or anabasine. Outcomes will be analysed by intention-to-treat and regression models used to compare the proportion of abstinent women between the two intervention groups and between each intervention group and the control group. An economic evaluation will assess the cost-effectiveness of offering incentives and a qualitative process evaluation will examine barriers and facilitators to trial retention, effectiveness and implementation.

Discussion

This pragmatic randomised controlled trial will test whether offering financial incentives is effective and cost-effective for helping women to avoid smoking relapse during the 12 months after the birth of their baby.

Trial registration

International Standard Randomised Controlled Trial Number 55218215. Registered retrospectively on 5th June 2019

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05480-6.

Pregnant women's use of e-cigarettes in the UK: a cross-sectional survey

OBJECTIVE

To estimate prevalence of vaping in pregnancy. Compare characteristics and attitudes between exclusive smokers and vapers, and between exclusive vapers and dual users (smoke and vape).

DESIGN

Cross-sectional survey.

SETTING

Hospitals across England and Scotland.

POPULATION

Pregnant women attending antenatal clinics in 2017.

METHODS

Women at 8-24 weeks' gestation completed screening questions about their smoking and vaping. Current or recent ex-smokers and/or vapers completed a full detailed survey about vaping and smoking.

MAIN OUTCOME MEASURES

The prevalence of vaping, characteristics and attitudes of women who vape and/or smoke.

RESULTS

Of 3360 pregnant women who completed screening questions, 515 (15.3%, 95% CI 14.1-16.6) were exclusive smokers, 44 (1.3%, 95% CI 1.0-1.8) exclusive vapers and 118 (3.5%, 95% CI 2.9-4.2) dual users. In total, 867 (25.8%) women completed the full survey; compared with smokers (n = 434), vapers (n = 140) were more likely to hold higher educational qualifications (odds ratio [OR) 1.51, 95% CI 1.01-2.25). Compared with exclusive vapers (n = 33), dual users (n = 107) were younger (OR 0.91 95% CI 0.85-0.98) and less likely to hold high qualifications (OR 0.43, 95% CI 0.20-0.96). Compared with smokers, dual users were more likely to be planning to quit smoking (OR 2.27, 95% CI 1.24-4.18). Compared with smokers, vapers were more likely to think vaping was safer than smoking (78.6% versus 36.4%).

CONCLUSIONS

One in 20 pregnant women report vaping, and most also smoke. Dual users are more motivated towards stopping smoking than smokers. Where women have tried but cannot stop smoking, clinicians could encourage them to consider vaping for smoking cessation.

TWEETABLE EXTRACT

One in 20 women report vaping during pregnancy but of those that do vape, most also smoke, despite having intentions to quit.

Interprofessional Education and the Diagnostic Radiography curriculum: Students' perceived value of a case-based, whole day activity

INTRODUCTION

This study aimed to examine Diagnostic Radiography (DR) students' perceptions and attitudes towards the Health Collaboration Challenge (HCC), as an interprofessional learning opportunity.

METHODS

DR students participated in the HCC, an annual intensive interprofessional collaboration and assessment activity involving case-based learning. Students' attitudes towards Interprofessional Education (IPE) were measured using a modified version of the Interprofessional Socialisation and Valuing Scale (ISVS-21) and a bespoke questionnaire with items relating to the HCC. Subsequent focus groups explored students' experience of IPE within the HCC context.

RESULTS

Survey results (n = 30) suggested a mostly positive attitude towards IPE alongside other health care students, acknowledging the value of interprofessional teams in patient health care. Qualitative themes from focus group participants (n = 8) revealed that DR students, while appreciating the value of shared-decision making, found the HCC assessment distracting. Challenges included the intensive nature of the HCC, roles that DR students undertook in addressing assessment criteria, case complexity and opportunities for DR students to showcase their knowledge.

CONCLUSION

Results suggest that the intensive and assessable nature of the HCC can overshadow the value of IPE for DR students, and immersive or staggered approaches to IPE could better align with DR professionals' unique role within the patient care spectrum.

IMPLICATIONS FOR PRACTICE

Revised IPE models for DR students could include a more immersive environment, conducted over a longer period of time, with meetings at semi-regular intervals to promote an interprofessional-focus over a task-focus approach.

Dark-field signal extraction in propagation-based phase-contrast imaging

A method for extracting the dark-field signal in propagation-based phase-contrast imaging is proposed. In the case of objects consisting predominantly of a single material, or several different materials with similar ratios of the real decrement to the imaginary part of the complex refractive index, the proposed method requires a single image for extraction of the dark-field signal in two-dimensional projection imaging. In the case of three-dimensional tomographic imaging, the method needs only one image to be collected at each projection angle. Initial examples using simulated and experimental data indicate that this method can improve visualization of small sharp features inside a larger object, e.g. the visualization of microcalcifications in propagation-based x-ray breast cancer imaging. It is suggested that the proposed approach may be useful in other forms of biomedical imaging, where it can help one to obtain additional small-angle scattering information without increasing the radiation dose to the sample.

The impact of COVID-19 upon student radiographers and clinical training

Introduction

To investigate student clinical placement concerns and opinions, during the initial COVID-19 pandemic outbreak and to inform educational institution support planning.

Methods

Between mid-June to mid-July 2020, educational institutions from 12 countries were invited to participate in an online survey designed to gain student radiographer opinion from a wide geographical spread and countries with varying levels of COVID-19 cases.

Results

1277 respondents participated, of these 592 had completed clinical placements during January to June 2020. Accommodation and cohabiting risks were identified as challenging, as was isolation from family, travel to clinical placements, and to a lesser extent childcare. Students stated they had been affected by the feeling of isolation and concerns about the virus whilst on placement. Overall 35.4% of all respondents were ‘Not at all worried’ about being a radiographer, however, 64.6% expressed varying levels of concern and individual domestic or health situations significantly impacted responses (p ≤ 0.05). Year 4 students and recent graduates were significantly more likely to be ‘Not worried at all’ compared to Year 2 and 3 students (p ≤ 0.05). The need for improved communication regarding clinical placements scheduling was identified as almost 50% of students on clinical placements between January to June 2020 identified the completion of assessments as challenging. Furthermore, only 66% of respondents with COVID-19 imaging experience stated being confident with personal protective equipment (PPE) use.

Conclusion

Student radiographers identified key challenges which require consideration to ensure appropriate measures are in place to support their ongoing needs. Importantly PPE training is required before placement regardless of prior COVID-19 imaging experience.

Implications for practice

As the next academic year commences, the study findings identify important matters to be considered by education institutions with responsibility for Radiography training and as students commence clinical placements during the on-going global COVID-19 pandemic.

Trimers Conjugated to Fibrin Hydrogels Promote Salivary Gland Function

New strategies for tissue engineering have great potential for restoring and revitalizing impaired tissues and organs, including the use of smart hydrogels that can be modified to enhance organization and functionality of the salivary glands. For instance, monomers of laminin-111 peptides chemically conjugated to fibrin hydrogel (L_1pM-FH) promote cell cluster formation in vitro and salivary gland regeneration in vivo when compared with fibrin hydrogel (FH) alone; however, L_1pM-FH produce only weak expression of acinar differentiation markers in vivo (e.g., aquaporin-5 and transmembrane protein 16). Since previous studies demonstrated that a greater impact can be achieved when trimeric forms were used as compared with monomeric or dimeric forms, we investigated the extent to which trimers of laminin-111 chemically conjugated to FH (L_1pT-FH) can increase the expression of acinar differentiation markers and elevate saliva secretion. In vitro studies using Par-C10 acinar cells demonstrated that when compared with L_1pM-FH, L_1pT-FH induced similar levels of acinar-like cell clustering, polarization, lumen formation, and calcium signaling. To assess the performance of the trimeric complex in vivo, we compared the ability of L_1pM-FH and L_1pT-FH to increase acinar differentiation markers and restore saliva flow rate in a salivary gland wound model of C57BL/6 mice. Our results show that L_1pT-FH applied to wounded mice significantly improved the expression of the acinar differentiation markers and saliva secretion when compared with the monomeric form. Together, these positive effects of L_1pT-FH warrant its future testing in additional models of hyposalivation with the ultimate goal of applying this technology in humans.

Health and fertility of ICSI-conceived young men: study protocol

STUDY QUESTIONS

What are the long-term health and reproductive outcomes for young men conceived using ICSI whose fathers had spermatogenic failure (STF)? Are there epigenetic consequences of ICSI conception?

WHAT IS KNOWN ALREADY

Currently, little is known about the health of ICSI-conceived adults, and in particular the health and reproductive potential of ICSI-conceived men whose fathers had STF. Only one group to date has assessed semen parameters and reproductive hormones in ICSI-conceived men and suggested higher rates of impaired semen quality compared to spontaneously conceived (SC) peers. Metabolic parameters in this same cohort of men were mostly comparable. No study has yet evaluated other aspects of adult health.

STUDY DESIGN SIZE DURATION

This cohort study aims to evaluate the general health and development (aim 1), fertility and metabolic parameters (aim 2) and epigenetic signatures (aim 3) of ICSI-conceived sons whose fathers had STF (ICSI study group). There are three age-matched control groups: ICSI-conceived sons whose fathers had obstructive azoospermia (OAZ) and who will be recruited in this study, as well as IVF sons and SC sons, recruited from other studies. Of 1112 ICSI parents including fathers with STF and OAZ, 78% (n = 867) of mothers and 74% (n = 823) of fathers were traced and contacted. Recruitment of ICSI sons started in March 2017 and will finish in July 2020. Based on preliminary participation rates, we estimate the following sample size will be achieved for the ICSI study group: mothers n = 275, fathers n = 225, sons n = 115. Per aim, the sample sizes of OAZ-ICSI (estimated), IVF and SC controls are: Aim 1-OAZ-ICSI: 28 (maternal surveys)/12 (son surveys), IVF: 352 (maternal surveys)/244 (son surveys), SC: 428 (maternal surveys)/255 (son surveys); Aim 2-OAZ-ICSI: 12, IVF: 72 (metabolic data), SC: 391 (metabolic data)/365 (reproductive data); Aim 3-OAZ-ICSI: 12, IVF: 71, SC: 292.

PARTICIPANTS/MATERIALS SETTING METHODS

Eligible parents are those who underwent ICSI at one of two major infertility treatment centres in Victoria, Australia and gave birth to one or more males between January 1994 and January 2000. Eligible sons are those aged 18 years or older, whose fathers had STF or OAZ, and whose parents allow researchers to approach sons. IVF and SC controls are age-matched men derived from previous studies, some from the same source population. Participating ICSI parents and sons complete a questionnaire, the latter also undergoing a clinical assessment. Outcome measures include validated survey questions, physical examination (testicular volumes, BMI and resting blood pressure), reproductive hormones (testosterone, sex hormone-binding globulin, FSH, LH), serum metabolic parameters (fasting glucose, insulin, lipid profile, highly sensitive C-reactive protein) and semen analysis. For epigenetic and future genetic analyses, ICSI sons provide specimens of blood, saliva, sperm and seminal fluid while their parents provide a saliva sample. The primary outcomes of interest are the number of mother-reported hospitalisations of the son; son-reported quality of life; prevalence of moderate-severe oligozoospermia (sperm concentration <5 million/ml) and DNA methylation profile. For each outcome, differences between the ICSI study group and each control group will be investigated using multivariable linear and logistic regression for continuous and binary outcomes, respectively. Results will be presented as adjusted odds ratios and 95% CIs.

STUDY FUNDING/COMPETING INTERESTS

This study is funded by an Australian National Health and Medical Research Council Partnership Grant (NHMRC APP1140706) and was partially funded by the Monash IVF Research and Education Foundation. L.R. is a minority shareholder and the Group Medical Director for Monash IVF Group, and reports personal fees from Monash IVF group and Ferring Australia, honoraria from Ferring Australia, and travel fees from Merck Serono, MSD and Guerbet; R.J.H. is the Medical Director of Fertility Specialists of Western Australia and has equity in Western IVF; R.I.M. is a consultant for and a shareholder of Monash IVF Group and S.R.C. reports personal fees from Besins Healthcare and non-financial support from Merck outside of the submitted work. The remaining authors have no conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

Not applicable.

TRIAL REGISTRATION DATE

Not applicable.

DATE OF FIRST PATIENT’S ENROLMENT

Not applicable.

Diagnostic radiographers' experience of COVID-19, Gauteng South Africa

Introduction

As of July 2020, South Africa (SA) had the fifth highest number of COVID-19 infections in the world, with the greatest contributor of these infections, being the province of Gauteng. Diagnostic radiographers in Gauteng providing chest CT, chest radiograph and MRI services are frontline workers experiencing these unprecedented times. Therefore, this study undertook to explore diagnostic radiographers’ experiences of COVID-19.

Methods

A qualitative approach using an asynchronous opened-ended online questionnaire was used to explore diagnostic radiographers’ experiences of COVID-19. Responses from purposively sampled diagnostic radiographers in Gauteng SA, underwent thematic analysis.

Results

Sixty diagnostic radiographers representing both the private and public health sector responded to the questionnaire. Thematic analysis revealed three themes: new work flow and operations, effect on radiographer well-being and radiographer resilience.

Conclusion

Besides experiencing a shift in their professional work routine and home/family dynamics, diagnostic radiographers’ well-being has also been impacted by COVID-19. Adapting to the “new way of work” has been challenging yet their resilience and dedication to their profession, providing quality patient care and skill expertise is their arsenal to combat these challenges.

Implications for practice

Understanding the impact of COVID-19 on diagnostic radiographers will allow radiology departments’ management, hospital management, professional bodies and educational institutions to re-evaluate provision of resources, training, employee wellness programs as well as policies and procedures.

Practical and effective diagnosis of animal anthrax in endemic low-resource settings

Anthrax threatens human and animal health, and people's livelihoods in many rural communities in Africa and Asia. In these areas, anthrax surveillance is challenged by a lack of tools for on-site detection. Furthermore, cultural practices and infrastructure may affect sample availability and quality. Practical yet accurate diagnostic solutions are greatly needed to quantify anthrax impacts. We validated microscopic and molecular methods for the detection of Bacillus anthracis in field-collected blood smears and identified alternative samples suitable for anthrax confirmation in the absence of blood smears. We investigated livestock mortalities suspected to be caused by anthrax in northern Tanzania. Field-prepared blood smears (n = 152) were tested by microscopy using four staining techniques as well as polymerase chain reaction (PCR) followed by Bayesian latent class analysis. Median sensitivity (91%, CI 95% [84-96%]) and specificity (99%, CI 95% [96-100%]) of microscopy using azure B were comparable to those of the recommended standard, polychrome methylene blue, PMB (92%, CI 95% [84-97%] and 98%, CI 95% [95-100%], respectively), but azure B is more available and convenient. Other commonly-used stains performed poorly. Blood smears could be obtained for <50% of suspected anthrax cases due to local customs and conditions. However, PCR on DNA extracts from skin, which was almost always available, had high sensitivity and specificity (95%, CI 95% [90-98%] and 95%, CI 95% [87-99%], respectively), even after extended storage at ambient temperature. Azure B microscopy represents an accurate diagnostic test for animal anthrax that can be performed with basic laboratory infrastructure and in the field. When blood smears are unavailable, PCR using skin tissues provides a valuable alternative for confirmation. Our findings lead to a practical diagnostic approach for anthrax in low-resource settings that can support surveillance and control efforts for anthrax-endemic countries globally.

"I realised it weren't about spending the money. It's about doing something together:" the role of money in a community empowerment initiative and the implications for health and wellbeing

Community initiatives aiming to reduce health inequalities are increasingly common in health policy. Though diverse many such initiatives aim to support residents of disadvantaged places to exercise greater collective control over decisions/actions that affect their lives - which research suggests is an important determinant of health - and some seek to achieve this by giving residents control over a budget. Informed by theoretical work in which community capabilities for collective control are conceptualised as different forms of power, and applying a relational lens, this paper presents findings on the potential role of money as a mechanism to enhance these capabilities from an on-going evaluation of a major place-based initiative being implemented in 150 neighbourhoods across England:The Big Local (BL). The research involved semi-structured interviews with 116 diverse stakeholders, including residents and participant observation in a diverse sample of 10 BL areas. We took a thematic constant comparative approach to the analysis of data from across the sites. The findings suggest that the money enabled the development of capabilities for collective control in these communities primarily by enhancing connectivity amongst residents and with external stakeholders. However, residents had to engage in significant 'relational work' to achieve these benefits and tensions around the money could hinder communities' 'power to act'. Greater social connectivity has been shown to directly affect individual and population health by increasing social cohesion and reducing loneliness. Additionally, supporting enhanced collective control of residents in these disadvantaged communities has the potential to improve population health and reduce health inequalities.