Primary care usage at the end of life: a retrospective cohort study of cancer patients using linked primary and hospital care data.

PURPOSE: Health service use is most intensive in the final year of a person's life, with 80% of this expenditure occurring in hospital. Close involvement of primary care services has been promoted to enhance quality end-of-life care that is appropriate to the needs of patients. However, the relationship between primary care involvement and patients' use of hospital care is not well described. This study aims to examine primary care use in the last year of life for cancer patients and its relationship to hospital usage. METHODS: Retrospective cohort study in Victoria, Australia, using linked routine care data from primary care, hospital and death certificates. Patients were included who died related to cancer between 2008 and 2017. RESULTS: A total of 758 patients were included, of whom 88% (n = 667) visited primary care during the last 6 months (median 9.1 consultations). In the last month of life, 45% of patients were prescribed opioids, and 3% had imaging requested. Patients who received home visits (13%) or anticipatory medications (15%) had less than half the median bed days in the last 3 months (4 vs 9 days, p < 0.001, 5 vs 10 days, p = 0.001) and 1 month of life (0 vs 2 days, p = 0.002, 0 vs 3 days, p < 0.001), and reduced emergency department presentations (32% vs 46%, p = 0.006, 31% vs 47% p < 0.001) in the final month. CONCLUSION: This study identifies two important primary care processes-home visits and anticipatory medication-associated with reduced hospital usage and intervention at the end of life.

NOD1 mediates interleukin-18 processing in epithelial cells responding to Helicobacter pylori infection in mice.

The interleukin-1 family members, IL-1ß and IL-18, are processed into their biologically active forms by multi-protein complexes, known as inflammasomes. Although the inflammasome pathways that mediate IL-1ß processing in myeloid cells have been defined, those involved in IL-18 processing, particularly in non-myeloid cells, are still not well understood. Here we report that the host defence molecule NOD1 regulates IL-18 processing in mouse epithelial cells in response to the mucosal pathogen, Helicobacter pylori. Specifically, NOD1 in epithelial cells mediates IL-18 processing and maturation via interactions with caspase-1, instead of the canonical inflammasome pathway involving RIPK2, NF-κB, NLRP3 and ASC. NOD1 activation and IL-18 then help maintain epithelial homoeostasis to mediate protection against pre-neoplastic changes induced by gastric H. pylori infection in vivo. Our findings thus demonstrate a function for NOD1 in epithelial cell production of bioactive IL-18 and protection against H. pylori-induced pathology.

The Hunter-8 Scale Prehospital Triage Workflow for Identification of Large Vessel Occlusion and Brain Haemorrhage.

OBJECTIVE: The Hunter-8 prehospital stroke scale predicts large vessel occlusion in hyperacute ischemic stroke patients (LVO) at hospital admission. We wished to test its performance in the hands of paramedics as part of a prehospital triage algorithm. We aimed to determine (a) the proportion of patients identified by the Hunter-8 algorithm, receiving reperfusion therapies, (b) whether a call to stroke team improved this, and (c) performance for LVO detection using an expanded LVO definition. METHODS: A prehospital workflow combining pre-morbid functional status, time from symptom onset, and the Hunter-8 scale was implemented from July 2019. A telephone call to the stroke team was prompted for potential treatment candidates. Classic LVO was defined as a proximal middle cerebral artery (MCA-M1), terminal internal carotid artery, or tandem occlusion. Extended LVO added proximal MCA-M2 and basilar occlusions. RESULTS: From July 2019 to April 2021, there were 363 Hunter-8 activations, 320 analyzed: 181 (56.6%) had confirmed ischemic strokes, 13 (4.1%) transient ischemic attack, 91 (28.5%) stroke mimics, and 35 (10.9%) intracranial hemorrhage. Fifty-two patients (16.3%) received reperfusion therapies, 35 with Hunter-8 ≥ 8. The stroke doctor changed the final destination for 76 patients (23.7%), and five received reperfusion therapies. The AUCs for classic and extended LVO were 0.73 (95% CI 0.66-0.79) and 0.72 (95% CI 0.65-0.77), respectively. CONCLUSION: The Hunter-8 workflow resulted in 28.7% of confirmed ischemic stroke patients receiving reperfusion therapies, with no secondary transfers to the comprehensive stroke center. The role of communication with stroke team needs to be further explored.

Spacecraft sample collection and subsurface excavation of asteroid (101955) Bennu.

Carbonaceous asteroids, such as (101955) Bennu, preserve material from the early Solar System, including volatile compounds and organic molecules. We report spacecraft imaging and spectral data collected during and after retrieval of a sample from Bennu's surface. The sampling event mobilized rocks and dust into a debris plume, excavating a 9-meter-long elliptical crater. This exposed material is darker, spectrally redder, and more abundant in fine particulates than the original surface. The bulk density of the displaced subsurface material was 500 to 700 kilograms per cubic meter, which is about half that of the whole asteroid. Particulates that landed on instrument optics spectrally resemble aqueously altered carbonaceous meteorites. The spacecraft stored 250 ± 101 grams of material, which will be delivered to Earth in 2023.

Artificial intelligence and machine learning algorithms for early detection of skin cancer in community and primary care settings: a systematic review.

Skin cancers occur commonly worldwide. The prognosis and disease burden are highly dependent on the cancer type and disease stage at diagnosis. We systematically reviewed studies on artificial intelligence and machine learning (AI/ML) algorithms that aim to facilitate the early diagnosis of skin cancers, focusing on their application in primary and community care settings. We searched MEDLINE, Embase, Scopus, and Web of Science (from Jan 1, 2000, to Aug 9, 2021) for all studies providing evidence on applying AI/ML algorithms to the early diagnosis of skin cancer, including all study designs and languages. The primary outcome was diagnostic accuracy of the algorithms for skin cancers. The secondary outcomes included an overview of AI/ML methods, evaluation approaches, cost-effectiveness, and acceptability to patients and clinicians. We identified 14 224 studies. Only two studies used data from clinical settings with a low prevalence of skin cancers. We reported data from all 272 studies that could be relevant in primary care. The primary outcomes showed reasonable mean diagnostic accuracy for melanoma (89·5% [range 59·7-100%]), squamous cell carcinoma (85·3% [71·0-97·8%]), and basal cell carcinoma (87·6% [70·0-99·7%]). The secondary outcomes showed a heterogeneity of AI/ML methods and study designs, with high amounts of incomplete reporting (eg, patient demographics and methods of data collection). Few studies used data on populations with a low prevalence of skin cancers to train and test their algorithms; therefore, the widespread adoption into community and primary care practice cannot currently be recommended until efficacy in these populations is shown. We did not identify any health economic, patient, or clinician acceptability data for any of the included studies. We propose a methodological checklist for use in the development of new AI/ML algorithms to detect skin cancer, to facilitate their design, evaluation, and implementation.

Characteristics of Posttraumatic Nightmares and Their Relationship to PTSD Severity Among Combat Veterans With PTSD and Hazardous Alcohol Use.

ABSTRACT: Although nightmares are known to predict the clinical course of posttraumatic stress disorder (PTSD), research on the relationship between specific nightmare characteristics and PTSD severity is sparse. This study conducted a secondary analysis to explore how five nightmare characteristics are cross-sectionally related to PTSD severity in 76 combat veterans with PTSD and at-risk alcohol use. Consistent with emotional processing theory, we hypothesized that more replicative, threatening, realistic, and easily recalled nightmares would be associated with more severe PTSD, whereas those with greater symbolism would predict lower PTSD severity. Nightmares narratives were audio-recorded and rated by multiple coders. Multiple analyses of variance explored the relationship between nightmare characteristics and PTSD clinical indicators. Most nightmares were realistic, easily recalled, and involved significant threat. Greater realism and replication were associated with greater PTSD severity. Realistic and replicative nightmares may be markers of more severe PTSD and may indicate that less emotional processing of the trauma has occurred.

Fine-regolith production on asteroids controlled by rock porosity.

Spacecraft missions have observed regolith blankets of unconsolidated subcentimetre particles on stony asteroids1-3. Telescopic data have suggested the presence of regolith blankets also on carbonaceous asteroids, including (101955) Bennu4 and (162173) Ryugu5. However, despite observations of processes that are capable of comminuting boulders into unconsolidated materials, such as meteoroid bombardment6,7 and thermal cracking8, Bennu and Ryugu lack extensive areas covered in subcentimetre particles7,9. Here we report an inverse correlation between the local abundance of subcentimetre particles and the porosity of rocks on Bennu. We interpret this finding to mean that accumulation of unconsolidated subcentimetre particles is frustrated where the rocks are highly porous, which appears to be most of the surface10. The highly porous rocks are compressed rather than fragmented by meteoroid impacts, consistent with laboratory experiments11,12, and thermal cracking proceeds more slowly than in denser rocks. We infer that regolith blankets are uncommon on carbonaceous asteroids, which are the most numerous type of asteroid13. By contrast, these terrains should be common on stony asteroids, which have less porous rocks and are the second-most populous group by composition13. The higher porosity of carbonaceous asteroid materials may have aided in their compaction and cementation to form breccias, which dominate the carbonaceous chondrite meteorites14.

Bright carbonate veins on asteroid (101955) Bennu: Implications for aqueous alteration history.

The composition of asteroids and their connection to meteorites provide insight into geologic processes that occurred in the early Solar System. We present spectra of the Nightingale crater region on near-Earth asteroid Bennu with a distinct infrared absorption around 3.4 micrometers. Corresponding images of boulders show centimeters-thick, roughly meter-long bright veins. We interpret the veins as being composed of carbonates, similar to those found in aqueously altered carbonaceous chondrite meteorites. If the veins on Bennu are carbonates, fluid flow and hydrothermal deposition on Bennu's parent body would have occurred on kilometer scales for thousands to millions of years. This suggests large-scale, open-system hydrothermal alteration of carbonaceous asteroids in the early Solar System.

Asteroid (101955) Bennu's weak boulders and thermally anomalous equator.

Thermal inertia and surface roughness are proxies for the physical characteristics of planetary surfaces. Global maps of these two properties distinguish the boulder population on near-Earth asteroid (NEA) (101955) Bennu into two types that differ in strength, and both have lower thermal inertia than expected for boulders and meteorites. Neither has strongly temperature-dependent thermal properties. The weaker boulder type probably would not survive atmospheric entry and thus may not be represented in the meteorite collection. The maps also show a high-thermal inertia band at Bennu's equator, which might be explained by processes such as compaction or strength sorting during mass movement, but these explanations are not wholly consistent with other data. Our findings imply that other C-complex NEAs likely have boulders similar to those on Bennu rather than finer-particulate regoliths. A tentative correlation between albedo and thermal inertia of C-complex NEAs may be due to relative abundances of boulder types.

Heterogeneous mass distribution of the rubble-pile asteroid (101955) Bennu.

The gravity field of a small body provides insight into its internal mass distribution. We used two approaches to measure the gravity field of the rubble-pile asteroid (101955) Bennu: (i) tracking and modeling the spacecraft in orbit about the asteroid and (ii) tracking and modeling pebble-sized particles naturally ejected from Bennu's surface into sustained orbits. These approaches yield statistically consistent results up to degree and order 3, with the particle-based field being statistically significant up to degree and order 9. Comparisons with a constant-density shape model show that Bennu has a heterogeneous mass distribution. These deviations can be modeled with lower densities at Bennu's equatorial bulge and center. The lower-density equator is consistent with recent migration and redistribution of material. The lower-density center is consistent with a past period of rapid rotation, either from a previous Yarkovsky-O'Keefe-Radzievskii-Paddack cycle or arising during Bennu's accretion following the disruption of its parent body.

Particle Ejection Contributions to the Rotational Acceleration and Orbit Evolution of Asteroid (101955) Bennu.

This paper explores the implications of the observed Bennu particle ejection events for that asteroid's spin rate and orbit evolution, which could complicate interpretation of the Yarkovsky-O'Keefe-Radzievskii-Paddack (YORP) and Yarkovsky effects on this body's spin rate and orbital evolution. Based on current estimates of particle ejection rates, we find that the overall contribution to Bennu's spin and orbital drift is small or negligible as compared to the Yarkovsky and YORP effects. However, if there is a large unseen component of smaller mass ejections or a strong directionality in the ejection events, it could constitute a significant contribution that could mask the overall YORP effect. This means that the YORP effect may be stronger than currently assumed. The analysis is generalized so that the particle ejection effect can be assessed for other bodies that may be subject to similar mass loss events. Further, our model can be modified to address different potential mechanisms of particle ejection, which are a topic of ongoing study.

Correction: External validation of risk prediction models for incident colorectal cancer using UK Biobank.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Episodes of particle ejection from the surface of the active asteroid (101955) Bennu.

Active asteroids are those that show evidence of ongoing mass loss. We report repeated instances of particle ejection from the surface of (101955) Bennu, demonstrating that it is an active asteroid. The ejection events were imaged by the OSIRIS-REx (Origins, Spectral Interpretation, Resource Identification, and Security-Regolith Explorer) spacecraft. For the three largest observed events, we estimated the ejected particle velocities and sizes, event times, source regions, and energies. We also determined the trajectories and photometric properties of several gravitationally bound particles that orbited temporarily in the Bennu environment. We consider multiple hypotheses for the mechanisms that lead to particle ejection for the largest events, including rotational disruption, electrostatic lofting, ice sublimation, phyllosilicate dehydration, meteoroid impacts, thermal stress fracturing, and secondary impacts.

Exploring the Business Case for Improving Quality of Care for Patients With Chronic Rotator Cuff Tears.

BACKGROUND AND OBJECTIVES: Currently, management of patients presenting with chronic rotator cuff tears in Alberta is in need of quality improvements. This article explores the potential impact of a proposed care pathway whereby all patients presenting with chronic rotator cuff tears in Alberta would adopt an early, conservative management plan as the first stage of care; ultrasound investigation would be the preferred tool for diagnosing a rotator cuff tear; and only patients are referred for surgery once conservative measures have been exhausted. METHODS: We evaluate evidence in support of surgery and conservative management, compare care in the current state with the proposed care pathway, and identify potential solutions in moving toward optimal care. RESULTS: A literature search resulted in an absence of indications for either surgical or conservative management. Conservative management has the potential to reduce utilization of public health care resources and may be preferable to surgery. The proposed care pathway has the potential to avoid nearly Can $87 000 in public health care costs in the current system for every 100 patients treated successfully with conservative management. CONCLUSION: The proposed care pathway is a low-cost, first-stage treatment that is cost-effective and has the potential to reduce unnecessary, costly surgical procedures.

Dermoscopy for melanoma detection and triage in primary care: a systematic review.

OBJECTIVE: Most skin lesions first present in primary care, where distinguishing rare melanomas from benign lesions can be challenging. Dermoscopy improves diagnostic accuracy among specialists and is promoted for use by primary care physicians (PCPs). However, when used by untrained clinicians, accuracy may be no better than visual inspection. This study aimed to undertake a systematic review of literature reporting use of dermoscopy to triage suspicious skin lesions in primary care settings, and challenges for implementation. DESIGN: A systematic literature review and narrative synthesis. DATA SOURCES: We searched MEDLINE, Cochrane Central, EMBASE, Cumulative Index to Nursing and Allied Health Literature, and SCOPUS bibliographic databases from 1 January 1990 to 31 December 2017, without language restrictions. INCLUSION CRITERIA: Studies including assessment of dermoscopy accuracy, acceptability to patients and PCPs, training requirements, and cost-effectiveness of dermoscopy modes in primary care, including trials, diagnostic accuracy and acceptability studies. RESULTS: 23 studies met the review criteria, representing 49 769 lesions and 3708 PCPs, all from high-income countries. There was a paucity of studies set truly in primary care and the outcomes measured were diverse. The heterogeneity therefore made meta-analysis unfeasible; the data were synthesised through narrative review. Dermoscopy, with appropriate training, was associated with improved diagnostic accuracy for melanoma and benign lesions, and reduced unnecessary excisions and referrals. Teledermoscopy-based referral systems improved triage accuracy. Only three studies examined cost-effectiveness; hence, there was insufficient evidence to draw conclusions. Costs, training and time requirements were considered important implementation barriers. Patient satisfaction was seldom assessed. Computer-aided dermoscopy and other technological advances have not yet been tested in primary care. CONCLUSIONS: Dermoscopy could help PCPs triage suspicious lesions for biopsy, urgent referral or reassurance. However, it will be important to establish further evidence on minimum training requirements to reach competence, as well as the cost-effectiveness and patient acceptability of implementing dermoscopy in primary care. TRIAL REGISTRATION NUMBER: CRD42018091395.

Evidence for widespread hydrated minerals on asteroid (101955) Bennu.

Early spectral data from the Origins, Spectral Interpretation, Resource Identification, and Security-Regolith Explorer (OSIRIS-REx) mission reveal evidence for abundant hydrated minerals on the surface of near-Earth asteroid (101955) Bennu in the form of a near-infrared absorption near 2.7 µm and thermal infrared spectral features that are most similar to those of aqueously altered CM carbonaceous chondrites. We observe these spectral features across the surface of Bennu, and there is no evidence of substantial rotational variability at the spatial scales of tens to hundreds of meters observed to date. In the visible and near-infrared (0.4 to 2.4 µm) Bennu's spectrum appears featureless and with a blue (negative) slope, confirming previous ground-based observations. Bennu may represent a class of objects that could have brought volatiles and organic chemistry to Earth.

Dermoscopy use in UK primary care: a survey of GPs with a special interest in dermatology.

BACKGROUND: Melanoma accounts for 90% of skin cancer mortality and typically presents in primary care, where it can be challenging to distinguish from benign lesions. Dermoscopy is a tool for skin visualization that is routinely used for melanoma diagnosis in secondary care. However, the role of dermoscopy in primary care remains unclear. OBJECTIVES: To determine views on, and use of, dermoscopy by dermatology-interested general practitioners (GPs). METHODS: An online questionnaire was emailed to the UK Primary Care Dermatology Society members in February 2018, and responses collected over the following 4 weeks. RESULTS: A total of 205 responses were analysed. Most respondents were GPs (94%), aged over 50 (53%), had a postgraduate dermatological qualification (67%) and used dermoscopy regularly when reviewing pigmented skin lesions (97%). Dermoscopy use was commoner amongst GPs who had worked longer in primary care and had experience of secondary care dermatology. Most had undertaken training in dermoscopy (91%), although one-fifth (20%) had not updated their training in over 5 years. Most of those who had received only 1 day of face-to-face training reported feeling confident using a dermatoscope. Few respondents (11%) reported access to teledermatology or teledermoscopy for urgent or routine referrals. CONCLUSIONS: UK GPs with a special interest in dermatology are routinely using dermoscopy in the primary care setting. More research is needed to establish optimal approaches to training and updating GP dermoscopy skills. When dermoscopy has been shown to be safe, effective, acceptable and cost-effective in this setting, more GPs may also be able to gain and maintain the skills to implement dermoscopy into routine primary care. Technological advances, including incorporation of artificial intelligence (AI) and algorithms to guide GPs, could also contribute to widening use of dermoscopy among GPs.

The unexpected surface of asteroid (101955) Bennu.

NASA'S Origins, Spectral Interpretation, Resource Identification and Security-Regolith Explorer (OSIRIS-REx) spacecraft recently arrived at the near-Earth asteroid (101955) Bennu, a primitive body that represents the objects that may have brought prebiotic molecules and volatiles such as water to Earth1. Bennu is a low-albedo B-type asteroid2 that has been linked to organic-rich hydrated carbonaceous chondrites3. Such meteorites are altered by ejection from their parent body and contaminated by atmospheric entry and terrestrial microbes. Therefore, the primary mission objective is to return a sample of Bennu to Earth that is pristine-that is, not affected by these processes4. The OSIRIS-REx spacecraft carries a sophisticated suite of instruments to characterize Bennu's global properties, support the selection of a sampling site and document that site at a sub-centimetre scale5-11. Here we consider early OSIRIS-REx observations of Bennu to understand how the asteroid's properties compare to pre-encounter expectations and to assess the prospects for sample return. The bulk composition of Bennu appears to be hydrated and volatile-rich, as expected. However, in contrast to pre-encounter modelling of Bennu's thermal inertia12 and radar polarization ratios13-which indicated a generally smooth surface covered by centimetre-scale particles-resolved imaging reveals an unexpected surficial diversity. The albedo, texture, particle size and roughness are beyond the spacecraft design specifications. On the basis of our pre-encounter knowledge, we developed a sampling strategy to target 50-metre-diameter patches of loose regolith with grain sizes smaller than two centimetres4. We observe only a small number of apparently hazard-free regions, of the order of 5 to 20 metres in extent, the sampling of which poses a substantial challenge to mission success.