Benefit-risk assessment for the Novavax COVID-19 vaccine (NVX-CoV2373).

A benefit-risk assessment of NVX-CoV2373, a vaccine to prevent COVID-19, was conducted to determine if the benefits of vaccination outweigh the risks of myocarditis/pericarditis. This analysis used data on myocarditis/pericarditis cases observed in the NVX-CoV2373 clinical studies, real-world data of mRNA COVID vaccine effectiveness against predominant SARS-CoV-2 strains in early 2023, and recent COVID-19 burden of disease data from the United States. The benefits of NVX-CoV2373 vaccination were estimated as the number of COVID-19 cases, hospitalizations, and deaths prevented. The risks of myocarditis/pericarditis cases and related hospitalizations and deaths occurring within 7 days of vaccination were also estimated. In our analysis, vaccination with NVX-CoV2373, per 100,000 vaccinated, resulted in an estimated 1805 COVID-19 cases prevented compared with an estimated 5.3 excess myocarditis/pericarditis cases. The number of COVID-19 hospitalizations and deaths prevented were also greater than vaccine-associated myocarditis/pericarditis hospitalizations and deaths. Our analysis indicates a positive benefit-risk balance for NVX-CoV2373.

A Brighton Collaboration standardized template with key considerations for a benefit/risk assessment for the Novavax COVID-19 Vaccine (NVX-CoV2373), a recombinant spike protein vaccine with Matrix-M adjuvant to prevent disease caused by SARS-CoV-2 viruses.

Novavax, a global vaccine company, began evaluating NVX-CoV2373 in human studies in May 2020 and the pivotal placebo-controlled phase 3 studies started in November 2020; five clinical studies provided adult and adolescent clinical data for over 31,000 participants who were administered NVX-CoV2373. This extensive data has demonstrated a well-tolerated response to NVX-CoV2373 and high vaccine efficacy against mild, moderate, or severe COVID-19 using a two-dose series (Dunkle et al., 2022) [1], (Heath et al., 2021) [2], (Keech et al., 2020) [3], (Mallory et al., 2022) [4]. The most common adverse events seen after administration with NVX-CoV2373 were injection site tenderness, injection site pain, fatigue, myalgia, headache, malaise, arthralgia, nausea, or vomiting. In addition, immunogenicity against variants of interest (VOI) and variants of concern (VOC) was established with high titers of ACE2 receptor-inhibiting and neutralizing antibodies in these studies (EMA, 2022) [5], (FDA, 2023) [6]. Further studies on correlates of protection determined that titers of anti-Spike IgG and neutralizing antibodies correlated with efficacy against symptomatic COVID-19 established in clinical trials (p < 0.001 for recombinant protein vaccine and p = 0.005 for mRNA vaccines for IgG levels) (Fong et al., 2022) [7]. Administration of a booster dose of the recombinant protein vaccine approximately 6 months following the primary two-dose series resulted in substantial increases in humoral antibodies against both the prototype strain and all evaluated variants, similar to or higher than the antibody levels observed in phase 3 studies that were associated with high vaccine efficacy (Dunkle et al., 2022) [1], (Mallory et al., 2022) [4]. These findings, together with the well tolerated safety profile, support use of the recombinant protein vaccine as primary series and booster regimens.

Young people's perspectives on addressing UK health inequalities: utopian visions and preferences for action.

INTRODUCTION: It is increasingly recognised by UK researchers and population health advocates that an important impetus to effective policy action to address health inequalities is activation of public dialogue about the social determinants of health and how inequalities might be addressed. The limited body of existing scholarship reaches varying conclusions on public preferences for responding to health inequalities but with consensus around the importance of tackling poverty. Young people's perspectives remain underexplored despite their increasingly visible role in activism across a range of policy issues and the potential impact of widening inequalities on their generation's health and wellbeing. METHODS: Six groups of young people (39 in total) from two UK cities (Glasgow and Leeds) were engaged in online workshops to explore views on health inequalities and potential solutions. Inspired by calls to employ notions of utopia, artist-facilitators and researchers supported participants to explore the evidence, debating solutions and imagining a more desirable society, using visual and performance art. Drawing together data from discussions and creative outputs, we analysed participants' perspectives on addressing health inequalities across four domains: governance, environment, society/culture and economy. FINDINGS: Proposals ranged from radical, whole-systems change to support for policies currently being considered by governments across the United Kingdom. The consensus was built around embracing more participatory, collaborative governance; prioritising sustainability and access to greenspace; promoting inclusivity and eliminating discrimination and improving the circumstances of those on the lowest incomes. Levels of acceptable income inequality, and how best to address income inequality were more contested. Individual-level interventions were rarely presented as viable options for addressing the social inequalities from which health differences emanate. CONCLUSION: Young people contributed wide-ranging and visionary solutions to debates around addressing the enduring existence of health inequalities in the United Kingdom. Their reflections signal support for 'upstream' systemic change to achieve reductions in social inequalities and the health differences that flow from these. PUBLIC CONTRIBUTION: An advisory group of young people informed the development of project plans. Participants shaped the direction of the project in terms of substantive focus and were responsible for the generation of creative project outputs aimed at influencing policymakers.

An exploration of stakeholder views and perceptions on taxing tobacco, alcohol and sugar-sweetened beverages in Ghana.

BACKGROUND: Non-communicable diseases (NCDs) account for nearly 43% of Ghana's all-cause mortality. Unhealthy commodities (such as alcohol, sugar and tobacco) are an important factor in the growing NCD burden in the region of sub-Saharan Africa (SSA). Despite health taxes on tobacco, alcohol and sugar-sweetened beverages (SSBs) gaining renewed attention, adoption and implementation in SSA remain limited. This study aims to unpack the contextual politics and to examine current perceptions of opportunities and barriers for health taxes in Ghana. METHODS: Semistructured qualitative interviews (n=19) conducted with purposively sampled stakeholders representing four sectors: government, civil society, media and international organisations, and two group interviews with nine industry stakeholders, informed by a review of relevant literature and policy/advocacy documents. RESULTS: Stakeholders had a general belief that such taxes are primarily useful for revenue generation (for health spending) rather than for reducing consumption and improving health. There do appear to be opportunities for health taxes with stakeholders broadly supportive of taxing SSBs. This support could be strengthened via 'health' framing of any new tax proposals, the generation of Ghana-specific evidence about the potential impacts of such taxes and greater public awareness. Industry actors and some government representatives opposed health taxes, citing concerns about the potential to increase illicit trade and economic harm. Some stakeholders also believed that links between politicians and affected industries represent an important barrier. CONCLUSION: These findings identify opportunities to introduce health taxes but also underline the potential resistance from affected industry stakeholders. Nevertheless, a strategic approach that focuses on achieving policy coherence (between central government, health and economic ministries), combined with efforts to strengthen stakeholder and public support, may weaken the lobbying position of industry. Such efforts could be supported by research to help demonstrate the value of different designs of health taxes for achieving Ghana's health goals and to better understand industry-political links.

Disparities in self-reported exposure to tobacco marketing among youth and young adults from low-socioeconomic status neighbourhoods in Mexico City.

Exposure to tobacco marketing is positively associated with smoking initiation and behaviours. There is limited literature examining disparities among reported exposure in low- and middle-income countries. This study sought to fill this gap with a survey among 1427 adolescents and 889 adult smokers in Mexico City in 2020. Data were analysed using chi-square and hierarchical regression models. Two-thirds of adolescents noticed cigarette pack displays in stores. Participants from low- and mid-socioeconomic status (SES) neighbourhoods were more exposed to tobacco marketing than their counterparts through several channels. After addressing the shared variance among participants from the same household nested in neighbourhood SES level and controlling for gender, adolescent non-smokers and adult smokers who noticed pack displays were more likely to be susceptible to smoking (OR = 1.8, 95% CI 1.4-2.4) and to smoke more (OR = 1.7, 95% CI 1.21-2.47); adult smokers who noticed tobacco marketing at more places were less likely to be certain about smoking risks (OR = 0.9, 95% CI 0.8-0.9). The results suggest that the tobacco industry targets youth and individuals from low-SES neighbourhoods through several channels. Greater exposure to tobacco marketing was associated with increased susceptibility to smoking and decreased risk perception. These findings support a comprehensive ban on tobacco marketing in Mexico.

Engaging Payors and Primary Care Physicians Together in Improving Diabetes Prevention.

BACKGROUND: Type 2 diabetes can be prevented through lifestyle programs like the Diabetes Prevention Programs (DPP), but few people with prediabetes participate in them, in part because their insurance does not reliably cover DPPs. Prior studies have not focused on payor-level barriers. OBJECTIVE: To understand barriers to DPP uptake that exist and intersect at different levels (patients, PCPs, and payors) to inform strategies to improve diabetes prevention in primary care settings through interviews with PCPs and payors. DESIGN: From May 2020 to October 2021, we conducted remote, semi-structured interviews with PCPs and payors. PARTICIPANTS: PCPs were from primary care practices affiliated with one mid-Atlantic academic system. Payor leaders were from regional commercial, Medicare, and Medicaid plans. APPROACH: Using a standardized interview guide focused on barriers, facilitators, and potential intervention components, interviews were audio-recorded using Zoom and professionally transcribed. Two reviewers double-coded transcripts using the framework analytic approach. KEY RESULTS: We interviewed 16 PCPs from 13 primary care clinics and 7 payor leaders representing 6 insurance plans. Two themes emerged from PCP reports of patient-level barriers: (1) lack of programs and insurance coverage of resources to address nutrition and exercise and (2) inadequate resources to address social determinants of health that impact diabetes prevention. Among barriers PCPs faced, we identified two themes: (1) low PCP knowledge about DPPs and misperceptions of insurance coverage of DPPs and (2) inadequate clinical staff to address diabetes prevention. Barriers common to PCPs and payors included (1) absence of prediabetes quality measures and (2) inadequate engagement of PCPs and patients with payors. CONCLUSIONS: Discussions with PCPs and payors revealed systemic barriers that suggest important priorities to improve prediabetes clinical care, including universal coverage of DPPs, clarity about coverage benefits, data reporting and outreach by payors to PCPs, and adoption of appropriate prediabetes quality measures.

Governance of Intersectoral Collaborations for Population Health and to Reduce Health Inequalities in High-Income Countries: A Complexity-Informed Systematic Review.

BACKGROUND: A 'Health in All Policies' (HiAP) approach has been widely advocated as a way to involve multiple government sectors in addressing health inequalities, but implementation attempts have not always produced the expected results. Explaining how HiAP-style collaborations have been governed may offer insights into how to improve population health and reduce health inequalities. METHODS: Theoretically focused systematic review. Synthesis of evidence from evaluative studies into a causal logic model. RESULTS: Thirty-one publications based on 40 case studies from nine high-income countries were included. Intersectoral collaborations for population health and equity were multi-component and multi-dimensional with collaborative activity spanning policy, strategy, service design and service delivery. Governance of intersectoral collaboration included structural and relational components. Both internal and external legitimacy and credibility delivered collaborative power, which in turn enabled intersectoral collaboration. Internal legitimacy was driven by multiple structural elements and processes. Many of these were instrumental in developing (often-fragile) relational trust. Internal credibility was supported by multi-level collaborations that were adequately resourced and shared power. External legitimacy and credibility was created through meaningful community engagement, leadership that championed collaborations and the identification of 'win-win' strategies. External factors such as economic shocks and short political cycles reduced collaborative power. CONCLUSION: This novel review, using systems thinking and causal loop representations, offers insights into how collaborations can generate internal and external legitimacy and credibility. This offers promise for future collaborative activity for population health and equity; it presents a clearer picture of what structural and relational components and dynamics collaborative partners can focus on when planning and implementing HiAP initiatives. The limits of the literature base, however, does not make it possible to identify if or how this might deliver improved population health or health equity.

Understanding commercial actors' engagement in policy debates on proposed e-cigarette regulation in Scotland.

INTRODUCTION: There is growing concern about transnational tobacco corporations' (TTCs) and other commercial actors' involvement in e-cigarette policy development. Previous analyses suggest that TTCs used e-cigarette debates to demonstrate alignment with public health and re-gain policy influence. Less is known about the engagement of other types of commercial actors in e-cigarette policy debates. METHODS: This paper is the first to empirically analyse commercial actors' engagement in an e-cigarette policy consultation process and to examine their views on proposed regulation. It applies mixed methods, drawing on policy consultation submissions (n=32), semi-structured interviews (n=9) and a social network analysis of website links among 32 commercial actors. RESULTS: The results show that commercial actors' positions on e-cigarette regulation aligned with business interests. TTCs, independent e-cigarette manufacturers and other non-licensed commercial actors were opposed to most aspects of potential e-cigarette regulation (except for age of sale restrictions), whereas licensed commercial actors, including pharmaceutical companies, supported more stringent regulation. While collaboration was viewed as strategically important to gain policy influence, distinct commercial interests and concerns about TTC credibility led to strategic distancing and to collaboration being largely confined to sector boundaries. In addition to reiterating arguments employed by TTCs in previous regulatory debates, commercial actors focused on highlighting the technical complexity and harm reduction potential of e-cigarettes. CONCLUSION: Awareness of the various commercial interests and strategic positioning of commercial actors in e-cigarette policy should inform public health advocacy and policy development, including managing conflicts of interest in the context of Framework Convention on Tobacco Control Article 5.3.

The Market for Bidis, Smokeless Tobacco, and Cigarettes in India: Evidence From Semi-Urban and Rural Areas in Five States.

Objectives: Compare the brand availability, pricing and presence of illicit products in semi-urban and rural areas in India across product types and states. Methods: In late 2017, 382 unique tobacco products were purchased from localities with populations under 50,000 in the states of Assam, Karnataka, Maharashtra, Rajasthan, and Uttar Pradesh. Brand, printed maximum retail price, price paid, tax, and health warning labels (HWLs) were used to compare the market for bidis, smokeless tobacco (SLT), and cigarettes. Results: Brand availability and pricing of SLT products was similar to cigarettes. Brand availability and pricing of bidis was consistent with having many small producers. Bidis and single serving SLT with spice mixtures were more affordable than cigarettes and SLT sold alone. 2% of SLT and 10% of cigarettes did not feature an India HWL. Conclusion: The elimination of single serving SLT packets and the removal of tax exemptions for small producers, often exploited by bidi producers, could reduce their respective affordability. State differences in illegal and illicit products could indicate a greater need for enforcement in some states.

Clinical Outcomes and Racial Disparities in Metastatic Hormone-Sensitive Prostate Cancer in the Era of Novel Treatment Options.

BACKGROUND: Docetaxel (DOC) and abiraterone (ABI) in the upfront setting have separately improved clinical outcomes for metastatic hormone-sensitive prostate cancer (mHSPC), but there are no studies comparing drug efficacies or the influence of racial disparities. MATERIALS AND METHODS: We performed a retrospective multicenter review from Winship Cancer Institute at Emory University and Georgia Cancer Center for Excellence at Grady Memorial Hospital (2014-2020) for patients with mHSPC treated with either upfront DOC or ABI. Outcomes evaluated were overall survival (OS), progression-free survival (PFS), and prostate-specific antigen complete response (PSA CR). RESULTS: A total of 168 patients were included, consisting of 92 (54.8%) Black patients and 76 (45.2%) non-Black patients (69 White and 7 Asian or Hispanic). Ninety-four (56%) received DOC and 74 (44%) received ABI. Median follow-up time was 22.8 months with data last reviewed June 2020. For OS, there was no significant difference between ABI versus DOC and Black versus non-Black patients. For PFS, DOC was associated with hazard ratio (HR) 1.7 compared with ABI for all patients based on univariate association and HR 2.27 compared with ABI for Black patients on multivariable analysis. For PSA CR, Black patients were less likely to have a CR (odds ratio [OR] = 0.27). CONCLUSION: ABI and DOC have similar OS with a trend toward better PFS for ABI in a cohort composed of 54% Black patients. Racial disparities were observed as prolonged PFS for Black patients treated with ABI, more so compared with all patients, and less PSA CR for Black patients. A prospective trial comparing available upfront therapies in a diverse racial population is needed to help guide clinical decision-making in the era of novel treatment options. IMPLICATIONS FOR PRACTICE: Overall survival is similar for abiraterone and docetaxel when used as upfront therapy in metastatic hormone-sensitive prostate cancer in a cohort composed of 54% Black patients. There is a trend towards improved progression-free survival for abiraterone in all patients and Black patients. Non-Black patients were more likely to achieve prostate-specific antigen (PSA) complete response regardless of upfront therapy.

Serial Neurologic Assessment in Pediatrics (SNAP): A New Tool for Bedside Neurologic Assessment of Critically Ill Children.

OBJECTIVES: We developed a tool, Serial Neurologic Assessment in Pediatrics, to screen for neurologic changes in patients, including those who are intubated, are sedated, and/or have developmental disabilities. Our aims were to: 1) determine protocol adherence when performing Serial Neurologic Assessment in Pediatrics, 2) determine the interrater reliability between nurses, and 3) assess the feasibility and acceptability of using Serial Neurologic Assessment in Pediatrics compared with the Glasgow Coma Scale. DESIGN: Mixed-methods, observational cohort. SETTING: Pediatric and neonatal ICUs. SUBJECTS: Critical care nurses and patients. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Serial Neurologic Assessment in Pediatrics assesses Mental Status, Cranial Nerves, Communication, and Motor Function, with scales for children less than 6 months, greater than or equal to 6 months to less than 2 years, and greater than or equal to 2 years old. We assessed protocol adherence with standardized observations. We assessed the interrater reliability of independent Serial Neurologic Assessment in Pediatrics assessments between pairs of trained nurses by percent- and bias- adjusted kappa and percent agreement. Semistructured interviews with nurses evaluated acceptability and feasibility after nurses used Serial Neurologic Assessment in Pediatrics concurrently with Glasgow Coma Scale during routine care. Ninety-eight percent of nurses (43/44) had 100% protocol adherence on the standardized checklist. Forty-three nurses performed 387 paired Serial Neurologic Assessment in Pediatrics assessments (149 < 6 mo; 91 ≥ 6 mo to < 2 yr, and 147 ≥ 2 yr) on 299 patients. Interrater reliability was substantial to near-perfect across all components for each age-based Serial Neurologic Assessment in Pediatrics scale. Percent agreement was independent of developmental disabilities for all Serial Neurologic Assessment in Pediatrics components except Mental Status and lower extremity Motor Function for patients deemed "Able to Participate" with the assessment. Nurses reported that they felt Serial Neurologic Assessment in Pediatrics, compared with Glasgow Coma Scale, was easier to use and clearer in describing the neurologic status of patients who were intubated, were sedated, and/or had developmental disabilities. About 92% of nurses preferred to use Serial Neurologic Assessment in Pediatrics over Glasgow Coma Scale. CONCLUSIONS: When used by critical care nurses, Serial Neurologic Assessment in Pediatrics has excellent protocol adherence, substantial to near-perfect interrater reliability, and is feasible to implement. Further work will determine the sensitivity and specificity for detecting clinically meaningful neurologic decline.

The SPECTRUM Consortium: a new UK Prevention Research Partnership consortium focussed on the commercial determinants of health, the prevention of non-communicable diseases, and the reduction of health inequalities.

The main causes of non-communicable diseases (NCDs), health inequalities and health inequity include consumption of unhealthy commodities such as tobacco, alcohol and/or foods high in fat, salt and/or sugar. These exposures are preventable, but the commodities involved are highly profitable. The economic interests of 'Unhealthy Commodity Producers' (UCPs) often conflict with health goals but their role in determining health has received insufficient attention. In order to address this gap, a new research consortium has been established. This open letter introduces the SPECTRUM ( S haping  Public h Ealth poli Cies  To  Reduce ineq Ualities and har M)Consortium: a multi-disciplinary group comprising researchers from 10 United Kingdom (UK) universities and overseas, and partner organisations including three national public health agencies in Great Britain (GB), five multi-agency alliances and two companies providing data and analytic support. Through eight integrated work packages, the Consortium seeks to provide an understanding of the nature of the complex systems underlying the consumption of unhealthy commodities, the role of UCPs in shaping these systems and influencing health and policy, the role of systems-level interventions, and the effectiveness of existing and emerging policies. Co-production is central to the Consortium's approach to advance research and achieve meaningful impact and we will involve the public in the design and delivery of our research. We will also establish and sustain mutually beneficial relationships with policy makers, alongside our partners, to increase the visibility, credibility and impact of our evidence. The Consortium's ultimate aim is to achieve meaningful health benefits for the UK population by reducing harm and inequalities from the consumption of unhealthy commodities over the next five years and beyond.

Knowledge of and Attitudes Toward Perinatal Home Visiting in Women with High-Risk Pregnancies.

INTRODUCTION: Published research indicates that some perinatal home visiting programs are highly effective. However, there is a dearth of information regarding how these services apply to women experiencing a high-risk pregnancy. The aim of this study was to determine the potential acceptability of home visiting services within this vulnerable population and identify what services women want. METHODS: Four focus groups (N = 32) were conducted with a population of low-income, pregnant individuals in medically underserved central Georgia (United States). Participants were evaluated based on their current exposure to home visiting, receptiveness to home visiting, and reasons for apprehension regarding home visiting. RESULTS: The results of this study were mixed, with women expressing both interest in and reluctance about home visiting programs. Themes of distrust and fear of judgment or persecution existed. Women also varied with regard to what home visiting services they would like offered. Those discussed included assistance with maternal or infant medical needs, maternal function tasks, household tasks, and child care. DISCUSSION: Home visiting programs can be effective for improving maternal and child health outcomes. However, not all home visiting programs effectively reach their target population. More research is needed to determine what women who have high-risk conditions during pregnancy want help with and how to increase receptiveness. The results of this study could be informative to health care providers who treat persons with high-risk conditions in identifying adjunctive services for those in need of additional support.

A novel approach for autism spectrum condition patients with eating disorders: Analysis of treatment cost-savings.

OBJECTIVE: In the current economic context, it is critical to ensure that eating disorder (ED) treatments are both effective and cost-effective. We describe the impact of a novel clinical pathway developed to better meet the needs of autistic patients with EDs on the length and cost of hospital admissions. METHOD: The pathway was based on the Institute for Healthcare's Model of Improvement methodology, using an iterative Plan, Do, Study, Act format to introduce change and to co-produce the work with people with lived experience and with healthcare professionals. We explored the change in length and cost of admissions before and after the pathway was introduced. RESULTS: Preliminary results suggest that the treatment innovations associated with this pathway have led to reduced lengths of admission for patients with the comorbidity, which were not seen for patients without the comorbidity. Estimated cost-savings were approximately £22,837 per patient and approximately £275,000 per year for the service as a whole. CONCLUSION: Going forward, our aim is to continue to evaluate the effectiveness and cost-effectiveness of investment in the pathway to determine whether the pathway improves the quality of care for patients with a comorbid ED and autism and is good value for money.

An atlas of health inequalities and health disparities research: "How is this all getting done in silos, and why?"

Research on health inequalities and health disparities has grown exponentially since the 1960s, but this expansion has not been matched by an associated sense of progress. Criticisms include claims that too much research addresses well-trodden questions and that the field has failed to gain public and policy traction. Qualitative studies have found researchers partly attribute these challenges to fragmentation resulting from disciplinary and methodological differences. Yet, empirical investigation ('research on research') is limited. This study addresses this gap, employing mixed-methods to examine, at scale, how and why this field is defined by insular research clusters. First, bibliometric analysis identifies and visualizes the 250 most-connected authors. Next, an algorithm was used to identify clustering via citation links between authors. We used researcher profiling to ascertain authors' geographical and institutional locations and disciplinary training, examining how this mapped onto clusters. Finally, causes of siloing were investigated via semi-structured interviews with 45 researchers. The resulting 'atlas' of health inequalities and health disparities research identifies eight clusters of authors with varying degrees of connectedness. No single factor neatly describes observed fragmentation, health equity scholars exhibit a diverse disciplinary backgrounds, and geographical, institutional, and historical factors appear to intersect to explain siloed citation patterns. While the configuration of research activity within clusters potentially helps render questions scientifically manageable, it affirms perceptions of the field as fragmented. We draw on Thomas Kuhn and Sheila Jasanoff to position results within theoretical pictures of scientific progress. Newcomers to the field can use our findings to orient themselves within the many streams of health equity scholarship, and existing health equity scholars can use the atlas to move beyond existing geo-disciplinary networks. However, although stronger cross-cluster engagement would be likely to improve insights, the complex nexus of factors underlying the field's structure will likely make this challenging in practice.

Gadoxetate-enhanced abbreviated MRI is highly accurate for hepatocellular carcinoma screening.

OBJECTIVES: The primary objective was to compare the performance of 3 different abbreviated MRI (AMRI) sets extracted from a complete gadoxetate-enhanced MRI obtained for hepatocellular carcinoma (HCC) screening. Secondary objective was to perform a preliminary cost-effectiveness analysis, comparing each AMRI set to published ultrasound performance for HCC screening in the USA. METHODS: This retrospective study included 237 consecutive patients (M/F, 146/91; mean age, 58 years) with chronic liver disease who underwent a complete gadoxetate-enhanced MRI for HCC screening in 2017 in a single institution. Two radiologists independently reviewed 3 AMRI sets extracted from the complete exam: non-contrast (NC-AMRI: T2-weighted imaging (T2wi)+diffusion-weighted imaging (DWI)), dynamic-AMRI (Dyn-AMRI: T2wi+DWI+dynamic T1wi), and hepatobiliary phase AMRI (HBP-AMRI: T2wi+DWI+T1wi during the HBP). Each patient was classified as HCC-positive/HCC-negative based on the reference standard, which consisted in all available patient data. Diagnostic performance for HCC detection was compared between sets. Estimated set characteristics, including historical ultrasound data, were incorporated into a microsimulation model for cost-effectiveness analysis. RESULTS: The reference standard identified 13/237 patients with HCC (prevalence, 5.5%; mean size, 33.7 ± 30 mm). Pooled sensitivities were 61.5% for NC-AMRI (95% confidence intervals, 34.4-83%), 84.6% for Dyn-AMRI (60.8-95.1%), and 80.8% for HBP-AMRI (53.6-93.9%), without difference between sets (p range, 0.06-0.16). Pooled specificities were 95.5% (92.4-97.4%), 99.8% (98.4-100%), and 94.9% (91.6-96.9%), respectively, with a significant difference between Dyn-AMRI and the other sets (p < 0.01). All AMRI methods were effective compared with ultrasound, with life-year gain of 3-12 months against incremental costs of US$ < 12,000. CONCLUSIONS: NC-AMRI has limited sensitivity for HCC detection, while HBP-AMRI and Dyn-AMRI showed excellent sensitivity and specificity, the latter being slightly higher for Dyn-AMRI. Cost-effectiveness estimates showed that AMRI is effective compared with ultrasound. KEY POINTS: • Comparison of different abbreviated MRI (AMRI) sets reconstructed from a complete gadoxetate MRI demonstrated that non-contrast AMRI has low sensitivity (61.5%) compared with contrast-enhanced AMRI (80.8% for hepatobiliary phase AMRI and 84.6% for dynamic AMRI), with all sets having high specificity. • Non-contrast and hepatobiliary phase AMRI can be performed in less than 14 min (including set-up time), while dynamic AMRI can be performed in less than 17 min. • All AMRI sets were cost-effective for HCC screening in at-risk population in comparison with ultrasound.

Inequalities, harm reduction and non-combustible nicotine products: a meta-ethnography of qualitative evidence.

BACKGROUND: We sought to review qualitative evidence on how smokers in different socioeconomic groups engage with non-combustible nicotine products (NCNP), including electronic cigarettes and nicotine replacement therapies, in order to provide insight into how these products might impact on smoking inequalities. METHODS: We searched ten electronic databases in February 2017 using terms relating to NCNP and socioeconomic status. We included qualitative studies that were published since 1980 and were available in English. We used guidelines adapted from the Critical Appraisal Skills Programme for appraising qualitative research. RESULTS: The review only identified studies exploring the attitudes of socioeconomically disadvantaged smokers towards NCNP for harm reduction or cessation purposes (i.e. we did not identify any relevant studies of more advantaged socioeconomic groups). Using a lines-of-argument meta-ethnographic approach, we identified a predominantly pessimistic attitude to NCNP for harm reduction or cessation of smoking due to: wider circumstances of socioeconomic disadvantage; lack of a perceived advantage of alternative products over smoking; and a perceived lack of information about relative harms of NCNP compared to smoking. Optimistic findings, although fewer, suggested the potential of NCNP being taken up among smokers experiencing socioeconomic disadvantage. CONCLUSIONS: Overall, our review highlights the importance of considering the social, cultural and economic circumstances that influence experiences of smoking and of alternative product use.

Development of the Inner City attitudinal assessment tool (ICAAT) for learners across Health care professions.

BACKGROUND: Many health professions learners report feeling uncomfortable and underprepared for professional interactions with inner city populations. These learners may hold preconceptions which affect therapeutic relationships and provision of care. Few tools exist to measure learner attitudes towards these populations. This article describes the development and validity evidence behind a new tool measuring health professions learner attitudes toward inner city populations. METHODS: Tool development consisted of four phases: 1) Item identification and generation informed by a scoping review of the literature; 2) Item refinement involving a two stage modified Delphi process with a national multidisciplinary team (n = 8), followed by evaluation of readability and response process validity with a focus group of medical and nursing students (n = 13); 3) Pilot testing with a cohort of medical and nursing students; and 4) Analysis of psychometric properties through factor analysis and reliability. RESULTS: A 36-item online version of the Inner City Attitudinal Assessment Tool (ICAAT) was completed by 214 of 1452 undergraduate students (67.7% from medicine; 32.3% from nursing; response rate 15%). The resulting tool consists of 24 items within a three-factor model - affective, behavioural, and cognitive. Reliability (internal consistency) values using Cronbach alpha were 0.87, 0.82, and 0.82 respectively. The reliability of the whole 24-item ICAAT was 0.90. CONCLUSIONS: The Inner City Attitudinal Assessment Tool (ICAAT) is a novel tool with evidence to support its use in assessing health care learners' attitudes towards caring for inner city populations. This tool has potential to help guide curricula in inner city health.