Development of a key performance indicator for breast cancer in Queensland, Australia.

PURPOSE: Using population-based data for women diagnosed with stage I-III breast cancer, our aim was to examine the impact of time to treatment completion on survival and to identify factors associated with treatment delay. METHODS: This retrospective study used clinical and treatment data from the Queensland Oncology Repository. Time from diagnosis to completing surgery, chemotherapy and radiation therapy identified a cut-off of 37 weeks as the optimal threshold for completing treatment. Logistic regression was used to identify factors associated with the likelihood of completing treatment > 37 weeks. Overall (OS) and breast cancer-specific survival (BCSS) were examined using Cox proportional hazards models. RESULTS: Of 8279 women with stage I-III breast cancer, 31.9% completed treatment > 37 weeks. Apart from several clinical factors, being Indigenous (p = 0.002), living in a disadvantaged area (p = 0.003) and receiving ≥ two treatment modalities within the public sector (p < 0.001) were associated with an increased likelihood of completing treatment > 37 weeks. The risk of death from any cause was about 40% higher for women whose treatment went beyond 37 weeks (HR 1.37, 95%CI 1.16-1.61), a similar result was observed for BCSS. Using the surgery + chemotherapy + radiation pathway, a delay of > 6.9 weeks from surgery to starting chemotherapy was significantly associated with poorer survival (p = 0.001). CONCLUSIONS: Several sociodemographic and system-related factors were associated with a greater likelihood of treatment completion > 37 weeks. We are proposing a key performance indicator for the management of early breast cancer where a facility should have > 90% of patients with a time from surgery to adjuvant chemotherapy < 6.9 weeks.

Assessment of hemodynamic indices of conjunctival microvascular function in patients with coronary microvascular dysfunction.

OBJECTIVE: Coronary microvascular dysfunction (CMD) is a cause of ischaemia with non-obstructive coronary arteries (INOCA). It is notoriously underdiagnosed due to the need for invasive microvascular function testing. We hypothesized that systemic microvascular dysfunction could be demonstrated non-invasively in the microcirculation of the bulbar conjunctiva in patients with CMD. METHODS: Patients undergoing coronary angiography for the investigation of chest pain or dyspnoea, with physiologically insignificant epicardial disease (fractional flow reserve ≥0.80) were recruited. All patients underwent invasive coronary microvascular function testing. We compared a cohort of patients with evidence of CMD (IMR ≥25 or CFR <2.0); to a group of controls (IMR <25 and CFR ≥2.0). Conjunctival imaging was performed using a previously validated combination of a smartphone and slit-lamp biomicroscope. This technique allows measurement of vessel diameter and other indices of microvascular function by tracking erythrocyte motion. RESULTS: A total of 111 patients were included (43 CMD and 68 controls). There were no differences in baseline demographics, co-morbidities or epicardial coronary disease severity. The mean number of vessel segments analysed per patient was 21.0 ± 12.8 (3.2 ± 3.5 arterioles and 14.8 ± 10.8 venules). In the CMD cohort, significant reductions were observed in axial/cross-sectional velocity, blood flow, wall shear rate and stress. CONCLUSION: The changes in microvascular function linked to CMD can be observed non-invasively in the bulbar conjunctiva. Conjunctival vascular imaging may have utility as a non-invasive tool to both diagnose CMD and augment conventional cardiovascular risk assessment.

Survival outcomes of head and neck melanoma patients in Queensland, Australia from 2009 to 2018.

BACKGROUND/OBJECTIVES: To compare survival outcomes for patients with cutaneous invasive head and neck melanoma (HNM) with those of patients with melanoma on other anatomical sites. METHODS: Retrospective cohort study using patient data extracted from the Cancer Alliance Queensland's Oncology Analysis System (OASYS) over a 10-year period from 2009 to 2018. Melanoma-specific survival was compared between patients with HNM and non-HNM. Kaplan-Meier survival estimates were calculated at 5 and 10 years. Univariable and multivariable Cox proportional hazards regression analysis determined factors associated with survival. RESULTS: The 5- and 10-year survival probabilities were 90.7% and 89.1%, respectively for HNM, compared with 94.7% and 93.0%, respectively, for non-HNM melanoma. The 5- and 10-year survival probabilities for scalp melanoma were 77.8% and 75.5%, respectively. Patients with HNM died of melanoma at 1.22 times (HR 1.22, 95% CI 1.09-1.37) the rate of those with non-HNM, controlling for sex, age, socioeconomic status, remoteness, Breslow thickness, the presence of multiple invasion melanoma and ulceration. Patients with scalp melanoma died of melanoma at 1.57 times (HR 1.57, 95% CI 1.26-1.95) the rate of those with non-scalp HNM. CONCLUSIONS: There is a statistically significant survival difference between patients with HNM and non-HNM, and between patients with scalp melanoma and non-scalp HNM, even after adjusting for prognostic factors.

Trends in surgery and adjuvant treatment for early-stage breast cancer: a population-based study in Queensland, Australia.

PURPOSE: Our aim was to describe variations in the treatment of early-stage breast cancer and to examine factors associated with disease-specific survival (DSS). METHODS: The study used linked data for 24,190 women with a T1 (≤ 20 mm) breast cancer who underwent surgery from 2005 to 2019. Multivariate logistic regression was used to model predictors of receiving breast-conserving surgery (BCS) compared to mastectomy and a multinomial model was used to examine factors associated with type(s) of treatment received. RESULTS: Overall, 70.3% had BCS, with a reduced likelihood of BCS observed for younger women (p < 0.001), rural residence, (p < 0.001), socioeconomic disadvantage (p = 0.004), higher tumour grade (p < 0.001) and surgery in a public versus private hospital (p < 0.001). Compared to women who received BCS and radiation therapy (RT), those having mastectomy alone or mastectomy plus RT were more likely to be younger (p < 0.001), live in a rural area (p < 0.001), have higher-grade tumours (p < 0.001) and positive lymph nodes (p < 0.001). Overall 5-year survival was 95.3% and breast cancer-specific survival was 98.3%. Highest survival was observed for women having BCS and RT and lowest for those having mastectomy and RT (p < 0.001). CONCLUSION: Our results indicate some variation in the management of early-stage breast cancer. Lower rates of BCS were observed for rural and disadvantaged women and for those treated in a public or low-volume hospital. Whilst survival was high for this cohort, differences in tumour biology likely explain the differences in survival according to treatment type.

Nonbreast cancer incidence, treatment received and outcomes: Are there differences in breast screening attendees versus nonattendees?

While reductions in breast cancer mortality have been evident since the introduction of population-based breast screening in women aged 50-74 years, participation in cancer screening programs can be influenced by several factors, including health system and those related to the individual. In our study, we compared cancer incidence and mortality for several cancer types other than breast cancer, noncancer mortality and patterns of treatment amongst women who did and did not participate in mammography screening. All women aged 50-65 years enrolled on the Queensland Electoral Roll in 2000 were included. The study population was then linked to records from the population-based breast screening program and private fee-for-service screening options to establish screened and unscreened cohorts. Diagnostic details for selected cancers and cause of death were obtained from the Queensland Oncology Repository. We calculated incidence rate ratios and hazard ratios comparing screened and unscreened cohorts. Among screened compared to unscreened women, we found a lower incidence of cancers of the lung, cervix, head and neck and esophagus and an increase in colorectal cancers. Cancer mortality (excluding breast cancer) was 35% lower among screened compared to unscreened women and they were also about 23% less likely to be diagnosed with distant disease. Screened compared to unscreened women were more likely to receive surgery and less likely to receive no treatment. Our study adds further to the population data examining outcomes among women participating in mammography screening.

Zika virus infection disrupts neurovascular development and results in postnatal microcephaly with brain damage.

Zika virus (ZIKV) infection of pregnant women can result in fetal brain abnormalities. It has been established that ZIKV disrupts neural progenitor cells (NPCs) and leads to embryonic microcephaly. However, the fate of other cell types in the developing brain and their contributions to ZIKV-associated brain abnormalities remain largely unknown. Using intracerebral inoculation of embryonic mouse brains, we found that ZIKV infection leads to postnatal growth restriction including microcephaly. In addition to cell cycle arrest and apoptosis of NPCs, ZIKV infection causes massive neuronal death and axonal rarefaction, which phenocopy fetal brain abnormalities in humans. Importantly, ZIKV infection leads to abnormal vascular density and diameter in the developing brain, resulting in a leaky blood-brain barrier (BBB). Massive neuronal death and BBB leakage indicate brain damage, which is further supported by extensive microglial activation and astrogliosis in virally infected brains. Global gene analyses reveal dysregulation of genes associated with immune responses in virus-infected brains. Thus, our data suggest that ZIKV triggers a strong immune response and disrupts neurovascular development, resulting in postnatal microcephaly with extensive brain damage.

Prediction of Postoperative Outcomes and Long-Term Survival in Cardiac Surgical Patients Using the Intensive Care National Audit & Research Centre Score.

OBJECTIVES: Scoring systems used in cardiac surgery, such as the European System for Cardiac Operative Risk Evaluation and the Society of Thoracic Surgeons scoring systems, do not adjust for events that take place intraoperatively. The authors hypothesized that intensive care unit scoring systems such as the Intensive Care National Audit & Research Centre (ICNARC) could predict accurately not only in-hospital mortality, but also other significant complications, as well as long-term survival after cardiac surgery. DESIGN: Prospective cohort study using perioperative data from the ICNARC Audit and Dendrite database. SETTING: Single tertiary referral cardiac surgery center. PARTICIPANTS: A total of 4,446 consecutive cardiac surgical patients who had surgery between January 2011 and April 2018. INTERVENTIONS: Comparison of scoring systems to predict postoperative outcomes. MEASUREMENTS AND RESULTS: Receiver operating curves (ROCs) were used to evaluate how well the ICNARC scores predicted in-hospital mortality and postoperative complications (renal failure, pulmonary complications, gastrointestinal complications, and multiorgan failure). Cox regression analysis was used to determine factors affecting long-term survival. The C-indices for the ROC graphs for the ICNARC score were 0.840 for in-hospital mortality, 0.858 for renal failure, 0.665 for pulmonary complications, 0.764 for gastrointestinal complications, 0.702 for neurological complications in general and 0.654 for confusion, and 0.885 for multiorgan failure. From Cox regression analysis, the significant (p < 0.05) predictors of midterm mortality (5 years) were a higher ICNARC score, a higher age at surgery, chronic obstructive pulmonary disease, preoperative renal failure, preoperative neurological comorbidity, arteriopathy, and non-coronary artery bypass graft surgery. CONCLUSION: The ICNARC scoring system is simple and can be used as an early warning screening tool to predict which patients are at higher risk for postoperative organ failure.

Relative survival of patients with lymphoma in Queensland according to histological subtype.

OBJECTIVE: To evaluate relative survival of patients in Queensland with different lymphoma subtypes; to determine whether outcomes have improved with recent changes in treatment; to evaluate relative survival according to place of residence and socio-economic status. DESIGN: Retrospective population-based study; analysis of data from the Oncology Analysis System, an online reporting tool for cancer incidence and outcomes in Queensland. PARTICIPANTS: Patients over 15 years of age diagnosed with lymphoma in Queensland during 1993-2012. MAIN OUTCOME MEASURES: Relative survival by lymphoma subtype; influence of place of residence and socio-economic status, age group, sex, year of diagnosis (in 5-year bands), and Pharmaceutical Benefits Scheme funding of rituximab for treating B-cell lymphomas on relative survival. RESULTS: 9509 people (56% men) were diagnosed with lymphoma during 1993-2012. Five-year relative survival improved significantly between 1993-1997 and 2008-2012 for patients with diffuse large B-cell lymphoma (47%; 95% CI, 42-51% v 64%; 95% CI, 61-67%) or follicular lymphoma (62%; 95% CI, 57-66% v 88%; 95% CI, 85-90%; each P < 0.001). Rituximab became available for treating these subtypes during 2003-2006. There was no change in relative survival for patients with Hodgkin lymphoma (81%; 95% CI, 76-85% v 80%; 95% CI, 75-84%; P = 0.22). The only statistically significant difference according to place of residence or socio-economic status was inferior relative survival for rural residents with diffuse large B-cell lymphoma (hazard ratio, 1.14; 95% CI, 1.01-1.28). CONCLUSION: Relative survival for patients with B-cell non-Hodgkin lymphoma improved significantly with the introduction of rituximab as first-line therapy in Australia.

Care Coordination: Empowering Families, a Promising Practice to Facilitate Medical Home Use Among Children and Youth with Special Health Care Needs.

Introduction This paper describes the care coordination training program and results of an evaluation from its pilot in seven states. Despite the importance of practice-based care coordination, only 42.3% of children with special health care needs (CYSHCN) met all needed components of care coordination as defined by the Maternal Child Health Bureau. Recognizing that children with medically complex conditions often have lower rates of achieving care coordination within a medical home, the Region 4 Midwest Genetics Collaborative worked with families to develop a training to empower families in care coordination. The Care Coordination: Empowering Families(CCEF) training provides families with the knowledge, tools, and resources to engage with health, education and family support systems. This article gives an overview of the training and comprehensive evaluation. Methods Participants were family caregivers of children with genetic conditions and other special health care needs recruited in one of seven pilot states. Evaluation data were collected from 190 participants prior to and immediately following the training. An additional follow-up assessment one full year post training was completed by 80 participants (a response rate of 42%). Results Families who attended the training report being the primary source of care coordination for their children and 83.7% see their role in their child's healthcare changing as a result of the training. The findings suggest that peer support and communication with providers increased as a result of the training over the course of the study. The data suggest that the training impacted how the family interacts with the child's doctor, including initiating conversations to prepare their child for transition to adult health care. Further, families report system-level improvements 1 year later compared to the pre-training assessment. Discussion CCEF training is a promising practice for facilitating medical home use among CYSHCN.

The Impact of the Project K Youth Development Program on Self-Efficacy: A Randomized Controlled Trial.

A key issue for youth development programs is whether the learning they provide is transferred to participants' daily lives. It is also important that they are effective for the diverse range of participants they attract. This study used a randomized controlled trial design to measure the impact of Project K, a New Zealand-based youth development program, on academic and social self-efficacy. Project K combines a 3-week wilderness adventure, a 10 day community service component, and 1 year of mentoring to promote positive growth in 14-15 year olds with low self-efficacy. At baseline, the evaluation included 600 Project K (46 % female) and 577 Control participants (48 % female) and revealed that Project K was effective in improving both social and academic self-efficacy from pre- to post-program with effects being sustained 1 year later. Parents' perceptions of changes in the participants' interpersonal skills supported these findings. Differential program effects were found across participant subgroups, particularly 1 year after program completion. The implications of these differences are discussed.

Engagement and Mentor Support as Drivers of Social Development in the Project K Youth Development Program.

Youth development programs can achieve positive social outcomes, however studies comparing the influence of different program components are rare. Structural equation modeling of longitudinal, multilevel data (N = 327) from Project K, a multi-component youth development program, assessed how experiences of engagement or support in each component affected social outcomes. Participants reported significant gains in social self-efficacy and sense of community after the program. Engagement in the outdoor adventure and support during the mentoring partnership components significantly contributed to observed social gains, while engagement in the community service component did not. Results confirm youth development programs can positively influence adolescent social development, while highlighting the importance of moving beyond "black box" investigations in order to maximize program impact and efficiency.

Parasite accumulation in placenta of non-immune baboons during Plasmodium knowlesi infection.

BACKGROUND: Placental malaria (PM) causes adverse pregnancy outcomes in the mother and her foetus. It is difficult to study PM directly in humans due to ethical challenges. This study set out to bridge this gap by determining the outcome of PM in non-immune baboons in order to develop a non-human primate model for the disease. METHODS: Ten pregnant baboons were acquired late in their third trimester (day 150) and randomly grouped as seven infected and three non-infected. Another group of four nulligravidae (non-pregnant) infected was also included in the analysis of clinical outcome. Malaria infection was intravenously initiated by Plasmodium knowlesi blood-stage parasites through the femoral vein on 160(th) day of gestation (for pregnant baboons). Peripheral smear, placental smear, haematological samples, and histological samples were collected during the study period. Median values of clinical and haematological changes were analysed using Kruskal-Wallis and Dunn's Multiple Comparison Test. Parasitaemia profiles were analysed using Mann Whitney U test. A Spearman's rank correlation was run to determine the relationship between the different variables of severity scores. Probability values of P <0.05 were considered significant. RESULTS: Levels of white blood cells increased significantly in pregnant infected (34%) than in nulligravidae infected baboons (8%). Placental parasitaemia levels was on average 19-fold higher than peripheral parasitaemia in the same animal. Infiltration of parasitized erythrocytes and inflammatory cells were also observed in baboon placenta. Malaria parasite score increased with increase in total placental damage score (rs = 0.7650, P <0.05) and inflammatory score (rs = 0.8590, P <0.05). Although the sample size was small, absence of parasitized erythrocytes in cord blood and foetal placental region suggested lack of congenital malaria in non-immune baboons. CONCLUSION: This study has demonstrated accumulation of parasitized red blood cells and infiltration of inflammatory cells in the placental intravillous space (IVS) of baboons that are non-immune to malaria. This is a key feature of placental falciparum malaria in humans. This presents the baboon as a new model for the characterization of malaria during pregnancy.

Validation of the Intensive Care National Audit and Research Centre Scoring System in a UK Adult Cardiac Surgery Population.

OBJECTIVE: The Intensive Care National Audit and Research Centre (ICNARC) scoring system was conceived in 2007, utilizing 12 physiologic variables taken from the first 24 hours of adult admissions to the general intensive care unit (ICU) to predict in-hospital mortality. The authors aimed to evaluate the ICNARC score in predicting mortality in cardiac surgical patients compared to established cardiac risk models such as logistic EuroSCORE as well as to the Acute Physiology and Chronic Health Evaluation (APACHE) II. DESIGN: Retrospective analysis of data collected prospectively. SETTING: Single-center study in a cardiac intensive care in a regional cardiothoracic center. PARTICIPANTS: Patients undergoing cardiac surgery between January 2010 and June 2012. METHODS: A total of 1,646 patients were scored preoperatively using the logistic EuroSCORE and postoperatively using ICNARC and APACHE II. Data for comparison of scoring systems are presented as area under the receiver operating characteristic curve. MEASUREMENTS AND MAIN RESULTS: The mean age at surgery was 67 years±10.1. The mortality from all cardiac surgery was 3.2%. The mean logistic EuroSCORE was 7.31±10.13, the mean ICNARC score was 13.42±5.055, while the mean APACHE II score was 6.32±7.731. The c-indices for logistic EuroSCORE, ICNARC, and APACHE II were 0.801, 0.847 and 0.648, respectively. CONCLUSION: The authors have, for the first time, validated the ICNARC score as a useful predictor of postoperative mortality in adult cardiac surgical patients. This could have implications for postoperative management, focusing the utilization of resources as well as a method to measure and compare performance in the cardiothoracic ICU.

Obstructing colorectal cancer: a population-based review of colonic stenting in Queensland, Australia.

PURPOSE: Stenting is a useful treatment option for malignant colonic obstruction, but its role remains unclear. This study was designed to establish how stents have been used in Queensland, Australia, and to review outcomes. METHODS: Patients diagnosed with colorectal cancer in Queensland from January 1, 2008, to December 31, 2014, who underwent colonic stent insertion were reviewed. Primary outcomes of 5-year survival, 30-day mortality, and overall length of survival were calculated. The secondary outcomes included patient and tumor factors, and stoma rates. RESULTS: In total, 319 patients were included, and distant metastases were identified in 183 patients (57.4%). The 30-day mortality rate was 6.6% (n=21), and the 5-year survival was 11.9% (n=38). Median survival was 11 months (interquartile range, 4-27 months). A further operation (hazard ratio [HR], 0.19; P<0.001) and chemotherapy and/or radiotherapy (HR, 0.718; P=0.046) reduced the risk of 5-year mortality. The presence of distant metastases (HR, 2.052; P<0.001) and a comorbidity score of 3 or more (HR, 1.572; P=0.20) increased mortality. Surgery was associated with a reduced risk of mortality even in patients with metastatic disease (HR, 0.14; P<0.001). Twenty-two patients (6.9%) ended the study period with a stoma. CONCLUSION: Colorectal stenting was used in Queensland in several diverse scenarios, in both localized and metastatic disease. Surgery had a survival advantage, even in patients with metastatic disease. There was no survival difference according to whether patients were socioeconomically disadvantaged, diagnosed in a major city or not, or treated at private or public hospitals. Stenting proved a valid treatment option with low stoma rates.

Effects of improved amino acid balance diet on lysine mammary utilization, whole body protein turnover and muscle protein breakdown on lactating sows.

BACKGROUND: The study objective was to test the hypothesis that low crude protein (CP) diet with crystalline amino acids (CAA) supplementation improves Lys utilization efficiency for milk production and reduces protein turnover and muscle protein breakdown. Eighteen lactating multiparous Yorkshire sows were allotted to 1 of 2 isocaloric diets (10.80 MJ/kg net energy): control (CON; 19.24% CP) and reduced CP with "optimal" AA profile (OPT; 14.00% CP). Sow body weight and backfat were recorded on d 1 and 21 of lactation and piglets were weighed on d 1, 14, 18, and 21 of lactation. Between d 14 and 18, a subset of 9 sows (CON = 4, OPT = 5) was infused with a mixed solution of 3-[methyl-2H3]histidine (bolus injection) and [13C]bicarbonate (priming dose) first, then a constant 2-h [13C]bicarbonate infusion followed by a 6-h primed constant [1-13C]lysine infusion. Serial blood and milk sampling were performed to determine plasma and milk Lys enrichment, Lys oxidation rate, whole body protein turnover, and muscle protein breakdown. RESULTS: Over the 21-d lactation period, compared to CON, sows fed OPT had greater litter growth rate (P < 0.05). Compared to CON, sows fed OPT had greater efficiency of Lys (P < 0.05), Lys mammary flux (P < 0.01) and whole-body protein turnover efficiency (P < 0.05). Compared to CON, sows fed OPT tended to have lower whole body protein breakdown rate (P = 0.069). Muscle protein breakdown rate did not differ between OPT and CON (P = 0.197). CONCLUSION: Feeding an improved AA balance diet increased efficiency of Lys and reduced whole-body protein turnover and protein breakdown. These results imply that the lower maternal N retention observed in lactating sows fed improved AA balance diets in previous studies may be a result of greater partitioning of AA towards milk rather than greater body protein breakdown.

Association between Patient Race and Ethnicity and Use of Invasive Ventilation in the United States.

Rationale: Outcomes for people with respiratory failure in the United States vary by patient race and ethnicity. Invasive ventilation is an important treatment initiated based on expert opinion. It is unknown whether the use of invasive ventilation varies by patient race and ethnicity. Objectives: To measure 1) the association between patient race and ethnicity and the use of invasive ventilation; and 2) the change in 28-day mortality mediated by any association. Methods: We performed a multicenter cohort study of nonintubated adults receiving oxygen within 24 hours of intensive care admission using the Medical Information Mart for Intensive Care IV (MIMIC-IV, 2008-2019) and Phillips eICU (eICU, 2014-2015) databases from the United States. We modeled the association between patient race and ethnicity (Asian, Black, Hispanic, White) and invasive ventilation rate using a Bayesian multistate model that adjusted for baseline and time-varying covariates, calculated hazard ratios (HRs), and estimated 28-day hospital mortality changes mediated by differential invasive ventilation use. We reported posterior means and 95% credible intervals (CrIs). Results: We studied 38,258 patients, 52% (20,032) from MIMIC-IV and 48% (18,226) from eICU: 2% Asian (892), 11% Black (4,289), 5% Hispanic (1,964), and 81% White (31,113). Invasive ventilation occurred in 9.2% (3,511), and 7.5% (2,869) died. The adjusted rate of invasive ventilation was lower in Asian (HR, 0.82; CrI, 0.70-0.95), Black (HR, 0.78; CrI, 0.71-0.86), and Hispanic (HR, 0.70; CrI, 0.61-0.79) patients compared with White patients. For the average patient, lower rates of invasive ventilation did not mediate differences in 28-day mortality. For a patient on high-flow nasal cannula with inspired oxygen fraction of 1.0, the odds ratios for mortality if invasive ventilation rates were equal to the rate for White patients were 0.97 (CrI, 0.91-1.03) for Asian patients, 0.96 (CrI, 0.91-1.03) for Black patients, and 0.94 (CrI, 0.89-1.01) for Hispanic patients. Conclusions: Asian, Black, and Hispanic patients had lower rates of invasive ventilation than White patients. These decreases did not mediate harm for the average patient, but we could not rule out harm for patients with more severe hypoxemia.

Appraisal of Cardiovascular Risk Factors, Biomarkers, and Ocular Imaging in Cardiovascular Risk Prediction.

Cardiovascular disease remains a leading cause of death worldwide despite the use of available cardiovascular disease risk prediction tools. Identification of high-risk individuals via risk stratification and screening at sub-clinical stages, which may be offered by ocular screening, is important to prevent major adverse cardiac events. Retinal microvasculature has been widely researched for potential application in both diabetes and cardiovascular disease risk prediction. However, the conjunctival microvasculature as a tool for cardiovascular disease risk prediction remains largely unexplored. The purpose of this review is to evaluate the current cardiovascular risk assessment methods, identifying gaps in the literature that imaging of the ocular microcirculation may have the potential to fill. This review also explores the themes of machine learning, risk scores, biomarkers, medical imaging, and clinical risk factors. Cardiovascular risk classification varies based on the population assessed, the risk factors included, and the assessment methods. A more tailored, standardised and feasible approach to cardiovascular risk prediction that utilises technological and medical imaging advances, which may be offered by ocular imaging, is required to support cardiovascular disease prevention strategies and clinical guidelines.

Trends and patterns of care of sentinel node biopsy in cutaneous melanoma: a population-based study in Queensland.

BACKGROUND: Sentinel node biopsy (SNB) has evolved from offering staging and prognostication to a procedure that guides therapeutic management. The aim was to evaluate the rate of SNB for patients with high-risk melanoma and assess factors that may have impacted on the procedure being performed. METHODS: Data of patients with primary invasive cutaneous melanoma from 01 January 2009 to 31 December 2019 were obtained from the Queensland Oncology Repository. High-risk melanoma was defined as ≥0.8 mm thick or < 0.8 mm with ulceration present (AJCC eighth edition pT1b -pT4 ). RESULTS: 14 006 (33.8%) of 41 412 patients diagnosed with cutaneous invasive melanoma were in the high-risk group. 2923(20.9%) patients had SNB, with the rate increasing from 14.2% (2009) to 36.8% (2019) (P = 0.002), and an increasing proportion being performed in public hospitals over the 11 year period (P = 0.02). Older age (OR0.96 (0.959-0.964) (P < 0.001)), female (OR0.91 (0.830-0.998) (P = 0.03)), head and neck primary (OR0.38 (0.33-0.45) (P < 0.001)), and pT1b (OR0.22 (0.19-0.25) (P < 0.001)) were factors associated with SNB not being performed. Travel out of the Hospital and Health Services of residence for SNB occurred in 26.2%. Although the travel rate decreased from 24.7% (2009) to 23.0% (2019) (P = 0.04), the absolute number increased due to the increase in SNB rate. Those most likely to travel were younger, from remote areas, or from affluent backgrounds. CONCLUSION: In this first Australian population-based study, there was an increased adherence to SNB guideline, although overall SLNB rates remain low, with nearly 2/3 of eligible cases not having the procedure in 2019. Although travel rates decreased marginally, the overall number increased. This study highlights the crucial need to further improve access to SNB for melanoma surgery for the Queensland population.

Maternal Psychosocial Stress Is Associated with Reduced Diversity in the Early Infant Gut Microbiome.

The developing infant gut microbiome is highly sensitive to environmental exposures, enabling its evolution into an organ that supports the immune system, confers protection from infection, and facilitates optimal gut and central nervous system function. In this study, we focus on the impact of maternal psychosocial stress on the infant gut microbiome. Forty-seven mother-infant dyads were recruited at the HEAL Africa Hospital in Goma, Democratic Republic of Congo. Extensive medical, demographic, and psychosocial stress data were collected at birth, and infant stool samples were collected at six weeks, three months, and six months. A composite maternal psychosocial stress score was created, based on eight questionnaires to capture a diverse range of stress exposures. Full-length 16S rRNA gene sequences were generated. Infants of mothers with high composite stress scores showed lower levels of gut microbiome beta diversity at six weeks and three months, as well as higher levels of alpha diversity at six months compared to infants of low stress mothers. Longitudinal analyses showed that infants of high stress mothers had lower levels of health-promoting Lactobacillus gasseri and Bifidobacterium pseudocatenulatum at six weeks compared to infants of low stress mothers, but the differences largely disappeared by three to six months. Previous research has shown that L. gasseri can be used as a probiotic to reduce inflammation, stress, and fatigue, as well as to improve mental state, while B. pseudocatenulatum is important in modulating the gut-brain axis in early development and in preventing mood disorders. Our finding of reduced levels of these health-promoting bacteria in infants of high stress mothers suggests that the infant gut microbiome may help mediate the effect of maternal stress on infant health and development.

Assessment of Indices of Conjunctival Microvascular Function in Patients With and Without Obstructive Coronary Artery Disease.

BACKGROUND: Atherosclerotic heart disease often remains asymptomatic until presentation with a major adverse cardiovascular event. Primary preventive therapies improve outcomes, but conventional screening often misattributes risk. Vascular imaging can be utilised to detect atherosclerosis, but often involves ionising radiation. The conjunctiva is a readily accessible vascular network allowing non-invasive hemodynamic evaluation. AIM: To compare conjunctival microcirculatory function in patients with and without obstructive coronary artery disease. METHODS: We compared the conjunctival microcirculation of myocardial infarction patients (MI-cohort) to controls with no obstructive coronary artery disease (NO-CAD cohort). Conjunctival imaging was performed using a smartphone and slit-lamp biomicroscope combination. Microvascular indices of axial (Va) and cross-sectional (Vcs) velocity; blood flow rate (Q); and wall shear rate (WSR) were compared in all conjunctival vessels between 5 and 45 µm in diameter. RESULTS: A total of 127 patients were recruited (66 MI vs 61 NO-CAD) and 3602 conjunctival vessels analysed (2414 MI vs 1188 NO-CAD). Mean Va, Vcs and Q were significantly lower in the MI vs NO-CAD cohort (Va 0.50 ± 0.17 mm/s vs 0.55 ± 0.15 mm/s, p < 0.001; Vcs 0.35 ± 0.12 mm/s vs 0.38 ± 0.10 mm/s, p < 0.001; Q 154 ± 116 pl/s vs 198 ± 130 pl/s, p < 0.001). To correct for differences in mean vessel diameter, WSR was compared in 10-36 µm vessels (3268/3602 vessels) and was lower in the MI-cohort (134 ± 64 s-1 vs 140 ± 63 s-1, p = 0.002). CONCLUSIONS: Conjunctival microcirculatory alterations can be observed in patients with obstructive coronary artery disease. The conjunctival microvasculature merits further evaluation in cardiovascular risk screening.