Lymph node ratio prognosticates overall survival in patients with stage IV colorectal cancer.

BACKGROUND: Lymph node ratio (LNR) is suggested to address the shortcomings of using only lymph node yield (LNY) or status in colorectal cancer (CRC) prognosis. This study explores how LNR affects survival in patients with metastatic colorectal cancer (mCRC), seeking to provide clearer insights into its application. METHODS: This observational cohort study investigated stage IV patients with CRC (1995-2021) who underwent an upfront resection of their primary tumour at Concord Hospital, Sydney. Clinicopathological data were extracted from a prospective database, and LNR was calculated both continuously and dichotomously (LNR of 0 and LNR > 0). The primary endpoint was overall survival (OS). The associations between LNR and various clinicopathological variables were tested using regression analyses. Kaplan-Meier and Cox regression analyses estimated OS in univariate and multivariate survival models. RESULTS: A total of 464 patients who underwent a primary CRC resection with clear margins (mean age 68.1 years [SD 13.4]; 58.0% M; colon cancer [n = 339,73.1%]) had AJCC stage IV disease. The median LNR was 0.18 (IQR 0.05-0.42) for colon cancer (CC) resections and 0.21 (IQR 0.09-0.47) for rectal cancer (RC) resections. A total of 84 patients had an LNR = 0 (CC = 66 patients; RC = 18 patients). The 5-year OS for the CC cohort was 10.5% (95% CI 8.7-12.3) and 11.5% (95% CI 8.4-14.6) for RC. Increasing LNR demonstrated a decline in OS in both CC (P < 0.001) and RC (P < 0.001). In patients with non-lymphatic dissemination only (LNR = 0 or N0 status), there was better survival compared with those with lymphatic spread (CC aHR1.50 [1.08-2.07;P = 0.02], RC aHR 2.21 [1.16-4.24;P = 0.02]). CONCLUSIONS: LNR is worthy of consideration in patients with mCRC. An LNR of 0 indicates patients have a better prognosis, underscoring the need for adequate lymphadenectomy to facilitate precise mCRC staging.

The value of allied health professional research engagement on healthcare performance: a systematic review.

BACKGROUND: Existing evidence suggests that clinician and organisation engagement in research can improve healthcare performance. With the increase in allied health professional (AHP) research activity, it is imperative for healthcare organisations, clinicians, managers, and leaders to understand research engagement specifically within allied health fields. This systematic review aims to examine the value of research engagement by allied health professionals and organisations on healthcare performance. METHODS: This systematic review had a two-stage search strategy. Firstly, the papers from a previous systematic review examining the effect of research engagement in healthcare were screened to identify papers published pre-2012. Secondly, a multi-database search was used to conduct a re-focused update of the previous review, focusing specifically on allied health to identify publications from 2012-2021. Studies which examined the value of allied health research engagement on healthcare performance were included. All stages of the review were conducted by two reviewers independently. Each study was assessed using the appropriate Joanna Briggs Institute critical appraisal tool. A narrative synthesis was completed to analyse the similarities and differences between and within the different study types. RESULTS: Twenty-two studies were included, comprising of mixed research designs, of which six were ranked as high importance. The findings indicated that AHP research engagement appears related to positive findings in improvements to processes of care. The review also identified the most common mechanisms which may link research engagement with these improvements. DISCUSSION: This landmark systematic review and narrative synthesis suggests value in AHP research engagement in terms of both processes of care and more tentatively, of healthcare outcomes. While caution is required because of the lack of robust research studies, overall the findings support the agenda for growing AHP research. Recommendations are made to improve transparent reporting of AHP research engagement and to contribute essential evidence of the value of AHP research engagement. TRIAL REGISTRATION: This systematic review protocol was registered with the international prospective register of systematic reviews, PROSPERO (registration number CRD42021253461 ).

Audit of PPI Prescribing Practices: A Risk to Patient Safety?

Aim Proton pump inhibitors (PPIs) are frequently prescribed to surgical patients (50-60%) to prevent gastrointestinal bleeding. However, most surgical patients are at low risk of significant bleeds. The aim of this audit was to identify inappropriate PPI prescribing, if any, in a cohort of surgical inpatients. Methods This was a prospective analysis completed over a 4 month period. Data was collected via review of clinical notes and drug charts. The audit standard was the consensus guideline on indications for PPI use issued by Scarpignato et al (2016). Results In total 89 patients were included (n = 89). 73% were on PPI therapy. 30% had a documented indication for therapy which was concordant with recommendations. However, the majority of PPI prescriptions (70%) were inappropriate. Conclusion PPIs are frequently prescribed to surgical patients without an appropriate indication. Indiscriminate use of these drugs has implications in the form of costs and potential complications.

Magnetic Stent Removal in a Nurse Led Clinic; a Nine Month Experience.

Ureteric stents are frequently inserted post endourological procedures. However, subsequent endoscopic stent removal requires a second procedure for the patient and the availability of necessary resources. Longer duration of indwelling stents can lead to increased risk of symptoms and complications. The use of magnetic stents removed with a magnetic retrieval device (BlackStar©), offers an alternative which obviates the need for cystoscopy. We assessed the outcomes for this novel method of stent removal in our institution. A retrospective analysis was performed of all patients undergoing magnetic stent insertion and subsequent removal in a nurse-led clinic over a nine-month period. Patients were followed up with a prospective validated Ureteral Stent Symptoms Questionnaire (USSQ)3. A cost analysis was also performed. In total, 59 patients were treated using magnetic stents. The complication rate was low (6.7%). The median duration of indwelling stent was 5.8 days (range 1-11 days). Patients reported haematuria and lower urinary tract symptoms but >90% experienced no functional impairment with minimal days of employment lost (mean 0.75 days). All patients reported satisfaction with nurse-led stent removal and 97% were happy to have stents removed via this method in the future. The total financial savings were estimated at €47,790 over this period. Nurse-led removal of magnetic stents is safe and well tolerated by patients and enables expedient stent removal. It also provides a significant cost benefit and frees up valuable endoscopic resources.

A low cost virtual reality system for home based rehabilitation of the arm following stroke: a randomised controlled feasibility trial.

OBJECTIVE: To assess the feasibility of conducting a randomised controlled trial of a home-based virtual reality system for rehabilitation of the arm following stroke. DESIGN: Two group feasibility randomised controlled trial of intervention versus usual care. SETTING: Patients' homes. PARTICIPANTS: Patients aged 18 or over, with residual arm dysfunction following stroke and no longer receiving any other intensive rehabilitation. INTERVENTIONS: Eight weeks' use of a low cost home-based virtual reality system employing infra-red capture to translate the position of the hand into game play or usual care. MAIN MEASURES: The primary objective was to collect information on the feasibility of a trial, including recruitment, collection of outcome measures and staff support required. Patients were assessed at three time points using the Wolf Motor Function Test, Nine-Hole Peg Test, Motor Activity Log and Nottingham Extended Activities of Daily Living. RESULTS: Over 15 months only 47 people were referred to the team. Twenty seven were randomised and 18 (67%) of those completed final outcome measures. Sample size calculation based on data from the Wolf Motor Function Test indicated a requirement for 38 per group. There was a significantly greater change from baseline in the intervention group on midpoint Wolf Grip strength and two subscales of the final Motor Activity Log. Training in the use of the equipment took a median of 230 minutes per patient. CONCLUSIONS: To achieve the required sample size, a definitive home-based trial would require additional strategies to boost recruitment rates and adequate resources for patient support.

Toxicities of the anti-PD-1 and anti-PD-L1 immune checkpoint antibodies.

Immune checkpoint antibodies that augment the programmed cell death protein 1 (PD-1)/PD-L1 pathway have demonstrated antitumor activity across multiple malignancies, and gained recent regulatory approval as single-agent therapy for the treatment of metastatic malignant melanoma and nonsmall-cell lung cancer. Knowledge of toxicities associated with PD-1/PD-L1 blockade, as well as effective management algorithms for these toxicities, is pivotal in order to optimize clinical efficacy and safety. In this article, we review selected published and presented clinical studies investigating single-agent anti-PD-1/PD-L1 therapy and trials of combination approaches with other standard anticancer therapies, in multiple tumor types. We summarize the key adverse events reported in these studies and their management algorithms.

Supporting Youth Participation in Health and Climate Justice Through Advocacy Training Comment on "Between Rhetoric and Reality: Learnings From Youth Participation in the Adolescent and Youth Health Policy in South Africa".

This paper responds to lessons from the Adolescent and Youth Health Policy (AYHP) process in South Africa by drawing comparisons with youth participation within the climate justice movement. Relationship building is essential to successful youth participation in health policy and climate change as it creates intergenerational learning and cross-cultural engagement. At the same time, both sets of youth also deal with compounding challenges due to contemporary and historical legacies of colonialism and inequality. Yet, tokenism challenges the participatory process as adults profess to value youth perspectives, yet recommendations by youth often do not get incorporated into policies or plans. For organizations and agencies trying to build youth's capacity, organizations and agencies should look to programs that train youth in advocacy. These programs help build youth's confidence, increase their optimism for change, and give youth a sense of ownership.

Detailed analysis of in-hospital transmission of SARS-CoV-2 using whole genome sequencing.

BACKGROUND: Hospital transmission of SARS-CoV-2 has proved difficult to control, with healthcare-associated infections troublesome throughout. AIM: To understand factors contributing to hospital transmission of infections, which is necessary for containing spread. METHODS: An outbreak of 56 staff and patient cases of COVID-19 over a 31-day period in a tertiary referral unit is presented, with at least a further 29 cases identified outside of the unit and the hospital by whole genome sequencing (WGS). FINDINGS: Transmission is documented from staff to staff, staff to patients, and patients to staff, showing disruption of a tertiary referral service, despite implementation of nationally recommended control measures, superior ventilation, and use of personal protective equipment. There was extensive spread from the index case, despite this patient spending only 10 h bed bound on the ward in strict cubicle isolation and with an initial single target low level (CT = 32) polymerase chain reaction test. CONCLUSION: This investigation highlights how effectively and rapidly SARS-CoV-2 can spread in certain circumstances. It raises questions about infection control measures in place at the time and calls into question the premise that transmissibility can be reliably detected by using lower sensitivity rapid antigen lateral flow tests. We also highlight the value of early intervention in reducing impact as well as the value of WGS in understanding outbreaks.

Measures of sensation in neurological conditions: a systematic review.

OBJECTIVE: To systematically review the psychometric properties and clinical utility of measures of sensation in neurological conditions to inform future research studies and clinical practice. DATA SOURCES: Electronic databases (MEDLINE, CINAHL, EMBASE and AMED) were searched from their inception to December 2010. REVIEW METHODS: Search terms were used to identify articles that investigated any sensory measures in neurological conditions. Data about their psychometric properties and clinical utility were extracted and analyzed independently. The strength of the psychometric properties and clinical utility were assessed following recommendations. (1) RESULTS: Sixteen sensory measures were identified. Inter-rater reliability and redundancy of testing protocols are particular issues for this area of assessment. Eleven were rejected because they were not available for a researcher or clinician to use. Of the remaining five measures, the Erasmus MC modifications of the Nottingham Sensory Assessment and the Sensory section of the Fugl-Meyer Assessment showed the best balance of clinical utility and psychometric properties. CONCLUSION: Many measures of sensory impairment have been used in research but few have been fully developed to produce robust data and be easy to use. At present, the sensory section of the Fugl-Meyer Assessment and the Erasmus MC modifications of the Nottingham Sensory Assessment show the most effective balance of usability and robustness, when delivered according to the operating instructions.

Further delineation of the 15q13 microdeletion and duplication syndromes: a clinical spectrum varying from non-pathogenic to a severe outcome.

BACKGROUND: Recurrent 15q13.3 microdeletions were recently identified with identical proximal (BP4) and distal (BP5) breakpoints and associated with mild to moderate mental retardation and epilepsy. METHODS: To assess further the clinical implications of this novel 15q13.3 microdeletion syndrome, 18 new probands with a deletion were molecularly and clinically characterised. In addition, we evaluated the characteristics of a family with a more proximal deletion between BP3 and BP4. Finally, four patients with a duplication in the BP3-BP4-BP5 region were included in this study to ascertain the clinical significance of duplications in this region. RESULTS: The 15q13.3 microdeletion in our series was associated with a highly variable intra- and inter-familial phenotype. At least 11 of the 18 deletions identified were inherited. Moreover, 7 of 10 siblings from four different families also had this deletion: one had a mild developmental delay, four had only learning problems during childhood, but functioned well in daily life as adults, whereas the other two had no learning problems at all. In contrast to previous findings, seizures were not a common feature in our series (only 2 of 17 living probands). Three patients with deletions had cardiac defects and deletion of the KLF13 gene, located in the critical region, may contribute to these abnormalities. The limited data from the single family with the more proximal BP3-BP4 deletion suggest this deletion may have little clinical significance. Patients with duplications of the BP3-BP4-BP5 region did not share a recognisable phenotype, but psychiatric disease was noted in 2 of 4 patients. CONCLUSIONS: Overall, our findings broaden the phenotypic spectrum associated with 15q13.3 deletions and suggest that, in some individuals, deletion of 15q13.3 is not sufficient to cause disease. The existence of microdeletion syndromes, associated with an unpredictable and variable phenotypic outcome, will pose the clinician with diagnostic difficulties and challenge the commonly used paradigm in the diagnostic setting that aberrations inherited from a phenotypically normal parent are usually without clinical consequences.

A new protein of adhesion plaques and ruffling membranes.

A protein with a molecular weight on SDS polyacrylamide gels of 215,000 (referred to here as 215K) was purified from chicken gizzard smooth muscle. Antibodies against this protein localized it in fibroblasts to adhesion plaques (focal contacts), to regions underlying cell surface fibronectin, and to ruffling membranes. In the first two distributions it was similar to vinculin in cellular location, and this was confirmed by double-label immunofluorescence microscopy, but the concentration of 215K in membrane ruffles distinguished it from vinculin. There was no cross-reaction of the antibody against 215K with vinculin, and immunoprecipitation and antibody staining of SDS gels of whole cells revealed a single cross-reactive component with a molecular weight of 215,000. Immunoprecipitation from cultures labeled with [32P]phosphate revealed 215K to be a phosphoprotein. Transformation of rat or chicken fibroblasts by Rous sarcoma virus resulted in a reorganization of 215K, in some cases into complex intracellular structures. The localization of 215K where microfilament bundles terminate as well as in close relation to cell surface fibronectin and in membrane ruffles suggests that the protein has some function in the organization of actin filaments at or close to regions of actin-membrane attachment.

How to measure balance in clinical practice. A systematic review of the psychometrics and clinical utility of measures of balance activity for neurological conditions.

OBJECTIVE: To identify psychometrically robust and clinically feasible measurement tools of balance activity in people with neurological conditions to recommend for use in clinical practice. DATA SOURCES: MEDLINE, CINAHL, EMBASE, PEDro and AMED. REVIEW METHODS: Independent reviewers selected and extracted data from articles that assessed the reliability, validity, sensitivity to change and clinical utility of measures of balance activity in adult neurological conditions. Quality assessment was based on Jorstad et al. Measures with 'good' psychometrics and > or =9/10 clinical utility scores were recommended. RESULTS: Nineteen measurement tools were selected. Of these, the Brunel Balance Assessment, Berg Balance Scale, Trunk Impairment Scale, arm raise and forward reach tests in sitting and standing, weight shift, step/tap and step-up tests reached the required standards and are usable in clinical practice. The Brunel Balance Assessment and its associated functional performance tests have the additional advantages of being a hierarchical scale with established lack of redundancy. CONCLUSION: The measurement tools identified above are psychometrically robust and feasible to use in clinical practice. Future objective measure development should consider the theoretical construct of the measure, the minimal detectable change and use in clinical populations other than stroke.

What treatment packages do UK physiotherapists use to treat postural control and mobility problems after stroke?

OBJECTIVE: The aim of this study was to identify the treatment packages (combinations of interventions) used to treat postural control and mobility problems for patients with stroke. METHOD: A convenience sample of 74 physiotherapists from 34 National Health Service hospitals recorded the interventions used to treat postural control and mobility problems for 251 patients with stroke in 1156 treatment sessions using the Stroke Physiotherapy Intervention Recording Tool (Tyson and Selley, Disabil Rehabil 2004;26:1184 - 1188). Descriptive statistics assessed the frequency with which the interventions were used and geometric coding identified treatment packages. RESULTS: The most frequently used interventions involved facilitation, practice of activities and their components and mobilisations. The least frequently used interventions involved the provision of equipment, teaching carers or professionals and exercise. Two treatment packages were identified; one involving the facilitation (of activities and their components) and the other involving whole activities (facilitation and practice). CONCLUSIONS: Interventions are often combined in two treatment packages to treat postural control and mobility problems after stroke. One involved facilitation (of whole and component activities) and the other involved practice and facilitation of whole activities. Future research in which conventional or standard UK stroke physiotherapy is delivered should focus on these interventions and exclude atypically used interventions.

What is Bobath? A survey of UK stroke physiotherapists' perceptions of the content of the Bobath concept to treat postural control and mobility problems after stroke.

OBJECTIVE: The aim of this study was to identify which interventions used to treat postural control and mobility are considered part of the Bobath concept (BC). DESIGN. Hospital-based UK stroke physiotherapists identified interventions which they perceived to be part of the BC from a pre-published list of interventions used to treat postural control and mobility problems. Interventions that > 75% of participants felt were part of the BC were classified as 'definitely Bobath'. Interventions that < 25% felt were part of the BC were classified as 'definitely not Bobath'. Other interventions were classified as 'unsure'; those indentified by 50-74% of participants as part of the BC were classified as 'probably Bobath' and those indentified 26-49% were classified as 'probably not Bobath'. RESULTS: Seventy-four physiotherapists from 33 hospitals participated. Facilitation, mobilizations and practicing components of activities were most strongly associated with the BC. Exercise and the use of equipment were identified as 'not' or 'probably not Bobath'. There was uncertainty about practicing activities, teaching patients and carers and arranging independent practice. CONCLUSIONS: UK stroke physiotherapists perceive that the BC involves interventions that focus on facilitating movement, mobilization, practicing components of activities and some whole activities. Their views about what is not part of the BC and the areas where they are uncertain contrast with British and international teachers of the BC. Consequently, it was not possible to define a 'typical package' of treatment for postural control and mobility that represents the BC. Future research into the BC should focus on the effectiveness of specific, well-defined interventions.

The approach to an isolated close anterior margin in breast conserving surgery.

INTRODUCTION: Although close radial margins after breast-conserving surgery routinely undergo re-excision, appropriate management of patients with close anterior margins remains a topic of controversy. An increasing body of literature suggests that re-excision of close anterior margins yields low rates of residual malignancy and may only be necessary in selected patients. The aim of this study was to examine the management of close anterior margins after breast conserving surgery in a single institution and to analyse the rate of residual disease in re-excised anterior margins. METHODS: All patients having breast conserving surgery at St Vincent's University Hospital from January 2008 to December 2012 were reviewed retrospectively. Data collected included patient demographics, tumour characteristics, margin positivity, re-excision rates and definitive histology of the re-excision specimens. A close margin was defined as les than 2 mm. RESULTS: A total of 930 patients were included with an average age of 65 years (range 29-94 years). Of these, 121 (13%) had a close anterior margin. Further re-excison of the anterior margin was carried out in 37 patients (30.6%) and a further 16 (13.2%) proceeded to mastectomy. Residual disease was found in 18.5% (7/36) of those who underwent re-excision and 7/16 (43.75%) of those who underwent mastectomy. Overall, 11.57% (14/121) of patients with close anterior margins were subsequently found to have residual disease. CONCLUSION: The low yield of residual disease in re-excised anterior margins specimens supports the concept that routine re-excision of close anterior margins is not necessary. Further research is required to definitively assess its influence on the risk of local recurrence.

Rates of bluetongue virus transmission between Culicoides sonorensis and sheep.

Two experiments were undertaken to estimate the transmission rates of bluetongue virus (BTV) serotype 1 between a biting midge vector, Culicoides sonorensis (Wirth & Jones) (Ceratopogonidae), and a natural host, sheep. In an experiment to measure the transmission rate from vector to host (V-->H), six batches of one, five and 20 intrathoracically infected midges were fed on a total of 18 bluetongue (BT)-naïve sheep. The sheep were then monitored for 21 days for clinical signs of BT, viraemia and antibody response. All sheep fed on by five or 20 midges and five of six sheep fed on by just one midge showed signs of BT, were viraemic and developed antibody. The sixth sheep fed on by a single infected midge did not show signs of BT or have detectable viraemia; it did, however, develop a weak antibody response. A bite from a single infected midge is therefore able to transmit BTV to naïve sheep with 80-100% efficiency. Sheep fed upon by larger numbers of infected midges took less time to reach maximum viraemia and developed stronger antibody responses. Sheep exposed to greater amounts of BTV in feeding midges developed a higher level of viraemia and stronger antibody responses. In a second experiment to measure the transmission rate from host to vector (H-->V), batches of up to 500 uninfected female C. sonorensis fed every 1-2 days on two experimentally infected sheep during the course of infection. Of 3929 engorged midges that were individually titrated after surviving the extrinsic incubation period, only 23 (0.6%) were infected with BTV. Viraemia in the sheep extended for up to 19 days post-inoculation. No infected midges, however, were detected from 14 days post-infection.