Understanding decision-making for and against oncoplastic breast-conserving surgery as an alternative to a mastectomy in early breast cancer: UK ANTHEM qualitative study.

BACKGROUND: Oncoplastic breast-conserving surgery may allow women with early breast cancer to avoid a mastectomy, but many women undergo more extensive surgery, even when breast-conserving options are offered. The aim of the ANTHEM qualitative study was to explore factors influencing women's surgical decision-making for and against oncoplastic breast-conserving surgery. METHODS: Semi-structured interviews were conducted with a purposive sample of women who had received either oncoplastic breast-conserving surgery or a mastectomy with or without immediate breast reconstruction to explore their rationale for procedure choice. Interviews were transcribed verbatim and analysed thematically. Trial registration number: ISRCTN18238549. RESULTS: A total of 27 women from 12 centres were interviewed. Out of these, 12 had chosen oncoplastic breast-conserving surgery and 15 had chosen a mastectomy with or without immediate breast reconstruction. Overwhelmingly, women's decisions were guided by their surgical teams. Decision-making for and against oncoplastic breast-conserving surgery was influenced by three key inter-related factors: perceptions of oncological safety; the importance of maintaining/restoring femininity and body image; and practical issues. Oncological safety was paramount. Women who reported feeling reassured that oncoplastic breast-conserving surgery was oncologically safe were happy to choose this option. Those who were not reassured were more likely to opt for a mastectomy, as a perceived 'safer' option. Most women wished to maintain/restore femininity, with the offer of immediate breast reconstruction essential to make a mastectomy an acceptable option. Practical issues such as the perceived magnitude of the surgery were a lesser concern. CONCLUSION: Decision-making is complex and heavily influenced by the surgical team. High-quality, accurate information about surgical options, including appropriate reassurance about the short- and long-term oncological safety of oncoplastic breast-conserving surgery is vital if women are to make fully informed decisions.

Impact of vertical integration on patients' use of hospital services in England: an analysis of activity data.

BACKGROUND: Debate surrounding the organisation and sustainability of primary care in England highlights the desirability of a more integrated approach to patient care across all settings. One such approach is 'vertical integration', where a provider of specialist care, such as a hospital, also runs general practices. AIM: To quantify the impact of vertical integration on hospital use in England. DESIGN & SETTING: Analysis of activity data for NHS hospitals in England between April 2013 and February 2020. METHOD: Analysis of NHS England data on hospital activity, which looked at the following seven outcome measures: accident and emergency (A&E) department attendances; outpatient attendances; total inpatient admissions; inpatient admissions for ambulatory care sensitive conditions; emergency admissions; emergency readmissions; and length of stay. Rates of hospital use by patients of vertically integrated practices and controls were compared, before and after the former were vertically integrated. RESULTS: In the 2 years after a GP practice changes, for the population registered at that practice, compared with controls, vertical integration is associated with modest reductions in rates of A&E attendances (2% reduction [incidence rate ratio {IRR} 0.98, 95% confidence interval {CI} = 0.96 to 0.99, P<0.0001]), outpatient attendances (1% reduction [IRR 0.99, 95% CI = 0.99 to 1.00, P = 0.0061]), emergency inpatient admissions (3% reduction [IRR 0.97, 95% CI = 0.95 to 0.99, P = 0.0062]), and emergency readmissions within 30 days (5% reduction [IRR 0.95, 95% CI = 0.91 to 1.00, P = 0.039]), with no impact on length of stay, overall inpatient admissions, or inpatient admissions for ambulatory care sensitive conditions. CONCLUSION: Vertical integration is associated with modest reductions in use of some hospital services and no change in others.

Identifying where hospital and community trusts are managing general practices in England: a service mapping study.

BACKGROUND: Organisations providing secondary care in the NHS in England have historically not also provided primary health care, but this is changing. Data on where this kind of 'vertical integration' is happening is lacking, making it difficult to evaluate its impact. AIM: To compile a comprehensive list of instances of secondary care trusts running general practices in England, to enable evaluation of the impact of such arrangements. DESIGN AND SETTING: Review, collation, synthesis and analysis of published information describing secondary and primary care provision in the NHS in England in March 2021. METHOD: Desk-based collection, including hand-searching, of secondary care organisations' statutory annual reports. Triangulation via comparison with national data on general practices, the general practice workforce and practice contracts. RESULTS: It was possible to construct a database of all instances of trusts running general practices in England as at end-March 2021. We have identified 26 trusts running a total of 85 general practices, operating across a total of 116 practice sites. These practices have on average fewer patients and fewer GP full-time equivalents than other general practices, and before becoming vertically integrated were performing less well in the Quality and Outcomes Framework. CONCLUSION: We recommend that national statistics recording the details of general practices contracting with the NHS should include whether each practice is owned by another organisation and, whether that is an NHS trust, another public body or a private organisation. Such data are required to enable evaluation of the impacts of this kind of vertical integration.

How to co-design a prototype of a clinical practice tool: a framework with practical guidance and a case study.

Clinical tools for use in practice-such as medicine reconciliation charts, diagnosis support tools and track-and-trigger charts-are endemic in healthcare, but relatively little attention is given to how to optimise their design. User-centred design approaches and co-design principles offer potential for improving usability and acceptability of clinical tools, but limited practical guidance is currently available. We propose a framework (FRamework for co-dESign of Clinical practice tOols or 'FRESCO') offering practical guidance based on user-centred methods and co-design principles, organised in five steps: (1) establish a multidisciplinary advisory group; (2) develop initial drafts of the prototype; (3) conduct think-aloud usability evaluations; (4) test in clinical simulations; (5) generate a final prototype informed by workshops. We applied the framework in a case study to support co-design of a prototype track-and-trigger chart for detecting and responding to possible fetal deterioration during labour. This started with establishing an advisory group of 22 members with varied expertise. Two initial draft prototypes were developed-one based on a version produced by national bodies, and the other with similar content but designed using human factors principles. Think-aloud usability evaluations of these prototypes were conducted with 15 professionals, and the findings used to inform co-design of an improved draft prototype. This was tested with 52 maternity professionals from five maternity units through clinical simulations. Analysis of these simulations and six workshops were used to co-design the final prototype to the point of readiness for large-scale testing. By codifying existing methods and principles into a single framework, FRESCO supported mobilisation of the expertise and ingenuity of diverse stakeholders to co-design a prototype track-and-trigger chart in an area of pressing service need. Subject to further evaluation, the framework has potential for application beyond the area of clinical practice in which it was applied.

Vertical integration of general practices with acute hospitals in England: rapid impact evaluation.

Background: Vertical integration means merging organisations that operate at different stages along the patient pathway. We focus on acute hospitals running primary care medical practices. Evidence is scarce concerning the impact on use of health-care services and patient experience. Objectives: To assess the impact of vertical integration on use of hospital services, service delivery and patient experience and whether patients with multiple long-term conditions are affected differently from others. Design: Rapid, mixed methods evaluation with four work packages: (1) review of NHS trust annual reports and other sources to understand the scale of vertical integration across England; (2) development of the statistical analysis; (3) analysis of national survey data on patient experience, and national data on use of hospital services over the 2 years preceding and following vertical integration, comparing vertically integrated practices with a variety of control practices; and (4) focus groups and interviews with staff and patients across three case study sites to explore the impact of vertical integration on patient experience of care. Results: At 31 March 2021, 26 NHS trusts were in vertically integrated organisations, running 85 general practices across 116 practice sites. The earliest vertical integration between trusts and general practices was in 2015; a mean of 3.3 practices run by each trust (range 1-12). On average, integrated practices have fewer patients, are slightly more likely to be in the most deprived decile of areas, are more likely to hold an alternative provider medical services contract and have worse Quality and Outcomes Framework scores compared with non-integrated practices. Vertical integration is associated with statistically significant, modest reductions in rates of accident and emergency department attendances: 2% reduction (incidence rate ratio 0.98, 95% confidence interval 0.96 to 0.99; p < 0.0001); outpatient attendances: 1% reduction (incidence rate ratio 0.99, 95% confidence interval 0.99 to 1.00; p = 0.0061), emergency inpatient admissions: 3% reduction (incidence rate ratio 0.97, 95% confidence interval 0.95 to 0.99; p = 0.0062) and emergency readmissions: 5% reduction (incidence rate ratio 0.95, 95% confidence interval 0.91 to 1.00; p = 0.039), with no impact on length of stay, overall inpatient admissions or inpatient admissions for ambulatory care sensitive conditions. The falls in accident and emergency department and outpatient attendance rates are temporary. Focus groups and interviews with staff (N = 22) and interviews with patients (N = 14) showed that with vertical integration, health service improvements are introduced following a period of cultural interchange. Patients with multiple long-term conditions continue to encounter 'navigation work' choosing and accessing health-care provision, with diminishing continuity of care. Limitations: In the quantitative analysis, we could not replicate the counterfactual of what would have happened in those specific locations had practices not merged with trusts. There was imbalance across three case study sites with regard to staff and patients recruited for interview, and the latter were drawn from patient participation groups who may not be representative of local populations. Conclusions: Vertical integration can lead to modest reductions in use of hospital services and has minor or no impact on patient experience of care. Our analysis does not reveal a case for widespread roll-out of the approach. Future research: Further quantitative follow-up of the longer-term impact of vertical integration on hospital usage and more extensive interviewing of patients and their carers about patient experiences of navigating care. Funding: This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (BRACE Project no. 16/138/31) and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. 17. See the NIHR Journals Library website for further project information.

Emollients for preventing atopic eczema: Cost-effectiveness analysis of the BEEP trial.

BACKGROUND: Recent discoveries have led to the suggestion that enhancing skin barrier from birth might prevent eczema and food allergy. OBJECTIVE: To determine the cost-effectiveness of daily all-over-body application of emollient during the first year of life for preventing atopic eczema in high-risk children at 2 years from a health service perspective. We also considered a 5-year time horizon as a sensitivity analysis. METHODS: A within-trial economic evaluation using data on health resource use and quality of life captured as part of the BEEP trial alongside the trial data. Parents/carers of 1394 infants born to families at high risk of atopic disease were randomised 1:1 to the emollient group, which were advised to apply emollient (Doublebase Gel or Diprobase Cream) to their child at least once daily to the whole body during the first year of life or usual care. Both groups received advice on general skin care. The main economic outcomes were incremental cost-effectiveness ratio (ICER), defined as incremental cost per percentage decrease in risk of eczema in the primary cost-effectiveness analysis. Secondary analysis, undertaken as a cost-utility analysis, reports incremental cost per Quality-Adjusted Life Year (QALY) where child utility was elicited using the proxy CHU-9D at 2 years. RESULTS: At 2 years, the adjusted incremental cost was £87.45 (95% CI -54.31, 229.27) per participant, whilst the adjusted proportion without eczema was 0.0164 (95% CI -0.0329, 0.0656). The ICER was £5337 per percentage decrease in risk of eczema. Adjusted incremental QALYs were very slightly improved in the emollient group, 0.0010 (95% CI -0.0069, 0.0089). At 5 years, adjusted incremental costs were lower for the emollient group, -£106.89 (95% CI -354.66, 140.88) and the proportion without eczema was -0.0329 (95% CI -0.0659, 0.0002). The 5-year ICER was £3201 per percentage decrease in risk of eczema. However, when inpatient costs due to wheezing were excluded, incremental costs were lower and incremental effects greater in the usual care group. CONCLUSIONS: In line with effectiveness endpoints, advice given in the BEEP trial to apply daily emollient during infancy for eczema prevention in high-risk children does not appear cost-effective.

Current practice and provision of oncoplastic breast-conserving surgery in the UK: results of the ANTHEM national practice questionnaire.

PURPOSE: Oncoplastic breast-conserving surgery (OPBCS) may be a better option than mastectomy ± immediate breast reconstruction (IBR) for women with breast cancer but studies directly comparing the techniques are lacking. We surveyed UK breast units to determine the current practice of OPBCS to inform the design of a future comparative study. METHODS: An electronic survey was developed to explore the current practice of OPBCS. This included the local availability of volume displacement and/or replacement techniques; number of cases performed; contraindications and approach to contralateral symmetrisation. Summary data for each survey item were calculated and overall provision of care examined. RESULTS: 58 UK centres completed the survey, including 43 (74%) stand-alone breast and 15 (26%) combined breast/plastics units. Over 40% of units (n = 24) treated more than 500 cancers/year. Most units offered volume displacement techniques (TMs) (97%). Over two-thirds (n = 39. 67%) of units offered local perforator flaps (LPF). Approximately a half of units (10/19) not performing LPF were planning to introduce them in the next 12-24 months. A third (n = 19, 33%) of units routinely performed simultaneous contralateral symmetrisation mostly with two-surgeon operating. There were limited oncological restrictions to OPBCS with no contraindications for multifocal cancers in most centres; 65% of units (36/55) offered OPBCS for multicentric disease. Extensive DCIS was a contraindication in a minority of units. CONCLUSIONS: OPBCS is widely available in the UK but contraindications and approaches to contralateral symmetrisation were variable. Work is now needed to prospectively evaluate the outcomes of OPBCS vs mastectomy ± IBR to support informed decision-making.

Multi-lingual multi-platform investigations of online trade in jaguar parts.

We conducted research to understand online trade in jaguar parts and develop tools of utility for jaguars and other species. Our research took place to identify potential trade across 31 online platforms in Spanish, Portuguese, English, Dutch, French, Chinese, and Vietnamese. We identified 230 posts from between 2009 and 2019. We screened the images of animal parts shown in search results to verify if from jaguar; 71 posts on 12 different platforms in four languages were accompanied by images identified as definitely jaguar, including a total of 125 jaguar parts (50.7% posts in Spanish, 25.4% Portuguese, 22.5% Chinese and 1.4% French). Search effort varied among languages due to staff availability. Standardizing for effort across languages by dividing number of posts advertising jaguars by search time and number of individual searches completed via term/platform combinations changed the proportions the rankings of posts adjusted for effort were led by Portuguese, Chinese, and Spanish. Teeth were the most common part; 156 posts offered at least 367 teeth and from these, 95 were assessed as definitely jaguar; 71 of which could be linked to a location, with the majority offered for sale from Mexico, China, Bolivia, and Brazil (26.8, 25.4, 16.9, and 12.7% respectively). The second most traded item, skins and derivative items were only identified from Latin America: Brazil (7), followed by Peru (6), Bolivia (3), Mexico (2 and 1 skin piece), and Nicaragua and Venezuela (1 each). Whether by number of posts or pieces, the most commonly parts were: teeth, skins/pieces of skins, heads, and bodies. Our research took place within a longer-term project to assist law enforcement in host countries to better identify potential illegal trade and presents a snapshot of online jaguar trade and methods that also may have utility for many species traded online.

Hematodinium sp. infection does not drive collateral disease contraction in a crustacean host.

Host, pathogen, and environment are determinants of the disease triangle, the latter being a key driver of disease outcomes and persistence within a community. The dinoflagellate genus Hematodinium is detrimental to crustaceans globally - considered to suppress the innate defences of hosts, making them more susceptible to co-infections. Evidence supporting immune suppression is largely anecdotal and sourced from diffuse accounts of compromised decapods. We used a population of shore crabs (Carcinus maenas), where Hematodinium sp. is endemic, to determine the extent of collateral infections across two distinct environments (open-water, semi-closed dock). Using a multi-resource approach (PCR, histology, haematology, population genetics, eDNA), we identified 162 Hematodinium-positive crabs and size/sex-matched these to 162 Hematodinium-free crabs out of 1191 analysed. Crabs were interrogated for known additional disease-causing agents; haplosporidians, microsporidians, mikrocytids, Vibrio spp., fungi, Sacculina, trematodes, and haemolymph bacterial loads. We found no significant differences in occurrence, severity, or composition of collateral infections between Hematodinium-positive and Hematodinium-free crabs at either site, but crucially, we recorded site-restricted blends of pathogens. We found no gross signs of host cell immune reactivity towards Hematodinium in the presence or absence of other pathogens. We contend Hematodinium sp. is not the proximal driver of co-infections in shore crabs, which suggests an evolutionary drive towards latency in this environmentally plastic host.

Large-scale analysis of interindividual variability in single and paired-pulse TMS data.

OBJECTIVE: This study brought together over 60 transcranial magnetic stimulation (TMS) researchers to create the largest known sample of individual participant single and paired-pulse TMS data to date, enabling a more comprehensive evaluation of factors driving response variability. METHODS: Authors of previously published studies were contacted and asked to share deidentified individual TMS data. Mixed-effects regression investigated a range of individual and study level variables for their contribution to variability in response to single and paired-pulse TMS data. RESULTS: 687 healthy participant's data were pooled across 35 studies. Target muscle, pulse waveform, neuronavigation use, and TMS machine significantly predicted an individual's single-pulse TMS amplitude. Baseline motor evoked potential amplitude, motor cortex hemisphere, and motor threshold (MT) significantly predicted short-interval intracortical inhibition response. Baseline motor evoked potential amplitude, test stimulus intensity, interstimulus interval, and MT significantly predicted intracortical facilitation response. Age, hemisphere, and TMS machine significantly predicted MT. CONCLUSIONS: This large-scale analysis has identified a number of factors influencing participants' responses to single and paired-pulse TMS. We provide specific recommendations to minimise interindividual variability in single and paired-pulse TMS data. SIGNIFICANCE: This study has used large-scale analyses to give clarity to factors driving variance in TMS data. We hope that this ongoing collaborative approach will increase standardisation of methods and thus the utility of single and paired-pulse TMS.

Assessing competition in the hip implant industry in the light of recent policy guidance.

NHS procurement is a highly topical area, attracting a great deal of recent policy focus. The pivotal report by Lord Carter of Coles (2016) highlighted unwarranted variation, estimating it to be worth approximately £5bn in efficiency savings. In relation to hip replacement surgery, recent procurement policy guidance has recommended the use of cemented hip implants for all patients aged 68 years and over in England and Wales. Previous work established that the hip implant supplying market was very concentrated, with only a few large suppliers, especially for cemented implants. The advocated major shift towards cemented implants would almost certainly increase further the market share of the dominant manufacturer of cemented sector thus raising potential competition and welfare issues. We carry out a market study to establish whether there might be a potential competition concern, using data from the National Joint Registry (2005-2018, 37 suppliers, nearly 700 models). We first establish the structure of the industry with a specific focus on seller concentration. Secondly we evaluate the dynamics underlying concentration in the market, assessing the innovative performance of the sector using a novel statistical analysis of the dynamics of market shares. We then look to three comparable but alternative markets for similarities or differences to the THR implant industry. We find a high and increasingly concentrated oligopolistic and static market structure, largely devoid of dynamics and with no real sign of innovation. These findings are further emphasized when compared with the three close alternative markets. Although this stability could just be a mature market where technical advances have already taken place, our findings highlight the potential welfare and policy implications of concentrating on cemented fixation. Given the current emphasis on efficiency in procurement, it is essential that there should also be scrutiny of the firms dealing with public procurement.

Content of Health Economics Analysis Plans (HEAPs) for Trial-Based Economic Evaluations: Expert Delphi Consensus Survey.

OBJECTIVES: Health economics analysis plans (HEAPs) currently lack consistency, with uncertainty surrounding appropriate content. We aimed to develop a list of essential items that should be included in HEAPs for economic evaluations conducted alongside randomized trials. METHODS: A list of potential items for inclusion was developed by examining existing HEAPs. An electronic Delphi survey was conducted among professional health economists. Respondents were asked to rate potential items from 1 (least important) to 9 (most important), suggest additional items, and comment on proposed items (round 1). A second survey (round 2) was emailed to participants, including the participant's own scores from round 1 along with summary results from the whole panel; participants were asked to rerate each item. Consensus criteria for inclusion in the final list were predefined as >70% of participants rating an item 7-9 and <15% rating it 1-3 after round 2. A final item selection meeting was held to scrutinize the results and adjudicate on items lacking consensus. RESULTS: 62 participants completed round 1 of the survey. The initial list included 72 potential items; all 72 were carried forward to round 2, and no new items were added. 48 round 1 respondents (77.4%) completed round 2 and reached consensus on 53 items. At the final meeting, the expert panel (n = 9) agreed that 58 items should be included in the essential list, moved 9 items to an optional list, and dropped 5 items. CONCLUSIONS: Via expert consensus opinion, this study identified 58 items that are considered essential in a HEAP.

Protocol for a mixed-method study to inform the feasibility of undertaking a large-scale multicentre study comparing the clinical and patient-reported outcomes of oncoplastic breast conservation as an alternative to mastectomy with or without immediate breast reconstruction in women unsuitable for standard breast-conserving surgery (the ANTHEM Feasibility Study).

INTRODUCTION: Approximately 40% of the 55 000 women diagnosed with breast cancer each year in the UK undergo mastectomy because they are considered unsuitable for standard breast-conserving surgery (BCS) due to tumour size or multiple tumour foci. Mastectomy can significantly impact women's quality of life, and only one in four women currently undergo immediate breast reconstruction (IBR).Level 2 oncoplastic breast-conserving surgery (OPBCS) combines removing the cancer with a range of plastic surgical volume replacement (eg, local perforator flaps) and volume displacement techniques (eg, therapeutic mammaplasty) that can extend the role of BCS and may allow some women not suitable for standard BCS to avoid mastectomy. High-quality research to determine whether OPBCS offers a safe and effective alternative to mastectomy±IBR is currently lacking. Preliminary work is needed to ensure a future large-scale study is feasible and well designed and addresses questions important to patients and the National Health Service. METHODS AND ANALYSIS: Mixed methods will be used to inform feasibility and design of a future large-scale study comparing the clinical effectiveness and cost-effectiveness of OPBCS and mastectomy±IBR. It will have four parts: (1) a National Practice Questionnaire to determine current practice and provision of oncoplastic breast and reconstructive surgery in the UK; (2) a pilot multicentre prospective cohort study to explore the proportion of patients choosing OPBCS versus mastectomy, the proportion in OPBCS is successful and clinical and patient-reported outcomes of different techniques at 3 and 12 months postsurgery; (3) a qualitative interview study to explore patients' attitudes to different procedures, rationale for decision-making and perceptions of outcomes; and (4) design of the future study.All centres offering OPBCS and mastectomy in the UK will be invited to participate. Recruitment is planned to commence winter 2020 and continue for 12 months. ETHICS AND DISSEMINATION: The study has ethical approval from the Wales Research Ethics Committee 6 National Research Ethics Service (REC Ref 20/WA/0225). Results will be presented at national and international meetings and published in peer-reviewed journals. We will work with patients to develop lay summaries and share these through patient groups and breast cancer charities. TRIAL REGISTRATION NUMBER: ISRCTN18238549.

Retrograde endovenous laser ablation of the great saphenous vein using the superficial inferior epigastric vein as access vessel illustrated by a case report.

Endovenous thermal ablation is a first-line treatment for symptomatic varicose veins due to truncal vein reflux. Ablation of an incompetent great saphenous vein is usually performed from distally, with the vein access at the lowest point of reflux, or just below the knee. Occasionally there are patients in whom the great saphenous vein is difficult to access distally for reasons such as small vein diameter, scar tissue, vasospasm, difficult anatomy or multiple attempts with haematoma formation. In such cases, we access the great saphenous vein in a retrograde fashion by percutaneous cannulation of the superficial inferior epigastric vein, passing the catheter into the great saphenous vein just distal to the saphenofemoral junction and then down the vein to the required distal position. Ablation can then be performed, stopping the ablation in the great saphenous vein just distal to the junction of superficial inferior epigastric vein and great saphenous vein. We present a patient to illustrate our technique.

Invertebrate health in marine protected areas (MPAs).

Marine protected areas (MPAs) consist of various categories of safeguarded areas in the marine environment, from semi-protected areas to total no take zones. The reported effects of MPAs are overwhelmingly positive, with numerous reports of fish size (biomass), abundance (recovery) and diversity increases, however, literature is lacking on the role and consequences of MPAs on parasite and disease dynamics, and in particular, invertebrate health. The implementation of MPAs has been known to alter trophic cascades and community dynamics, and with invertebrates commonly at the base of these systems, it is vital that their status is investigated. Overcrowding in areas closed to fishing is known to have parasitological consequences in some scenarios, and land/water use change has been known to alter host and vector communities, possibly elevating disease risk. Equally, reserves can be used as tools for alleviating impacts of marine disease. This review aims to consolidate extant literature and provide a comprehensive viewpoint on how invertebrates (and their health status) can be affected by MPAs, which are increasingly being implemented based on the relative urgency now being placed on protecting global biodiversity. In highlighting the paucity of knowledge surrounding MPAs and disease, especially that of the unenigmatic invertebrate groups, this review, published in the Special Issue on 'Invertebrates as One Health Sentinels', provides an opportunity for wide dissemination and provocation of further research in this area.

Comparison of laser power output from the fiber tip during endovenous laser ablation against displayed power and the "first treatment" effect.

OBJECTIVE: International guidelines recommend endovenous laser ablation as one of the first-line treatments for truncal venous reflux associated with varicose veins. Clinicians use linear endovenous energy density to measure the energy used during treatment. The aim of this study was to investigate the power output from the fiber tip and to see if this changed with use. METHODS: We placed 15 mL of water in a thermally insulated 25-mL beaker. Two thermocouples were placed equidistantly adjacent to the laser fiber tip. A 1470-nm laser was fired at 5W for 2 minutes and the temperature change was measured. Three fibers were used on different days to allow the laser to cool for 24 hours between fibers. Each fiber was tested three times in a row. We also tested the "first treatment" effect by comparing the power output when the fiber was fired immediately after the laser was switched on, compared with treatments when the laser had been switched on for 1 hour. To assess whether this was due to the console being "cold" on the first firing of the day, we repeated the experiment having switched on the laser console 1 hour before firing to "prewarm" the console. However, the diode was not fired during this hour. To measure fiber degradation, three runs of the experiment were performed successively before firing the laser continuously for 20 minutes, then three more runs were conducted, resulting in delivery of approximately 10,000 J. RESULTS: The actual power output seemed to be lower than the console suggested. The power output from the first fiber used in a succession of three with the same laser had a significantly lower power output than the following two runs (P = .0004 and P < .0001, respectively). When the laser was prewarmed for 1 hour without firing, no change in this output pattern was noted (P = .293). Fiber degradation was not found in any of the fibers that were tested within the maximum recommended for the fiber (10,000 J). CONCLUSIONS: The first use of a fiber in a treatment session has a significantly lower power output from the treatment tip than subsequent uses, even if the machine is prewarmed and the console displays the same power for each. The authors believe that this phenomenon is due to the diode being less efficient when first used after switching it on. Clinicians need to be aware that the true power output at the fiber tip may not be as indicated by the console display and may be variable during a treatment session.

Pattern of thermal damage and tissue carbonisation from endovenous radiofrequency ablation catheter - Using an in vitro porcine liver model.

BACKGROUND: Successful endovenous thermoablation relies on transmural vein wall ablation. We investigated the pattern of thermal spread and tissue carbonisation from RadioFrequency-induced ThermoTherapy (RFiTT) at different powers and pull back methods, using a porcine liver model. METHODS: We used a previously validated in-vitro porcine liver model. Different powers from 5-25 W were used to administer 150 J. We compared continuous and pulsed energy delivery. Length, lateral spread, and total area of thermal damage, together with any tissue carbonisation, was measured using digital analysis software. RESULTS: All experiments used 150 J total energy. Total thermal damage area was smaller with lower power and pulsed energy. Continuous energy caused more tissue carbonisation than pulsed except at 25 W. CONCLUSION: Reduced thermal damage with lower power or pulsed energy results from cooling due to increased time of treatment. Increasing the power increases tissue carbonisation. Optimal treatment is determined by the highest power used continuously that does not cause tissue carbonisation.

Large-scale analysis of interindividual variability in theta-burst stimulation data: Results from the 'Big TMS Data Collaboration'.

BACKGROUND: Many studies have attempted to identify the sources of interindividual variability in response to theta-burst stimulation (TBS). However, these studies have been limited by small sample sizes, leading to conflicting results. OBJECTIVE/HYPOTHESIS: This study brought together over 60 TMS researchers to form the 'Big TMS Data Collaboration', and create the largest known sample of individual participant TBS data to date. The goal was to enable a more comprehensive evaluation of factors driving TBS response variability. METHODS: 118 corresponding authors of TMS studies were emailed and asked to provide deidentified individual TMS data. Mixed-effects regression investigated a range of individual and study level variables for their contribution to iTBS and cTBS response variability. RESULTS: 430 healthy participants' TBS data was pooled across 22 studies (mean age = 41.9; range = 17-82; females = 217). Baseline MEP amplitude, age, target muscle, and time of day significantly predicted iTBS-induced plasticity. Baseline MEP amplitude and timepoint after TBS significantly predicted cTBS-induced plasticity. CONCLUSIONS: This is the largest known study of interindividual variability in TBS. Our findings indicate that a significant portion of variability can be attributed to the methods used to measure the modulatory effects of TBS. We provide specific methodological recommendations in order to control and mitigate these sources of variability.

Mycosis is a Disease State Encountered Rarely in Shore Crabs, Carcinus maenas.

There is a paucity of knowledge regarding the diversity and impact(s) of disease-causing fungi in marine animals, especially shellfish. In efforts to address this knowledge gap for the shore crab Carcinus maenas, a year-long disease screen was carried out across two sites in Swansea Bay (Wales, UK) with a view to characterising putative fungal infections. Crabs were sampled between November 2017 and October 2018, and screened systematically for disease signatures using haemolymph (blood) preparations, targeted PCR and tissue histopathology. Strikingly, mycosis was confirmed in ~0.4% of total crabs tested (n = 1191) and restricted to one location only (Mumbles Pier). Clinical infections were observed in four out of four infected crabs. In these animals, the gills and hepatopancreas were congested with fungal morphotypes. In addition, some evidence indicates haemocyte (immune cell) reactivity toward the fungi. Phylogenetic placement of the partial internal transcribed spacer (ITS1) gene regions amplified from three mycotic crabs revealed the causative agent to be related to hypocrealean fungi, thereby representing a novel species.