A change in surgical margin: do wider surgical margins lead to decreased rates of local recurrence in T1 and T2 oral tongue cancer?

The purpose of this study was to assess the impact of a change in macroscopic/surgical margin width upon histological margins and loco-regional failure in early oral tongue squamous cell carcinoma (OTSCC). In 2009, the surgical margin protocol was increased from 10 mm to 15 mm. A retrospective review was performed of all patients who underwent treatment for early OTSCC between 2009 and 2016 with a 15-mm surgical margin (n = 142), and these patients were compared to those treated between 1999 and 2008 with a 10-mm surgical margin (n = 78). There was a significant increase in the rate of clear histological margins (P < 0.001). The rates of close (P = 0.002) and involved (P < 0.001) histological margins decreased significantly. There were significant reductions in local (P < 0.001) and regional (P < 0.001) recurrence rates. This study demonstrated that a surgical margin of 15 mm delivered significantly lower rates of close/involved histological margins and improved local and regional disease recurrence in early OTSCC when compared with a surgical margin of 10 mm.

Single-shot spinal diamorphine for laparoscopic nephrectomy: A retrospective study.

Single-shot spinal diamorphine is becoming common practice in urological surgery to aid post-operative pain; however, its safety and efficacy require investigation. This study is a retrospective analysis of 113 laparoscopic or robotic-assisted nephrectomies over 4 years under one consultant urologist. Data were collected on demographic, pre-operative scores, anaesthesia, surgical information, post-operative outcomes and opioid consumption. Two main groups were established: no spinal diamorphine (NSD) and spinal diamorphine (SD). Four subgroups were then created, separating those who received patient-controlled anaesthesia (PCA) or not: Group 1 [general anaesthetic (GA)]; Group 2 [GA and PCA]; Group 3 [GA and spinal diamorphine] and Group 4 [GA, spinal diamorphine and PCA]. Ninety-eight eligible patients were identified. At 6 hours, pain scores were significantly higher for all non-spinal groups (p < 0.05); at 9 h, pain scores were significantly higher in NSD patients compared to SD (p = 0.026); at 12 h, pain scores were significantly higher for NSD patients compared to SD (p = 0.024), and Group 1 compared to Group 3 (p = 0.023). Total opioid consumption in the first 24 h post-surgery was higher in Group 1 compared to Group 3 (p = 0.024). There was no higher incidence of urinary retention, or any neurological complications reported within the SD patients. The study found a reduction in post-operative pain scores with the use of spinal diamorphine prior to laparoscopic and robotic-assisted nephrectomies. The findings may also suggest that pre-operative spinal diamorphine use can reduce the total volume of opioids administered via other routes in the first 24 h post-operatively. It recommends its routine administration but encourages prospective investigation.

"I'm at breaking point"; Exploring pharmacists' resilience, coping and burnout during the COVID-19 pandemic.

BACKGROUND: There is a lack of evidence on how the multimodal dynamic process of resilience has impacted personal adaptation of frontline healthcare professionals, working under extreme pressure during the COVID-19 global pandemic. OBJECTIVES: To explore resilience, burnout and wellbeing for UK pharmacists in patient-facing roles, including individual and organisational factors that align to the ABC-X theoretical model of the dynamic process of resilience. METHODS: A non-experimental pragmatist research design was adopted, with a cross-sectional online survey distributed via social media and professional networks between June and July 2020. Quantitative data aligned to a positivist research paradigm was collected using validated scores, to statistically analyse wellbeing, burnout and resilience. Qualitative textual data, consistent with an interpretivist research paradigm, were analysed following an inductive thematic approach. RESULTS: A total of 199 surveys from pharmacists working within community, hospital and GP sectors were analysed. Wellbeing scores were strongly correlated to resilience scores. Wellbeing and resilience scores were both inversely correlated with burnout scores. Two-thirds of participants were classified as high-risk within the burnout scales.Key stressors were highlighted by participants, who described how individual resources and perceptions shaped their experience, which overall contributed to their burnout. Organisations that supported pharmacists embraced change and quickly adopted new ways of working, such as teleconsultations, flexible and remote working, redesign of workflow, alongside clear guidance. However, there was also reported frustration at lack of, slow or conflicting guidance from employers. CONCLUSIONS: This study adds to the growing evidence base for how individuals are affected by adverse events in a dynamic environment, alongside the role that employers can play in supporting individual and organisational resilience. It provides an opportunity to learn from pharmacists' responses to the COVID-19 pandemic, and a call to action for healthcare organisations to rebuild and invest resources into sustained support for staff wellbeing.

Anesthesia providers' perspectives on abortion provision: deductive findings from a qualitative study.

INTRODUCTION: A clinician's willingness to provide abortion care is complex. Anesthesia providers' experiences in providing anesthesia for abortion are not well studied. We aimed to explore anesthesia providers' perspectives on abortion provision. METHODS: We conducted semi-structured, qualitative interviews with currently practising anesthesia providers in the southeastern United States. Participants were recruited from scientific meetings of two regional anesthesiology organizations and via snowball sampling. A semi-structured interview guide included domains of standardized second trimester abortion cases and personal abortion attitudes. Data were coded and analyzed iteratively using both inductive and deductive approaches with MAXQDA software. Deductive results are presented. RESULTS: Fifteen participants completed interviews from February 2018 to February 2019, at which point thematic saturation occurred. Participants represented a range of provider type, years of experience, workplace setting, and prior abortion experience. Participants demonstrated varied personal abortion attitudes, with greater acceptability of maternal or fetal health indications than social or financial indications for abortion. Most participants were willing to provide anesthesia for abortion in specific clinical scenarios. CONCLUSIONS: Southeastern United States anesthesia providers hold a spectrum of personal views on abortion and are willing to provide anesthesia for second trimester abortion in specific clinical scenarios. Findings may inform future research or professional development activities, which are important efforts toward improving multidisciplinary abortion care.

Improve the clinical effective decision of the oral feeding readiness in preterm infants: Revise and validate the TC-POFRAS.

BACKGROUND: Currently there is limited information to guide health professionals regarding the optimal time frame to initiate safe and effective oral feedings to preterm infants. The study aims to revise and validate a streamlined version of the Traditional Chinese-Preterm Oral Feeding Readiness Assessment Scale, the TC-POFRAS®, and evaluate its construct validity in the clinical decisions regarding feeding readiness of preterm infants. METHODS: Eighty-one clinically stable preterm infants were assessed using the TC-POFRAS for oral feeding readiness. Item-total correlation analysis was used to check if any item was inconsistent with the averaged TC-POFRAS scores. Cronbach's α coefficient was used to evaluate the inter-item consistency. Exploratory factor analysis was used to determine the coherence of variables to reorganize assessment domains. The revised version of TC-POFRAS (TC-POFRAS®) was developed and a new cut-off score based on discriminant accuracy was established. RESULTS: Based on the results from statistical analysis, five items ("lips posture," "tongue posture," "biting reflex," "gag reflex," and "tongue cupping") were deleted from the original TC-POFRAS to form the TC-POFRAS®. The TC-POFRAS®'s global accuracy was 92.1%. The cut-off value of 19 was the one that presented the most optimization of sensitivity based on specificity. The TC-POFRAS® was reconstructed into corrected gestational age and five behavioral domains. CONCLUSIONS: The TC-POFRAS® is considered a valid, safe, and accurate objective instrument to assist health professionals to initiate oral feeding of preterm infants.

The Effective Management of Idiopathic Intracranial Hypertension Delivered by In-person and Virtual Group Consultations: Results and Reflections from a Phase One Service Delivery.

The increasing incidence of idiopathic intracranial hypertension (IIH) with the obesity epidemic is leading to increased pressures on service capacity. Evidence shows that group consultations (GCs) deliver effective, person-centred healthcare, but the feasibility for IIH is unknown. We set out to develop and test a safe and effective GC service for IIH. Through an interactive approach, we co-designed a bespoke in-person and virtual GC model, where patients are reviewed in a group setting. Improvements were made following each session following patient input and team reflections. Outcomes measured included patient satisfaction, self-perceived health literacy, and successful implementation of the GCs. During the pilot, eight in-person GCs were delivered: once-monthly (Oct-Dec 2019), then twice-monthly (Jan-Feb 2020). Feedback was received from 49/53 patients. 100% felt more satisfied and heard, 100% felt more involved in decision-making, 98% had a better understanding of their condition, 96% felt more able to cope with their condition and keep themselves healthy, 94% rated this as a positive experience, and 90% reported improved access and more time with their clinician compared with existing 1:1 appointments. Since September 2020, in response to the COVID-19 pandemic, we transitioned to weekly virtual GCs, receiving overwhelmingly positive feedback (median scores: patient satisfaction 9.5/10; being listened to by clinician 10/10; involved by clinician in treatment decisions 10/10; clinician explanation of treatment 10/10; and opportunity to discuss condition or treatment 10/10). GCs are safe and effective for IIH, and preferred in our patient cohort. This allowed ongoing high-quality, person-centred care despite challenges from the COVID-19 pandemic.

Benefit of pazopanib in advanced gastrointestinal stromal tumours: results from a phase II trial (SSG XXI, PAGIST).

BACKGROUND: Patients with advanced gastrointestinal stromal tumours (GISTs) resistant to the tyrosine kinase inhibitors imatinib and sunitinib may be treated with regorafenib, which resulted in a median progression-free survival (PFS) of 4.8 months in the GRID trial. Also, pazopanib, another tyrosine kinase inhibitor, has been studied in a randomized, placebo-controlled trial (PAZOGIST) in the third line, which showed a PFS of 45.2% 4 months after study entry, but patients intolerant to sunitinib were also included. We designed another trial evaluating pazopanib, enrolling only patients with progression on both imatinib and sunitinib. PATIENTS AND METHODS: Since all eligible patients had progressive disease, we preferred a non-randomized, phase II multicentre trial so that all patients could receive a potentially active drug. Patients had a progressive metastatic or locally advanced GIST and were ≥18 years of age, with a performance status of 0-2, and sufficient organ functions. The primary endpoint was disease control rate (defined as complete remission + partial remission + stable disease) at 12 weeks on pazopanib. A Simon's two-stage analysis was used with an interim analysis 12 weeks after enrollment of the first 22 patients, and if passed, there was a full enrolment of 72 patients. GIST mutational analysis was done, and most patients had pazopanib plasma concentration measured after 12 weeks. RESULTS: Seventy-two patients were enrolled. The disease control rate after 12 weeks was 44%, and the median PFS was 19.6 weeks (95% confidence interval 12.6-23.4 weeks). Pazopanib-related toxicity was moderate and manageable. No statistically significant differences were found related to mutations. Plasma concentrations of pazopanib had a formal but weak correlation with outcome. CONCLUSION: Pazopanib given in the third line to patients with GIST progressing on both imatinib and sunitinib was beneficial for about half of the patients. The PAGIST trial confirms the results from the PAZOGIST trial, and the median PFS achieved seems comparable to the PFS achieved with regorafenib in the third-line setting.

Associations between perceived discrimination and contraceptive method use: why we need better measures of discrimination in reproductive healthcare.

Discrimination has historically contributed to coercive contraceptive in the United States. We investigated associations between perceived discrimination, or the perception of unequal treatment in everyday life, and contraceptive method use among U.S. women. We analyzed population-based data from a 2013 study of U.S. women who were premenopausal, age 18-50, sexually active with a male partner in the last year and were not attempting pregnancy. Perceived discrimination was measured using the Everyday Discrimination Scale. Contraceptive method use was categorized into five method categories: permanent, highly effective reversible, moderately effective, barrier and no method. We analyzed relationships between perceived discrimination and contraceptive method use with several regression models, controlling for covariates. Among 539 women in our analytic sample, those with high perceived discrimination had lower incomes, less educational attainment and were less likely to be insured. Perceived discrimination was associated with a reduced odds of using any contraceptive method (aOR 0.43, CI 0.21-0.87, p < .001). Contraceptive method users with high perceived discrimination had an increased odds of using highly effective reversible methods versus moderately effective methods (aOR 5.28, CI 1.63-17.07 p = < .001). Women who perceived discrimination were at risk for contraceptive nonuse; however, among contraceptive users, perceived discrimination was associated with the use of more effective reversible methods.

Suppression of decoherence tied to electron-phonon coupling in telecom-compatible quantum dots: low-threshold reappearance regime for quantum state inversion.

We demonstrate suppression of dephasing tied to deformation potential coupling of confined electrons to longitudinal acoustic (LA) phonons in optical control experiments on large semiconductor quantum dots (QDs) with emission compatible with the low-dispersion telecommunications band at 1.3 µm. By exploiting the sensitivity of the electron-phonon spectral density to the size and shape of the QD, we demonstrate a fourfold reduction in the threshold pulse area required to enter the decoupled regime for exciton inversion using adiabatic rapid passage (ARP). Our calculations of the quantum state dynamics indicate that the symmetry of the QD wave function provides an additional means to engineer the electron-phonon interaction. Our findings will support the development of solid-state quantum emitters in future distributed quantum networks using semiconductor QDs.

Hydrogel particles improve detection of SARS-CoV-2 RNA from multiple sample types.

Here we present a rapid and versatile method for capturing and concentrating SARS-CoV-2 from contrived transport medium and saliva samples using affinity-capture magnetic hydrogel particles. We demonstrate that the method concentrates virus from 1 mL samples prior to RNA extraction, substantially improving detection of virus using real-time RT-PCR across a range of viral titers (100-1,000,000 viral copies/mL) and enabling detection of virus using the 2019 nCoV CDC EUA Kit down to 100 viral copies/mL. This method is compatible with commercially available nucleic acid extraction kits (i.e., from Qiagen) and a simple heat and detergent method that extracts viral RNA directly off the particle, allowing a sample processing time of 10 min. We furthermore tested our method in transport medium diagnostic remnant samples that previously had been tested for SARS-CoV-2, showing that our method not only correctly identified all positive samples but also substantially improved detection of the virus in low viral load samples. The average improvement in cycle threshold value across all viral titers tested was 3.1. Finally, we illustrate that our method could potentially be used to enable pooled testing, as we observed considerable improvement in the detection of SARS-CoV-2 RNA from sample volumes of up to 10 mL.

Diagnosis and management of tropomyosin receptor kinase (TRK) fusion sarcomas: expert recommendations from the World Sarcoma Network.

Sarcomas are a heterogeneous group of malignancies with mesenchymal lineage differentiation. The discovery of neurotrophic tyrosine receptor kinase (NTRK) gene fusions as tissue-agnostic oncogenic drivers has led to new personalized therapies for a subset of patients with sarcoma in the form of tropomyosin receptor kinase (TRK) inhibitors. NTRK gene rearrangements and fusion transcripts can be detected with different molecular pathology techniques, while TRK protein expression can be demonstrated with immunohistochemistry. The rarity and diagnostic complexity of NTRK gene fusions raise a number of questions and challenges for clinicians. To address these challenges, the World Sarcoma Network convened two meetings of expert adult oncologists and pathologists and subsequently developed this article to provide practical guidance on the management of patients with sarcoma harboring NTRK gene fusions. We propose a diagnostic strategy that considers disease stage and histologic and molecular subtypes to facilitate routine testing for TRK expression and subsequent testing for NTRK gene fusions.

The role of health anxiety in the experience of perceived stress across the menstrual cycle.

Background: Hormonal variation throughout the menstrual cycle influences physiological and psychological symptoms, although not for all women. Individual differences in health anxiety (HA) might help to explain the differences in physiological and psychological symptoms and perceived stress observed across women. Design: We examined the moderating role of HA in the relation between menstrual phase and premenstrual symptom severity and perceived stress. Methods: A total of 38 women completed visits in both late luteal and follicular phases, with visit order randomized. Menstrual phase was verified using day-count, a luteinizing hormone test, and progesterone assay. Results: Linear mixed models revealed that women experienced more premenstrual symptoms during the late luteal phase vs. the follicular phase; however, HA did not moderate this effect. There was a significant HA × menstrual cycle phase interaction for perceived stress. During the late luteal phase, women with higher HA reported greater perceived stress compared to women with lower HA. In the follicular phase, women with higher and lower HA reported similar levels of perceived stress. Conclusion: Higher levels of HA may play a role in the experience of perceived stress in specific phases of the menstrual cycle.

Risk factors for oral health in young, urban, Aboriginal and Torres Strait Islander children.

BACKGROUND: The caries process follows a strong social gradient which can commence in the first years of life. Yet data on young children remain limited. This study reports the potential risk factors and indicators in urban, Aboriginal and Torres Strait Islander children aged less than 5 and estimates the prevalence of caries. METHODS: Demographic and risk factor and risk indicator data were collected at baseline in a cohort study of children attending a health clinic in north Brisbane. Dentulous children received a basic oral examination to explore the presence of decayed, missing and filled teeth (dmft). Descriptive analyses were performed. A backwards stepwise logistic regression model was performed to identify potential associations with dmft status. RESULTS: In this study, 180 children enrolled: 111 children received the oral examination, of whom 14 (12.6%) (mean age 35 months) were estimated to have dmft >0. There was a high prevalence of socio-economic, dietary and behavioural risk factors/indicators present for children. Due to the small sample size, planned regression was not performed. CONCLUSIONS: Overall, the prevalence of risk factors and risk indicators for caries in the study population is high. More culturally appropriate resources that support preventive care need to be invested before children are school aged.

PTSD in women is associated with a block in conversion of progesterone to the GABAergic neurosteroids allopregnanolone and pregnanolone measured in plasma.

There is a need to identify new and more effective treatments for posttraumatic stress disorder (PTSD). Allopregnanolone and its stereoisomer pregnanolone (together termed ALLO) are metabolites of progesterone that positively and allosterically modulate GABA effects at GABAA receptors, thereby reducing anxiety and depression. Previous research revealed that women with PTSD had low cerebrospinal fluid (CSF) ALLO levels and a low ratio of ALLO to the allopregnanolone precursor 5α-DHP, consistent with deficient activity of the ALLO synthetic enzyme 3α-hydroxysteroid dehydrogenase (3α-HSD). The current study examined ALLO and the ratio of ALLO to 5α-DHP in plasma at rest and in response to psychophysiological stressors in trauma-exposed, medication-free women with and without PTSD. Participants were examined twice in random order during the early follicular phase (eFP) and mid-luteal phase (mLP) of the menstrual cycle. Plasma neurosteroids were measured using gas chromatography-mass spectrometry. Results indicate that the ALLO to 5α-DHP ratio in plasma increases between the eFP and mLP. In addition, women with PTSD have a lower ratio of ALLO to 5α-DHP than trauma-exposed healthy women, as well as blunted increases in this ratio in response to a moderately stressful laboratory procedure, i.e., differential fear conditioning, across the menstrual cycle. Clinically feasible testing for 3α-HSD dysfunction is critical to translating this line of research into clinical care. Measurement of this ratio in plasma could facilitate patient stratification in clinical treatment trials, as well as precision medicine targeting of treatments that address ALLO synthesis deficits in women with PTSD.

Genotype and risk of tumour rupture in gastrointestinal stromal tumour.

BACKGROUND: Tumour rupture is a strong predictor of poor outcome in gastrointestinal stromal tumours (GISTs) of the stomach and small intestine. The objective was to determine whether tumour genotype was associated with risk of rupture. METHODS: Rupture was classified according to the definition proposed by the Oslo Sarcoma Group. Since January 2000, data were registered retrospectively for all patients at Oslo University Hospital undergoing surgery for localized GIST of the stomach or small intestine. Tumour genotype was analysed by Sanger sequencing. RESULTS: Two hundred and nine patients with mutation data available were identified. Tumour rupture occurred in 37 patients. Among the 155 patients with KIT exon 11 mutations, an increased risk of rupture was observed with a deletion or insertion-deletion (25 of 86, 29 per cent) compared with substitutions (5 of 50, 10 per cent) or duplications/insertions (2 of 19, 11 per cent) (P = 0·014). Notably, rupture occurred in 17 of 46 tumours (37 per cent) with deletions involving codons 557 and 558 (del557/558) versus 15 of 109 (13·8 per cent) with other exon 11 mutations (P = 0·002). This association was confined to gastric tumours: 12 of 34 (35 per cent) with del557/558 ruptured versus six of 77 (8 per cent) with other exon 11 mutations (P = 0·001). In multivariable logistic regression analysis, del557/558 and tumour size were associated with an increased likelihood of tumour rupture, but mitotic count was not. CONCLUSION: Gastric GISTs with KIT exon 11 deletions involving codons 557 and 558 are at increased risk of tumour rupture. This high-risk feature can be identified in the diagnostic evaluation and should be included in the assessment when neoadjuvant imatinib treatment is considered.

Cannula cricothyroidotomy and rescue oxygenation with the Rapid-O2™ oxygen insufflation device in the management of a can't intubate/can't oxygenate scenario.

We describe the successful use of cannula cricothyroidotomy and the Rapid-O2™ oxygen insufflation device (Meditech Systems Ltd, Dorset, UK) for rescue of a can't intubate/can't oxygenate (CICO) scenario in a patient with severe airway haemorrhage post-debridement of laryngeal amyloidosis. This case highlights the practical utility of a cannula technique for CICO rescue when appropriate equipment is used and when institutional measures are taken to prepare for this rare anaesthetic crisis.

3D gait analysis with and without an orthopedic walking boot.

INTRODUCTION: Orthopedic walking boots have been widely used in place of traditional fiberglass casts for a variety of orthopedic injuries and post-surgical interventions. These walking boots create a leg length discrepancy (LLD). LLD has been shown to alter the kinematics and kinetics of gait and are associated with lumbar and lower limb conditions such as: foot over pronation, low back pain, scoliosis, and osteoarthritis of the hip and knee joints. Past gait analyses research with orthopedic boots is limited to findings on the ipsilateral limb. Thus, the purpose of the study was to examine bilateral gait kinematics & kinetics with and without a walking boot. METHODS: Forty healthy participants (m=20, f=20, age 20.7±1.8 yrs., ht. 171.6±9.5cm, wt. 73.2±11.0kg, BMI 24.8±3.2) volunteered. An eight camera Vicon Motion Capture System with PIG model and two AMTI force plates were utilized to record the walking trial conditions: (1) bilateral tennis shoes (2) boot on right foot, tennis shoe on left foot (3) boot on right foot, barefoot on left foot. Data were processed in Nexus 2.2.3 and exported to Visual 3D for analysis. RESULTS: When wearing the boot, there were significant differences in most joint angles and moments, with larger effects on long limb. CONCLUSION: The walking boot alters the gait in the same way as those with existing LLD, putting them at risk for development of secondary knee, hip, and low back pain during treatment protocol.

A review of the carbohydrate-insulin model of obesity.

This corrects the article DOI: 10.1038/ejcn.2017.21.