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This qualitative study explores player and stakeholder perceptions of menstrual health support in elite female soccer.Semi-structured interviews were conducted with 47 participants including players (n = 12), parents (n = 9), coaches (n = 9), sport scientists (n = 7), nutritionists (n = 5) and medical staff (n = 5).Via thematic analysis, data demonstrate that elite female soccer players experience a range of physical and psychological symptoms primarily at the onset of and during menses (as also perceived by stakeholders), with most participants perceiving these symptoms to impact performance. Nonetheless, menstrual health support is perceived as minimal and although players have their menstrual status tracked, they report little understanding as to why or how this information is used. This confusion was also present among stakeholders, often as a result of uncertainty about the evidence supporting the need for menstrual health support. The perceived lack of support may also be reflective of a culture where conversations about the menstrual cycle are not normalised. Overall, this may result in failure to identify and treat menstrual irregularities despite non-coaching staff members perceiving them to be common amongst players.These data support the need for individualised support based on the lived experiences of individual players and support staff. Furthermore, our research identifies the need for organisational, stakeholder, and player centred education programmes (led by experts in female athlete health) that create an environment where players receive personalised menstrual health support.

Frequency of PD-L1 expression and the role of immunotherapy in malignant peritoneal mesothelioma (MPM) have not been well characterized. The purpose of this study was to determine PD-L1 expression in patients with MPM and perform an exploratory analysis for associations between PD-L1 and its biological behavior in MPM.Tumor samples were collected from patients undergoing surgical interventions between January 2018 and June 2020. Specimens were stained with anti-PD-L1 antibodies (Dako 22c3) and positivity was determined by tumor proportion score (TPS) or combined positive score (CPS) being ≥1%.Twenty one samples were obtained from 21 patients. Sixteen of 21 (76%) samples were CPS positive and 9 of 21 (43%) were TPS positive. Three samples had more aggressive biphasic/sarcomatoid histology and a high CPS and TPS (CPS: 3, 75, 95%; TPS: 2, 60, 90%). On an exploratory analysis, as the CPS or TPS threshold increased, there was a trend towards worse survival.MPM has a high frequency of PD-L1 expression, which may be associated with more aggressive tumor biology. These data provide the foundation for continued evaluation of checkpoint inhibition in patients with MPM.

The physiological effects of low energy availability (EA) have been studied using a homogenous daily EA pattern in laboratory settings. However, whether this daily EA pattern represents those of free-living athletes and is therefore ecologically valid is unknown. To investigate this, we assessed daily exercise energy expenditure, energy intake and EA in 10 free-living elite male road cyclists (20 min Mean Maximal Power: 5.27 ± 0.25 W · kg−1) during 7 consecutive days of late pre-season training. Energy intake was measured using the remote-food photography method and exercise energy expenditure estimated from cycling crank-based power-metres. Seven-day mean ± SD energy intake and exercise energy expenditure was 57.9 ± 10.4 and 38.4 ± 8.6 kcal · kg FFM−1 · day−1, respectively. EA was 19.5 ± 9.1 kcal · kg FFM−1 · day−1. Within-participants correlation between daily energy intake and exercise energy expenditure was .62 (95% CI: .43 – .75; P < .001), and .60 (95% CI: .41 – .74; P < .001) between carbohydrate intake and exercise energy expenditure. However, energy intake only partially compensated for exercise energy expenditure, increasing 210 kcal · day−1 per 1000 kcal · day−1 increase in expenditure. EA patterns displayed marked day-to-day fluctuation (range: −22 to 76 kcal · kg FFM−1 · day−1). The validity of research using homogenous low EA patterns therefore requires further investigation.

Context Exaggerated postprandial incretin and insulin responses are well documented in postbariatric surgery hypoglycemia (PBH) after Roux-en-Y gastric bypass (RYGB). However, less is known about PBH after sleeve gastrectomy (SG). Objective We sought to compare meal-stimulated hormonal response in those with PBH after SG vs RYGB. Methods We enrolled 23 post-SG (12 with and 11 without PBH) and 20 post-RYGB (7 with and 13 without PBH) individuals who underwent bariatric surgery at our institution. PBH was defined as plasma glucose less than 60 mg/dL on 4-hour mixed-meal tolerance test (MTT). Islet and incretin hormones were compared across the 4 groups. Results Participants (N = 43) were on average 5 years post surgery, with a mean age of 48 years, mean preoperative body mass index of 48.4, 81% female, 61% White, and 53% post SG. Regardless of PBH, the SG group showed lower glucose, glucagon, and glucagon-like peptide 1 (GLP-1) responses to MTT and similar insulin and glucose-dependent insulinotropic polypeptide (GIP) responses compared to the RYGB group. Among those with PBH, the SG group following the MTT showed a lower peak glucose (P = .02), a similar peak insulin (90.3 mU/L vs 171mU/L; P = .18), lower glucagon (P Conclusion Among individuals with PBH, those who underwent SG were significantly different compared to RYGB in meal-stimulated hormonal responses, including lower glucagon and GLP-1 responses, but similar insulin and GIP responses. Future studies are needed to better understand the differential contribution of insulin and non–insulin-mediated mechanisms behind PBH after SG vs RYGB.

OBJECTIVES: People with HIV (PWH) are at increased risk for premature cardiovascular disease (CVD). Clonal hematopoiesis is a common age-related condition that may be associated with increased CVD risk. The goal of this study was to determine the prevalence of clonal hematopoiesis and its association with chronic inflammation and CVD in PWH. DESIGN: Cross-sectional study utilizing archived specimens and data from 118 men (86 PWH and 32 HIV-uninfected) from the Baltimore-Washington DC center of the Multicenter AIDS Cohort Study (MACS) who had had coronary computed tomography angiography (CTA) and measurement of 34 serologic inflammatory biomarkers. METHODS: Clonal hematopoiesis was assessed on peripheral blood mononuclear cells utilizing targeted error-corrected next generation sequencing (NGS) focused on 92 genes frequently mutated in hematologic malignancies. Clinical and laboratory data were obtained from the MACS database. RESULTS: Clonal hematopoiesis with a variant allele frequency (VAF) greater than 1% was significantly more common in PWH [20/86 (23.3%)] than in HIV-uninfected men [2/32 (6.3%)] (P = 0.035). PWH with clonal hematopoiesis (VAF > 1%) were more likely to have coronary artery stenosis of at least 50% than those without clonal hematopoiesis [6/20 (30%) vs. 6/64 (9%); P = 0.021]. Presence of clonal hematopoiesis was not significantly associated with serological inflammatory markers, except for significantly lower serum leptin levels; this was not significant after adjustment for abdominal or thigh subcutaneous fat area. CONCLUSION: Clonal hematopoiesis was more common in PWH and among PWH was associated with the extent of coronary artery disease. Larger studies are needed to further examine the biological and clinical consequences of clonal hematopoiesis in PWH.

The COVID-19 pandemic has caused health professionals to deal with new situations they have not encountered before. Nurses were forced to cope with increased workloads, seriously ill patients, numerous patient deaths, and unresolved ethical dilemmas. This study aimed to examine the lived experiences of nurses across Europe during the first wave of the COVID-19 pandemic. This was a qualitative narrative research study. Eighteen nurses from eight European countries (four each from the UK and Israel, three from Portugal, two each from the Netherlands and Ireland, and one each from Belgium, Italy, and Sweden) submitted narratives about their professional experiences during May-June 2020. The narratives were analyzed using thematic analysis. Seven categories across the narratives were condensed and interpreted into three themes: opportunities and growth, care management, and emotional and ethical challenges. The COVID-19 pandemic has affected nurses emotionally and provided an opportunity to actively develop systems and skills needed to minimize harm and maximize benefits to patients and nurses.

Despite advances in precision medicine, the clinical prospects for patients with ovarian and uterine cancers have not substantially improved. Here, we analyzed genome-scale CRISPR-Cas9 loss-of-function screens across 851 human cancer cell lines and found that frequent overexpression of SLC34A2-encoding a phosphate importer-is correlated with sensitivity to loss of the phosphate exporter XPR1, both in vitro and in vivo. In patient-derived tumor samples, we observed frequent PAX8-dependent overexpression of SLC34A2, XPR1 copy number amplifications and XPR1 messenger RNA overexpression. Mechanistically, in SLC34A2-high cancer cell lines, genetic or pharmacologic inhibition of XPR1-dependent phosphate efflux leads to the toxic accumulation of intracellular phosphate. Finally, we show that XPR1 requires the novel partner protein KIDINS220 for proper cellular localization and activity, and that disruption of this protein complex results in acidic "vacuolar" structures preceding cell death. These data point to the XPR1-KIDINS220 complex and phosphate dysregulation as a therapeutic vulnerability in ovarian cancer.

BackgroundVitamin D has immunomodulatory effects, but any association with herpes zoster (HZ) is unclear.AimTo explore the association between vitamin D status and risk of incident HZ in adults in the UK.Design and settingA cohort study involving participants of UK Biobank (a database containing the health information from half a million individuals) across England, Wales, and Scotland, who had at least one vitamin D testing result with linked primary care electronic health records.MethodThe primary exposure was vitamin D status, categorised as deficient (ResultsIn total, 177 572 eligible participants were included in the analysis, with a mean follow-up time of 10.1 years (standard deviation 1.9 years). No evidence showed that low vitamin D was associated with a higher incidence of HZ, compared with people with sufficient vitamin D (deficient: adjusted hazard ratio [HR] 0.99, 95% confidence interval [CI] = 0.90 to 1.10; insufficient: HR 1.03, 95% CI = 0.96 to 1.10). No evidence was found that supplementing vitamin D or receiving vitamin D prescription was associated with HZ incidence (supplementation: HR 0.88, 95% CI = 0.67 to 1.16; prescription: HR 1.11, 95% CI = 0.91 to 1.34).ConclusionNo association of vitamin D status, supplementation, or prescription with incident HZ was observed. No evidence supported vitamin D supplementation as a strategy to prevent HZ.

To identify the incidence of Obstetric Cholestasis in a Maternity unit. To compare our investigation, criteria for diagnosis and management plan with National Guidelines. To assess adverse maternal and neonatal outcomes associated with this condition.Serum Bile Acid requests are sent to an external laboratory, Biomnis in Dublin, for processing. A log of 2018 requests was obtained from Biochemistry. The pregnant patients with values 8 mmol/L were selected. A data collection proforma was designed and retrospective chart review performed.Of the 1302 births in SUH in 2018, 42 women met the criteria resulting in a suspected incidence of 3.2% (n = 42). 9.5%(n = 4) of patients had a history of OC in a previous pregnancy. Bile acid values ranged from 8.1 to 124 mmol/L. LFTs were deranged in 81% (n = 34) of patients. Gestation at delivery ranged from 35 weeks to 40 + 9. OC alone was the indication for induction in 57%9n = 24). CS in 43% (n = 20) and Vaginal birth in 57% (n = 25). Neonatal outcome: 7% (n = 3) reduced APGAR, 7% (n = 3) passed meconium, 9% (n = 4) NICU admission, no stillbirths.Suspected incidence of 3.2% (n = 42) is significantly higher than the stated 0.7% across multi-ethnic populations. Greater congruence is required on the BA cut off value for diagnosis as there is no specified value in guidelines. While we may be over diagnosing patients based on BA level, we are also undertreating them, with 55% (n = 23) receiving Ursofalc. There was no neonatal mortality.

Purpose The force–velocity relationship of muscular contraction has been extensively studied. However, previous research has focussed either on isolated muscle or single-joint movements, whereas human movement consists of multi-joint movements (e.g. squatting). Therefore, the purpose of this study was to investigate the force–velocity relationship of isovelocity squatting. Methods Fifteen male participants (24 ± 2 years, 79.8 ± 9.1 kg, 177.5 ± 6 cm) performed isovelocity squats on a novel motorised isovelocity device (Kineo Training System) at three concentric (0.25, 0.5, and 0.75 m s−1) and three eccentric velocities (− 0.25, − 0.5, and − 0.75 m s−1). Peak vertical ground reaction forces, that occurred during the isovelocity phase, were collected using dual force plates (2000 Hz) (Kistler, Switzerland). Results The group mean squat force–velocity profile conformed to the typical in vivo profile, with peak vertical ground reaction forces during eccentric squatting being 9.5 ± 19% greater than isometric (P = 0.037), and occurring between − 0.5 and − 0.75 m s−1. However, large inter-participant variability was identified (0.84–1.62 × isometric force), with some participants being unable to produce eccentric forces greater than isometric. Sub-group analyses could not identify differences between individuals who could/could not produce eccentric forces above isometric, although those who could not tended to be taller. Conclusions These finding suggest that variability exists between participants in the ability to generate maximum eccentric forces during squatting, and the magnitude of eccentric increase above isometric cannot be predicted solely based on a concentric assessment. Therefore, an assessment of eccentric capabilities may be required prior to prescribing eccentric-specific resistance training.

Contains fulltext : 237219.pdf (Publisher’s version ) (Open Access) Objective: To describe characteristics of randomised controlled trials (RCTs) conducted using electronic health records (EHRs), including completeness and transparency of reporting assessed against the 2021 CONSORT Extension for RCTs Conducted Using Cohorts and Routinely Collected Data (CONSORT-ROUTINE) criteria. Study design: MEDLINE and Cochrane Methodology Register were searched for a sample of RCTs published from 2011–2018. Completeness of reporting was assessed in a random sample using a pre-defined coding form. Results 183 RCT publications were identified; 122 (67%) used EHRs to identify eligible participants, 139 (76%) used the EHR as part of the intervention and 137 (75%) to ascertain outcomes. When 60 publications were evaluated against the CONSORT 2010 item and the corresponding extension for the 8 modified items, four items were 'adequately reported' for the majority of trials. Five new reporting items were identified for the CONSORT-ROUTINE extension; when evaluated, one was 'adequately reported', three were reported 'inadequately or not at all', the other 'partially'. There were, however, some encouraging signs with adequate and partial reporting of many important items, including descriptions of trial design, the consent process, outcome ascertainment and interpretation. Conclusion: Aspects of RCTs using EHRs are sub-optimally reported. Uptake of the CONSORT-ROUTINE Extension may improve reporting. 12 p.

BACKGROUND Increasing interest in physiological pacing has been countered with challenges such as accurate lead deployment and increasing pacing thresholds with His-bundle pacing (HBP). More recently, left bundle branch area pacing (LBBAP) has emerged as an alternative approach to physiologic pacing. OBJECTIVE To compare procedural outcomes and pacing parameters at follow-up during initial adoption of HBP and LBBAP at a single center. METHODS Retrospective review, from September 2016 to January 2020, identified the first 50 patients each who underwent successful HBP or LBBAP. Pacing parameters were then assessed at first follow-up after implantation and after approximately one year, evaluating for acceptable pacing parameters defined as sensing R-wave amplitude >5 mV, threshold

Eczema and asthma are allergic diseases and two of the commonest chronic conditions in high-income countries. Their co-existence with other allergic conditions is common, but little research exists on wider multimorbidity with these conditions. We set out to identify and compare clusters of multimorbidity in people with eczema or asthma and people without. Using routinely-collected primary care data from the U.K. Clinical Research Practice Datalink GOLD, we identified adults ever having eczema (or asthma), and comparison groups never having eczema (or asthma). We derived clusters of multimorbidity from hierarchical cluster analysis of Jaccard distances between pairs of diagnostic categories estimated from mixed-effects logistic regressions. We analysed 434,422 individuals with eczema (58% female, median age 47 years) and 1,333,281 individuals without (55% female, 47 years), and 517,712 individuals with asthma (53% female, 44 years) and 1,601,210 individuals without (53% female, 45 years). Age at first morbidity, sex and having eczema/asthma affected the scope of multimorbidity, with women, older age and eczema/asthma being associated with larger morbidity clusters. Injuries, digestive, nervous system and mental health disorders were more commonly seen in eczema and asthma than control clusters. People with eczema and asthma of all ages and both sexes may experience greater multimorbidity than people without eczema and asthma, including conditions not previously recognised as contributing to their disease burden. This work highlights areas where there is a critical need for research addressing the burden and drivers of multimorbidity in order to inform strategies to reduce poor health outcomes.

There is evidence of benefit to patients from transitional care and medical respite programs that does not substantially increase the overall societal cost of care; however, health systems commonly require evidence of cost savings and benefit as a return on investment.

Objective To investigate the presence, degree, predictors and trajectory of dysphagia, dysphonia and dysarthria amongst adults hospitalised with COVID-19 across the Republic of Ireland (ROI) during the first wave of the pandemic. Study design Prospective observational cohort study METHODS: Adults with confirmed COVID-19 who were admitted into fourteen participating acute hospitals across ROI and referred to speech and language therapy between March 1st to June 30th 2020 were recruited. Outcomes obtained at initial SLT evaluation and at discharge were oral intake status (Functional Oral Intake Scale), perceptual voice quality (GRBAS), and global dysarthria rating (Dysarthria Severity Scale). Results Data from 315 adults were analysed. At initial SLT assessment, 84% required modified oral diets, and 31% required tube feeding. There were high rates of dysphonia (42%) and dysarthria (23%). History of intubation (OR 19.959, 95% CI 6.272, 63.513; p=.000), COVID-19 neurological manifestations (OR 3.592, 95% CI 1.733, 7.445; p=.001) and age (OR 1.034; 95% CI 1.002, 1.066; p=0.036) were predictive of oral intake status. History of intubation was predictive of voice quality (OR 4.250, 95% CI 1.838, 9.827; p=.001) and COVID-19 neurological manifestations were predictive of dysarthria (OR 2.275; 95% CI 1.162, 4.456; p=0.017). At discharge, there were significant improvements in oral intake (Z=-7.971; p=.000), voice quality (Z=-5.971; p=.000), and dysarthria severity (Z=-2.619; p=0.009), although need for modified oral intake (59%), dysphonia (23%) and dysarthria (14%) persisted. Conclusion Dysphagia, dysphonia and dysarthria were widespread amongst adults hospitalised with COVID-19 and they persisted for many at discharge. Prompt SLT evaluation is required to minimise complications. This article is protected by copyright. All rights reserved.

BackgroundOral prednisolone is the mainstay treatment for bullous pemphigoid, an autoimmune blistering skin disorder affecting older people. Treatment with moderate-to-high doses is often initiated in secondary care, but then continued in primary care.AimTo describe long-term oral prednisolone prescribing in UK primary care for adults with bullous pemphigoid from 1998 to 2017.Design and settingA prospective cohort study using routinely collected data from the Clinical Practice Research Datalink, a primary care database containing the healthcare records for over 17 million people in the UK.MethodOral prednisolone exposure was characterised in terms of the proportion of individuals with incident bullous pemphigoid prescribed oral prednisolone following their diagnosis, and the duration and dose of prednisolone.ResultsIn total, 2312 (69.6%) of 3322 people with bullous pemphigoid were prescribed oral prednisolone in primary care. The median duration of exposure was 10.6 months (interquartile range [IQR] 3.4–24.0). Of prednisolone users, 71.5% were continuously exposed for >3 months, 39.7% for >1 year, 14.7% for >3 years, 5.0% for >5 years, and 1.7% for >10 years. The median cumulative dose was 2974 mg (IQR 1059–6456). Maximum daily doses were ≥10 mg/day in 74.4% of prednisolone users, ≥20 mg/day in 40.7%, ≥30 mg/day in 18.2%, ≥40 mg/day in 6.6%, ≥50 mg/day in 3.8%, and ≥60 mg/day in 1.9%.ConclusionA high proportion of people with incident bullous pemphigoid are treated with oral prednisolone in UK primary care. Action is required by primary and second care services to encourage use of steroid-sparing alternatives and, where switching is not possible, ensure prophylactic treatments and proactive monitoring of potential side effects are in place.

Background Current clinical post-mortem imaging techniques do not provide sufficiently high-resolution imaging for smaller fetuses after pregnancy loss. Post-mortem micro-CT is a non-invasive technique that can deliver high diagnostic accuracy for these smaller fetuses. The purpose of the study is to identify the main predictors of image quality for human fetal post-mortem micro-CT imaging. Methods Human fetuses were imaged using micro-CT following potassium tri-iodide tissue preparation, and axial head and chest views were assessed for image quality on a Likert scale by two blinded radiologists. Simple and multivariable linear regression models were performed with demographic details, iodination, tissue maceration score and imaging parameters as predictor variables. Results 258 fetuses were assessed, with median weight 41.7 g (2.6–350 g) and mean gestational age 16 weeks (11–24 weeks). A high image quality score (> 6.5) was achieved in 95% of micro-CT studies, higher for the head (median = 9) than chest (median = 8.5) imaging. The strongest negative predictors of image quality were increasing maceration and body weight (p Conclusions High micro-CT image quality score is achievable following early pregnancy loss despite fetal maceration, particularly in smaller fetuses where conventional autopsy may be particularly challenging. These findings will help establish clinical micro-CT imaging services, addressing the need for less invasive fetal autopsy methods.

Indirect excess morbidity in the COVID-19 pandemic may arise from public health risk-mitigation efforts such as stay-at-home orders and re-purposing of healthcare services1 . Increased mental health disorders and shortfalls in the care of long-term conditions are described.

BackgroundIncident diabetes risk is inversely proportional to 25-hydroxyvitamin D [25(OH)D] levels among non-Hispanic white but is unclear among African American (AA) populations. Serum 25(OH)D2 may be an important component of total 25(OH)D among AA populations due to higher levels of melanin.ObjectiveTo assess the association of serum 25(OH)D with incident diabetes among AAs and stratify by detectable 25(OH)D2.DesignSerum 25(OH)D2 and 25(OH)D3 were collected from 2000 to 2004 among AA participants in the Jackson Heart Study. A cosinor model was used to adjust for the seasonality of 25(OH)D3; 25(OH)D3 and 25(OH)D2 were combined to ascertain total 25(OH)D. Incident diabetes (fasting glucose ≥126 mg/dl, use of diabetes drugs, or HbA1c ≥6.5%) was assessed over 12 years among adults without diabetes at baseline. Participants with missing baseline covariates or diabetes follow-up were excluded. Hazard ratios (HR) were estimated using Cox modeling, adjusting for age, sex, education, occupation, smoking, physical activity, alcohol use, aldosterone, and body-mass index.ResultsAmong 3311 adults (mean age 53.3 years, 63% female) 584 participants developed diabetes over a median of 7.7 years. After adjustment, 25(OH)D ≥20 compared to n = 1671), 25(OH)D ≥ 20 ng/ml compared to ConclusionsHigher levels of 25(OH)D may be protective against the development of diabetes among AA individuals, particularly among those with detectable 25(OH)D2 and 25(OH)D3.

Refereed/Peer-reviewed Objectives: Ambiguity in communication of key study parameters limits the utility of real-world evidence (RWE) studies in healthcare decision-making. Clear communication about data provenance, design, analysis, and implementation is needed. This would facilitate reproducibility, replication in independent data, and assessment of potential sources of bias. Methods: The International Society for Pharmacoepidemiology (ISPE) and ISPOR–The Professional Society for Health Economics and Outcomes Research (ISPOR) convened a joint task force, including representation from key international stakeholders, to create a harmonized protocol template for RWE studies that evaluate a treatment effect and are intended to inform decision-making. The template builds on existing efforts to improve transparency and incorporates recent insights regarding the level of detail needed to enable RWE study reproducibility. The over-arching principle was to reach for sufficient clarity regarding data, design, analysis, and implementation to achieve 3 main goals. One, to help investigators thoroughly consider, then document their choices and rationale for key study parameters that define the causal question (e.g., target estimand), two, to facilitate decision-making by enabling reviewers to readily assess potential for biases related to these choices, and three, to facilitate reproducibility. Strategies to Disseminate and Facilitate Use: Recognizing that the impact of this harmonized template relies on uptake, we have outlined a plan to introduce and pilot the template with key international stakeholders over the next 2 years. Conclusion: The HARmonized Protocol Template to Enhance Reproducibility (HARPER) helps to create a shared understanding of intended scientific decisions through a common text, tabular and visual structure. The template provides a set of core recommendations for clear and reproducible RWE study protocols and is intended to be used as a backbone throughout the research process from developing a valid study protocol, to registration, through implementation and reporting on those implementation decisions.

ObjectiveTo assess implementation and ease of implementation of control measures in schools as reported by staff and parents.DesignA descriptive cross-sectional survey.SettingStaff and parents/guardians of the 132 primary schools and 19 secondary schools participating in COVID-19 surveillance in school kids (sKIDs and sKIDsPLUS Studies).Main outcome measurePrevalence of control measures implemented in schools in autumn 2020, parental and staff perception of ease of implementation.ResultsIn total, 56 of 151 (37%) schools participated in this study, with 1953 parents and 986 staff members completing the questionnaire. Most common measures implemented by schools included regular hand cleaning for students (52 of 56, 93%) and staff (70 of 73, 96%), as reported by parents and staff, respectively, and was among the easiest to implement at all times for students (57%) and even more so, for staff (78%). Maintaining 2-metre distancing was less commonly reported for students (24%–51%) as it was for staff (81%–84%), but was one of the most difficult to follow at all times for students (25%) and staff (16%) alike. Some measures were more commonly reported by primary school compared to secondary school parents, including keeping students within the same small groups (28 of 41, 68% vs 8 of 15, 53%), ensuring the same teacher for classes (29 of 41, 71% vs 6 of 15, 40%). On the other hand, wearing a face covering while at school was reported by three-quarters of secondary school parents compared with only parents of 4 of 41 (10%) primary schools. Other measures such as student temperature checks (5%–13%) and advising staff work from home if otherwise healthy (7%–15%) were rarely reported.ConclusionsVariable implementation of infection control measures was reported, with some easier to implement (hand hygiene) than others (physical distancing).

Scrotal and testicular masses can be broadly categorized into painful conditions, which include testicular torsion, torsion of the testicular appendage, and epididymitis, and painless conditions, which include hydrocele, varicocele, and testicular cancer. Testicular torsion is a urologic emergency requiring prompt surgical intervention to save the testicle, ideally within six hours of presentation when the salvage rate is about 90%. The Testicular Workup for Ischemia and Suspected Torsion score can be used to help physicians identify patients at high risk of torsion and those at lower risk who would benefit from imaging first. Torsion of the testicular appendage presents with gradual onset of superior unilateral pain, is diagnosed using ultrasonography, and is treated supportively with analgesics. Epididymitis is usually caused by infection with Chlamydia trachomatis, Neisseria gonorrhoeae, or enteric bacteria and is treated with antibiotics, analgesics, and scrotal support. Hydroceles are generally asymptomatic and are managed supportively. Varicoceles are also generally asymptomatic but may be associated with reduced fertility. It is uncertain if surgical or radiologic treatment of varicoceles in subfertile men improves the rate of live births. Testicular cancer often presents as a unilateral, painless mass discovered incidentally. Ultrasonography is used to evaluate any suspicious masses, and surgical treatment is recommended for suspected cancerous masses.

Combined immunotherapy is associated with a significant risk of severe and potentially fatal immune-related adverse events (irAEs). Therefore, we retrospectively analyzed the side profile and efficacy of low-dose ipilimumab (1 mg/kg, IPI1) combined with anti-PD-1 immunotherapy in patients who progressed after anti-PD-1 monotherapy. Nine patients with unresectable stage III or IV melanoma treated with combined low-dose ipilimumab (1 mg/kg, IPI1) and anti-PD-1 immunotherapy, following progression after anti-PD-1 treatment, were identified. Treatment response and irAEs were recorded. Grade 3 irAEs occurred in one-third of patients. Interestingly, there were no grade 4 or 5 irAEs. In fact, four out of the nine patients experienced no irAEs at all. One patient discontinued combined immunotherapy due to immune-related colitis. The mean time to the onset of grade 3 irAEs was 14.3 weeks. The objective response rate was 33.3% and a disease control rate of 66.7% was achieved. Median progression-free survival (PFS) was 5.7 months and median overall survival (OS) was 21.6 months. The median PFS when IPI1 and anti-PD-1 treatment was administered in the second-line setting was not reached, but only 2.8 months when used in subsequent treatment settings. Combined IPI1 and anti-PD-1 immunotherapy was well tolerated. Its use in the third-line or above setting was associated with a significantly poorer prognosis than in the second-line setting. Larger, prospective studies are required to evaluate the safety and efficacy of this dosing regimen following anti-PD-1 treatment failure.

BACKGROUND: Emerging evidence suggests an association between common inflammatory skin diseases and chronic kidney disease (CKD). OBJECTIVES: To explore the association between CKD stages 3-5 (CKD3-5) and atopic eczema, psoriasis, rosacea and hidradenitis suppurativa. METHODS: We undertook two complementary analyses; a prevalent case-control study and a cohort study using routinely collected primary care data [UK Clinical Practice Research Datalink (CPRD)]. We matched individuals with CKD3-5 in CPRD in March 2018 with up to five individuals without CKD for general practitioner practice, age and sex. We compared the prevalence of CKD3-5 among individuals with and without each inflammatory skin disease. We included individuals in CPRD with diabetes mellitus (2004-2018) in a cohort analysis to compare the incidence of CKD3-5 among people with and without atopic eczema and psoriasis. RESULTS: Our study included 56 602 cases with CKD3-5 and 268 305 controls. Cases were more likely than controls to have a history of atopic eczema [odds ratio (OR) 1·14, 99% confidence interval (CI) 1·11-1·17], psoriasis (OR 1·13, 99% CI 1·08-1·19) or hidradenitis suppurativa (OR 1·49, 99% CI 1·19-1·85), but were slightly less likely to have been diagnosed with rosacea (OR 0·92, 99% CI 0·87-0·97), after adjusting for age, sex, practice (matching factors), index of multiple deprivation, diabetes, smoking, harmful alcohol use and obesity. Results remained similar after adjusting for hypertension and cardiovascular disease. In the cohort with diabetes (N = 335 827), there was no evidence that CKD3-5 incidence was associated with atopic eczema or psoriasis. CONCLUSIONS: Atopic eczema, psoriasis and hidradenitis suppurativa are weakly associated with CKD3-5. Future research is needed to elucidate potential mechanisms and the clinical significance of our findings.

AimsAlternative alignment concepts, including kinematic and restricted kinematic, have been introduced to help improve clinical outcomes following total knee arthroplasty (TKA). The purpose of this study was to evaluate the clinical results, along with patient satisfaction, following TKA using the concept of restricted kinematic alignment.MethodsA total of 121 consecutive TKAs performed between 11 February 2018 to 11 June 2019 with preoperative varus deformity were reviewed at minimum one-year follow-up. Three knees were excluded due to severe preoperative varus deformity greater than 15°, and a further three due to requiring revision surgery, leaving 109 patients and 115 knees to undergo primary TKA using the concept of restricted kinematic alignment with advanced technology. Patients were stratified into three groups based on the preoperative limb varus deformity: Group A with 1° to 5° varus (43 knees); Group B between 6° and 10° varus (56 knees); and Group C with varus greater than 10° (16 knees). This study group was compared with a matched cohort of 115 TKAs and 115 patients using a neutral mechanical alignment target with manual instruments performed from 24 October 2016 to 14 January 2019.ResultsMean overall patient satisfaction for the entire cohort was 4.7 (SE 0.1) on a 5-point Likert scale, with 93% being either very satisfied or satisfied compared with a Likert of 4.3 and patient satisfaction of 81% in the mechanical alignment group (p < 0.001 and p < 0.006 respectively). At mean follow-up of 17 months (11 to 27), the mean overall Likert, Knee Injury and Osteoarthritis Outcome Score for Joint Replacement, Western Ontario and McMaster Universities Osteoarthritis Index, Forgotten Joint Score, and Knee Society Knee and Function Scores were significantly better in the kinematic group than in the neutral mechanical alignment group. The most common complication in both groups was contracture requiring manipulation under anaesthesia, involving seven knees (6.1%) in the kinematic group and nine knees (7.8%) in the mechanical alignment group.ConclusionWith the advent of advanced technology, and the ability to obtain accurate bone cuts, the target limb alignment, and soft-tissue balance within millimetres, using a restricted kinematic alignment concept demonstrated excellent patient satisfaction following primary TKA. Longer-term analysis is required as to the durability of this method. Cite this article: Bone Joint J 2021;103-B(6 Supple A):59–66.

Intimate partner violence (IPV) frequently leads to housing instability and homelessness among survivors. While the client populations of many housing support programs are likely to include IPV survivors who have unique safety needs, the organizational readiness of these housing providers to identify and support IPV survivors is not clear. This study assessed organizational readiness for IPV response among Rapid Re-Housing (RRH) and Transitional Housing (TH) providers in Maryland, whose client populations include women ( n = 32). We adapted the Physician Readiness to Manage Intimate Partner Violence Survey (PREMIS) to create the Housing provider Readiness to Manage IPV Survey (H-REMIS), inclusive of IPV-related perceptions, policies, staff training and capability, and resources. The 12-point H-REMIS demonstrated acceptable internal consistency reliability (Cronbach’s α = 0.748). Descriptive and comparative analyses domains by IPV-specific ( n = 4) and general ( n = 28) housing providers assessed readiness and identified areas for improvement. IPV-specific providers had higher mean organizational readiness for IPV response scores relative to non-IPV specific providers (11.3 and 7.5, respectively). High readiness areas included perceiving the importance of IPV and staff having adequate time, space, and comfort level to address IPV. Areas of low readiness included development and use of IPV response policies as well as staff training on IPV. This assessment documents concerning gaps in organizational readiness for IPV response among supportive housing providers, and pinpoints areas where training and capacity building can be most valuable. The process of improving readiness in the supportive housing sector must involve capacity building and a systems-level approach in order to ensure that all supportive housing providers are prepared to meet the needs of IPV survivors among their client population.