Professor Simon Skene

Inoperable maliganant bowel obstruction (IBO) is very common in ovarian cancer patients. A lack of guidelines and research in this area means that nutrition support for patients with IBO is challenging. Parenteral nutrition (PN) is the recommended route for patients with a prognosis of > 2 months1, otherwise patients are encouraged to drink sips of clear fluids only. An elemental diet (ED) is licensed for strictures in Crohn’s disease and been used in one case report of a pregnant woman in bowel obstruction2. The aim of the EDMONd study was to evaluate ED as an alternative to PN in patients with IBO and to provide a ‘Proof of Concept’ of ED as an acceptable feeding option.

Introduction/Background: Inoperable bowel obstruction (IBO) occurs in up to 50% of patients diagnosed with ovarian cancer. Nutrition support for patients with IBO is challenging. Parenteral feeding (PN) is the recommended route for patients with a prognosis of > 2 months, however there is little evidence that it improves quality of life and the cost of it is very high. If PN is not available patients are frequently discharged home from hospital with sips of clear fluids only. Management of inoperable bowel obstruction remains a major challenge and clear guidelines are needed. Elemental diet (ED) is a liquid diet that contains proteins in the form of amino acids, fats in the form of medium chain triglycerides, vitamins and trace minerals. ED is almost completely absorbed in the upper small intestine. Methodology The primary objective of the study was to establish if ED can be used as an alternative to home PN in patients with IBO. The secondary aim was to examine the impact of ED on quality of life. The primary endpoints of the study were acceptability and tolerability of ED with respect to taste, and incidence of vomiting and pain. The secondary endpoints included the number of patients alive at the end of the study, quality of life, nutritional intake, and the number of women who can tolerate ED and subsequently be treated with palliative chemotherapy (as per standard of care).Results29 women with IBO caused by metastatic ovarian cancer were recruited into the EDMONd study. Of those 8 could not complete the trial due to disease progression, and 2 had missing data that was deemed irretrievable, leaving 19 patients who contributed data to the primary endpoint analysis. The mean age of the patients who continued the trial was 68 (SD 12.5). Preliminary analysis shows that 68.4% of patients met the primary endpoint and tolerated ED; the ED did not worsen the vomiting or pain as measured by Memorial Symptoms Assessment Scale. At baseline 72% of patients experienced vomiting and this number reduced to 28% by the end of week1 of the study and to 23.5% by the end of week 2. 96% of patients reported pain at baseline and this proportion reduced to 72% and 76% by the end of week 1 and 2 respectively. Conclusion ED is well tolerated by patients with IBO and can provide an acceptable feeding option for this group of patients.

DERM is an AI algorithm for detecting skin cancer. Developed by Skin Analytics, the algorithm analyses images of skin lesions and determines if the lesion is likely to be cancerous. DERM is already being used by some NHS providers, and is integrated with existing skin cancer pathways, triaging patients before being assessed by dermatologists. The Department of Health and Social Care (DHSC) funded deployment and a real-world evaluation of DERM as part of the AI in Health and Care Award. The evaluation aimed to inform future implementation by assessing key domains such as safety, accuracy, effectiveness, value and sustainability. Working as a collaborative Technology Specific Evaluation Team (TSET), Unity Insights and University of Surrey conducted an evaluation of DERM in four NHS sites, across 9,649 patients between February 2022 and April 2023. The resulting evaluation report is presented in full.

TPS1614 Background: Cancer is the leading contributor of disease burden worldwide, and incidence rates are estimated to rise 47% by 2040. With increasing numbers of people living with cancer, alongside healthcare workforce shortages, current models for cancer monitoring and surveillance are unsustainable. Within the UK’s National Health Service (NHS), this is exacerbated by a rising backlog following the COVID-19 pandemic. Furthermore, a 2020 Macmillan Cancer Support survey showed that current patient information and support is scattered, inaccessible, and poorly personalized. There is an urgent need for effective personalized tools to support cancer patient self-management and data collection to enable healthcare professional (HCP) monitoring and remote follow-up. Methods: A multi-site randomized controlled trial is underway within the NHS to evaluate the implementation of a novel digital oncology platform (Vinehealth) for personalized support. Vinehealth consists of a mobile patient application, integrated wearables data, and a clinician dashboard. The study aims to recruit 180 patients across 8 NHS Trusts diagnosed with (i) colorectal, breast, or lung cancer undergoing adjuvant systemic treatment (chemotherapy +/- targeted therapies) post surgery, or (ii) asymptomatic breast cancer undergoing neoadjuvant treatment. A power calculation was conducted relating to the primary objective demonstrating the efficacy in improvement of QoL in the interventional arm, providing 80% power and at a significance level of 0.05. Enrolled patients will be randomized (1:1) between standard of care (SoC) and interventional arms (SoC plus Vinehealth platform). The main objective is to assess if implementation of Vinehealth improves patients’ quality of life (QoL) compared to SoC based on EQ-5D-5L, EORTC QLQ-C30, and FACT-G (PWB) questionnaires. Secondary objectives include assessing patient compliance with electronic patient-reported outcome (ePRO) data collection and patient self-management of symptoms. The study will further evaluate whether Vinehealth improves the process of care (assessed through medication adherence) and reduces emergency healthcare utilization (including ED/GP visits/admissions and acute oncology hotline use). Questionnaires are completed by all patients at baseline, 6, 12, 18 and 24 weeks. Qualitative interviews will be conducted with a subset of interventional arm patients and HCPs from each NHS Trust to understand engagement with the Vinehealth platform. To our knowledge, this is the first multi-site RCT within the NHS to evaluate the impact of a digital oncology platform on cancer patients’ QoL, ePRO compliance, process of care, and healthcare utilization. The trial is expected to end by September 2023 with results being reported in January 2024. Clinical trial information: ISRCTN44293246 .

Introduction Accurate and timely dispatch of emergency medical services (EMS) is vital due to limited resources and patients’ risk of mortality and morbidity increasing with time. Currently, most UK emergency operations centres (EOCs) rely on audio calls and accurate descriptions of the incident and patients’ injuries from lay 999 callers. If dispatchers in the EOCs could see the scene via live video streaming from the caller’s smartphone, this may enhance their decision making and enable quicker and more accurate dispatch of EMS. The main aim of this feasibility randomised controlled trial (RCT) is to assess the feasibility of conducting a definitive RCT to assess the clinical and cost effectiveness of using live streaming to improve targeting of EMS.Methods and analysisThe SEE-IT Trial is a feasibility RCT with a nested process evaluation. The study also has two observational substudies: (1) in an EOC that routinely uses live streaming to assess the acceptability and feasibility of live streaming in a diverse inner-city population and (2) in an EOC that does not currently use live streaming to act as a comparator site regarding the psychological well-being of EOC staff using versus not using live streaming.Ethics and disseminationThe study was approved by the Health Research Authority on 23 March 2022 (ref: 21/LO/0912), which included NHS Confidentiality Advisory Group approval received on 22 March 2022 (ref: 22/CAG/0003). This manuscript refers to V.0.8 of the protocol (7 November 2022). The trial is registered with the ISRCTN (ISRCTN11449333). The first participant was recruited on 18 June 2022.The main output of this feasibility trial will be the knowledge gained to help inform the development of a large multicentre RCT to evaluate the clinical and cost effectiveness of the use of live streaming to aid EMS dispatch for trauma incidents.Trial registration numberISRCTN11449333.

Controlled clinical intervention studies have demonstrated that cocoa flavanols (CF) can decrease blood pressure and arterial stiffness in healthy humans, although a large variability in the effect size across trials has been reported. Here, we evaluated intra- and inter-individual variability of responses to CF in everyday life using a series of n-of-1 trials in healthy free-living individuals with normal blood pressure carrying personal devices. Eleven healthy young humans participated in a repeated cross-over randomized controlled double-blind n-of-1 trial. On eight consecutive days, each volunteer consumed on alternating days 6 CF capsules (862 mg CF) on four days and 6 matched placebo capsules (P, 0 mg CF/day) on another 4 days in one of two randomized sequences (CF-P-CF-P-CF-P-CF-P or P-CF-P-CF-P-CF-P-CF). On each day the capsules were taken at the same time in the morning with breakfast after baseline measurements. Each subject was provided with an upper arm blood pressure monitor and a finger clip that measures pulse wave velocity (PWV). Measurements of blood pressure, heart rate and PWV were taken at least hourly over 12 hours during the day by the participants. On the first 2 days measurements were performed under supervision to provide training. The overall mixed model analysis showed that CF significantly decreased 12 h systolic blood pressure and PWV by -1.4±0.3 mmHg and - -0.11±0.03 m/s, respectively. Peak effects were observed within the first 3 hours (1.5 h SBP: -4.9±2.2 mmHg, PWV: -0.32±0.17 m/s)and again after 8 h post ingestion. Large inter-individual variation in responses was found (intra-cluster correlation coefficients [ICC]: 0.41, 0.41). When analysing single individuals’ datasets, there was also considerable between-day variation in individual responses that varied greatly between subjects (ICC: 0-0.30, 0-0.22, 0-0.45). Effect sizes inversely correlated with baseline blood pressure values both between-- and within-subjects. The data confirm that cocoa can decrease blood pressure and arterial stiffness in everyday life when elevated within the normal range. The large inter- and intra-individual variation in responses call for more personalized nutritional intervention strategies.

Lipid nanoparticle (LNP) encapsulated self-amplifying RNA (saRNA) is well tolerated and immunogenic in SARS-CoV-2 seronegative and seropositive individuals aged 18–75. A phase 2a expanded safety and immunogenicity study of a saRNA SARS-CoV-2 vaccine candidate LNP-nCoVsaRNA, was conducted at participating centres in the UK between 10th August 2020 and 30th July 2021. Participants received 1 μg then 10 μg of LNP-nCoVsaRNA, ∼14 weeks apart. Solicited adverse events (AEs) were collected for one week post-each vaccine, and unsolicited AEs throughout. Binding and neutralisating anti-SARS-CoV-2 antibody raised in participant sera was measured by means of an anti-Spike (S) IgG ELISA, and SARS-CoV-2 pseudoneutralisation assay. (The trial is registered: ISRCTN17072692, EudraCT 2020-001646-20). 216 healthy individuals (median age 51 years) received 1.0 μg followed by 10.0 μg of the vaccine. 28/216 participants were either known to have previous SARS-CoV2 infection and/or were positive for anti-Spike (S) IgG at baseline. Reactogenicity was as expected based on the reactions following licensed COVID-19 vaccines, and there were no serious AEs related to vaccination. 80% of baseline SARS-CoV-2 naïve individuals (147/183) seroconverted two weeks post second immunization, irrespective of age (18–75); 56% (102/183) had detectable neutralising antibodies. Almost all (28/31) SARS-CoV-2 positive individuals had increased S IgG binding antibodies following their first 1.0 μg dose with a ≥0.5log10 increase in 71% (22/31). Encapsulated saRNA was well tolerated and immunogenic in adults aged 18–75 years. Seroconversion rates in antigen naïve were higher than those reported in our dose-ranging study. Further work is required to determine if this difference is related to a longer dosing interval (14 vs. 4 weeks) or dosing with 1.0 μg followed by 10.0 μg. Boosting of S IgG antibodies was observed with a single 1.0 μg injection in those with pre-existing immune responses. Grants and gifts from the Medical Research Council UKRI (MC_PC_19076), the National Institute for Health Research/Vaccine Task Force, Partners of Citadel and Citadel Securities, Sir Joseph Hotung Charitable Settlement, Jon Moulton Charity Trust, Pierre Andurand, and Restore the Earth.

12009 Background: Older and frail patients with cancer (Ca) often receive less aggressive treatment and as a result have worse survival. Current methods of assessing fitness (performance status) for intensive treatment such as chemotherapy are inadequate. The complexity of geriatric assessments, lack of training and time pressures in busy clinics, mean that better solutions are needed. A UK initiative - the electronic frailty index (eFI) - is derived from a cumulative deficit frailty model and provides a measure of frailty alongside pre-existing conditions such as issues with mobility, fractures, falls, memory, sight, hearing , anaemia, tremor, diabetes, heart, thyroid, skin, respiratory, cerebrovascular, circulation, social vulnerability, and polypharmacy (36 fields) (Clegg et al). Patients are classified into the following groups: no frailty, mild, moderate or severe frailty. We used the same methodology to investigate whether eFI predicts adverse outcomes of chemotherapy in frail patients with Ca. Methods: The study conducted retrospective data analysis of Ca patients treated with chemotherapy from Public Health England (PHE) Systemic Chemotherapy Dataset (SACT) years 2015-2018. Eligible patients had stage II - III breast Ca, stage III colon Ca or stage IIIB–IV non-small-cell lung Ca (NSCLC). The data from SACT was linked with hospital episodes' statistics (obtained from NHS-Digital) to calculate 30-day SACT mortality, overall survival and hospital admissions. EFI was calculated from the above 35 fields; polypharmacy was not available from NHS-Digital data. Results: The eFI was calculated for 78799 patients: colorectal 17951, lung 22052, and breast 38796. 20388 patients were ≥ 70y. o. and 58411 were < 70y.o. Most patients were fit with an eFI score of 0-69% (54563), 19% (15,295) had mild frailty, 7.7% (6104)- moderate, and 3.6% (2837) had severe frailty. 4.2% (3356) of patients died within 30 days of SACT. For colorectal Ca patients the risk of dying within 30 days of SACT in patients ≥70y.o was twice that of the < 70y.o (OR 2.04 -CI 1.58 - 2.64); patients with mild eFI did not differ- OR: 1.07 (CI 0.78-1.45), moderate frailty: 1.6 (CI 1.1-2.33) and severe frailty: 2.13 (CI 1.34-3.39). In breast Ca patients, 30-day mortality for ≥70y.o. was 6.38 times higher than for < 70y.o (95% CI 4.29-9.49); eFI for mild frailty- OR of 1.45 (95% CI 0.78-2.71), moderate frailty-OR of 3.5 (95%CI 1.82-6.75) and severe frailty 5.73 (95% CI 2.66-12.3). The 30-day mortality in lung cancer in ≥70y.o and < 70y.o did not differ with OR 0.95 (95% CI 0.88-1.03) for ≥70y.o. Patients with mild frailty had OR for 30-day mortality of 1.17 (95% CI 1.07-1.28), moderate frailty-OR of 1.28 (95%CI 1.15-1.44) and severe frailty 1.48 (95% CI 1.28-1.77). Conclusions: The eFI closely predicts poor outcomes from SACT, particularly in early breast and colon cancer, and requires further evaluation in a prospective study.

Femoral artery (FA) endothelial function is a promising biomarker of lower extremity vascular health for peripheral artery disease (PAD) prevention and treatment; however, the impact of age on FA endothelial function has not been reported in healthy adults. Therefore, we evaluated the reproducibility and acceptability of flow-mediated dilation (FMD) in the FA and brachial artery (BA) (n = 20) and performed cross-sectional FA- and BA-FMD measurements in healthy non-smokers aged 22–76 years (n = 50). FMD protocols demonstrated similar good reproducibility. Leg occlusion was deemed more uncomfortable than arm occlusion; thigh occlusion was less tolerated than forearm and calf occlusion. FA-FMD with calf occlusion was lower than BA-FMD (6.0 ± 1.1% vs 6.4 ± 1.3%, p = 0.030). Multivariate linear regression analysis indicated that age (−0.4%/decade) was a significant independent predictor of FA-FMD (R2 = 0.35, p = 0.002). The age-dependent decline in FMD did not significantly differ between FA and BA (pinteraction agexlocation = 0.388). In older participants, 40% of baseline FA wall shear stress (WSS) values were

Background: Diabetes and age are major risk factors for the development of lower extremity peripheral artery disease (PAD). Cocoa flavanol (CF) consumption is associated with lower risk for PAD and improves brachial artery (BA) endothelial function. Objectives: to assess if femoral artery (FA) endothelial function and dermal microcirculation are impaired in individuals with type 2 diabetes mellitus (T2DM) and evaluate the acute effect of CF consumption on FA endothelial function. Methods: In a randomised, controlled, double-blind, cross-over study, 22 individuals (n = 11 healthy, n = 11 T2DM) without cardiovascular disease were recruited. Participants received either 1350 mg CF or placebo capsules on 2 separate days in random order. Endothelial function was measured as flow-mediated dilation (FMD) using ultrasound of the common FA and the BA before and 2 hours after interventions. The cutaneous microvasculature was assessed using optical coherence tomography angiography. Results: Baseline FA-FMD and BA-FMD were significantly lower in T2DM (FA: 3.2 ± 1.1% [SD], BA: 4.8 ± 0.8%) compared to healthy (FA: 5.5 ± 0.7%, BA: 6.0 ± 0.8%); each p < 0.001. Whereas in healthy individuals FA-FMD did not significantly differ from BA-FMD (p = 0.144), FA-FMD was significantly lower than BA-FMD in T2DM (p = 0.003) indicating pronounced and additional endothelial dysfunction of lower limb arteries (FA-FMD/BA-FMD: 94 ± 14% [healthy] vs. 68 ± 22% [T2DM], p = 0.007). The baseline FA blood flow rate (0.42 ± 0.23 vs. 0.73 ± 0.35 l min−1, p = 0.037) and microvascular dilation in response to occlusion in hands and feet were significantly lower in T2DM subjects than in healthy ones. CF increased both FA- and BA-FMD at 2 hours, compared to placebo, in both healthy and T2DM subgroups (FA-FMD effect: 2.9 ± 1.4%, BA-FMD effect 3.0 ± 3.5%, each pintervention< 0.001). In parallel, baseline FA blood flow and microvascular diameter significantly increased in feet (3.5 ± 3.5 μm, pintervention< 0.001) but not hands. Systolic blood pressure and pulse wave velocity significantly decreased after CF in both subgroups (−7.2 ± 9.6 mmHg, pintervention = 0.004; −1.3 ± 1.3 m s−1, pintervention = 0.002). Conclusions: Individuals with T2DM exhibit decreased endothelial function that is more pronounced in the femoral than in the brachial artery. CFs increase endothelial function not only in the BA but also the FA both in healthy individuals and in those with T2DM who are at increased risk of developing lower extremity PAD and foot ulcers.

To evaluate the effectiveness of the symptom management after radiotherapy (SMaRT) group intervention to improve urinary symptoms in men with prostate cancer. The randomised controlled trial (RCT) recruited men from one radiotherapy centre in the UK after curative radiotherapy or brachytherapy and with moderate to severe urinary symptoms defined as scores ≥ 8 on the International Prostate Symptom Score (IPSS) questionnaire. Sixty-three men were randomised either; to SMaRT, a 10-week symptom-management intervention including group support, education, pelvic floor muscle exercises, or a care-as-usual group. The primary outcome was the IPSS at 6 months from baseline assessment. Secondary outcomes were IPSS at 3 months, and International Continence Society Male Short Form (ICS), European Organisation for Research and Treatment of Cancer Quality of Life prostate scale (EORTC QLQ-PR25), EORTC QLQ-30 and Self-Efficacy for Symptom Control Inventory (SESCI) at 3 and 6 months from baseline. Analysis of covariance (ANCOVA) was used to analyse the effect of the intervention. SMaRT group intervention did not improve urinary symptoms as measured by IPSS at 6-months. The adjusted difference was - 2.5 [95%CI - 5.0 to 0.0], p = 0.054. Significant differences were detected at 3 months in ICS voiding symptoms (- 1.1 [- 2.0 to - 0.2], p = 0.017), ICS urinary incontinence (- 1.0 [- 1.8 to - 0.1], p = 0.029) and SESCI managing symptoms domain (13.5 [2.5 to 24.4], p = 0.017). No differences were observed at 6 months. SMaRT group intervention provided short-term benefit in urinary voiding and continence and helped men manage symptoms but was not effective long term.

Objective: To evaluate effects of remote monitoring of adjuvant chemotherapy related side effects via the Advanced Symptom Management System (ASyMS) on symptom burden, quality of life, supportive care needs, anxiety, self-efficacy, and work limitations. Design: Multicentre, repeated measures, parallel group, evaluator masked, stratified randomised controlled trial. Setting: Twelve cancer centres in Austria, Greece, Norway, Republic of Ireland, and UK. Participants: 829 patients with non-metastatic breast cancer, colorectal cancer, Hodgkin’s disease, or non-Hodgkin’s lymphoma receiving first line adjuvant chemotherapy or chemotherapy for the first time in five years. Intervention: Patients were randomised to ASyMS (intervention; n=415) or standard care (control; n=414) over six cycles of chemotherapy. Main outcome measures: The primary outcome was symptom burden (Memorial Symptom Assessment Scale; MSAS). Secondary outcomes were health related quality of life (Functional Assessment of Cancer Therapy—General; FACT-G), Supportive Care Needs Survey Short-Form (SCNS-SF34), State-Trait Anxiety Inventory—Revised (STAI-R), Communication and Attitudinal Self-Efficacy scale for cancer (CASE-Cancer), and work limitations questionnaire (WLQ). Results: For the intervention group, symptom burden remained at pre-chemotherapy treatment levels, whereas controls reported an increase from cycle 1 onwards (least squares absolute mean difference −0.15, 95% confidence interval −0.19 to −0.12; P

Aims: Children and young people (CYP) with type 1 diabetes (T1D) are at increased risk of disordered eating. This study aimed to determine the feasibility and acceptability of a novel, theoretically informed, two-session psychoeducational intervention for parents to prevent disordered eating in CYP with T1D.Methods: Parents of CYP aged 11-14 years with T1D were randomly allocated to the intervention or wait-list control group. Self-reported measures including the Diabetes Eating Problem Survey-Revised (DEPS-R), Problem Areas in Diabetes Parent Revised (PAID-PR), Child Eating Behaviour Questionnaire subscales (CEBQ), Warwick Edinburgh Mental Wellbeing Scale (WEMWBS), clinical outcomes (e.g. HbA1c, BMI, medication and healthcare utilisation) and process variables, were collected at baseline, 1-and 3-month assessments. Acceptability data were collected from intervention participants via questionnaire.Results: Eighty-nine parents were recruited, which exceeded recruitment targets, with high intervention engagement and acceptability (

Background Ankle brachial pressure index can be estimated (eABPI) using cuffless ankle Doppler ultrasound. We evaluated the prognostic value of eABPI measured during pre- and post-procedural ultrasound exams to predict the clinical outcome after endovascular revascularisations. Methods In this prospective, single-centre, service evaluation, consecutive patients with symptomatic peripheral artery disease undergoing lower limb endovascular revascularisations between July, 26 2018 and January, 13 2022 at Surrey and Sussex Healthcare NHS Trust (Redhill, UK) were analysed. eABPI was determined using the higher acceleration index measured with angle-corrected duplex ultrasound in ankle arteries before and ≤1 month post-procedure. Clinical outcomes (mortality, major amputations, amputation-free survival [AFS], clinically driven target lesion revascularization [cdTLR], major adverse limb events [MALE; cdTLR and major amputation], wound healing) were assessed over 1 year. Findings Of 246 patients treated, for 219 patients (median 75 [IQR 66–83] years) pre- and post-procedural eABPI (0.50 [0.33–0.59] and 0.90 [0.69–1.0], p < 0.0001) were available, respectively. In n = 199 patients with chronic limb-threatening ischaemia (CLTI) Kaplan–Meier survival analyses showed that higher post-procedural, but not pre-procedural, eABPI was associated with favourable AFS, MALE, cdTLR, and wound healing. This was confirmed in Cox regression analysis and remained significant with adjustment for pre-procedural eABPI, age, sex, co-morbidities, treated levels, wound score, and foot infection. Whereas all clinical outcomes, except for survival, were significantly better at ≥0.7 vs

Ankle brachial pressure index (ABPI) is the first-line test to diagnose peripheral artery disease (PAD). Its adoption in clinical practice is poor and its validity, particularly in diabetes, is limited. We hypothesised that ABPI can be accurately and precisely estimated based on cuffless Doppler waveforms. Retrospective analysis of standard ABPI and handheld Doppler waveform characteristics (n = 200). Prospective analysis of angle-corrected Doppler acceleration index (AccI, n = 148) and standard ABPI with testing of performance to diagnose PAD as assessed with imaging reference standards in consecutive patients. The highest AccI from handheld Doppler at ankle arteries was significantly logarithmically associated with the highest standard ABPI (E[y] = 0.32 ln [1.71 ∗ x + 1], p < 0.001, R2 = 0.68, n = 100 limbs). Estimated ABPI (eABPI) based on AccI closely resembled ABPI (r = 0.81, p < 0.001, average deviation −0.01 ± 0.13 [SD], n = 100 limbs). AccI from angle-corrected Doppler in patients without overt media sclerosis (ABPI ≤ 1.1) improved ABPI prediction (E[y] = 0.297 ∗ ln[0.039 ∗ x + 1], R2 = 0.92, p = 0.006, average deviation 0.00 ± 0.08, n = 100). In a population (n = 148 limbs) including diabetes (56%), chronic limb-threatening ischaemia (51%) and media sclerosis (32%), receiver operating characteristics analysis of (angle-corrected) eABPI performed significantly better than standard ABPI to diagnose PAD defined by ultrasound (ROC AUC = 0.99 ± 0.01, p < 0.001; sensitivity: 97%, specificity: 96%) at the ≤0.9 cut-off. This was confirmed with CT angiography (ROC AUC = 0.98, p < 0.001, sensitivity: 97%, specificity: 100%) and was independent of the presence of diabetes (p = 0.608). ABPI can be estimated based on ankle Doppler AccI without compression, and eABPI performs better than standard ABPI to diagnose PAD independent of diabetes. eABPI has the potential to be included as a standard component of lower extremity ultrasound.

Aims: Endothelial function is essential for cardiovascular health, and flow-mediated dilation (FMD) is an established technique to measure it. This paper is to assess FMD values in apparently healthy individuals and provide reference values to facilitate wider clinical use.Methods and Results: In 1,579 apparently healthy individuals (aged 18-76), fasted FMD values (data from 44 studies, 6 institutions, 22 operators) were normally distributed and inversely univariately correlated with age, body-mass-index, glucose, cholesterol, blood pressure, and brachial artery diameter. Significant multivariate predictors of FMD were age (-0.4%/decade), BMI (0.04%/kg/m2), smoking (-0.7%), and brachial artery diameter (-0.44%/mm) that together explained 19% of the variability independent of operator, institution or ultrasound machine. Individuals in the high FMD tertile (>6.8%) were younger, had smaller brachial artery diameter, lower blood pressure and cholesterol. In individuals with low- and intermediate fatal cardiovascular risk (SCORE), 26% and 53% of individuals, respectively, had FMD values in the low tertile (<5.4%). After adding data from 385 patients with stable coronary artery disease (CAD), ROC analysis (c=0.841, p<0.001) showed that FMD of >6.5% excluded CAD (95% sensitivity; 60% specificity) and FMD <3.1% excluded 95% healthy individuals (95% specificity, 31% sensitivity). A meta-analysis and meta-regression of 82 clinical trials (11 countries, n=3,509) using similar FMD methodology showed that despite considerable heterogeneity (I2=0.97) FMD in healthy individuals was on average 6.4% (95%CI: 6.2%, 6.7%) with no significant differences between countries but a significant age-dependent decline (-0.3%/decade, R2=0.13).Conclusions: We provide an age-adapted frame of FMD reference intervals in apparently healthy individuals for use as a biomarker of CV health. As the degree of vascular endothelial function integrates environmental and genetic factors with classical CV risk factors, FMD may more comprehensively classify individuals with and without standard modifiable cardiovascular risk factors and serve as a target for cardiovascular prevention.

Royal Surrey NHS Foundation Trust introduced robotic surgery for uterine corpus cancer in 2010 to support increased access to minimally invasive surgery, a central element of an enhanced recovery after surgery (ERAS) pathway. More than 1750 gynaecological oncology robotic procedures have now been performed at Royal Surrey NHS Foundation Trust. A retrospective cohort study was performed of patients undergoing surgery for uterine corpus cancer between the 1 January 2010 and the 31 December 2019 to evaluate its success. Data was extracted from the dedicated gynaecological oncology database and a detailed notes review performed. During this time; 952 patients received primary surgery for uterine corpus cancer; robotic: n = 734; open: n = 164; other minimally invasive surgery: n = 54. The introduction of the Da Vinci (TM) robot to Royal Surrey NHS Foundation Trust was associated with an increase in the minimally invasive surgery rate. Prior to the introduction of robotic surgery in 2008 the minimally invasive surgery (MIS) rate was 33% for women with uterine corpus cancer undergoing full surgical staging. In 2019, 10 years after the start of the robotic surgery program 91.3% of women with uterine corpus cancer received robotic surgery. Overall the MIS rate increased from 33% in 2008 to 92.9% in 2019. Robotic surgery is associated with a low 30-day mortality (0.1%), low return to theatre (0.5%), a low use of blood transfusion and intensive care (1.8% & 7.2% respectively), low conversion to open surgery (0.5%) and a reduction in median length of stay from 6 days (in 2008) to 1 day, regardless of age/BMI. Robotic survival is consistent with published data. Introduction of the robotic program for the treatment of uterine cancer increased productivity and was associated with a highly predicable patient pathway of care, for high-risk patients, with reduced demands on health services. Future health care commissioning should further expand access to robotic surgery nationally for women with uterine corpus cancer.

Aims Increasing evidence suggests that children and young people with type 1 diabetes (T1D) are at greater risk of disordered eating compared to children without T1D. Disordered eating in T1D has been linked to impaired well-being, increased health service use, and early mortality. To address this problem, we will co-develop a psycho-education intervention for parents of children and young people with T1D, informed by the Information Motivation Behavioural Skills model. Methods The objective of this study is to assess the feasibility and acceptability of the intervention compared to a waitlist control group using a feasibility randomised controlled trial (RCT) design. We aim to recruit 70 parents of children and young people with T1D (11-14 years), 35 in each arm. Those assigned to the intervention will be invited to participate in two workshops of two hours each. Parents will be asked to complete outcome measures regarding eating habits, diabetes management, as well as a questionnaire based on the Information Motivation Behavioural Skills model which provides a theoretical foundation for the intervention. These will be completed at baseline, 1- month and 3-months post intervention. Children and young people will be asked to complete questionnaires on their eating behaviours at the same time intervals. Parents randomised to receive the intervention will be invited to take part in interviews to feedback on the intervention and research protocol acceptability. Conclusion It is anticipated that the psycho-education intervention aimed at parents will help prevent the development of disordered eating in children and young people with T1D and improve parental wellbeing. The results of this feasibility trial will determine whether this intervention approach is acceptable to families living with T1D, and whether a definitive RCT of intervention effectiveness is justified. Qualitative findings will be used to refine the intervention and study protocols.

Most older adults with traumatic brain injuries (TBI) reach the emergency department via the ambulance service. Older adults, often with mild TBI symptoms, risk being under-triaged and facing poor outcomes. This study aimed to identify whether sufficient information is available on the scene to an ambulance clinician to identify an older adult at risk of an intracranial haemorrhage following a head injury. This was a retrospective case-control observational study involving one regional ambulance service in the UK and eight emergency departments. 3545 patients aged 60 years and over presented to one regional ambulance service with a head injury between the 1st of January 2020 and the 31st of December 2020. The primary outcome was an acute intracranial haemorrhage on head computed tomography (CT) scan in patients conveyed to the emergency department (ED). A secondary outcome was factors associated with conveyance to the ED by the ambulance clinician. In 2020, 2111 patients were conveyed to the ED and 162 patients were found to have an intracranial haemorrhage on their head CT scan. Falls from more than 2 m (adjusted odds ratio (aOR) 3.45, 95% CI 1.78-6.40), chronic kidney disease (CKD) (aOR 2.80, 95% CI 1.25-5.75) and Clopidogrel (aOR 1.98, 95% CI 1.04-3.59) were associated with an intracranial haemorrhage. Conveyance to the ED was associated with patients taking anticoagulant and antiplatelet medication or a visible head injury or head injury symptoms. This study highlights that while most older adults with a head injury are conveyed to the ED, only a minority will have an intracranial haemorrhage following their head injury. While mechanisms of injury such as falls from more than 2 m remain a predictor, this work highlights that Clopidogrel and CKD are also associated with an increased odds of tICH in older adults following a head injury. These findings may warrant a review of current ambulance head injury guidelines.

Introduction Provision of clinically assisted hydration (CAH) at the end of life is one of the most contentious issues in medicine. The aim of the ‘CHELsea II’ trial is to evaluate CAH in patients in the last days of life. The objectives are to assess the effect of CAH on delirium, audible upper airway secretions, pain and other symptoms, and overall survival, as well as the tolerability of CAH, and the health economic impact. Methods and analysis The study is a cluster randomised trial, involving 80 sites/clusters (mainly hospices) and 1600 patients. Sites will be randomised to an intervention, and this will become the standard of care during the trial. Intervention ‘A’ involves continuance of drinking (if appropriate), mouth care and usual end-of-life care. Intervention ‘B’ involves continuance of drinking, mouth care, usual end-of-life care and CAH, that is, parenteral fluids. The fluid may be given intravenously or subcutaneously, the type will be dextrose saline (4% dextrose, 0.18% sodium chloride) and the volume will be dependent on weight.Participants will be assessed every 4 hours by the clinical team. The primary endpoint is the proportion of participants who develop delirium determined using the Nursing Delirium Screening Scale (using a cut-off score of ≥2). A mixed-effects logistic regression will be used to assess the difference in the odds of developing delirium between the interventions. Ethics and dissemination Ethical committee approval has been granted by the Brighton and Sussex Research Ethics Committee (REC) (main REC for the UK: reference—IRAS 313640), and by the Scotland A REC (REC for adults with incapacity in Scotland: reference—22/SS/0053-IRAS-317637). The consent process follows the Mental Capacity Act: if the patient has capacity, then consent will be sought in the normal way; if the patient does not have capacity, then a personal/nominated consultee will be approached for advice about the patient entering the study. The consent process is slightly different in Scotland.The results of the trial will be published in general medical/palliative care journals, and presented at general medical/palliative care conferences.

Background Chronic viral hepatitis (CVH) is a leading contributor to the UK liver disease epidemic, with global migration from high prevalence areas (e.g., South Asia). Despite international guidance for testing high-risk groups in line with elimination targets, there is no consensus on how to achieve this. The objectives of this study were to assess the following: (1) the feasibility of recruiting South Asian migrants to view an educational film on CVH, (2) the effectiveness of the film in promoting testing and increasing knowledge of CVH, and (3) the methodological issues relevant to scale-up to a randomized controlled trial. Methods South Asian migrants were recruited to view the film (intervention) in community venues (primary care, religious, community), with dried blood spot CVH testing offered immediately afterwards. Pre/post-film questionnaires assessed the effectiveness of the intervention. Results Two hundred and nineteen first-generation migrants ≥18 years of age (53% female) were recruited to view the film at the following sites: religious, n = 112 (51%), community n = 98 (45%), and primary care, n = 9 (4%). One hundred and eighty-four (84%) underwent CVH testing; hepatitis B core antibody or hepatitis C antibody positivity demonstrated exposure in 8.5%. Pre-intervention (n = 173, 79%) and post-intervention (n = 154, 70%) questionnaires were completed. Conclusions This study demonstrated the feasibility of recruiting first-generation migrants to view a community-based educational film promoting CVH testing in this higher risk group, confirming the value of developing interventions to facilitate the global World Health Organization plan for targeted case finding and elimination, and a future randomized controlled trial. We highlight the importance of culturally relevant interventions including faith and culturally sensitive settings, which appear to minimize logistical issues and effectively engage minority groups, allowing ease of access to individuals ‘at risk’.

We evaluated the impact of COVID-19 restriction on the angioplasty service and outcome of chronic limb threatening ischaemia (CLTI) patients undergoing lower limb angioplasty in a UK secondary care setting. Consecutive patients were analysed retrospectively. Pre-COVID-19 (08/2018-02/2020), 106 CLTI-patients (91% Fontaine 4; 60% diabetes mellitus) and during COVID-19 (03/2020-07/2021) 94 patients were treated (86% Fontaine 4; 66% diabetes mellitus). While the average monthly number of patients treated did not change, the proportion of day cases significantly increased (53% to 80%) and hospitalised patients decreased. Patients treated in £14/5 days after referral significantly increased to 64/63%. Kaplan-Meier survival analysis (30-day/1-year) showed that neither wound healing nor mortality were significantly changed during COVID-19. In day cases, 1-year but not 30-day major amputations significantly increased, and clinically driven target lesion revascularisation decreased during COVID-19. 1-year mortality was significantly worse in hospitalised as compared to day cases (14% vs 43%) at similar wound healing rates (83% vs 84%). The most frequent known-causes-of-death were infectious disease (64%) and cardiovascular (21%) was less frequent. Despite COVID-19 restriction a safe and effective angioplasty service was maintained while shortening waiting times. Very high mortality rates in hospitalised patients may indicate that CLTI patients need to be referred and treated more aggressively earlier.

Bariatric surgery is an effective treatment for obesity. However, around one in five people experience significant weight regain. Acceptance and Commitment Therapy (ACT) teaches acceptance of and defusion from thoughts and feelings which influence behaviour, and commitment to act in line with personal values. To test the feasibility and acceptability of ACT following bariatric surgery a randomised controlled trial of 10 sessions of group ACT or Usual Care Support Group control (SGC) was delivered 15-18 months post bariatric surgery (ISRCTN registry ID: ISRCTN52074801). Participants were compared at baseline, 3, 6 and 12 months using validated questionnaires to assess weight, wellbeing, and healthcare use. A nested, semi-structured interview study was conducted to understand acceptability of the trial and group processes. 80 participants were consented and randomised. Attendance was low for both groups. Only 9 (29%) ACT participants completed > = half of the sessions, this was the case for 13 (35%) SGC participants. Forty-six (57.5%) did not attend the first session. At 12 months, outcome data were available from 19 of the 38 receiving SGC, and from 13 of the 42 receiving ACT. Full datasets were collected for those who remained in the trial. Nine participants from each arm were interviewed. The main barriers to group attendance were travel difficulties and scheduling. Poor initial attendance led to reduced motivation to return. Participants reported a motivation to help others as a reason to join the trial; lack of attendance by peers removed this opportunity and led to further drop out. Participants who attended the ACT groups reported a range of benefits including behaviour change. We conclude that the trial processes were feasible, but that the ACT intervention was not acceptable as delivered. Our data suggest changes to recruitment and intervention delivery that would address this.

Background Use of bystander video livestreaming from scene to Emergency Medical Services (EMS) is becoming increasingly common to aid decision making about the resources required. Possible benefits include earlier, more appropriate dispatch and clinical and financial gains, but evidence is sparse. Methods A feasibility randomised controlled trial with an embedded process evaluation and exploratory economic evaluation where working shifts during six trial weeks were randomised 1:1 to use video livestreaming during eligible trauma incidents (using GoodSAM Instant-On-Scene) or standard care only. Pre-defined progression criteria were: (1) ≥70% callers (bystanders) with smartphones agreeing and able to activate live stream; (2) ≥50% requests to activate resulting in footage being viewed; (3) Helicopter Emergency Medical Services (HEMS) stand-down rate reducing by ≥10% as a result of live footage; (4) no evidence of psychological harm in callers or staff/dispatchers. Observational sub-studies included (i) an inner-city EMS who routinely use video livestreaming to explore acceptability in a diverse population; and (ii) staff wellbeing in an EMS not using video livestreaming for comparison to the trial site. Results Sixty-two shifts were randomised, including 240 incidents (132 control; 108 intervention). Livestreaming was successful in 53 incidents in the intervention arm. Patient recruitment (to determine appropriateness of dispatch), and caller recruitment (to measure potential harm) were low (58/269, 22% of patients; 4/244, 2% of callers). Two progression criteria were met: (1) 86% of callers with smartphones agreed and were able to activate livestreaming; (2) 85% of requests to activate livestreaming resulted in footage being obtained; and two were indeterminate due to insufficient data: (3) 2/6 (33%) HEMS stand down due to livestreaming; (4) no evidence of psychological harm from survey, observations or interviews, but insufficient survey data from callers or comparison EMS site to be confident. Language barriers and older age were reported in interviews as potential challenges to video livestreaming by dispatchers in the inner-city EMS. Conclusions Progression to a definitive RCT is supported by these findings. Bystander video livestreaming from scene is feasible to implement, acceptable to both 999 callers and dispatchers, and may aid dispatch decision-making. Further assessment of unintended consequences, benefits and harm is required. Trial registration Trial registration: ISRCTN 11449333 (22 March 2022). https://www.isrctn.com/ISRCTN11449333

Abstract Background Femoral artery (FA) endothelial function is a promising biomarker for peripheral artery disease (PAD) prevention. We assessed FA flow-mediated dilation (FMD) in healthy adults of various ages. Material and methods Repeated common FA and brachial artery (BA) FMD measurements were performed with ultrasound induced by5 minutes distal cuff occlusion (thigh, calf, forearm) to assess intra- and interindividual variability and acceptability (n = 10). We then performeda cross-sectional study with FA- and BA-FMD measurements in healthy participants aged 18–80 (n = 53). Results and conclusions All FMD protocols had good reproducibility with average deviation of −0.1% (SD 0.6%, 0.9%, 0.6%) but thigh occlusion was less well tolerated. BA- and FA-FMD with thigh occlusion did not significantly differ while FA-FMD with calf occlusion was significantly lower (−1.0 ± 0.9%). Both FA-FMD and BA-FMD inversely correlated with age and baseline diameter and positively with wall shear stress (WSS). FA-FMD and BA-FMD correlated significantly (r = 0.57, P < 0.001). The baseline diameter was significantly greater in the FA as compared to the BA while the WSS was significantly lower. At the onset of reactive hyperaemia, the mean flow velocity, WSS and flow reserve were lower in the FA as compared to the BA. A large proportion of FA WSS values in older participants were below 5 dyne/ cm2 which is regarded as pro-atherogenic. FA endothelial function declines with age in parallel with the BA. FAs exhibits stronger age-dependent enlargement as compared to the BA leading to a critical decrease in WSS that may explain part of the age-dependent predisposition for PAD.

Background Exenatide, a glucagon-like peptide-1 (GLP-1) receptor agonist, has neuroprotective effects in preclinical models of Parkinson's disease. We investigated whether these effects would be apparent in a clinical trial. Methods In this single-centre, randomised, double-blind, placebo-controlled trial, patients with moderate Parkinson's disease were randomly assigned (1:1) to receive subcutaneous injections of exenatide 2 mg or placebo once weekly for 48 weeks in addition to their regular medication, followed by a 12-week washout period. Eligible patients were aged 25–75 years, had idiopathic Parkinson's disease as measured by Queen Square Brain Bank criteria, were on dopaminergic treatment with wearing-off effects, and were at Hoehn and Yahr stage 2·5 or less when on treatment. Randomisation was by web-based randomisation with a two strata block design according to disease severity. Patients and investigators were masked to treatment allocation. The primary outcome was the adjusted difference in the Movement Disorders Society Unified Parkinson's Disease Rating Scale (MDS-UPDRS) motor subscale (part 3) in the practically defined off-medication state at 60 weeks. All efficacy analyses were based on a modified intention-to-treat principle, which included all patients who completed any post-randomisation follow-up assessments. The study is registered at ClinicalTrials.gov (NCT01971242) and is completed. Findings Between June 18, 2014, and March 13, 2015, 62 patients were enrolled and randomly assigned, 32 to exenatide and 30 to placebo. Our primary analysis included 31 patients in the exenatide group and 29 patients in the placebo group. At 60 weeks, off-medication scores on part 3 of the MDS-UPDRS had improved by 1·0 points (95% CI −2·6 to 0·7) in the exenatide group and worsened by 2·1 points (−0·6 to 4·8) in the placebo group, an adjusted mean difference of −3·5 points (−6·7 to −0·3; p=0·0318). Injection site reactions and gastrointestinal symptoms were common adverse events in both groups. Six serious adverse events occurred in the exenatide group and two in the placebo group, although none in either group were judged to be related to the study interventions. Interpretation Exenatide had positive effects on practically defined off-medication motor scores in Parkinson's disease, which were sustained beyond the period of exposure. Whether exenatide affects the underlying disease pathophysiology or simply induces long-lasting symptomatic effects is uncertain. Exenatide represents a major new avenue for investigation in Parkinson's disease, and effects on everyday symptoms should be examined in longer-term trials. Funding Michael J Fox Foundation for Parkinson's Research.

INTRODUCTION/SCENARIO Distributions of measured data are often well modelled by known probability distributions, which provide a useful description of their underlying properties such as location (average), spread (variation) and shape. Statisticians use probability distributions to interpret and attribute meaning, draw conclusions and answer research questions using the measurements or data that researchers gather during their studies. Different types of data follow different probability distributions, and these distributions are characterised by certain features called parameters. Even the most statistically averse of researchers is likely to have heard of the normal distribution, which is often used to approximate the distribution of continuous or measurement data such as intraocular pressure, central retinal thickness and degree of proptosis. The normal distribution follows a ‘bell-shaped curve’ (although with a rim stretching to ±infinity) the shape of which is specified by the mean and SD, with different values of each, giving rise to different bell-shaped curves (see figure 1). Other distributions such as the binomial and Poisson probability distributions are less commonly reported in ophthalmic research and are characterised by different parameters. The binomial distribution is used for dichotomous data and is characterised by the probability of success, that is, the number of ‘successes’ out of a total number of observed events, for example, the proportion of graft transplants that fail within 6 months of transplantation. The Poisson distribution is used for counts data and is characterised by the mean number of events, for example, endophthalmitis rates. The assumption that the observed data follow such probability distributions allows a statistician to apply appropriate statistical tests, which are known as parametric tests. The normal distribution is a powerful tool provided the data plausibly arise from that distribution or can be made to reasonably approximate this following a suitable transformation such as by taking natural logarithms to reduce asymmetry. The normal distribution also serves as an approximating distribution to the Poisson or binomial distribution under certain circumstances or can be used for large samples to approximate the distribution of the sample mean via the central limit theorem. Tests based on the normal distribution are therefore extremely useful and form the basis of many analyses, the usual tests being z tests or t tests, which rely on approximate normality or normality, respectively.1 If we can assume a normal distribution, then we expect 95% of values to lie within 1.96 SDs of the mean. Parametric tests make assumptions about the distribution of the data and sometimes it may be impossible to assess these assumptions, perhaps because the sample size is small or because that data do not follow any of the more common probability distributions. Alternatively, we may be interested in making inferences about medians rather than means or about ordinal or ranked data. In such circumstances, statisticians may adopt an alternative class of statistical tests, which are known as non-parametric or distribution-free methods. These methods work by ranking the data in numerical order and analysing these ranks rather than the actual measurements observed. Two of the most well-known non-parametric methods are the Mann–Whitney test (or U test) and the Wilcoxon matched-pairs signed-rank test, which are suitable for data from two unpaired samples or two paired samples, respectively.2 3 The Wilcoxon matched-pairs signed-rank test calculates the differences between each matched pair in the two samples and replaces their absolute values with their ordered ranks (1, 2, 3, etc), ignoring zeros. Under the null hypothesis of no difference between samples, the sum of the positive and negative ranks should be similar. The test statistic is usually taken to be the smaller of the two sums, and exact p values can be found using statistical software or by comparison with statistical tables. The Mann–Whitney U test effectively considers all pairs of observations from two independent samples and calculates the number of pairs for which an observation in one sample is preceded by an observation from the other. Again, the U statistic can be calculated from the summed ranks within each sample, found by ordering the pooled observations. Such tests depend only on the rank ordering of the observed values and not on any assumptions about their underlying distributions, so that there are no associated parameters to be estimated, and in that sense such methods are considered non-parametric or distribution-free. These are easily implemented in standard statistical software packages such as R, Stata, SAS or SPSS.

The statistical analysis of repeated measures or longitudinal data always requires the accommodation of the covariance structure of the repeated measurements at some stage in the analysis. The general linear mixed model is often used for such analyses, and allows for the specification of both a mean model and a covariance structure. Often the covariance structure itself is not of direct interest, but only a means to producing valid inferences about the response. Existing methods of analysis are often inadequate where the sample size is small. More precisely, statistical measures of goodness of fit are not necessarily the right measure of the appropriateness of a covariance structure and inferences based on conventional Wald-type procedures do not approximate sufficiently well their nominal properties when data are unbalanced or incomplete. This is shown to be the case when adopting the Kenward–Roger adjustment where the sample size is very small. A generalization of an approach to Wald tests using a bias-adjusted empirical sandwich estimator for the covariance matrix of the fixed effects parameters from generalized estimating equations is developed for Gaussian repeated measurements. This is shown to attain the correct test size but has very low power.

Introduction Total ankle replacement (TAR) or ankle arthrodesis (fusion) is the main surgical treatments for end-stage ankle osteoarthritis (OA). The popularity of ankle replacement is increasing while ankle fusion rates remain static. Both treatments have efficacy but to date all studies comparing the 2 have been observational without randomisation, and there are no published guidelines as to the most appropriate management. The TAR versus arthrodesis (TARVA) trial aims to compare the clinical and cost-effectiveness of TAR against ankle arthrodesis in the treatment of end-stage ankle OA in patients aged 50–85 years. Methods and analysis TARVA is a multicentre randomised controlled trial that will randomise 328 patients aged 50–85 years with end-stage ankle arthritis. The 2 arms of the study will be TAR or ankle arthrodesis with 164 patients in each group. Up to 16 UK centres will participate. Patients will have clinical assessments and complete questionnaires before their operation and at 6, 12, 26 and 52 weeks after surgery. The primary clinical outcome of the study is a validated patient-reported outcome measure, the Manchester Oxford foot questionnaire, captured preoperatively and 12 months after surgery. Secondary outcomes include quality-of-life scores, complications, revision, reoperation and a health economic analysis. Ethics and dissemination The protocol has been approved by the National Research Ethics Service Committee (London, Bloomsbury 14/LO/0807). This manuscript is based on V.5.0 of the protocol. The trial findings will be disseminated through peer-reviewed publications and conference presentations. Trial registration number NCT02128555.

We read with interest the revised consensus recommendations for management of acute kidney injury (AKI) ) in cirrhosis by the International Club of Ascites.1 We are concerned that plasma volume expansion only with albumin is recommended for stage 2 and 3 AKI and do not believe that this represents a balanced view of the available evidence. No one doubts that fluid resuscitation is an integral part of the management of AKI; however, studies to date have not established class 1 evidence for an advantage of the use of albumin over other colloids or crystalloids.

Aims: Previous studies have shown that ultraviolet light can lead to release of nitric oxide (NO) from the skin and decrease blood pressure. In contrast to visible light local application of UV light bears a cancerogenic risk. Here, we investigated whether whole body exposure to visible blue light can also decrease blood pressure and increase endothelial function in healthy subjects. Methods: In a randomized cross-over study, 14 healthy male subjects were exposed on 2 days to monochromatic blue light or blue light with a filter foil (control light) over 30 min. We measured blood pressure (primary endpoint), heart rate, forearm vascular resistance, forearm-blood-flow, endothelial function (flow-mediated dilation), pulse wave velocity, and plasma NO species (NOx), nitrite, and nitroso compounds (RXNO) (secondary endpoints) during and up to 2 hours after exposure. Results: Blue light exposure significantly decreased systolic blood pressure and increased heart rate as compared to control. In parallel, blue light significantly increased forearm-blood-flow, flow-mediated dilation, circulating NOx and RXNO while it decreased forearm vascular resistance and pulse wave velocity. Conclusion: Whole body irradiation with visible blue light at real world doses improves blood pressure, endothelial function, and arterial stiffness by NO released from photolabile intracutanous NO metabolites into circulating blood.

There is a need for appropriate methods for the analysis of very small samples of continuous repeated measurements. A key feature of such analyses is the role played by the covariance matrix of the repeated observations. When subjects are few it can be difficult to assess the fit of parsimonious structures for this matrix, while the use of an unstructured form may lead to a serious lack of power. The Kenward–Roger adjustment is now widely adopted as a means of providing an appropriate inferences in small samples, but does not perform adequately in very small samples. Adjusted tests based on the empirical sandwich estimator can be constructed that have good nominal properties, but are seriously underpowered. Further, when such data are incomplete, or unbalanced, or non‐saturated mean models are used, exact distributional results do not exist that justify analyses with any sample size. In this paper, a modification of Box's correction applied to a linear model‐based F‐statistic is developed for such small sample settings and is shown to have both the required nominal properties and acceptable power across a range of settings for repeated measurements.

Introduction: Circulating prostaglandin E2 levels are elevated in acutely decompensated cirrhosis and have been shown to contribute to immune suppression. Albumin binds to and inactivates this immune-suppressive lipid mediator. Human albumin solution (HAS) could thus be repurposed as an immune-restorative drug in these patients. This is a phase III randomised controlled trial (RCT) to verify whether targeting a serum albumin level of ≥35 g/L in hospitalised patients with decompensated cirrhosis using repeated intravenous infusions of 20% HAS will reduce incidence of infection, renal dysfunction and mortality for the treatment period (maximum 14 days or discharge if

Background & Aims Infections are life-threatening to patients with acute decompensation and acute-on-chronic liver failure (AD/ACLF). Patients with AD/ACLF have prostaglandin E2–mediated immune suppression, which can be reversed by administration of albumin; infusion of 20% human albumin solution (HAS) might improve outcomes of infections. We performed a feasibility study to determine optimal trial design, assess safety, and validate laboratory assessments of immune function to inform design of a phase 3 trial. Methods We performed a prospective multicenter, single-arm, open-label trial of 79 patients with AD/ACLF and levels of albumin lower than 30 g/L, seen at 10 hospitals in the United Kingdom from May through December 2015. Patients were given daily infusions of 20% HAS, based on serum levels, for 14 days or until discharge from the hospital. Rates of infection, organ dysfunction, and in-hospital mortality were recorded. The primary end point was daily serum albumin level during the treatment period. Success would be demonstrated if 60% achieved and maintained serum albumin levels at or above 30 g/L on at least one third of days with recorded levels. Results The patients’ mean model for end-stage disease score was 20.9 ± 6.6. The primary end point (albumin ≥30 g/L on at least one third of days recorded) was achieved by 68 of the 79 patients; 75% of administrations were in accordance with suggested dosing regimen. Mean treatment duration was 10.3 days (104 ± 678 mL administered). There were 8 deaths and 13 serious adverse events, considered by the independent data-monitoring committee to be consistent with those expected. Twelve of 13 patients that developed either respiratory or cardiovascular dysfunction (based on ward-based clinical definitions) as their only organ dysfunction were alive at 30 days compared with 1 of 3 that developed renal dysfunction. Only 1 case of brain dysfunction was recorded. Conclusions In a feasibility trial, we found that administration of HAS increased serum levels of albumin in patients with AD/ACLF. The dosing regimen was acceptable at multiple sites and deemed safe by an independent data-monitoring committee. We also developed a robust system to record infections. The poor prognosis for patients with renal dysfunction was confirmed. However, patients with cardiovascular or respiratory dysfunction had good outcomes, which is counterintuitive. Severe encephalopathy appeared substantially under-reported, indicating that ward-based assessment of these parameters cannot be recorded with sufficient accuracy for use as a primary outcome in phase 3 trials. Trial registration no: EudraCT 2014-002300-24 and ISRCTN14174793.

Background & Aims Infection is a common cause of death in patients with cirrhosis. We investigated the association between the innate immune response and death within 3 months of hospitalization. Methods Plasma samples were collected on days 1, 5, 10, and 15 from participants recruited into the albumin to prevent infection in chronic liver failure feasibility study. Patients with acute decompensated cirrhosis were given albumin infusions at 10 hospitals in the United Kingdom. Data were obtained from 45 survivors and 27 non-survivors. We incubated monocyte-derived macrophages from healthy individuals with patients’ plasma samples and measured activation following lipopolysaccharide administration, determined by secretion of tumor necrosis factor and soluble mediators of inflammation. Each analysis included samples from 4 to 14 patients. Results Plasma samples from survivors vs non-survivors had different inflammatory profiles. Levels of prostaglandin E2 were high at times of patient hospitalization and decreased with albumin infusions. Increased levels of interleukin 4 (IL4) in plasma collected at day 5 of treatment were associated with survival at 3 months. Incubation of monocyte-derived macrophages with day 5 plasma from survivors, pre-incubated with a neutralizing antibody against IL4, caused a significant increase in tumor necrosis factor production to the level of non-survivor plasma. Although baseline characteristics were similar, non-survivors had higher white cell counts and levels of C-reactive protein and renal dysfunction. Conclusions We identified profiles of inflammatory markers in plasma that are associated with 3-month mortality in patients with acute decompensated cirrhosis given albumin. Increases in prostaglandin E2 might promote inflammation within the first few days after hospitalization, and increased levels of plasma IL4 at day 5 are associated with increased survival. Clinicaltrialsregister.eu: EudraCT 2014-002300-24

Background In addition to pain, sickle cell anaemia (HbSS) complications include neurocognitive difficulties in attention and processing speed associated with low daytime and night-time oxygen saturation compounded by obstructive sleep apnoea (OSA). In the general population OSA is treated with continuous positive airways pressure (CPAP). The aim of this single-blind, randomised, controlled phase II trial is to compare auto-adjusting CPAP (APAP) with standard care to standard care alone in individuals with HbSS to determine whether the intervention improves attention and processing speed, brain structure, pain and quality of life. Methods/Design Eligibility criteria include: ability to provide informed consent; age > 8 years; diagnosis of HbSS; and mean overnight saturation of  90% or 

Background: Flavanols are an important class of food bioactives that can improve vascular function even in healthy subjects. Cocoa flavanols (CFs) are comprised principally of the monomer, (−)-epicatechin (~20%) with a degree of polymerisation of 1 (DP1), and oligomeric procyanidins (~80%, DP2-10). Objective: To investigate the relative contribution of procyanidins and (−)-epicatechin to CF intake-related improvements in vascular function in healthy volunteers. Design: In a randomized, controlled, double-masked, parallel-group dietary intervention trial, 45 healthy men, (18-35 years), consumed once daily for 1 month (a) a DP1-10 cocoa extract containing 130 mg of (−)-epicatechin and 560 mg of procyanidins (b) a DP2-10 cocoa extract containing 20 mg (−)-epicatechin and 540 mg procyanidins or (c) a Control that was flavanol-free with identical micro- and macronutrient composition. (ClinicalTrials.gov NCT02728466) Results: Consumption of DP1-10, but neither DP2-10 nor the Control, significantly increased flow-mediated vasodilation (primary endpoint), and the level of structurally-related (−)-epicatechin metabolites (SREMs) in the circulatory system, while decreasing pulse wave velocity and blood pressure. Total cholesterol significantly decreased after daily intake of both DP1-10 and DP2-10 as compared to the Control. Conclusions: CF-related improvements in vascular function predominantly relate to intake of flavanol monomers and circulating SREMs in healthy humans, but not to the more abundant procyanidins and gut microbiome-derived CF-catabolites. Reduction in total cholesterol was linked to consumption of procyanidins but not necessarily that of (-)-epicatechin.

Background & Aims Patients with acute decompensation and acute-on-chronic liver failure (AD/ACLF) have immune dysfunction, which increases their risk for infections; however, there are no effective treatments to restore their immune function. We investigated whether the potentially immune-restorative effects of albumin are mediated by its effects on prostaglandin E2 (PGE2) and other lipids. Methods We analyzed bloods samples from 45 of 79 patients with AD/ACLF and serum levels of albumin less than 30 g/L for whom infusion of 20% human albumin solution (HAS) increased serum levels of albumin 30 g/L or more in a feasibility study of effects of 20% HAS. Immune function was determined by comparison of macrophage function following addition of plasma samples. We also used samples from 12 healthy individuals. We measured binding of plasma proteins to PGE2 and serum levels of endotoxin (lipopolysaccharide) and cytokines; using 10 patients’ samples, we investigated the effects of PGE2 inhibitors. We performed a comprehensive lipid metabolomic analysis using samples from 10 different patients, before and after HAS administration. Results At baseline, AD/ACLF patient plasma induced significantly lower production of tumor necrosis factor by healthy macrophages than plasma from healthy individuals (P < .0001). Plasma from patients after HAS infusion induced significantly higher levels of tumor necrosis factor production by macrophages (19.5 ± 4.8 ng/mL) compared with plasma collected before treatment (17.7 ± 4.5 ng/mL; P = .0013). There was a significantly lower proportion of plasma protein (albumin) binding to PGE2 from patients with AD/ACLF plasma (mean, 61.9%) compared with plasma from control subjects (77.1%; P = .0012). AD/ACLF plasma protein binding to PGE2 increased following HAS treatment compared with baseline (mean increase, 8.7%; P < .0001). Circulating levels of PGE2, lipopolysaccharide, and inflammatory or anti-inflammatory cytokines were higher in patients with AD/ACLF than healthy volunteers. Unexpectedly, HAS infusion had no effect on mediator levels. Principal component analysis of baseline levels of lipids that induce or resolve inflammation identified 2 distinct groups of patients that differed according to baseline plasma level of lipopolysaccharide. Sample analyses after HAS treatment indicated that albumin regulates circulating levels of lipid mediators, but this effect was distinct in each group. Conclusions Analysis of blood samples from patients with AD/ACLF participating in a feasibility study of 20% HAS infusions has shown that infusions to raise serum albumin above 30 g/L reversed plasma-mediated immune dysfunction by binding and inactivating PGE2. We also describe a method to classify the inflammatory response in AD/ACLF, based on lipid profile, which could improve identification of patients most likely to respond to HAS treatment. A randomized controlled trial is needed to determine whether these effects of HAS reduce infections in AD/ACLF. Trial registered with European Medicines Agency (EudraCT 2014-002300-24) and adopted by NIHR (ISRCTN14174793).

BackgroundExenatide is a GLP-1 receptor agonist that was recently studied for potential disease-modifying effects in a randomised, placebo-controlled clinical trial in patients with moderate stage Parkinson’s disease, and showed positive effects on the motor severity of the disease which were sustained 12 weeks beyond the period of exenatide exposure. Analysis of pre-defined secondary outcomes revealed no statistically significant differences between patients treated with exenatide in total non-motor symptom burden and overall quality of life measures. Objective:The response of individual non-motor symptoms to an intervention may vary and thus this post hoc analysis was conducted to explore the possible effects of exenatide compared to placebo on individual non-motor symptoms. Results:Compared to placebo, patients treated with exenatide-once weekly had greater improvements in individual domains assessing mood/depression across all observer-rated outcome measures after 48 weeks including the “mood/apathy” domain of the NMSS, –3.3 points (95% CI –6.2, –0.4), p = 0.026; the “mood” score (Q1.3+Q1.4 of the MDS-UPDRS Part 1), –0.3 points (95%CI –0.6, –0.1), p = 0.034; and a trend in the MADRS total score, –1.7 points (95%CI –3.6, 0.2), p = 0.071. In addition, there was an improvement in the “emotional well-being” domain of the PDQ-39 of 5.7 points ((95%CI –11.3, –0.1), p = 0.047 though these improvements were not sustained 12 weeks after exenatide withdrawal. At 48 weeks these changes were of a magnitude that would be subjectively meaningful to patients and were not associated with changes in motor severity or other factors, suggesting exenatide may exert independent effects on mood dysfunction. Conclusions: These exploratory findings will contribute to the design of future trials to confirm the extent of motor and non-motor symptom effects of exenatide in larger cohorts of patients.

Exenatide, a glucagon-like peptide-1 agonist and a licensed treatment for Type 2 diabetes significantly reduced deterioration in motor symptoms in patients with Parkinson’s disease in a randomized, placebo-controlled trial. In addition, there were trends favouring the exenatide group in assessments of nonmotor symptoms, cognition, and quality of life. The aim of this exploratory post hoc analysis was to generate new hypotheses regarding (a) whether candidate baseline factors might predict the magnitude of response to exenatide; and (b) whether the beneficial effects of exenatide reported for the overall population are consistent in various subgroups of patients. Univariate and multi-variate analyses were conducted to determine possible predictors of motor response to exenatide in this cohort. Potential treatment by subgroup interactions for changes in; motor severity, nonmotor symptoms, cognition, and quality of life after 48-weeks treatment with exenatide were evaluated among post hoc subgroups defined by age, motor phenotype, disease duration, disease severity, body mass index (BMI), and insulin resistance. In the subgroup analyses, exenatide once- weekly was associated with broadly improved outcome measures assessing motor severity, nonmotor symptoms, cognition, and quality of life across all subgroups, however, tremor- dominant phenotype and lower Movement Disorder Society-Sponsored Revision of the Unified Parkinson’s Disease Rating Scale (MDS-UPDRS) Part-2 scores predicted greatest motor response to exenatide and there was an indication that patients with older age of onset and disease duration over 10 years responded less well. While patients with a range of demographic and clinical factors can potentially benefit from exenatide once-weekly, these data support an emphasis towards recruiting patients at earlier disease in future planned clinical trials of gluacagon-like peptide-1 (GLP-1) receptor agonists in Parkinson’s disease (PD).

Importance: Exenatide, a glucagon-like peptide 1 agonist used in type 2 diabetes, was recently found to have beneficial effects on motor function in a randomized, placebo-controlled trial in Parkinson disease (PD). Accumulating evidence suggests that impaired brain insulin and protein kinase B (Akt) signaling play a role in PD pathogenesis; however, exploring the extent to which drugs engage with putative mechnisms in vivo remains a challenge. Objective: To assess whether participants in the Exenatide-PD trial have augmented activity in brain insulin and Akt signaling pathways. Design, Setting, and Participants: Serum samples were collected from 60 participants in the single-center Exenatide-PD trial (June 18, 2014, to June 16, 2016), which compared patients with moderate PD randomized to 2 mg of exenatide once weekly or placebo for 48 weeks followed by a 12-week washout period. Serum extracellular vesicles, including exosomes, were extracted, precipitated, and enriched for neuronal source by anti–L1 cell adhesion molecule antibody absorption, and proteins of interest were evaluated using electrochemiluminescence assays. Statistical analysis was performed from May 1, 2017, to August 31, 2017. Main Outcomes and Measures: The main outcome was augmented brain insulin signaling that manifested as a change in tyrosine phosphorylated insulin receptor substrate 1 within neuronal extracellular vesicles at the end of 48 weeks of exenatide treatment. Additional outcome measures were changes in other insulin receptor substrate proteins and effects on protein expression in the Akt and mitogen-activated protein kinase pathways. Results: Sixty patients (mean [SD] age, 59.9 [8.4] years; 43 [72%] male) participated in the study: 31 in the exenatide group and 29 in the placebo group (data from 1 patient in the exenatide group were excluded). Patients treated with exenatide had augmented tyrosine phosphorylation of insulin receptor substrate 1 at 48 weeks (0.27 absorbance units [AU]; 95% CI, 0.09-0.44 AU; P = .003) and 60 weeks (0.23 AU; 95% CI, 0.05-0.41 AU; P = .01) compared with patients receiving placebo. Exenatide-treated patients had elevated expression of downstream substrates, including total Akt (0.35 U/mL; 95% CI, 0.16-0.53 U/mL; P 

Abstract Introduction Circulating prostaglandin E2 levels are elevated in acutely decompensated cirrhosis and have been shown to contribute to immune suppression. Albumin binds and inactivates this hormone. Human albumin solution could thus be repurposed as an immune restorative drug in these patients. This feasibility study aims to determine whether it is possible and safe to restore serum albumin to >30 g/L and maintain it at this level in patients admitted with acute decompensated cirrhosis using repeated 20% human albumin infusions according to daily serum albumin levels. Methods and analysis Albumin To prevenT Infection in chronic liveR failurE (ATTIRE) stage 1 is a multicentre, open label dose feasibility trial. Patients with acutely decompensated cirrhosis admitted to hospital with a serum albumin of

Children and young people are usually given liquid morphine by mouth for breakthrough pain, which can take thirty minutes to work. A faster-acting, quickly absorbed, needle-free pain medicine, that is easy to administer is needed such as transmucosal (sublingual, buccal, intranasal) diamorphine. Research evidence relating to the administration of medication for breakthrough pain in children and young people is limited. This study aims to describe the experiences and preferences of parents and/or children and young people regarding the route of administration of diamorphine, barriers and facilitators comparative to oral morphine, and participation in a randomised controlled trial. In-depth, semi-structured interviews with parents and/or children and young people at home or hospital/hospice. Thirteen interviews with: nine mothers, one father, and three sets of parents jointly. No interviews took place with a child/young person. Most families had experience of the buccal route which was effective in ease of administration and time to control pain. The intranasal route was preferred by parents irrespective of experience. Parents' willingness for their child to take part in a trial depended on the time commitment, their child's pain trajectory and the stability of analgesic requirements. A randomised controlled trial of oral morphine versus transmucosal diamorphine would need to consider trial logistics, especially time commitment. Parents felt that the trial should be introduced initially by the clinical team, with written information from the research team, and sufficient time to ask questions. Patients who had discontinued oral morphine because of side effects, or those with gastrointestinal failure, should be excluded. Maintaining stability in pain management was essential to families, so the timing of the trial is a potential issue.

Introduction/Background MIRRORS is a UK based prospective feasibility study opened June 2020, following ethics approval. Its purpose is to establish the feasibility of launching a randomised control trial (RCT) of Robotic interval debulking surgery for ovarian cancer (including cancer of the fallopian tube & peritoneum) MIRRORS-RCT in the future. MIRRORS will focus on the feasibility of obtaining consent from women and the acceptability of Robotic interval debulking surgery for advanced ovarian cancer. Methodology Women will be identified through the Gynaecological Oncology multi-disciplinary team meeting. Inclusion Criteria adult women ≥18 years with stage IIIc–IVb ovarian cancer (including cancer of the fallopian tube & peritoneum) undergoing neo–adjuvant chemotherapy considered suitable for interval debulking surgery (IDS). ≤8 cm pelvic mass on CT Exclusion Criteria Pelvic Mass >8 cm open surgical approach considered necessary following MDT review. Women lacking capacity to the extent they are unable to understand or complete trial documentation/questionnaires will be excluded from the trial. MIRRORS inclusion criteria are intentionally wide, not restricting by Body Mass Index (BMI), patient comorbidity or Ca125 values. Surgery will commence with an initial laparoscopic assessment followed by a decision to proceed to robotic or open interval debulking surgery. The aim of surgery is to remove all visible disease safely by whichever route. If conversion to open surgery is required to complete this, then it will be done. Results All women recruited to MIRRORS, whether eventually undergoing robotic or open surgery, will be followed up to assess recovery, complication rate, pain and quality of life. If the following Success Criteria are met, we will progress to MIRRORS-RCT: ≥20% of women eligible for the study accept inclusion in MIRRORS. Robotic IDS Complication rate is not higher than for open interval debulking surgery Conversion to open surgery rate not greater than 50% in patient group deemed suitable for Robotic IDS following initial diagnostic laparoscopy.Abstract 255 Figure 1 Conclusion Robotic surgery is unlikely to be suitable in all cases of ovarian cancer, particularly those with large pelvic masses or extensive disease around the upper part of the abdomen, however, it has the potential to provide significant recovery and quality of life benefits. Ultimately we would like to determine whether, in selected women, robotic surgery offers improved quality of life and recovery with equivalent overall and progression free survival. Disclosures Anil Tailor: Proctor for Intuitive Surgical Jayanta Chatterjee: paid-lectures on behalf of pharmaceutical companies Agnieszka Michael: Educational-grants: Clovis, GSK, Ipsen, Novartis, Pfizer, and Tesaro Simon Butler-Manuel: Proctor for Intuitive Surgical, Plasma Surgical & Ethicon

We aimed to compare the clinical effectiveness, cost-effectiveness and complication rates of total ankle replacement with those of arthrodesis (i.e. ankle fusion) in the treatment of end-stage ankle osteoarthritis. This was a pragmatic, multicentre, parallel-group, non-blinded randomised controlled trial. Patients with end-stage ankle osteoarthritis who were aged 50-85 years and were suitable for both procedures were recruited from 17 UK hospitals and randomised using minimisation. The primary outcome was the change in the Manchester-Oxford Foot Questionnaire walking/standing domain scores between the preoperative baseline and 52 weeks post surgery. Between March 2015 and January 2019, 303 participants were randomised using a minimisation algorithm: 152 to total ankle replacement and 151 to ankle fusion. At 52 weeks, the mean (standard deviation) Manchester-Oxford Foot Questionnaire walking/standing domain score was 31.4 (30.4) in the total ankle replacement arm (  = 136) and 36.8 (30.6) in the ankle fusion arm (  = 140); the adjusted difference in the change was -5.6 (95% confidence interval -12.5 to 1.4;  = 0.12) in the intention-to-treat analysis. By week 52, one patient in the total ankle replacement arm required revision. Rates of wound-healing issues (13.4% vs. 5.7%) and nerve injuries (4.2% vs.

Assessing pain in infants, children and young people with life-limiting conditions remains a challenge due to diverse patient conditions, types of pain and often a reduced ability or inability of patients to communicate verbally. To systematically identify pain assessment tools that are currently used in paediatric palliative care and examine their psychometric properties and feasibility and make recommendations for clinical practice. A systematic literature review and evaluation of psychometric properties of pain assessment tools of original peer-reviewed research published from inception of data sources to April 2021. PsycINFO via ProQuest, Web of Science Core, Medline via Ovid, EMBASE, BIOSIS and CINAHL were searched from inception to April 2021. Hand searches of reference lists of included studies and relevant reviews were performed. From 1168 articles identified, 201 papers were selected for full-text assessment. Thirty-four articles met the eligibility criteria and we examined the psychometric properties of 22 pain assessment tools. Overall, the Faces Pain Scale-Revised (FPS-R) had high cross-cultural validity, construct validity (hypothesis testing) and responsiveness; while the Faces, Legs, Activity, Cry and Consolability (FLACC) scale and Paediatric Pain Profile (PPP) had high internal consistency, criterion validity, reliability and responsiveness. The number of studies per psychometric property of each pain assessment tool was limited and the methodological quality of included studies was low. Balancing aspects of feasibility and psychometric properties, the FPS-R is recommended for self-assessment, and the FLACC scale/FLACC Revised and PPP are the recommended observational tools in their respective age groups.

Background Respiratory complications are an important cause of postoperative morbidity. We aimed to investigate whether continuous positive airway pressure (CPAP) administered immediately after major abdominal surgery could prevent postoperative morbidity. Methods PRISM was an open-label, randomised, phase 3 trial done at 70 hospitals across six countries. Patients aged 50 years or older who were undergoing elective major open abdominal surgery were randomly assigned (1:1) to receive CPAP within 4 h of the end of surgery or usual postoperative care. Patients were randomly assigned using a computer-generated minimisation algorithm with inbuilt concealment. The primary outcome was a composite of pneumonia, endotracheal re-intubation, or death within 30 days after randomisation, assessed in the intention-totreat population. Safety was assessed in all patients who received CPAP. The trial is registered with the ISRCTN registry, ISRCTN56012545. Findings Between Feb 8, 2016, and Nov 11, 2019, 4806 patients were randomly assigned (2405 to the CPAP group and 2401 to the usual care group), of whom 4793 were included in the primary analysis (2396 in the CPAP group and 2397 in the usual care group). 195 (8.1%) of 2396 patients in the CPAP group and 197 (8.2%) of 2397 patients in the usual care group met the composite primary outcome (adjusted odds ratio 1.01 [95% CI 0.81-1.24]; p=0.95). 200 (8.9%) of 2241 patients in the CPAP group had adverse events. The most common adverse events were claustrophobia (78 [3.5%] of 2241 patients), oronasal dryness (43 [1.9%]), excessive air leak (36 [1.6%]), vomiting (26 [1.2%]), and pain (24 [1.1%]). There were two serious adverse events: one patient had significant hearing loss and one patient had obstruction of their venous catheter caused by a CPAP hood, which resulted in transient haemodynamic instability. Interpretation In this large clinical effectiveness trial, CPAP did not reduce the incidence of pneumonia, endotracheal re-intubation, or death after major abdominal surgery. Although CPAP has an important role in the treatment of respiratory failure after surgery, routine use of prophylactic post-operative CPAP is not recommended. Copyright (C) 2021 Elsevier Ltd. All rights reserved.

INTRODUCTION Diagnosing the level of consciousness in patients suffering from severe brain lesions is still a major challenge. EEG-based systems can help discriminate conscious from unconscious patients. This study aims to confront the results from two of the most reliable methods: the Perturbational Complexity Index (PCI) which is based on Transcranial Magnetic Stimulation (TMS-EEG), and a recent machine learning approach using EEG-extracted markers from a standardized oddball auditory stimulation paradigm (EEG-ERP). METHODS Patients presenting either an unresponsive wakefulness syndrome (UWS), a minimally conscious state (MCS) or an emergence of MCS (EMCS) underwent both TMS-EEG and EEG-ERP. We computed PCI value by compressing the spatiotemporal pattern of cortical responses to the perturbation of the cortex with TMS. For EEG-ERP, we extracted 60 markers corresponding to quantification of power spectrum and complexity in individual EEG sensors and information sharing between them. Using machine-learning, we predicted the individual probability of being (minimally) conscious. RESULTS PCI and EEG markers, when considered categorically (i.e. UWS vs MCS), were consistent for all UWS and EMCS patients, whereas the results for MCS patients showed less consistency. Nevertheless, we found a significant correlation between PCI values and the probability of being conscious with the multivariate classifier. CONCLUSION PCI correlated positively with the combination of EEG markers in severely brain-injured patients. These findings imply that EEG signatures of consciousness can be reliably extracted from different contexts and combined into coherent predictive models, encouraging future efforts in large-scale data-driven clinical neuroscience. Peer reviewed

BackgroundIntranasal diamorphine is a potential treatment for breakthrough pain but few paediatric data are available to assist dose estimation.AimTo determine an intranasal diamorphine dose in children through an understanding of pharmacokinetics.DesignA systematic review of the literature was undertaken to seek diamorphine pharmacokinetic parameters in neonates, children and adults. Parenteral and enteral diamorphine bioavailability were reviewed with respect to formation of the major metabolite, morphine. Clinical data quantifying equianalgesic effects of diamorphine and morphine were reviewed.Review sourcesPubMed (1960–2020); EMBASE (1980–2020); IPA (1973–2020) and original human research studies that reported diacetylmorphine and metabolite after any dose or route of administration.ResultsThe systematic review identified 19 studies: 16 in adults and 1 in children and 2 neonatal reports. Details of study participants were extracted. Age ranged from premature neonates to 67 years and weight 1.4–88 kg. Intranasal diamorphine bioavailability was predicted as 50%. The equianalgesic intravenous conversion ratio of morphine:diamorphine was 2:1. There was heterogeneity between pharmacokinetic parameter estimates attributed to routes of administration, lack of size standardisation, methodology and pharmacokinetic analysis. Estimates of the pharmacokinetic parameters clearance and volume of distribution were reduced in neonates. There were insufficient paediatric data to characterise clearance or volume maturation of either diamorphine or its metabolites.ConclusionsWe estimate equianalgesic ratios of intravenous morphine:diamorphine 2:1, intravenous morphine:intranasal diamorphine 1:1 and oral morphine:intranasal diamorphine of 1:3. These ratios are based on adult literature, but are reasonable for deciding on an initial dose of 0.1 mg/kg in children 4–13 years.

ObjectivesNo randomised controlled trials have been conducted for breakthrough pain in paediatric palliative care and there are currently no standardised outcome measures. The DIPPER study aims to establish the feasibility of conducting a prospective randomised controlled trial comparing oral and transmucosal administration of opioids for breakthrough pain. The aim of the current study was to achieve consensus on design aspects for a small-scale prospective study to inform a future randomised controlled trial of oral morphine, the current first-line treatment, versus transmucosal diamorphine.MethodsThe nominal group technique was used to achieve consensus on best practice for mode of administration, dose regimen and a range of suitable pain intensity outcome measures for transmucosal diamorphine in children and young people with breakthrough pain. An expert panel of ten clinicians in paediatric palliative care and three parent representatives participated. Consensus was achieved when agreement was reached and no further comments from participants were forthcoming.ResultsThe panel favoured the buccal route of administration, with dosing according to the recommendations in the Association for Paediatric Palliative Medicine formulary (fifth Edition, 2020). The verbal Numerical Rating Scale was selected to measure pain in children 8 years old and older, the Faces Pain Scale-Revised for children between 4 and 8 years old, and Face, Legs, Activity, Cry and Consolability (FLACC)/FLACC-Revised as the observational tools.ConclusionsThe nominal group technique allowed consensus to be reached for a small-scale, prospective, cohort study and provided information to inform the design of a randomised controlled trial.

IntroductionParkinson’s disease (PD) is a common neurodegenerative disorder with substantial morbidity. No disease-modifying treatments currently exist. The glucagon like peptide-1 receptor agonist exenatide has been associated in single-centre studies with reduced motor deterioration over 1 year. The aim of this multicentre UK trial is to confirm whether these previous positive results are maintained in a larger number of participants over 2 years and if effects accumulate with prolonged drug exposure.Methods and analysisThis is a phase 3, multicentre, double-blind, randomised, placebo-controlled trial of exenatide at a dose of 2 mg weekly in 200 participants with mild to moderate PD. Treatment duration is 96 weeks. Randomisation is 1:1, drug to placebo. Assessments are performed at baseline, week 12, 24, 36, 48, 60, 72, 84 and 96 weeks.The primary outcome is the comparison of Movement Disorders Society Unified Parkinson’s Disease Rating Scale part 3 motor subscore in the practically defined OFF medication state at 96 weeks between participants according to treatment allocation. Secondary outcomes will compare the change between groups among other motor, non-motor and cognitive scores. The primary outcome will be reported using descriptive statistics and comparisons between treatment groups using a mixed model, adjusting for baseline scores. Secondary outcomes will be summarised between treatment groups using summary statistics and appropriate statistical tests to assess for significant differences.Ethics and disseminationThis trial has been approved by the South Central-Berkshire Research Ethics Committee and the Health Research Authority. Results will be disseminated in peer-reviewed journals, presented at scientific meetings and to patients in lay-summary format.Trial registration numbersNCT04232969, ISRCTN14552789.

End-stage ankle osteoarthritis causes severe pain and disability. There are no randomized trials comparing the 2 main surgical treatments: total ankle replacement (TAR) and ankle fusion (AF). To determine which treatment is superior in terms of clinical scores and adverse events. A multicenter, parallel-group, open-label randomized trial. (ISRCTN registry number: 60672307). 17 National Health Service trusts across the United Kingdom. Patients with end-stage ankle osteoarthritis, aged 50 to 85 years, and suitable for either procedure. Patients were randomly assigned to TAR or AF surgical treatment. The primary outcome was change in Manchester-Oxford Foot Questionnaire walking/standing (MOXFQ-W/S) domain scores between baseline and 52 weeks after surgery. No blinding was possible. Between 6 March 2015 and 10 January 2019, a total of 303 patients were randomly assigned; mean age was 68 years, and 71% were men. Twenty-one patients withdrew before surgery, and 281 clinical scores were analyzed. At 52 weeks, the mean MOXFQ-W/S scores improved for both groups. The adjusted difference in the change in MOXFQ-W/S scores from baseline was -5.6 (95% CI, -12.5 to 1.4), showing that TAR improved more than AF, but the difference was not considered clinically or statistically significant. The number of adverse events was similar between groups (109 vs. 104), but there were more wound healing issues in the TAR group and more thromboembolic events and nonunion in the AF group. The symptomatic nonunion rate for AF was 7%. A post hoc analysis suggested superiority of fixed-bearing TAR over AF (-11.1 [CI, -19.3 to -2.9]). Only 52-week data; pragmatic design creates heterogeneity of implants and surgical techniques. Both TAR and AF improve MOXFQ-W/S and had similar clinical scores and number of harms. Total ankle replacement had greater wound healing complications and nerve injuries, whereas AF had greater thromboembolism and nonunion, with a symptomatic nonunion rate of 7%. National Institute for Health and Care Research Heath Technology Assessment Programme.

INTRODUCTION: Sleep disturbances are prevalent in Alzheimer’s disease (AD), but it is currently not known whether night-to-night variation in sleep predicts day-to-day variation in vigilance, cognition, mood, and behavior (daytime measures). METHODS: Subjective and objective sleep and daytime measures were collected daily for two weeks in 15 participants with mild AD, 8 mild cognitive impairment (MCI) and 22 with no cognitive impairment (NCI). Associations between daytime measures and four principal components of sleep (duration, quality, continuity and latency) were quantified using mixed-model regression. RESULTS: Sleepiness, alertness, contentedness, everyday memory errors, serial subtraction and behavioral problems were predicted by at least one of the components of sleep, and in particular sleep duration and continuity. Associations between variation in sleep and daytime measures were linear or quadratic and often different in AD from NCI. DISCUSSION: These findings imply that daytime functioning in AD may be improved by interventions that target sleep continuity.

Background The total ankle replacement versus ankle arthrodesis (TARVA) trial aims to determine which surgical procedure confers the greatest improvement in pain-free function for patients with end-stage ankle osteoarthritis. Both procedures are effective but there has not yet been a direct comparison to establish which is superior. This article describes the statistical analysis plan for this trial as an update to the published protocol. It is written prior to the end of patient follow-up, while the outcome of the trial is still unknown. Design and methods TARVA is a randomised, un-blinded, parallel group trial of total ankle replacement versus ankle arthrodesis. The primary outcome is the Manchester-Oxford Foot Questionnaire walking/standing domain score at 52 weeks post-surgery. Secondary outcomes include measures of pain, social interaction, physical function, quality of life, and range of motion. We describe in detail the statistical aspects of TARVA: the outcome measures, the sample size calculation, general analysis principles including treatment of missing data, the planned descriptive statistics and statistical models, and planned subgroup and sensitivity analyses. Discussion The TARVA statistical analysis will provide comprehensive and precise information on the relative effectiveness of the two treatments. The plan will be implemented in January 2020 when follow-up for the trial is completed.

Objectives This review aimed to identify the demographic and clinical differences between those older adults admitted directly under neurosurgical care and those that were not, and whether EMS clinicians could use these differences to improve patient triage. Methods The authors searched for papers that included older adults who had suffered a TBI and were either admitted directly under neurosurgical care or were not. Titles and abstracts were screened, shortlisting potentially eligible papers before performing a full-text review. The Newcastle-Ottawa Scale was used to assess the risk of bias. Results A total of nine studies were eligible for inclusion. A high abbreviated injury score head, Marshall score or subdural hematoma greater than 10 mm were associated with neurosurgical care. There were few differences between those patients who did and did not receive neurosurgical intervention. Conclusions Absence of guidelines and clinician bias means that differences between those treated aggressively and conservatively observed in the literature are fraught with bias. Further work is required to understand which patients would benefit from an escalation of care and whether EMS can identify these patients so they are transported directly to a hospital with the appropriate services on-site.

Infection and increased systemic inflammation cause organ dysfunction and death in patients with decompensated cirrhosis. Preclinical studies provide support for an antiinflammatory role of albumin, but confirmatory large-scale clinical trials are lacking. Whether targeting a serum albumin level of 30 g per liter or greater in these patients with repeated daily infusions of 20% human albumin solution, as compared with standard care, would reduce the incidences of infection, kidney dysfunction, and death is unknown. We conducted a randomized, multicenter, open-label, parallel-group trial involving hospitalized patients with decompensated cirrhosis who had a serum albumin level of less than 30 g per liter at enrollment. Patients were randomly assigned to receive either targeted 20% human albumin solution for up to 14 days or until discharge, whichever came first, or standard care. Treatment commenced within 3 days after admission. The composite primary end point was new infection, kidney dysfunction, or death between days 3 and 15 after the initiation of treatment. A total of 777 patients underwent randomization, and alcohol was reported to be a cause of cirrhosis in most of these patients. A median total infusion of albumin of 200 g (interquartile range, 140 to 280) per patient was administered to the targeted albumin group (increasing the albumin level to ≥30 g per liter), as compared with a median of 20 g (interquartile range, 0 to 120) per patient administered to the standard-care group (adjusted mean difference, 143 g; 95% confidence interval [CI], 127 to 158.2). The percentage of patients with a primary end-point event did not differ significantly between the targeted albumin group (113 of 380 patients [29.7%]) and the standard-care group (120 of 397 patients [30.2%]) (adjusted odds ratio, 0.98; 95% CI, 0.71 to 1.33; P = 0.87). A time-to-event analysis in which data were censored at the time of discharge or at day 15 also showed no significant between-group difference (hazard ratio, 1.04; 95% CI, 0.81 to 1.35). More severe or life-threatening serious adverse events occurred in the albumin group than in the standard-care group. In patients hospitalized with decompensated cirrhosis, albumin infusions to increase the albumin level to a target of 30 g per liter or more was not more beneficial than the current standard care in the United Kingdom. (Funded by the Health Innovation Challenge Fund; ATTIRE EudraCT number, 2014-002300-24; ISRCT number, N14174793.).

Oral morphine is frequently used for breakthrough pain but the oral route is not always available and absorption is slow. Transmucosal diamorphine is administered by buccal, sublingual or intranasal routes, and rapidly absorbed. To explore the perspectives of healthcare professionals in the UK caring for children with life-limiting conditions concerning the assessment and management of breakthrough pain; prescribing and administration of transmucosal diamorphine compared with oral morphine; and the feasibility of a comparative clinical trial. Three focus groups, analysed using a Framework approach. Doctors, nurses and pharmacists (  = 28), caring for children with life-limiting illnesses receiving palliative care, participated. Oral morphine is frequently used for breakthrough pain across all settings; with transmucosal diamorphine largely limited to use in hospices or given by community nurses, predominantly buccally. Perceived advantages of oral morphine included confidence in its use with no requirement for specific training; disadvantages included tolerability issues, slow onset, unpredictable response and unsuitability for patients with gastrointestinal failure. Perceived advantages of transmucosal diamorphine were quick onset and easy administration; barriers included lack of licensed preparations and prescribing guidance with fears over accountability of prescribers, and potential issues with availability, preparation and palatability. Factors potentially affecting recruitment to a trial were patient suitability and onerousness for families, trial design and logistics, staff time and clinician engagement. There were perceived advantages to transmucosal diamorphine, but there is a need for access to a safe preparation. A clinical trial would be feasible provided barriers were overcome.

Background: Complications in sickle cell anemia (SCA, HbSS) include neurocognitive difficulties in attention and processing speed associated with low daytime and night-time oxygen saturation. These effects can be compounded by obstructive sleep apnea (OSA).However, there is concern that oxygen supplementation in SCA may lead to bone marrow suppression. Continuous Positive Airways Pressure (CPAP) is an accepted treatment for OSA in the general population and prevents dips in oxygen saturation.. The aim of this single-blind, randomised, controlled phase II trial is to compare Auto-adjusting CPAP (APAP) with standard care to standard care alone in subjects with HbSS to determine whether the intervention is safe and improves Cancellation, a measure of selective attention and processing speed. Methods: Eligibility criteria included ability to provide informed consent, age >8 and 50% were not adherent by the pre-defined definition, those who were compliant appeared to have more benefit in terms of improvement in attention/processing speed. There appears to be an interaction with HU use, consistent with the importance of oxygen supply and carriage for brain function. If delivery of the intervention can be improved, avoidance of oxygen desaturation with overnight respiratory support alongside HU use may play a role in improving cognition in SCD. Disclosures: No relevant conflicts of interest to declare.

Objective: To further explore the mechanism of action of exenatide, a glucagon-like peptide-1 agonist, underlying the positive effects on motor function in a recently reported in a clinical trial of Parkinson’s disease. Background: Exenatide, a glucagon-like peptide-1 agonist licensed for the treatment of Type 2 diabetes was recently found to have beneficial effects on motor function in a placebo-controlled trial in patients with moderate stage Parkinson’s disease (PD). Accumulating evidence suggests that impaired insulin and Akt signalling with consequent relative deactivation of cell survival pathways play a role in PD pathogenesis. Design/Methods: We isolated serum extracellular vesicles (EVs) enriched for neuronal origin from trial participants and measuring concentrations of total and phosphorylated signalling proteins at various timepoints. Neuronal insulin receptor mediated downstream signalling cascades were investigated by measuring levels of IRS-1 proteins, whereas evidence of potential Akt and MAPK pathway activation was determined by measurement of total and phosphorylated forms of key kinases Akt, mTOR, GSK-3B, p38, Erk1/2 and JNK. Results: We found that, compared to placebo, peripherally administered exenatide can engage neuronal signalling pathways and promote activating phosphorylations on IRS-1 tyrosine residues and downstream substrates including Akt and mechanistic target of rapamycin (mTOR). Furthermore, the beneficial clinical effects of exenatide on motor function were associated with EV biomarker changes suggesting a reduction in neuronal insulin resistance and concomitant activation of mTOR signalling Conclusions: The results suggest target engagement of insulin/Akt/mTOR signalling pathways in neurons by exenatide and provide a mechanistic context for the recent clinical findings of the trial.

Introduction/Background MIRRORS is a UK based prospective feasibility study opened June 2020, following ethics approval. Its purpose is to establish the feasibility of launching a randomised control trial (RCT) of Robotic interval debulking surgery for ovarian cancer (including cancer of the fallopian tube & peritoneum) MIRRORS-RCT in the future. MIRRORS will focus on the feasibility of obtaining consent from women and the acceptability of Robotic interval debulking surgery for advanced ovarian cancer. Methodology Women will be identified through the Gynaecological Oncology multi-disciplinary team meeting. Inclusion Criteria adult women ≥18 years with stage IIIc–IVb ovarian cancer (including cancer of the fallopian tube & peritoneum) undergoing neo–adjuvant chemotherapy considered suitable for interval debulking surgery (IDS). ≤8 cm pelvic mass on CT Exclusion Criteria Pelvic Mass >8 cm open surgical approach considered necessary following MDT review. Women lacking capacity to the extent they are unable to understand or complete trial documentation/questionnaires will be excluded from the trial. Exclusion CriteriaMIRRORS inclusion criteria are intentionally wide, not restricting by Body Mass Index (BMI), patient comorbidity or Ca125 values. Surgery will commence with an initial laparoscopic assessment followed by a decision to proceed to robotic or open interval debulking surgery. The aim of surgery is to remove all visible disease safely by whichever route. If conversion to open surgery is required to complete this, then it will be done. Results All women recruited to MIRRORS, whether eventually undergoing robotic or open surgery, will be followed up to assess recovery, complication rate, pain and quality of life. If the following Success Criteria are met, we will progress to MIRRORS-RCT: ≥20% of women eligible for the study accept inclusion in MIRRORS. Robotic IDS Complication rate is not higher than for open interval debulking surgery Conversion to open surgery rate not greater than 50% in patient group deemed suitable for Robotic IDS following initial diagnostic laparoscopy.

Background and Aims: Patients with cirrhosis are at a greatly increased risk of severe bacterial infection with survival directly related to extra-hepatic organ dysfunction. A defective innate immune response is considered to underlie this risk. There is however no medical strategy to restore immune competence in these patients. Elevated circulating Prostaglandin E2 (PGE2) levels contribute to immune suppression in acutely decompensated (AD) cirrhosis. PGE2 is more bioavailable because of decreased serum albumin levels in AD patients as albumin binds PGE2. The binding capacity of endogenous albumin is also known to be defective in cirrhosis. Human Albumin Solution (HAS), a safe and common intervention, could thus be repurposed as an immune restorative drug in AD patients. The primary aim of ATTIRE is to determine if raising serum albumin to >30 g/L in patients with decompensated cirrhosis will decrease rates of infection, extra hepatic organ dysfunction and death.

TARVA is an NIHR HTA funded portfolio randomised controlled trial (RCT) comparing total ankle replacement (TAR) and arthrodesis (fusion) surgery in NHS patients aged 50-85 with end-stage ankle arthritis. 328 patients will be randomly allocated to TAR or arthrodesis on an equal basis. Clinician and patient treatment equipoise is critical to recruit surgeons and patients successfully. The TARVA Trial team has developed novel surgeon and patient engagement techniques involving technology and multi-media tools to achieve our aims. Examples include an award-winning video, a white-labelled patient information brochure, professional newsletters and blogs, and a particular focus on the use of social networking tools to engage both investigators and patients. The impartial trial information video featuring consultant foot and ankle surgeons and patients who have undergone TAR or fusion surgery can be accessed through the trial website (http://anklearthritis.co.uk). The pilot phase began with the randomisation of the first patient in March 2015. An overview of our techniques alongside recruitment data accumulated until November will be presented at the ICTM conference.

Unfortunately, the original version of this article [1] contained an error. The title was written as “Novel patient engagement and recruitment strategies for an RCY of two NHS treatments for ankle osteoarthritis - total ankle replacement versus arthrodesis - the TARVA trial” and should instead have been written as follows: “Novel patient engagement and recruitment strategies for an RCT of two NHS treatments for ankle osteoarthritis - total ankle replacement versus arthrodesis - the TARVA trial” where RCY should be RCT which stands for Randomised Controlled Trial.

Introduction/Background: Ovarian cancer is the most lethal gynaecological malignancy and the 6th most common cancer among women globally. The incidence of malignant bowel obstruction (MBO) in patients with advanced disease is up to 51%. It presents a very distressing scenario for patients, their families and clinicians. Management of MBO can be divided into surgical and medical management. Surgical management can involve direct resection, bypass surgery or stoma formation. Medical management includes endoscopic procedures, nasogastric tubes for decompression, bowel rest, parenteral feeding and symptom control such as chemotherapy, steroids, antisecretory drugs, analgesia and anti-emetics. The rationale in choosing between surgical or medical management strategies is not well defined. High perioperative morbidity (up to 90%) and mortality (up to 40%) can make surgery a risky choice and there is increasing evidence that non-surgical management can significantly improve symptoms and quality of life. The objective of this study was to evaluate the outcomes of patients with advanced ovarian cancer who undergo non-surgical management of malignant bowel obstruction and conduct a meta-analysis to estimate median survival. Methodology: A literature search was carried out using the Pubmed, Embase and Medline online libraries up until November 2019. We also searched abstracts of scientific meetings, reference lists of included studies and contacted experts in the field. Relevant studies that met the inclusion criteria were independently selected by two of the co-authors and the data extracted and analysed separately. Results: In total 24 studies were found to be relevant for the systematic review and 9 met the eligibility criteria for the meta-analysis, a total of 2236 patients were included. Median survival for patients managed medically for bowel obstruction was 44 days (95% CI 38–49 days, I2 = 0%, P = 0.128).Abstract 296 Figure 1ConclusionThe quality of the included studies was relatively low, however the evidence shows that non-surgical management of bowel obstruction in advanced ovarian cancer patients results in a short survival period, but with controlled symptoms. Where quality of life is the main concern, this may be a feasible and effective strategy.