Reducing delays in the diagnosis and treatment of muscle-invasive bladder cancer using simulation modelling

This is the author accepted manuscript. The final version is available from SAGE Publications via the DOI in this record Objective: To develop a simulation model to identify key bottlenecks in the bladder cancer pathway at Royal Cornwall Hospital and predict the impact of potential changes to reduce these delays. Materials and methods: The diagnosis and treatment of muscle-invasive bladder cancer can suffer numerous delays, which can significantly affect patient outcomes. We developed a discrete event computer simulation model of the flow of patients through the bladder cancer pathway at the hospital, using anonymised patient records from 2014 and 2015. The changes tested in the model were for patients suspected to have muscle-invasive disease on flexible cystoscopy. Those patients were ‘fast-tracked’ to receive their transurethral resection of bladder tumour (TURBT) treatment using operating slots kept free for these patients. A staging computed tomography scan was booked in the haematuria clinic. Pathology requests were marked as 48 hour turnaround. The nurse specialist would then speak to the patient whilst they were on the ward following their TURBT to give information about their ongoing treatment and provide support. Results: The model predicted that if the changes were implemented, delays in the system could be reduced by around 5 weeks. The changes were implemented, and analysis of 3 months of the data post-implementation shows that the average time in the system was reduced by 5 weeks. The environment created by the changes in the pathway improved referral to treatment times in both muscle-invasive and non-muscle-invasive groups. Conclusion: The simulation model proved an invaluable tool for facilitating the implementation of changes. Simple changes to the pathway led to significant reductions in delays for bladder cancer patients at Royal Cornwall Hospital. Level of evidence: Not applicable for this cohort study.National Institute for Health Research (NIHR

Challenges and opportunities for classroom-based formative assessment and AI: a perspective article

The integration of artificial intelligence (AI) into educational contexts may give rise to both positive and negative ramifications for teachers’ uses of formative assessment within their classrooms. Drawing on our diverse experiences as academics, researchers, psychometricians, teachers, and teacher educators specializing in formative assessment, we examine the pedagogical practices in which teachers provide feedback, facilitate peer- and self-assessments, and support students’ learning, and discuss how existing challenges to each of these may be affected by applications of AI. Firstly, we overview the challenges in the practice of formative assessment independently of the influence of AI. Moreover, based on the authors’ varied experience in formative assessment, we discuss the opportunities that AI brings to address the challenges in formative assessment as well as the new challenges introduced by the application of AI in formative assessment. Finally, we argue for the ongoing importance of self-regulated learning and a renewed emphasis on critical thinking for more effective implementation of formative assessment in this new AI-driven digital age

Scaling the nexus: towards integrated frameworks for analysing water, energy and food

The emergence of the water-energy-food (WEF) nexus concept following the 2011 Bonn Nexus Conference has resulted in a change to the way we perceive our natural resources. Global pressures such as climate change, and population growth have highlighted the fragility of our WEF systems, necessitating integrated solutions across multiple scales and levels. Whilst a number of frameworks and analytical tools have been developed since 2011, a comprehensive WEF nexus tool remains elusive, hindered in part by our limited data and understanding of the interdependencies and connections across the WEF systems. To achieve this, the community of academics, practitioners and policy-makers invested in WEF nexus research are addressing several critical areas that currently remain as barriers. Firstly, the plurality of scales (e.g., spatial, temporal, institutional, jurisdictional) necessitates a more comprehensive effort to assess interdependencies between water, energy and food, from household to institutional and national levels. Secondly, and closely related to scale, a lack of available data often hinders our ability to quantify physical stocks and flows of resources. In this paper, we elucidate many of the challenges that have arisen across nexus research, including the impact of multiple scales in operation across the nexus, and concomitantly, what impact these scales have on data accessibility. We review some of the critical frameworks and tools that are applied by nexus researchers and discuss some of the steps required to develop from nexus thinking to an operationalizable concept, with a consistent focus on scale and data availability

Loss of tolerance to gut immunity protein; glycoprotein 2 (GP2) is associated with progressive disease course in primary sclerosing cholangitis

Abstract Glycoprotein 2[GP2] is a specific target of pancreatic autoantibodies[PAbs] in Crohn’s disease(CD) and is involved in gut innate immunity processes. Our aim was to evaluate the prevalence and prognostic potential of PAbs in primary sclerosing cholangitis(PSC). Sixty-five PSC patients were tested for PAbs by indirect immunofluorescence and compared with healthy (n = 100) and chronic liver disease controls(CLD, n = 488). Additionally, a panel of anti-microbial antibodies and secretory (s)IgA levels were measured, as markers of bacterial translocation and immune dysregulation. PAbs were more frequent in PSC(46.2%) compared to controls(healthy:0% and CLD:4.5%), [P < 0.001, for each]. Occurrence of anti-GP2 antibody was 30.8% (20/65) and was exclusively of IgA isotype. Anti-GP2 IgA positive patients had higher sIgA levels (P = 0.021). With flow-cytometry, 68.4% (13/19) of anti-GP2 IgA antibodies were bound with secretory component, suggesting an active retro-transportation of anti-GP2 from the gut lumen to the mucosa. Anti-GP2 IgA was associated with shorter transplant-free survival [PLogRank < 0.01] during the prospective follow-up (median, IQR: 87 [9–99] months) and remained an independent predictor after adjusting for Mayo risk score(HR: 4.69 [1.05–21.04], P = 0.043). These results highlight the significance of gut-liver interactions in PSC. Anti-GP2 IgA might be a valuable tool for risk stratification in PSC and considered as a potential therapeutic target

An RBP4 promoter polymorphism increases risk of type 2 diabetes

Aims/hypothesis: Retinol-binding protein 4 (RBP4), originally known for retinol transport, was recently identified as an adipokine affecting insulin resistance. The RBP4 -803GA promoter polymorphism influences binding of hepatic nuclear factor 1α and is associated with type 2 diabetes in case-control studies. We hypothesised that the RBP4 -803GA polymorphism increases type 2 diabetes risk at a population-based level. In addition, information on retinol intake and plasma vitamin A levels enabled us to explore the possible underlying mechanism. Methods: In the Rotterdam Study, a prospective, population-based, follow-up study, the -803GA polymorphism was genotyped. In Cox proportional hazards models, associations of the -803GA polymorphism and retinol intake with type 2 diabetes risk were examined. Moreover, the interaction of the polymorphism with retinol intake on type 2 diabetes risk was assessed. In a subgroup of participants the association of the polymorphism and vitamin A plasma levels was investigated. Results: Homozygous carriers of the -803A allele had increased risk of type 2 diabetes (HR 1.83; 95% CI 1.26-2.66). Retinol intake was not associated with type 2 diabetes risk and showed no interaction with the RBP4 -803GA polymorphism. Furthermore, there was no significant association of the polymorphism with plasma vitamin A levels. Conclusions/interpretation: Our results provide evidence that homozygosity for the RBP4 -803A allele is associated with increased risk of type 2 diabetes in the Rotterdam population. This relationship was not clearly explained by retinol intake and vitamin A plasma levels. Therefore, we cannot differentiate between a retinol-dependent or -independent mechanism of this RBP4 variant

Identification and management of chronic pain in primary care:a review

Chronic pain is a common, complex, and challenging condition, where understanding the biological, social, physical and psychological contexts is vital to successful outcomes in primary care. In managing chronic pain the focus is often on promoting rehabilitation and maximizing quality of life rather than achieving cure. Recent screening tools and brief intervention techniques can be effective in helping clinicians identify, stratify and manage both patients already living with chronic pain and those who are at risk of developing chronic pain from acute pain. Frequent assessment and reassessment are key to ensuring treatment is appropriate and safe, as well as minimizing and addressing side effects. Primary care management should be holistic and evidence-based (where possible) and incorporates both pharmacological and non-pharmacological approaches, including psychology, self-management, physiotherapy, peripheral nervous system stimulation, complementary therapies and comprehensive pain-management programmes. These may either be based wholly in primary care or supported by appropriate specialist referral

Permanent Campaigning: A Meta-Analysis and Framework for Measurement

Permanent campaigning emerged as a concept in the 1970s in studies of US politics but is now recognized as a universal phenomenon. Despite its long history, there has been no attempt to build a holistic picture of the elements that constitute a permanent campaign. Generally, researchers focus on tactical elements, situating their use within an overall strategy, but there is a lack of a broader methodological framework for holistically measuring adherence to the permanent campaigning. This article presents results of a meta-analysis of relevant research to provide a framework to understand how permanent campaigning is practiced. Our study showed there were three reasonably discrete forms of campaigning activities that had been identified: those in which permanent campaign strategies are related to capacity building and strategy; a second, in which permanent campaigning relates to paid and owned media; and a third in which earned media is the main focus. In mapping these studies, we identify the common features of permanent campaigning, identifying strong and weak indicators and the extent these are employed by the government, parties, or elected representatives and within which political systems: parliamentarism or presidentialism. Our framework can be applied in future comparative research to understand trends in political communication