Current imaging practice for suspected scaphoid fracture in patients with normal initial radiographs: UK-wide national audit

BACKGROUND: The prevalence of scaphoid fractures in the young and active patient population is high. Initial suspicion relies on the combination of a clinical examination and scaphoid series. Both of these are imperfect and often result in premature wrist immobilisation, itself associated with significant lifestyle and socioeconomic implications. MRI has been shown to be an effective modality for the investigation of radiographically-occult scaphoid fractures, yet there remains a stark inconsistency in the modality of choice both in the UK and internationally.METHODS: A survey monkey questionnaire was sent to 140 eligible NHS trusts derived from the NHS England database following exclusion of all non-acute and specialist centres. Four questions were asked regarding the provision of MRI for radiographically-occult scaphoid injuries, time-to-MRI, number of MRI scanners in the trust and any alternative imaging offered.RESULTS: Responses were received from 74 trusts (53%). Thirty-eight offered MRI as a first-line test in plain-film occult scaphoid injury, 25 preferred CT and 11 opted for repeat plain radiographs. Of the 38 trusts who offered MRI, 26 were able to offer this within 1 week; the remainder provided it within 2 weeks. No trends were identified based on the size of the hospital or its geographical location. Statistical analysis of the data using logit regression, Pearson correlation coefficients and a negative binomial regression revealed no statistically significant relationship between the number of MRI scanners in the department and the ability to provide an MRI, nor between the numbers of MRI scanners and the time-to-MRI.CONCLUSIONS: There remains a clear disparity, in the UK, in the modality of choice for plain film occult scaphoid injuries. MRI has been consistently recognised in the literature to be a highly-specific, highly-sensitive and cost-effective tool, yet only 51% of trusts who responded provide this service in the UK. Given the patient demographic affected and the resultant loss of working hours from overzealous wrist immobilisation, MRI should be considered as the first-line imaging modality of choice in plain-film occult scaphoid injury, if not a first-line test for acute wrist trauma

Mainstreamed Genetic Testing in Ovarian Cancer: Patient Experience of the Testing Process

Objective: Pathogenic BRCA variants account for between 5.8-24.8% of ovarian cancers. The identification of such a variant can have a significant impact on the affected individual and their relatives – determining eligibility for targeted therapies, predicting treatment response and granting access to disease prevention strategies. Cancer services are responding to the increased demand for genetic testing with the introduction of mainstreamed genetic testing via oncology clinics. The study aimed to evaluate patient experience of the mainstreamed genetic testing pathway at a tertiary referral centre in London. / Methods: Study participants were patients diagnosed with high-grade non-mucinous ovarian cancer, tested via a mainstreamed genetic testing pathway at the tertiary referral centre between February 2015 and June 2017. Eligible participants were invited to complete the retrospective study questionnaire. Five quantitative measures with additional free-text items evaluated the patient experience of mainstreamed genetic testing. / Results: The tertiary referral centre tested 170 ovarian cancer patients. Twenty-three pathogenic BRCA mutations were identified (23/170, 13.5%). One-hundred and six patients (106/170, 62.4%) met the study inclusion criteria. Twenty-nine of those invited (29/106, 27.4%) to participate returned the retrospective study questionnaire. Pathogenic BRCA1/2 variants were identified within four respondents (4/29, 13.8%). Motivations for genetic testing related to improved medical management, and the ability to provide relatives with genetic information. Participants did not appear to be adversely affected by result disclosure post mainstreamed genetic testing. Two individuals with a pathogenic variant reported that the support provided by the tertiary referral centre post-result disclosure could have been improved. / Conclusion: Results of the current study support further psychosocial research into the expansion of the mainstreamed genetic testing pathway. The results although promising have also highlighted the importance of genetic awareness within the multidisciplinary team and the provision of timely psychological support from genetic specialists

Multiparametric ultrasound versus multiparametric MRI to diagnose prostate cancer (CADMUS): a prospective, multicentre, paired-cohort, confirmatory study

BACKGROUND: Multiparametric MRI of the prostate followed by targeted biopsy is recommended for patients at risk of prostate cancer. However, multiparametric ultrasound is more readily available than multiparametric MRI. Data from paired-cohort validation studies and randomised, controlled trials support the use of multiparametric MRI, whereas the evidence for individual ultrasound methods and multiparametric ultrasound is only derived from case series. We aimed to establish the overall agreement between multiparametric ultrasound and multiparametric MRI to diagnose clinically significant prostate cancer. METHODS: We conducted a prospective, multicentre, paired-cohort, confirmatory study in seven hospitals in the UK. Patients at risk of prostate cancer, aged 18 years or older, with an elevated prostate-specific antigen concentration or abnormal findings on digital rectal examination underwent both multiparametric ultrasound and multiparametric MRI. Multiparametric ultrasound consisted of B-mode, colour Doppler, real-time elastography, and contrast-enhanced ultrasound. Multiparametric MRI included high-resolution T2-weighted images, diffusion-weighted imaging (dedicated high B 1400 s/mm2 or 2000 s/mm2 and apparent diffusion coefficient map), and dynamic contrast-enhanced axial T1-weighted images. Patients with positive findings on multiparametric ultrasound or multiparametric MRI underwent targeted biopsies but were masked to their test results. If both tests yielded positive findings, the order of targeting at biopsy was randomly assigned (1:1) using stratified (according to centre only) block randomisation with randomly varying block sizes. The co-primary endpoints were the proportion of positive lesions on, and agreement between, multiparametric MRI and multiparametric ultrasound in identifying suspicious lesions (Likert score of ≥3), and detection of clinically significant cancer (defined as a Gleason score of ≥4 + 3 in any area or a maximum cancer core length of ≥6 mm of any grade [PROMIS definition 1]) in those patients who underwent a biopsy. Adverse events were defined according to Good Clinical Practice and trial regulatory guidelines. The trial is registered on ISRCTN, 38541912, and ClinicalTrials.gov, NCT02712684, with recruitment and follow-up completed. FINDINGS: Between March 15, 2016, and Nov 7, 2019, 370 eligible patients were enrolled; 306 patients completed both multiparametric ultrasound and multiparametric MRI and 257 underwent a prostate biopsy. Multiparametric ultrasound was positive in 272 (89% [95% CI 85-92]) of 306 patients and multiparametric MRI was positive in 238 patients (78% [73-82]; difference 11·1% [95% CI 5·1-17·1]). Positive test agreement was 73·2% (95% CI 67·9-78·1; κ=0·06 [95% CI -0·56 to 0·17]). Any cancer was detected in 133 (52% [95% CI 45·5-58]) of 257 patients, with 83 (32% [26-38]) of 257 being clinically significant by PROMIS definition 1. Each test alone would result in multiparametric ultrasound detecting PROMIS definition 1 cancer in 66 (26% [95% CI 21-32]) of 257 patients who had biopsies and multiparametric MRI detecting it in 77 (30% [24-36]; difference -4·3% [95% CI -8·3% to -0·3]). Combining both tests detected 83 (32% [95% CI 27-38]) of 257 clinically significant cancers as per PROMIS definition 1; of these 83 cancers, six (7% [95% CI 3-15]) were detected exclusively with multiparametric ultrasound, and 17 (20% [12-31]) were exclusively detected by multiparametric MRI (agreement 91·1% [95% CI 86·9-94·2]; κ=0·78 [95% CI 0·69-0·86]). No serious adverse events were related to trial activity. INTERPRETATION: Multiparametric ultrasound detected 4·3% fewer clinically significant prostate cancers than multiparametric MRI, but it would lead to 11·1% more patients being referred for a biopsy. Multiparametric ultrasound could be an alternative to multiparametric MRI as a first test for patients at risk of prostate cancer, particularly if multiparametric MRI cannot be carried out. Both imaging tests missed clinically significant cancers detected by the other, so the use of both would increase the detection of clinically significant prostate cancers compared with using each test alone. FUNDING: The Jon Moulton Charity Trust, Prostate Cancer UK, and UCLH Charity and Barts Charity

Evaluating Forecasting Methods

Ideally, forecasting methods should be evaluated in the situations for which they will be used. Underlying the evaluation procedure is the need to test methods against reasonable alternatives. Evaluation consists of four steps: testing assumptions, testing data and methods, replicating outputs, and assessing outputs. Most principles for testing forecasting methods are based on commonly accepted methodological procedures, such as to prespecify criteria or to obtain a large sample of forecast errors. However, forecasters often violate such principles, even in academic studies. Some principles might be surprising, such as do not use R-square, do not use Mean Square Error, and do not use the within-sample fit of the model to select the most accurate time-series model. A checklist of 32 principles is provided to help in systematically evaluating forecasting methods

Let it be what it is: fact and fiction in Helen Garner\u27s Monkey Grip and The Spare Room & Deepwater

In literature, the line between fiction and real life is often seductively thin. Taking the example of Helen Garner\u27s autobiographical fictions in her first novel, Monkey Grip (1977), and her last, The Spare Room (2008), the theoretical component of my Masters project examines how the first person narratives are vivified by their connection to the author’s life. The thirty-one years separating the novels\u27 publication saw distinct changes in the critical landscape, and I argue that while Monkey Grip was condemned for its likeness to a journal, The Spare Room capitalised on its correlation with reality. This dynamic constructs an extra-textual \u27real\u27 life for Garner\u27s novels which acts as a diegetic device, magnifying the gravity of the narratives. The creative component of my project, my short novel Deepwater, was inspired by personal experience. However, finding the strictures of reality a restraint the story I\u27d envisioned as an autobiographical fiction grew into a work of pure fiction. The extra-textual \u27real\u27 life of the novel remained my entry point to the narrative, with small truths providing the flint to my imagination, but unlike in Garner\u27s examples the \u27I\u27 of personal narrative was a hindrance rather than a portal

La Grange Mission, W.A. October 1979 [picture] /

Part of the Aboriginal rights movement collection, 1978-1980.; Title from captions list.; The town of Lagrange was renamed Bidyadanga Community in 1999 following the closure of La Grange Mission. Inappropriate housing and metal play equipment which became hot in the sun and unsuitable for use at La Grange Mission

Amy French with children, Jigalong, Pilbara, Western Australia, October 1979 [picture] /

Part of: Aboriginal rights movement collection, 1978-1980.; Title devised by cataloguer based on accompanying documentation.; Also available in an electronic version via the Internet at: http://nla.gov.au/nla.pic-an24174006

Black ban uranium [picture] /

Part of the Aboriginal rights movement collection, 1978-1980.; Title taken from captions list. Dallas Brooks Hall, Victoria Parade, East Melbourne, ACTU Congress, 11 September 1979, MAUM (Movement Against Uranium Mining) rally