The population of people living with HIV (PLWH) is ageing consequent to effective treatment and a steady stream of new diagnoses among older adults. PLWH experience a greater burden of age‐related comorbidities and poorer social determinants of health compared to their HIV‐negative peers, yet comprehensive requisites for care and support as PLWH age remain poorly understood. Preferences And Needs for Ageing Care among HIV‐positive Elderly people in Ontario, Canada (PANACHE ON), explored the health and community care and social support needs and preferences of a diverse group of older PLWH (age 60+) and described life course experiences among older PLWH that shape these needs and preferences and whether they are met.PANACHE ON was a qualitative community‐based participatory research study. In‐person focus groups using a semi‐structured interview guide were co‐facilitated by pairs of trained older PLWH from July to October 2019. Purposive sampling bolstered the inclusion of communities disproportionately affected by HIV in Ontario. Descriptive analysis was used to summarize demographic data; participatory data analysis was conducted by a subset of the research team, with transcripts double‐coded and analysed using NVIVO 12 Plus.A total of 73 PLWH participated, 66% identified as men. The mean age was 64 years (range 55–77) and median time living with HIV was 23 years (range 2–37). The current and anticipated needs of older PLWH, many of which were only partially met, included necessities such as food and housing, mobility and sensory aids, in‐home support, social and emotional support, transportation and information. Three experiences—trauma, stigma and uncertainty—intersected in the lives of many of our participants, shaping their needs for care and support, and impacting the ease with which these needs were met.Unmet health and social needs and limited control over the availability and accessibility of ageing‐related care and support due to resource constraints or reduced capacity for self‐advocacy results in anxiety about the future among older PLWH, despite their well‐developed coping strategies and experience navigating systems of care. These study findings will inform the development of the first national needs assessment of older PLWH in Canada. Four qualitative studies have provided most of the information available on the multi‐dimensional wellbeing of PLWH50+ in Ontario. Of these, only one garnered detailed narratives on service use and unmet needs, engaging 11 PLWH50+ in one city in 2009 . Data frA literature review reveals gaps in our understanding of the comprehensive care and support needs of older PLWH in Ontario. Prior studies engaged PLWH50+ so findings were shaped by the responses of predominantly middle‐aged participants, most of whom resided in urban settings in Southern Ontario. Involvement by women and racialized people has been underreported or lacking; data from the single study focused on service use are outdated; and an explicit focus on “ageing successfully” may have the limited analysis of the impact of poor social determinants of health among older PLWH lacking personal resilience strategies.To address these gaps and inform development of the first national‐level comprehensive needs assessment survey of older PLWH in Canada, we conducted a qualitative pilot study. The purpose was to describe the health and community care and social support needs and preferences of a diverse group of PLWH60+ from across Ontario. Additionally, we aimed to describe the life course experiences which shape their needs and the extent to which they are being met.2n = 18), many with academic research training, extensive CBPR experience and/or front‐line roles in community‐based HIV organizations (CBHO). The team was rounded out by clinician–researchers (n = 2), CBHO staff (n = 8) and academic researchers (n = 4). Our work was guided by CBPR principles like equitable partnerships, community and researcher capacity‐building, mutual respect for all forms of knowledge and a commitment to translating research into action  people that are positive because they're going well you're on bonus time anyway and…” “You know, 60‐some years old and you've got HIV, so we're not going to bother looking into that… but it seems to be happening at a younger age than [Few participants described experiencing or observing HIV stigma when accessing health services; however, several shared the belief that doctors were dismissive towards people ageing with HIV, with one woman saying:“I phoned my partner right away and I said “I'm clean.” And he goes “what are you talking about?” I said “I can't give it to you. I'm clean now.” And for 20‐some years I felt dirty because that's how the public perceived me, that because I had AIDS at that one time, that I was dirty.” Several participants, especially gbMSM, adamantly refused to internalize HIV stigma and ended relationships to protect against it. In contrast, internalized stigma was evident in the narratives of others who described feeling ashamed about living or dying with HIV/AIDS or were hard on themselves for not disclosing to loved ones. One woman living with HIV long‐term described how learning that Undetectable = Untransmittable changed her whole view of herself:“… and it's really strikingly so around the issue of age too, in this age… in this era of identity politics, and ageing issues just are not there, they're not ever there and you usually get a blank look when you bring them up at the conferences and so on.” Ageist assumptions and behaviours transcended multiple interactions and environments from dating to healthcare and community services to society. Participants described instances where they were tokenized, rejected and ignored by individuals and institutions. One individual observed that ageism in the HIV community is not addressed with the same urgency as other forms of stigma:Internalized ageism and ableism were also observed. One participant depicted ageing as the process of “transitioning from a productive life… to one where…you become someone who requires care.” Another did not discuss ageing or their chronic illness with family to avoid being a “hindrance.” Increasing difficulty with activities of daily living was “embarrassing.”Both internalized stigma and past and present experiences of discrimination increased anticipated stigma. We observed widespread fear of neglect and mistreatment in ageing care that may impact willingness to engage regardless of need.3.4.3“…it just keeps evolving and it takes time to accept each one of these conditions. And we seem to hold in that pattern of waiting to be able to accept it and then something else happens.” Some participants described experiencing uncertainty in their daily lives. Constant worry about paying for food and medicine tested their coping ability. One individual reflected on the need to adapt to the onslaught of new age‐related illnesses:Overall, participants did not see their circumstances improving with time. Ageing was seen as an anxiety‐provoking process of becoming more vulnerable and having insufficient resources to compensate for decreasing personal capacity. Participants used the words dread, worry, concern and panic to describe anticipated ageing‐related changes in financial security, health, safety, autonomy, independence, care and social support.“I don't want to give up my independence. Like since moving in with my brother I've given up my artwork, it's sitting at home not being done, I've given up my writing, I don't have a computer to work on, you know, I'm sitting there… I'm isolated with him for my safety, but I'm not able to do any of the things that make my life worthwhile.” Uncertainty about the availability and accessibility of appropriate formal ageing care and supports was common. In the women's focus group (Group 6), the eligibility criteria for assistive devices subsidies were not perceived as transparent or equitable. Some participants were unaware of existing subsidized or low‐cost formal home and community care services that support ageing in place. Many worried their current income or future pension would be insufficient to meet basic needs or permit access to reputable residential ageing care. Inability to exercise control over how their current or future needs were met contributed to uncertainty and anxiety. One woman described giving up meaningful occupations while staying with family after a series of falls:4This qualitative study aimed to identify the care and social support needs and preferences of a diverse group of PLWH60+ in Ontario, Canada; and to describe lived experiences shaping these needs and affecting whether they are met. Our findings add to the existing body of literature since we purposively engaged PLWH60+, rather than PLWHIV50+; as well as those residing outside urban centres and those identifying as women and/or racialized persons.We found that the basic needs of older PLWH, including safe, affordable housing and high‐quality sufficient food, are only partially met by the existing social service infrastructure; previous studies have reported similar findings , 14, 38.The needs and preferences of our older PLWH are shaped by past and present experiences of trauma, stigma and uncertainty, a life course triad also described by other researchers , 20, 31.The care and support needs raised in this study reflect those identified by community‐dwelling older people with other chronic conditions or multimorbidity , 47. BotOlder PLWH require care and support that accounts for a different life course trajectory than the ageing general population consequent to the impact of trauma, intersecting forms of stigma and uncertainty on their mental health , 49, 50.The alternative is to access support to age in place, at home, but this option is also fraught with barriers. As in previous studies involving PLWH and sexual minority older adults , 55, 56,Our findings are consistent with needs assessments conducted with older PLWH in other jurisdictions. Income, housing and food insecurity were common in older PLWH in other high‐income countries , 57, 58.Our research demonstrates that older PLWH draw on their internal resources—knowledge, skills, strategies and self‐efficacy—developed over years of living with a chronic illness, to plan for and manage ageing‐related changes. As in previous studies, our participants described an array of practical and emotional coping strategies , 28, 29.In addition to our primary findings, we noted a few population‐specific differences. First, many of the older gbMSM living with HIV were outspoken about their HIV status as a strategy to identify and dismiss people who might stigmatize them, a strategy previously coined as pruning social networks . SimilarThis qualitative project was an important precursor to a planned national needs assessment of PLWH60+ in Canada. Inherent limitations in this pilot, such as the use of anonymous surveys to collect participant demographic information, limited our ability to contextualize individual participants’ responses, except in cases where the speaker's own narrative identified aspects of their identity.Despite our targeted recruitment strategy, our findings are based on the narratives of a small sample and not generalizable to all PLWH60+ in Ontario, especially those who are transgender, rural dwelling, not connected to community organizations or newly diagnosed. Furthermore, as two‐thirds of our participants were HIV long‐term survivors, our findings likely confound care and support needs related to ageing with HIV with those of long‐term survivorship . Ageing Our semi‐structured interview guide did not prompt study participants to frame their needs for care and support in the context of formal health or social support services. Barriers to service access arose organically in the discussion, baring the question which explored participants’ ability to pay for services, support and resources to help meet their self‐identified needs. As physician‐ and hospital‐based services are paid by Ontario's provincial health insurance programme, the focus was more on needs related to the social determinants of health.We illustrated the multidimensional needs of older PLWH in Ontario and described how a combination of life experiences common to PLWH60+ contributes to discrepancies in access to care and support services that address these needs in older adulthood. These findings draw attention to some of the existing policy and practice gaps and barriers for older PLWH in Ontario. Income support programmes, both disability‐ and ageing‐related, and government‐funded health insurance, for example, do not provide adequate benefits coverage to meet the holistic health needs of low‐income older people, including many PLWH. CBHOs are an important and safe source of emotional and peer support for many older PLWH with small social networks, but lack programming specifically designed for older PLWH. Our study findings will inform advocacy in these areas and justify our next step to quantify the prevalence of certain experiences and the frequency of unmet service needs.5PLWH experience ageing with the addition of three major burdens: trauma, stigma and uncertainty, which impact their health and social care and support needs and may not intersect as commonly among their ageing HIV‐negative peers. Despite the resilience demonstrated by PLWH60+ in this study, systemic and structural barriers continue to contribute to inequities in the potential to meet ageing‐related needs enabling PLWH to age in comfort and dignity. Changes to health and social policy are required to address these gaps.The authors declare no competing interests.KM and SLW are Co‐Principal Investigators of PANACHE and coordinate all activities of the research team. KM and ER trained PANACHE ON PRAs, implemented the study protocol, oversaw the participatory data analysis and interpretation process and prepared the draft manuscript. SLW provided research mentorship to KM and ER, participated in data analysis and interpretation, and edited the manuscript. ER managed study data in NVivo. DMB, TC, GDS, EF and JDL participated actively in data analysis and interpretation and provided feedback on the manuscript.Ontario HIV Treatment Network—CBR‐1106.


We systematically reviewed all studies published between 2000 and June 2021 that estimated under 5 diarrhoea rates in low‐ and middle‐income countries and extracted data on diarrhoea rates, measurement methods and reactivity.We summarised data from studies that performed direct comparisons of methods, and indirectly compared studies which utilised only one method using meta‐regression to determine the association between methods and estimated diarrhoea rates.In total, 288 studies met our inclusion criteria: 4 direct comparisons and 284 studies utilising only one measurement method. Meta‐regression across all studies showed that diarrhoea rates were sensitive to method of measurement. We estimated that passive surveillance methods were associated with a 97% lower estimated rate than active surveillance . Among active surveillance studies, a doubling of recall period was associated with a 48% lower rate , while decreased questioning frequency was associated with a higher estimated rate: at the extreme, one time questioning yielded an over 4× higher rate than daily questioning .Estimated diarrhoea rates are sensitive to their measurement methods. There is a need for a standardisation of diarrhoea measurement methods, and for the use of other outcomes in the measurement of population‐level gastrointestinal health. Effective surveillance of diarrhoea in children under 5 at the population level is required to track outbreaks, allocate public health resources and evaluate water, sanitation and hygiene (WASH) interventions . HoweverActive surveillance, based on door‐to‐door surveys, provides a more complete report of diarrhoea rates than passive surveillance, but may also be subject to measurement error and bias . Carers In order to examine the association between the method used in diarrhoea measurement and diarrhoea rates, we conducted a systematic review of all studies published between 2000 and June 2021 that report under five diarrhoea rates in low‐ and middle‐income countries (LMICs). We examined studies that perform direct ‘head‐to‐head’ comparisons of different methods in order to estimate differences in diarrhoea rates by method. However, we found only four such studies. We therefore obtained studies that used only one measurement method so that we could compare the estimated diarrhoea rates of each method across studies indirectly by means of meta‐analytical methods , 17.The aims of the systematic review and meta‐analysis were to determine: (1) the frequency of the use of the different diarrhoea measurement methods; (2) the association between passive and active surveillance methods and estimated diarrhoea rates; (3) the association between recall periods, questioning frequencies and prospective (diary) versus retrospective recall on estimated diarrhoea rates among active surveillance studies; and (4) the extent of reactivity in diarrhoea measurement.We conducted a systematic review of studies published between 2000 and June 2021 that made quantitative measurements of diarrhoea rates among children under the age of 5 in LMICs (as defined by OECD) . The seaWe searched the MEDLINE, Embase and PubMed databases for studies matching the inclusion and exclusion criteria. The search string Appendix  includedSW and RR independently screened each title and abstract, and any disagreements were resolved through discussion with RL. Full texts were screened in a similar manner. Where full texts were not available, we requested the article from the University of Warwick's Article Reach Service. We excluded unavailable studies and duplicate studies. In the event that multiple studies used the same data source, we selected a random study for inclusion.RR extracted the data, with SW duplicating data extraction for random 15% of the included studies. The random 15% extracted by SW matched completely with the extraction by RR. As a single reported study may have included several independent reports of diarrhoea rates, we treated each report as separate ‘observations’ within one study. This would not only apply to all the direct studies but also arose in indirect studies when conducted in more than one site, included multiple rounds of data collection and/or was a trial with multiple arms. For example, a two‐armed trial which estimated diarrhoea rates at baseline and end‐line yielded four observations.Data extracted Table  includedWe indirectly compared the diarrhoea rates from included observations, including those from studies that performed direct comparisons of measurement methods, and studies using only a single method of measurement. We summarised the key variables in each individual observation, including estimated diarrhoea rates, measurement type, year and region (as defined by UNDP). We estimated a hierarchical meta‐regression model for log diarrhoea rate (incidence in episodes per child year), adjusting for region and time (in years) and interactions between time and region. We also adjusted for study design, including a categorical variable with levels: (1) observational studies which use primary data sources; (2) observational studies which use secondary data sources; (3) RCT intervention arms before the intervention, or the control arm (if reported) and (4) RCT experimental arm after the intervention. The model was estimated in StataSE Version 15 using generalised least squares with random effects at the study level, to account for within‐study correlation, and weighting by the study sample size , 20.We estimated two separate meta‐regression models. The first iteration included the observations from both passive and active surveillance studies to estimate the effect of surveillance types (passive/active) on estimated diarrhoea rates, and as such included a dummy variable for surveillance type. We also estimated pooled temporal and regional trends from this model.The second iteration included only observations from active surveillance studies to examine the effects of variables exclusive to active surveillance studies on estimated diarrhoea rates. These included variables for recall period (as a continuous numeric term in days), and questioning frequency and recall type . Furthermore, any other variations found between active surveillance studies, including reactivity and questioning type , were included Table .n = 64), not including data on diarrhoea rates (n = 58), and not being able to obtain the full text (n = 4). Thus, 288 full‐text studies , sub‐Saharan Africa was the setting for the largest number of observations , followed by The Americas , Central and Southern Asia , East and South‐East Asia , North Africa and the Middle East  and finally Oceania . Rural  and mixed geography  areas provided more observations than urban areas .None of the included active surveillance observations used non‐verbal methods of diarrhoea measurement (e.g. showing carers pictures of stool), and no studies made mention of a ‘gold standard’ of diarrhoea measurement.Four of the included studies performed direct head‐to‐head comparisons of diarrhoea measurement methods: three examining the effect of differing recall periods on diarrhoea rates, and one examining the effect of questioning frequency on estimated diarrhoea rates. No studies were identified that analysed reactivity in diarrhoea measurement.As stated in the Introduction, the two main categories of disease surveillance are active surveillance (community surveying) and passive surveillance . No studies performed direct ‘head‐to‐head’ comparisons of active and passive surveillance. After model‐based adjustment to perform an indirect comparison of passive and active surveillance, passive surveillance was associated with a 97% lower estimated diarrhoea rate than active surveillance  Table .Specific to active surveillance studies, questioning frequency (how often participants are surveyed), recall period of diarrhoea surveying and retrospective versus prospective questioning may differ.One study directly examined the effect of differing questioning frequencies on estimated diarrhoea rates; Zwane et al. estimated that biweekly surveys had a 7–15% lower diarrhoea rate than six‐monthly surveys when using the same recall period . Our indThree studies directly examined the effect of differing recall periods on estimated diarrhoea rates, though the recall periods examined were different. Melo et al. found that diarrhoea rates were cut by a third when carers recall over 4 weeks versus 24 h . Feikin Based on an indirect comparison of the included active surveillance observations, we estimated that recall periods and estimated diarrhoea rates were inversely associated. After model‐based adjustment, we found that a doubling of recall period was associated with a 48% reduction in diarrhoea rate  recall designs against retrospective. We estimated through indirect comparison that retrospective recall observations were associated with a lower rate than prospective (diary) observations, but the effect size was relatively uncertain , recall bias (forgetting events that have occurred in the past), perception bias (not understanding the question being asked) and reactivity (answering differently due to experiencing an intervention).Declining diarrhoea rates with increasing questioning frequency  suggest respondent fatigue – participants may be inclined to pay attention to their bowel movements at first, but lose motivation with further rounds of questioning.Recall bias is the effect of forgetting: participants are more likely to recall recent than older events. We would expect a lower reported number of diarrhoea episodes with longer recall periods and this was borne out by our analysis including two of the three head‐to‐head comparisons – the exception examined a much smaller gap between questions than the other two , 22. ThiOther factors outside the scope of this review can further influence estimated diarrhoea rates. For example, poor caregiver perception of diarrhoea (understanding what is or is not diarrhoea) can result in error in diarrhoea measurement. Voskuijl et al. determined that carers of children under 5 were only able to identify 56–75% of loose or watery stool and 80% healthy stools .Another relevant phenomenon is ‘reactivity’, whereby participants adjust their answers to a survey according to how they believe they ought to respond, regardless of any true underlying difference. We did not identify any studies of reactivity in this review, but it has been discussed as a potential explanatory factor in previous trials. Luby et al. mentioned courtesy bias as a potential source of reactivity, stating ‘people who received the intervention might have been grateful and, out of courtesy, reported less diarrhoea’ . Wood etThe magnitude of the variation in diarrhoea rates, even among active methods of surveillance, suggests the need for standardisation of diarrhoea measurement methods to facilitate comparisons between studies. Despite the 14‐day UNICEF and DHS standard, there does seem to be a trend towards using a 7‐day recall period. It was the most frequently used recall period (51%) among RCTs in our review. Three of the three recent large integrated WASH trials  also used a 7‐day retrospective recall to measure diarrhoea , 28, 29,It could be argued that lack of standardisation simply introduces measurement error in trials that can be counteracted by increasing sample size. However, this is only likely to be true if it is assumed that the different methods affect only the propensity of someone with a true case of diarrhoea (or indeed enteric infection) to report a case of diarrhoea (the ‘sensitivity’ of the method) . If, howWhile a widely accepted standard would facilitate comparisons across different observational and experimental studies, this raises the question of what the optimal standard may be that would also produce reliable reports of diarrhoea rates. There is no ‘gold standard’ method for measurement of diarrhoea rates. In part, this is because of the difficulty in defining the underlying construct and providing a culturally and linguistically consistent definition of a case or episode of ‘diarrhoea’. Direct observation by an expert might constitute a gold standard against which other methods could be compared, as has been described above in the study by Voskuiljl and colleagues . HoweverWe propose two policies to mitigate the problem. First, an agreed consensus method for the measurement of diarrhoea rates in surveys. Second, triangulation of diarrhoea rates with other observations that reflects on gastrointestinal health when interventions are evaluated. Many WASH studies already include anthropometric measurements as outcomes alongside diarrhoea. Furthermore, direct measurement of environmental contamination and pathogen levels in stool samples should complement diarrhoea rates in clinical studies. This would also allow for determination of how much diarrhoea is attributable to infection (and which can be reduced by WASH interventions), rather than non‐infective reasons (which would likely not be impacted by WASH interventions) . Investi


Soluble nitrogen is highly mobile in soil and susceptible to leaching. It is important to identify nitrogen transport pathways so that the sources can be efficiently targeted in environment management. This study quantified the contribution of direct runoff and baseflow to nitrate + nitrite loading by separating flow and nitrate + nitrite concentration measurements into two periods depending on whether only baseflow was present or not using baseflow separation methods. When both direct runoff and baseflow were present in streamflow, their nitrate + nitrite concentrations were assumed based on the hydrological reasoning that baseflow does not change rapidly, and streamflow mostly consists of direct runoff within a rainfall event. For this study, we obtained and investigated daily flow and nitrate + nitrite concentration observations made at the outlets of 22 watersheds located in the Western Lake Erie area. Results showed that baseflow was responsible for 26 to 77% of the nitrate + nitrite loads. The relative nitrate + nitrite load contributions of direct runoff and baseflow substantially varied with the sizes of drainage areas and agricultural land uses. Increases in drainage areas tend to prolong the travel time of surface runoff and thus help its reinfiltration into soil, which then could increase the baseflow contribution. In addition, the artificial drainage networks common in the agricultural fields of the study areas would promote the drainage of nutrient-laden excess water from soils. Such findings suggest the need for environmental management customized considering nitrogen transport pathways. On the other hand, soluble nutrients are highly mobile, making it is difficult to identify their sources and transport routes5. Studies showed that the appropriate treatment of soluble nutrients is necessary for water quality improvement, especially in agricultural areas where intensive farming activities are taking place9.Quantifying loads of nutrients, including nitrogen and phosphorus, and identifying their transport paths are critical when developing management plans to protect the designated uses of downstream water bodies. Nutrient loads are generated and carried in the two principal forms, particulate and soluble. Most particulate nutrients move with direct runoff along flow paths on the ground surface. Thus, it is relatively easy to control its transport with conservation practices such as terraces and filter strips15. Tile drainage practices implemented to quickly drain excess soil water from agricultural fields may accelerate soluble nutrient loading to downstream water bodies including Lake Erie and make nutrient loading paths be more complicated to be identified clearly19. The contribution of tile drainage and baseflow to nutrient loading to Lake Erie needs to be quantified to develop targeted agricultural conservation practices for improved water quality of the lake.As a part of the Corn Belt, the Western Lake Erie basin plays a vital role in providing land resources for food and energy production. However, intensive crop production systems have been identified as the primary sources of excessive nutrient loads resulting in water quality problems such as eutrophication and hypoxia of Lake Erie21. Miller et al.21 linearly related the baseflow index (BFI) to the nitrate concentrations of winter streamflow to approximate the nitrate loading contribution of groundwater and runoff. They found that a significant portion of the annual nitrate loads were attributed to groundwater discharge. Liang et al.20 calibrated a Soil and Water Assessment Tool (SWAT) to stream discharge measurements made at the outlet of a study watershed to investigate the annual variations of groundwater and runoff contributions to total nitrate loads. Their study demonstrated that groundwater is the dominant pathway of nitrate loading throughout the year, regardless of seasons. However, it is still unclear how nitrogen loading is associated with watershed characteristics and how the contributions of baseflow and direct runoff may change depending on land uses and watershed management. In addition, the previous studies did not clearly isolate baseflow from direct runoff. For instance, baseflow was separated from direct runoff by applying an arbitrary threshold of 90% to streamflow22 or by implicitly assuming winter stream flows consist primarily of groundwater21. In addition, the nitrate concentrations of direct runoff and baseflow were assumed to be constant for the simplicity of analysis21. Such limitations might bring biases in the estimates of nitrogen loading contribution.Studies investigated how nitrogen can be loaded through different transport pathways using regression and watershed modelsIn this study, we quantified the contributions of direct runoff and baseflow to the loading of soluble nitrogen, nitrate + nitrite, to downstream water bodies using baseflow separation methods and hydrological reasoning about the temporal variations of baseflow’s nutrient concentrations and streamflow composition during a rainfall event. We collected and analyzed daily flow and nitrate + nitrite concentration measurements made at the outlets of 22 study watersheds, which have different land cover compositions draining water and nutrients to a downstream waterbody, to see the relationship between nitrogen loading pathways and watershed features.25. The West Lake Erie basin is known as the largest source of nutrients transported to the lake in particulate and dissolved forms27. Due to poorly drained soils, tile drainage systems have been widely used in the West Lake Erie basin28, and they can reduce the amount of direct runoff generated at fields by promoting infiltration and subsurface water movement29. However, studies showed that tile drainage systems could accelerate the loss of soluble nutrients from crop  fields and then may increase nutrient loading to Lake Erie30.Lake Erie is one of the water bodies that have been suffering water quality issues such as harmful algal blooms (HABs) and hypoxia due to excessive nutrient loading from large agricultural fields (part of the corn belt) distributed in its drainage areas Fig. 7,16,23–232. The water quality data are open to the public and available at https://ncwqr.org/monitoring/data/. All 22 monitoring stations identified from the NCWQR database were included in this study  statistical testIn this study, the contributions of direct runoff and baseflow to nitrate + nitrite loadings are quantified based on a mass balance relationship between total runoff, direct runoff, baseflow, and nitrate + nitrite concentrations associated with each of the hydrograph components Fig. . When noentclass1pt{minimaentclass1pt{minima38, we can assume that its nitrate + nitrite concentration also may not change rapidly within a rainfall event. In the smallest watershed , for instance, baseflow nitrate + nitrite concentrations increased from 1.41 mg L−1 on 4/30/12, right before a rainfall event (50.0 mm) to 1.60 mg L−1 on 5/10/12 right after the event  but increased from 1.19 to 1.41 mg L−1 after another event of 67.8 mm (5/12/12 to 5/23/12). From the concentration data, we could not find mechanisms that can explain the different responses of baseflow nitrate + nitrite concentrations to rainfall events; however, we could see the differences in the baseflow nitrate + nitrite concentrations before and after rainfall events ranged from 0.17 to 3.31 mg L−1 (14 to 39% compared to the before- or after-event baseflow nitrate + nitrite concentrations) on average. Such a finding led us to making two assumptions: the nitrate + nitrite concentrations of baseflow would be close to the concentrations measured at (1) the beginning of a storm event  Figs. , and S3..0% Fig. . Streamf−1 year−1  ranged from 2.9 to 55.1 kg ha05) Fig. . A relatune Fig. . Intensi40. In addition, the early-season discharge during March to May can occur by melted snowpack and high antecedent soil moisture conditions8. It is known that the March to July period strongly relates to the extent of algae bloom in the western basin41. Stow et al.8 showed that the early flow and load peaks during the critical season might reflect agricultural activities occurred during the preceding winter.The nitrate + nitrite loads were relatively large in high-flow events from March to July. The summer months (May to August) generally receive a large amount of rainfall in a yearp < 0.05). Such a finding implies land management changes  toward increasing the drainage efficiency, especially in the agricultural drainage areas of the monitoring sites, one of the major sources of nitrogen29.The analysis showed that baseflow accounts for 26 to 77% of the total nitrate + nitrite loadings at the monitoring sites, and the relative loading contributions of direct runoff and baseflow vary greatly by the drainage areas Figs. . Overall2) to identify their potential relationship with the contribution proportions. Overall, the baseflow contribution to the nitrate + nitrite loading decreased with increases in the sizes of agricultural areas. The correlation structure between the baseflow contributions and the land use compositions of the drainage watersheds was investigated to identify key factors  rather than overland flow  might be the primary nitrate + nitrite loading pathway to streams in the study basins.The relative contributions (%) of direct runoff and baseflow to nitrate + nitrite loading were compared by the stations Figs.  and S6. ors Fig. . The staMultiple linear regression was carried out to relate the nitrate + nitrite loading (dependent variables) to the watershed land use compositions and watershed characteristics (independent variables), which allows the development of a predictive model for the soluble nitrogen loads. Log-transformed drainage area sizes and the percentages of agricultural areas were selected as explanatory variables from the previous analysis Figs.  and 8. IZea mays L.) and soybean (Glycine max L.). The vast majority (> 80%) of agricultural fields were reported to have subsurface tile drainage systems to quickly drain excess water to ditches and streams from soils23. The results imply that the artificial drainage network in the study watersheds might be the primary nitrate + nitrite loading pathway to streams . Such a result agrees with Williams et al.19 who showed that subsurface tile drains were key components driving nutrient transport processes during storm events in the western Lake Erie watersheds.The study results show that the extent of agricultural land use in given watersheds impact total and direct runoff loads Fig. . The majams Fig. . For ins43 who showed that there was no significant difference in the total nitrogen and phosphorus load estimates made using four different baseflow separation methods including the United Kingdom Institute of Hydrology method, the Lyne–Hollick method, the Eckhardt method, and the SWAT model.There are a few ways to isolate baseflow from direct runoff, and many of them employ digital filters that are not fully based on hydrological reasoning and concepts (Supplementary Information). Thus, the baseflow separation methods were reasonably suspected to be a source of uncertainty in the results of this analysis. However, the comparison between load estimates made using both filters showed that the nitrate + nitirite load estimates and the baseflow and direct runoff contribution estimates were not sensitive to the selection of the baseflow separation methods. Such a finding is supported by Zhu et al.45. Yang et al.45 demonstrated that baseflow separated from streamflow  using different methods  would include different flow components . In addition, they measured the conductivities of streamflow, direct runoff , and baseflow and used them as a tracer to separate the baseflow (or direct runoff) from the streamflow. We used only flow discharge and nitrate + nitrite concentration data available for the study watersheds, which prevented this study from considering transient flow  in the analysis. Although the use of an environmental tracer can be expensive and laborious, it is expected to provide quality reference data that can help evaluate the reliability of baseflow separation methods and further understand water transport processes through the complex landscape45.This study roughly classified total runoff (or streamflow) into two components, direct runoff (fast runoff) and baseflow (slow runoff), according to the speed of their response to rainfall. In reality, there would be other water flow traveling at a variety of speeds. For example, direct runoff may include surface runoff and quick tile drainage, while baseflow may include groundwater flow, slow tile drainage, and bank storage return flow22 assumed that the nutrient concentrations of baseflow would be the same as those of streamflow as long as the proportions of baseflow are equal to or greater than 90% of total runoff (or streamflow). Zhu et al.43 assumed the average nutrient concentrations of streamflow would be similar to those of baseflow during dry seasons (or winter in their study) presumably because the concentrations could be relatively stable compared to those in wet seasons (or summer) when rainfall events are relatively frequent (and thus non-point source pollutants are less likely to be transported). However, these and our studies could not explicitly consider the variations of the baseflow nutrient concentrations within rainfall events when baseflow as well as direct runoff increase due to the lack of data. The hydrological reasoning about the temporal variations of baseflow and streamflow composition helped develop assumptions about the nitrate + nitrite concentrations of baseflow during a storm event. The two assumptions . In addition, our findings on the relationship between flow and nitrate + nitrite concentrations may not be true for other areas, depending on the hydrological conditions, including management practices, landscape and geological features.Although the nitrate + nitrite concentration assumptions did not add large uncertainty to the load estimates, they are not universally applicable. For instance, the ns Figs.  and S8. ns Figs. , but thens Figs. ” section50. The results indicate that the relative importance of direct runoff and baseflow vary spatially as a function of watershed sizes and land use compositions   created by surface runoff and soil compaction can increase the proportion of direct runoff in agricultural fields55. Tile drainage, which is essential to efficient agricultural production in the Western Lake Erie watersheds with soils that have poor drainage capacity, can accelerate the soluble nitrogen leaching56. From a tile drainage monitoring study implemented in the Maumee watershed, Smith et al.2 found that tile discharge reached its peak at the same time when surface runoff was at its maximum discharge or even shortly before the surface runoff peak. Schilling and Helmers57 observed that peak tile discharge occurred even early in storm events. Such finding implies the significance of tile drainage and macropore flow in the nutrient loading in the Western Lake Erie areas, recommending advanced tile drainage management and implementation plans and practices58.The findings of the contribution of nitrogen loading pathways are expected to help advance the implementation plans and practices of agricultural conservation practices and guide the development of new practices for improved nitrogen load reduction efficiencyea) Fig. . The relThis study quantified how much direct runoff and baseflow contributed to nitrate + nitrite loading to downstream water bodies in agricultural areas using baseflow separation methods and hydrological reasoning. In the 22 watersheds with water quality monitoring sites distributed in the Western Lake Erie areas, the nitrate + nitrite loading from the drainage areas ranged from 2.9 to 55.1 kg/ha/year depending on the sizes and land use compositions of the watersheds. The results showed that direct runoff was responsible for 23 to 74% of nitrate + nitrite loads. Baseflow was accountable to the other 26 to 77% of the loads. The relative nitrate + nitrite loading contributions of direct runoff and baseflow were significantly positively correlated with the proportions of agricultural areas and negatively correlated with the total drainage areas of the monitoring sites. The findings suggest that watershed management practices can be customized based on the watershed characteristics, such as sizes, cropping systems, and farming practices. The information of nitrate + nitrite load partitioning controlled by different watershed land cover configurations is expected to help better understand soluble nutrient loading mechanisms and develop targeted watershed management plans for improved downstream water quality.Supplementary Information.


The SPIRIT  2013 Statement provides evidence‐based recommendations for the minimum content of clinical trial protocols. The Cellular Molecular Pathology Initiative, hosted by the UK National Cancer Research Institute, developed an extension, SPIRIT‐Path, describing how to effectively incorporate pathology support into clinical trial protocols. The current study assessed the inclusion of SPIRIT‐Path items in protocols of active clinical trials. Publicly available clinical trial protocols were identified for assessment against the new guidelines using a single UK hospital as the ‘test site’. One hundred and ninety interventional clinical trials were identified as receiving support from the pathology department. However, only 38 had publicly available full trial protocols (20%) and following application of the inclusion/exclusion criteria, 19 were assessed against the SPIRIT‐Path guidelines. The reviewed clinical trial protocols showed some areas of compliance and highlighted other items that were inadequately described. The latter lacked information about the individuals responsible for the pathology content of the trial protocol, how pathology activities and roles were organised in the trial, where the laboratory work would be carried out, and the accreditation status of the laboratory. Only one trial had information specific to digital pathology, a technology certain to become more prevalent in the future. Adoption of the SPIRIT‐Path checklist will facilitate comprehensive trial protocols that address all the key cellular and molecular pathology aspects of interventional clinical trials. This study highlights once again the lack of public availability of trial protocols. Full trial protocols should be available for scrutiny by the scientific community and the public who participate in the studies, increasing the transparency of clinical trial activity and improving quality. The British Medical Journal, The Journal of the American Medical Association, The Lancet) and industry  [The SPIRIT  2013 Statement provides evidence‐based recommendations for the minimum content of clinical trial protocols [Johnson) . The cheJohnson) .This study assessed baseline compliance with the SPIRIT‐Path guidelines ; first, The Integrated Laboratory Medicine Business Unit for a list of clinical trials held on a Microsoft Access Invoicing Database.The laboratory manager of the research arm of Cellular Pathology for a list of active clinical trials supported by the facility.Consultant pathologists for information about their involvement in clinical trial work.The Newcastle upon Tyne Hospitals NHS Foundation Trust is host to one of the UK Experimental Cancer Medicine Centres facilitating early phase clinical trials  and one ClinicalTrials.gov database [Trial details were investigated using ScanMedicine , which sdatabase , Internadatabase , and EU database . For tridatabase .Interventional clinical trial.Publicly available full trial protocol.Active clinical trial (open: recruiting or in follow‐up).Exclusion criteria:Abridged protocols.Redacted protocols.Journal articles summarising trial design.Inclusion criteria:The full version trial protocols were assessed to determine compliance with the SPIRIT 2013 Statement. The assessment was carried out by the senior author (MR), who co‐led the development of the SPIRIT‐Path guidelines and was familiar with all the items in the SPIRIT 2013 Statement. The items were categorised as included, not included, or not applicable; the latter was defined as an item that was not included but was irrelevant to the study.We developed a search strategy to assess full version trial protocols with the aim of efficiently identifying all relevant pathology items. The search strategy and data collection methods were piloted on six protocols that were not publicly available. Two assessors (PR and MR) independently analysed the protocols against the SPIRIT‐Path checklist. Where interpretation differed, consensus was reached by discussion. The pilot was used to train and calibrate the assessors and to refine the search strategy. The final search strategy included the search criteria from the ‘pathology‐specific terms’ employed in the systematic review of cellular and molecular pathology input into clinical trials . AdditioData were recorded on an Excel spreadsheet . For cancer trials, the area of study was assigned according to the volumes of the ‘WHO Classification of Tumours’ Bluebook series .Two hundred and ten clinical trials were identified for screening Figure . FollowiThere was generally good compliance with the SPIRIT 2013 Statement, consistent with protocols written after the publication of guidelines and possibly reflecting publicly accessible documents open to scrutiny by the scientific community and patients Figure .Compliance with the SPIRIT‐Path items is summarised in Figure 5a elaboration: Specify the individual(s) responsible for pathology content of the trial protocol and 5d elaboration: Specify how pathology activities and roles are organised in the trial.Six trial protocols named the individuals responsible for the pathology content of the protocol and described how pathology activities and roles were organised. The compliant protocols were all non‐commercial trials. By contrast, no commercial studies provided this information. Specifically, there was documentation of a pathologist in the Trial Management Group in all the compliant studies. In addition, one trial included a pathologist on the Trial Steering Committee  and anot6a elaboration: Describe the pathogenesis of the disease and rationale for any pathology‐specific inclusion criteria or endpoints.Seventeen trial protocols described the pathogenesis of the disease being studied and the rationale for pathology‐specific inclusion criteria and/or endpoints. Two trials, one commercial and one non‐commercial, were categorised as ‘partially included’ as they failed to adequately describe pathogenesis, but included pathology relevant inclusion criteria.9 elaboration: Describe where the laboratory work will be carried out and the accreditation status of the laboratory/site.This elaboration was fully satisfied by eight study protocols: two included explicit accreditation details  , 33 and 10 extension: Where trial‐specific pathology reporting is required, document specimen pathway requirements, and any requirement for pathologist ‘double reporting’ or central review.The majority of protocols (17 of 19) fully addressed this extension. Twelve documented a requirement for central pathology review .12 extension: Outline the assessment methods and the timing of tissue sampling required for any pathology‐specific outcomes.Seventeen trials were assessable for this extension; two trials did not contain pathology‐specific outcomes. Fourteen trials ‘fully included’ the assessment methods and timing for pathology‐specific outcomes. Two trials partially satisfied the extension as they documented the timing of sampling for pathology‐specific outcomes but did not document the assessment methods. One trial outlined a pathology‐specific outcome in the trial design but did not provide sufficient details and was categorised as ‘not included’.18a (i) extension: Describe any specific accreditation, training, and performance assessment requirements for trial pathologists and laboratory staff.Nine protocols fully satisfied this extension, all stating requirements for investigator Good Clinical Practice (GCP) accreditation. Two documented further investigator requirements, for example, ‘qualified by education, training, and experience to assume responsibility for the proper conduct of the trial at their site and should provide evidence of such qualifications through an up‐to‐date curriculum vitae and/or other relevant documentation’  and ‘all18a (ii) extension: Describe the specimen documentation requirements and full specimen handling pathway.Eighteen trials fully included this extension; only one trial did not. Sixteen trial protocols referred to an additional laboratory manual where further information on sampling, sample collection, storage, and shipping procedures was documented.18a (iii) extension: Define any methods for specimen assessment by histochemical, immunohistochemical, or molecular techniques.Sixteen trials ‘fully included’ this extension. One trial was categorised as ‘partially included’ as it described the assessment methods for pathology‐specific inclusion criteria, but not the pathology‐specific outcome. Two protocols did not document any assessment methods for pathology‐specific activities. All commercial studies ‘fully included’ this extension.19 extension: Describe any intended use of a digital pathology slide archive.Only one trial was assessable for this extension and ‘fully included’ details of a digital pathology slide archive.20a elaboration: Describe any methods to be used for adjusting for diagnostic drift during the trial.Diagnostic drift is defined as ‘a gradual change in nomenclature, grading of lesions, or scoring of a biomarker within a single study over time’ . Diagnos26b elaboration: Document enduring consent for future translational studies using tissue or any digital pathology images, if applicable.Fifteen trials were assessable for this elaboration. Twelve fully documented enduring consent for future translational studies and three also addressed procedures for the withdrawal of enduring consent.31c extension: Describe the mechanism and timing for making digital pathology images available, if applicable.Only one trial was assessable for this extension but did not include the mechanism or timing for making digital pathology images available.33 elaboration: Specify the regulatory approvals required for clinical trial samples to be used in future work.Fifteen trials were assessable for this elaboration, of which 13 ‘fully included’ the required information. Two were categorised as ‘not included’ as they did not document where tissue samples were being stored or approvals for their future use.ClincalTrials.gov registry [This is the first study to assess current clinical trial protocols against the recently published SPIRIT‐Path guidance. Newcastle upon Tyne Hospitals was chosen as a ‘test site’ based on its high recruitment to a broad range of clinical trials; nevertheless, it is conceivable that the process of vetting trials in Newcastle may have led to selection bias in favour of high‐quality trial protocols. To some extent, this is supported by the high levels of compliance of the protocols with the SPIRIT 2013 Statement , a searcregistry  or the Iregistry . Some trregistry , 37, 38.registry .Of the 190 interventional clinical trials screened, only 38 (20%) had publicly available full trial protocols. The lack of patient and public access to clinical trial information has been highlighted previously and raises issues around transparency and scrutiny . The EurFollowing the application of the inclusion and exclusion criteria, there were 25 publicly available clinical trial protocols available for assessment against the SPIRIT‐Path guidelines. However, four trials had no cellular pathology input and two protocols were so heavily redacted that they could not be assessed. The decision to assess publicly available protocols is likely to have selected for high‐quality trials and consequently our findings cannot necessarily be extrapolated to protocols that are not in the public domain. The consideration of pathology items in the excluded studies could be significantly worse.Of the 14 SPIRIT‐Path items, 8 , 18a(iii), 19, 26b, 33) were adequately addressed by the majority of trial protocols. Examples of good practice are provided in supplementary material, Table No commercial trials provided a list of investigators or trial personnel. The SPIRIT 2013 Statement recommends that ‘individuals who contribute substantively to protocol development and drafting should have their contributions reported’ and the ‘naming of contributors can also help to identify competing interests and reduce ghost authorship’ . The SPIThe utility of the SPIRIT‐Path extensions is exemplified by areas that showed compliance against the SPIRIT 2013 Statement, but did not satisfy SPIRIT‐Path guidance. For example, while the all the studies were compliant with the SPIRIT 2013 Statement item 9 (‘study set up’), only half described where the laboratory work will be carried out and the accreditation status and no commercial studies provided this information. Furthermore, the majority of protocols that ‘fully included’ this elaboration only implied the accreditation of the laboratory by naming a clinical provider. It would have been more informative to include the accreditation standard . Approximately half of the protocols specifically stated investigator GCP accreditation. The decision to judge the remaining trials to be non‐compliant is a moot point as they all documented the requirement for the study to be conducted in line with GCP; however, the SPIRIT‐Path extension is specifically related to trial personnel. There was only one trial assessable for the digital pathology extensions; however, in the future, digital pathology is likely to become more widespread and has the potential to provide greater accuracy, reproducibility, and standardisation of pathology‐based trial entry criteria and endpoints .in situ may evolve from a three‐tier system  to a binary classification (high‐grade versus non‐high grade). To mitigate this, they emphasise the importance of central review of the pathology and indicate that changes to the trial protocol may be required if the evidence base for an alternative grading system emerges. It is worth highlighting that companion diagnostic tests incorporated into trial design are also at risk of changing over time as new tests are adopted and scoring algorithms and decision thresholds are modified. Consideration of diagnostic drift is important, but difficult to predict. A statement recognising the phenomenon with active monitoring over the course of the study is sufficient to ‘future proof’ studies that are subject to long recruitment phases and prolonged follow‐up periods.Disease classification evolves and refinements based on molecular information are increasingly incorporated into clinical practice. Late‐phase clinical trials are particularly prone to changes in classification, grading, and staging information . For exaIn conclusion, the publicly available clinical trial protocols published prior to the SPIRIT‐Path guidelines show areas of good compliance and items that are inadequately described. The SPIRIT‐Path guidelines, first and foremost, encourage early engagement of clinical trial protocol writers with pathologists and laboratory scientists. The extensions and elaborations provide both trialists and the pathology community with sufficient guidance to be able to incorporate precise information into protocols thereby facilitating effective trial implementation. The guidance emphasises the importance of planning molecular pathology eligibility criteria, pathology‐specific end points, and the role of the laboratory in translational research. We encourage industry, academics, sponsors, and funders to adopt SPIRIT‐Path to produce comprehensive interventional clinical trial protocols. Furthermore, SPIRIT‐Path, along with SPIRIT‐PRO and SPIRIT‐AI , 50, proMR and TJK conceived the study. All the authors contributed to the development of the protocol. MR and PR extracted, analysed and synthesised the data. MR and PR wrote the first draft of the manuscript, and all authors critically reviewed and approved the final version of the manuscript.Figure S1. Assessment of publicly available trial protocols against the SPIRIT 2013 Statement with sub‐grouping by commercial and non‐commercial trialsFigure S2. Assessment of publicly available trial protocols against the SPIRIT‐Path items with sub‐grouping by commercial and non‐commercial trialsTable S1. Details of the clinical trial protocols assessedTable S2. Examples of where SPIRIT‐Path items were fully addressedClick here for additional data file.


To evaluate outcomes of patients diagnosed with oncocytic renal neoplasms on routine renal mass biopsy and to describe the natural history of these tumours when managed with surveillance as opposed to immediate intervention. To report disease‐specific survival.Patients were identified from a retrospective review of pathology databases from three tertiary referral centres that utilise renal mass biopsy in routine clinical practice. All patients with biopsy‐proven oncocytic tumours were included and a retrospective review of online patient records was undertaken.There were 184 biopsy‐proven oncocytic renal neoplasms identified in 172 patients. There were two biopsy complications . Of these lesions, 135 were reported as oncocytomas or oncocytic renal neoplasms that were not further classified and 37 were reported as chromophobe carcinoma (ChRCC). The median age at diagnosis was 70 (33–88). The average tumour diameter at diagnosis was 33 mm. One hundred seven tumours were initially managed with surveillance (including 13 ChRCC) with a minimum follow‐up of 6 months and a median of 39 months (6–144) whereas 49 patients underwent immediate treatment. The mean growth rate across all oncocytic renal neoplasms managed by surveillance was 3 mm/year. There was no statistically significant difference in growth rates between oncocytic renal neoplasms and ChRCC. Thirteen patients with oncocytic renal neoplasms initially managed by surveillance moved on to an active management strategy during follow‐up. The clinical indication given for a change from surveillance was tumour growth in 12 cases and patient choice in 1 case. Where definitive pathology was available, there was 85% concordance with the biopsy. There were no cases of development of metastatic disease or disease‐related morbidity or mortality during the study.This multicentre retrospective cohort study supports the hypothesis that selected biopsy‐proven oncocytic renal neoplasms can be safely managed with surveillance in the medium term. Routine renal mass biopsy may reduce surgery for benign or indolent renal tumours and the potential associated morbidity for these patients. The 2016 WHO ClassificationThe diagnosis of renal tumours has increased in the last decades with much of this increase being put down to the expanding use of cross‐sectional imaging.Routine renal mass biopsy may reduce surgery for benign tumours and the potential for short‐term and long‐term morbidity associated with these procedures.ng between different types of benign and malignant oncocytic neoplasms, the safety of core biopsy and the accuracy of grading on such samples. Significant nondiagnostic rates have also been reported,Oncocytoma is the second most common benign renal tumour accounting for 3%–7% of all renal masses whilst ChRCC is the third commonest subtype of renal malignancy making up about 5% of all renal cancers.Previous studies have reported on the growth kinetics of oncocytic renal neoplasms; however, they are often limited by small numbers and short follow‐up. In this study, we will report data on a large series of oncocytic renal neoplasms from three centres where routine renal mass biopsy has been adopted as standard of care. We aim to show how renal mass biopsy is safe to use in a contemporary clinical setting. We report the outcomes of patients diagnosed with oncocytic renal neoplasms when managed with surveillance or immediate intervention and describe the natural history of tumours managed with surveillance.2In this multicentre retrospective cohort review, patients with a diagnosis of an oncocytic renal neoplasm on a renal mass biopsy were identified from pathology records of three tertiary referral centres that have used routine small renal mass biopsy in their practice from 2014 onwards: The Queen Elizabeth University Hospital, Glasgow; Western General Hospital, Edinburgh; and Addenbrooke's Hospital, Cambridge University Hospital's NHS Foundation Trust. All lesions <4 cm were considered for biopsy as well as selected larger lesions where it was considered biopsy may influence management decisions.The primary outcome measure was tumour growth rate calculated by measuring maximum tumour diameter at first and last scan and time of follow‐up. Initial and final management decisions, including the reason for any change of management, and the clinical outcome were recorded. Demographic data were recorded as well as tumour complexity (PADUA score) and multifocality, symptomatic status, estimated glomerular filtration rate (eGFR) and biopsy complications. The surveillance protocol and imaging modality were at the discretion of the treating physician. Tumours where less than 6 months of follow‐up was available were excluded from the analysis.Biopsies were undertaken according to local protocol. They were performed under local anaesthetic and either computed tomography (CT)‐ or ultrasound scan (USS)‐guided using a 16 or 18G needle and a coaxial technique. Two or more cores were sampled.The diagnosis and classification of oncocytic renal neoplasm was made by specialist histopathologists after analysis of the biopsy using the classically described criteria of granular cytoplasm following staining with haematoxylin and eosin. Immunohistochemistry included staining for CD117, PAX‐8, CK7, CD15, vimentin, CD10 and RCC was also employed. Classification was made with reference to the WHO Classification of Tumours of the Urinary System. For the purposes of analysis, oncocytic neoplasms were grouped based on histopathology reports into those favouring benign or indolent pathology  and those where the histopathology report favoured a diagnosis of ChRCC.χ2 testing for categorical variables with significance taken at p < 0.05.Statistical analysis was performed in SPSS  using one‐way ANOVA for continuous variables and 3SDHB gene.The total cohort of oncocytic renal neoplasms included 184 lesions in 172 patients. The baseline demographic, clinical and tumour data are depicted in Table In 102 tumours (55%) specialist histopathologists reported Oncocytoma or an oncocytic neoplasm favouring Oncocytoma. There were 34 cases (18%) where the histopathologist reported ChRCC or an oncocytic lesion favouring ChRCC. Three cases were reported as hybrid oncocytic/chromophobe tumours, and in the remaining 45 lesions (24%), the histopathologist did not further subclassify the oncocytic neoplasm . In six cases, a second renal mass biopsy was performed. This was because the initial biopsy was nondiagnostic in one case and in five cases, a repeat biopsies was undertaken due to growth of the tumour. In four of these cases, an initial diagnosis of oncocytoma was confirmed and in the remaining case an oncocytic tumour that was not further classified remained uncategorised and subsequently underwent a radical nephrectomy. There were two reported biopsy complications .n = 2), oncocytic variant of papillary RCC (n = 1) and oncocytic RCC unclassified (n = 1). Importantly, there was no disease‐related morbidity or mortality in patients undergoing immediate treatment throughout the follow‐up period.Forty‐nine patients (28%) elected to undergo immediate treatment of at least 1 tumour whilst 117 (68%) patients were initially managed with surveillance. Of these patients, 107 (62%) had at least 6‐months follow‐up and were included in the analysis. Six (3%) were discharged after diagnosis. Details are given in the consort diagram . Importantly, there was no statistical difference in growth rate between oncocytic neoplasms favouring benign or indolent pathology and those diagnosed as ChRCC , although the number of lesions where the renal mass biopsy favoured a malignant diagnosis but were initially managed with surveillance was small (13 lesions)  were initially managed with surveillance and had at least 6‐months follow‐up. The surveillance protocol was at the discretion of the treating physician. The maximum diameter of the tumour was measured on the initial and final imaging. The median diameter of tumours initially managed by surveillance was 33 mm (11–89), but this included 29 (25%) of tumours >4 cm. There was a median follow‐up of 39 months (6–144) including 52 (46%) of tumours followed up for greater than 3 years and 15 (13%) for greater than 5 years. The mean growth rate across all oncocytic renal neoplasms was 3.0 mm/year, but there was a wide range within the surveillance cohort with 13 lesions actually regressing in size and a minimum growth rate of −18.7 mm/year to a maximum of 31.5 mm/year. There was no statistical difference in average growth rates for tumours less than 4 cm when compared with larger tumours. .Of patients, 19% had an eGFR of <60 mL at diagnosis, 27 (24%) in the surveillance group and 7 (14%) in the treatment group. Follow‐up data on renal function were available in 107 (69%) patients, 62 (58%) in the surveillance group and 42 (86%) in the treatment group. In the surveillance group, there was an average decrease in eGFR of 0.9 mL/min/year with a median follow‐up of 55 months compared with the immediate treatment group where there was an average decrease in eGFR of 0.4 mL/min/year with a median follow‐up of 54 months   were recorded in patients undergoing surveillance. All deaths were from causes unrelated to the diagnosis of oncocytic renal neoplasm. In five cases, cause of death was recorded as pneumonia, in three cases ischaemic heart disease, one patient died of unrelated malignancy, one of advanced Parkinson's disease and one patient died following a hip fracture. Of note, there were no cases of development of metastatic disease or disease‐related morbidity or mortality during the study in any of the surveyed patients.F = 17.3, p < 0.01) and have an initial biopsy favouring ChRCC . When looking at sex, genetic predisposition, multifocality, initial size of lesion, decreased eGFR at diagnosis and nephrometry scores, there were no statistically significant differences between surveillance and immediate treatment groups (p = 0.39–0.92.)  were initially managed with surveillance in this study and were followed up for a median of 39 months without the development of metastases or any disease‐related morbidity. Growth rates reported in previous studies have ranged from 1.4–5.2 mm/yearThe EAU guidelines recommend nephron sparing surgery is offered to all patients with T1 tumours. In the United Kingdom, 3.7% of all renal surgical procedures are performed for oncocytomas, and few of these patients had preoperative biopsies. We would argue that is becoming increasingly difficult to justify surgical treatment for benign or indolent tumours as the default option, particularly in a comorbid population and considering 20% of the patients are known to have in hospital complications and 4% have complications of Clavien–Dindo Grade III or above with a mortality rate of 0.1%.Perhaps the biggest concern for clinicians not using routine renal mass biopsy in their practice is the ability to distinguish between types of oncocytic renal neoplasms, especially oncocytoma and ChRCC, and accurately grade a tumour. There is a fear that some lesions may be inappropriately labelled as benign or indolent. Oncocytic renal tumours present a challenge for the histopathologist. The 2016 WHO classification of tumours of the urinary system recognises ChRCC and oncocytoma as separate entities, both of which can display oncocytic features and obviously have different clinical significance. In our study, definitive histopathology was available in 31 cases following surgery and the pathology of lesions reported on an initial renal biopsy showed concordance with the definitive pathology in 87% of cases. This is better than a recent meta‐analysis reporting on over 200 renal mass biopsies of oncocytic renal neoplasms suggestive of oncocytoma and giving a positive predictive value (PPV) of 67% compared with final pathology post‐surgery, with significant heterogeneity noted between the studies.The safety of renal mass biopsy has been questioned; however, in our series, there were no significant biopsy complications. A previous meta‐analyses has shown percutaneous renal tumour biopsy to be safe with major complications in <0.1% of cases and transfusion rates of 0.1%. Seeding has also historically been a concern; however, this is thought to be rare.Some authors have expressed concern that tumour growth, even of non‐malignant lesions, will lead to a decline in renal function and development of symptoms. In one recent study the authors concluded that surveillance was associated with a greater decline in renal function than partial nephrectomy in patients with Oncocytoma and so justifying surgery for some of these tumours.We are aware of a few similar series looking at surveillance of oncocytomas; however, this study is one of the largest cohorts in the literature with one of the longest follow‐up periods. Another strength of the current study is that it includes all oncocytic renal neoplasms and not just oncocytomas making in more relevant to a contemporary clinical setting. A criticism of our study could be that it specifically looked at a cohort of patients selected for surveillance by the treating physician and not all oncocytic neoplasms therefore possibly introducing bias. As discussed, younger patients with pathology favouring malignancy were more likely to be immediately treated. However, what it does show is that the real world selection of patients for surveillance, although not well defined, appears to be effective at identifying patients where this is a safe strategy. This study does highlight an inconsistency in our current approach to decision making around the management of small renal masses. In this cohort, patients were more likely to be managed with ablation or surgery if they were diagnosed with an oncocytic renal neoplasm at a younger age; however, we know the incidence of benign tumours is higher in younger age groups.Enhanced immunohistochemical and molecular testing is now increasing our ability to differentiate between oncocytic renal neoplasms and has also lead to the identification of several other distinct entities with oncocytic features such as eosinophilic solid and cystic renal cell carcinoma (ESC RCC), low‐grade oncocytic renal tumour (LOT) and high‐grade oncocytic renal tumour (HOT). Modern imaging techniques such as diffusion‐weighted magnetic resonance imaging (MRI) and technetium‐99m ([99mTc])‐sestamibi single‐photon emission computed tomography/x‐ray CT (SPECT/CT) may also have a role in differentiating between oncocytomas and malignant tumours.If adopting a surveillance strategy for oncocytic renal tumours is to become standard further work is needed to develop a protocol. In most instances clinicians rely on changes in diameter of the lesion on cross‐sectional imaging or ultrasound to influence management decisions. Trigger points for definitive intervention following an initial period of surveillance have not been clearly identified although a fast growth rate was the most commonly cited reason here. Previous reports have suggested that oncocytomas measuring more than 5 cm or growing more than 5 mm/year should be definitively treated.In conclusion, we hope that this paper challenges a perceived wisdom that an enhancing mass in the kidney represents a surgical lesion that automatically requires excision without the need for a pretreatment biopsy. We acknowledge that the accurate diagnosis of oncocytic renal neoplasms relies on coordinated multidisciplinary expertise in urology, interventional radiology and histopathology. Where such resources exist, selected patients with oncocytic renal neoplasms diagnosed on renal mass biopsy can be safely managed conservatively with surveillance without the development of disease‐related morbidity or mortality in the medium term. Advances in immunohistochemistry, genetics and imaging in the future will allow more accurate categorisation of these tumours enabling a more individualised approach to management.None.


One strategy to eliminate latently infected cells that persist in people with HIV on antiretroviral therapy is to activate virus transcription and virus production to induce virus or immune‐mediated cell death. This is called latency reversal. Despite clear activity of multiple latency reversal agents in vitro, clinical trials of latency‐reversing agents have not shown significant reduction in latently infected cells. We review new insights into the biology of HIV latency and discuss novel approaches to enhance the efficacy of latency reversal agents. HIV latency occurs when the virus is integrated into the host cell DNA but does not produce viral proteins or virions, and therefore, the infected cells are not visible to immune‐mediated clearance. One strategy to eliminate or reduce the pool of latently infected cells is termed shock and kill, where the latent provirus is activated leading to immune‐mediated clearance or death through viral cytolysis  are a new class of LRA that can activate the HIV LTR via the non‐canonical nuclear factor kappa B (NFkB) pathway.3.2+ T cells that are enriched for HIV latency.Immunomodulatory LRAs have the benefit of dual function—reversing HIV latency and also enhancing HIV‐specific immunity. Immune checkpoint (IC) inhibitor molecules such as programmed cell death protein 1 (PD‐1), Lymphocyte activation gene 3 (LAG‐3) and T‐cell immunoreceptor with Ig and ITIM domains (TIGIT) are expressed on CD4Agonism of TLRs have also been shown to induce latency reversal and can enhance innate immune function.3.3Nanoparticles provide a novel pathway to enhance the specificity and potency of LRAs. Nanoparticle formulations loaded with LRAs including the protein kinase C agonist Bryostatin‐2 and the histone deacetylase inhibitor suberoylanilide hydroxamic acid have been shown to increase potency of latency reversal combined with targeted delivery to T cells.4+ T cells.+ T cells with venetoclax reduced intact and inducible proviruses ex vivo using cells from PWH on ART.An emerging concept in HIV latency is that infected cells are primed for survival and therefore targeting this survival mechanism will facilitate selective death of infected cells. Factors that regulate apoptosis such as proteins from the B‐cell lymphoma (BCL)‐2 family and inhibitors of apoptosis proteins (IAPs) have been shown to be over‐expressed in latently infected CD45Our understanding of the complexity of HIV latency is rapidly expanding. The level of HIV transcriptional activity on ART is influenced by the HIV integration site, the differentiation status of the T‐cell and its anatomical location, as well as extrinsic factors such as sex, time and stress. New approaches that combine latency reversal and enhancement of immunity show some promise in animal models; however, the success achieved to date is yet to be replicated in human clinical trials. There is now high interest in the combination of LRAs with pro‐apoptotic agents, to specifically enhance elimination of latently infected cells. In conclusion, it is highly unlikely that latency reversal alone will eliminate the reservoir; however, this approach is critical to reduce the pool of infected cells and remains a core part of HIV cure strategies.Open access publishing facilitated by The University of Melbourne, as part of the Wiley ‐ The University of Melbourne agreement via the Council of Australian University Librarians.SRL is an NHMRC practitioner fellow and is supported by the National Institutes of Health (NIH) Delaney AIDS Research Enterprise (DARE UM1 AI164560‐01).SRL's institution has received funding from the National Health and Medical Research Council (NHMRC) of Australia, National Institutes for Health, Wellcome Trust American Foundation for AIDS Research; Merck, ViiV and Gilead for investigator‐initiated research; Merck, ViiV and Gilead for educational activities. She is on the advisory boards of Vaxxinity, Immunocore, Gilead and Abbvie.