Creating a Digital Psychoeducation Programme for bipolar disorder in the COVID-19 pandemic

Introduction

The Covid-19 pandemic profoundly affected delivery and accessibility of mental health care services at a time when most needed. The OPTIMA Mood Disorder Service, a specialist bipolar disorder service, adapted group psychoeducation programme for delivery on-line.

Objectives

We report the feasibility of creating a digital psychoeducation programme.

Methods

The OPTIMA ten session group psychoeducation programme was converted into a ‘Digital’ intervention using video-conferencing. Sessions offered a range of key topics, derived from the initial Barcelona Group Psychoeducation Programme. At the time of writing, OPTIMA had fully completed two 10 session digital courses.

Results

A total of 12 people (6 in each group) consented to be part of a service evaluation of the digital groups. Just over half of the participants were women (7/12; 58.3%) and one identified as being non-binary (8.3); remaining participants were men. Age of participants ranged from 25 years to 65 years (Mean=42.3; SD=13.1). Data showed a high level of engagement (77%) All participants reported some improvement with a mean Bipolar Self-Efficacy scale (BPSES) post-group score of 105.6 (SD=14.8). At group level, this change was not statistically significant (F (1, 15) = 0.71, p=0.41). At an individual level, two out of five showed a reliable change index >1.96.

Conclusions

Delivering a ‘digital’ group psychoeducation programme was possible due to careful planning and programme development. There was good uptake from service users suggesting it is a feasible approach with preliminary evidence of clinical benefit.

Disclosure

No significant relationships.

Changes in cancer incidence and survival among Aboriginal and Torres Strait Islander children in Australia, 1997-2016

BACKGROUND

This study reports cancer incidence and survival among Aboriginal and Torres Strait Islander children and other Australian children, and assesses changes over time.

PROCEDURE

Data were from the population-based Australian Childhood Cancer Registry. The study comprised children aged under 15 diagnosed between 1997 and 2016 and with mortality follow-up until 31 December 2017. Incidence trends were analysed using JoinPoint regression. Five-year cancer-specific survival was calculated using the semi-complete approach with survival comparisons made using multivariable flexible parametric models.

RESULTS

Aboriginal and Torres Strait Islander children accounted for 506 of 13,299 eligible cases (3.8%). Incidence rates for Aboriginal and Torres Strait Islander children across the study period increased by 2.3% annually (95% confidence interval [CI]: +0.6% to +4.0%) and for other Australian children increased by 0.6% annually (95% CI: +0.3% to +0.9%; p = .05). Nonetheless, cancer incidence was consistently lower for Aboriginal and Torres Strait Islander children, with an incidence rate ratio of 0.73 (95% CI: 0.62-0.85; p < .01) between 2012 and 2016. Survival for Aboriginal and Torres Strait Islander children with solid tumours was 70.6% (95% CI: 62.5%-77.3%) and for other Australian children was 83.5% (95% CI: 82.3%-84.7%; p < .01), with indications of this difference diminishing in recent years.

CONCLUSIONS

Improvements in identification, particularly in urban areas, most likely accounts for the greater increase in cancer incidence rates among Aboriginal and Torres Strait Islander children. Examination of data on stage at diagnosis and treatment may provide important insights into survival for children with solid tumours.

Immune Response in Heart Transplant Patients Following COVID-19 Vaccination

Purpose

Previous studies have described poor outcomes in heart transplant patients who develop COVID-19 infection. Therefore, we sought to characterize a single center's experience with heart transplant patient outcomes during the COVID-19 pandemic and the recent role of vaccination in mitigating the risk of mortality.

Methods

From a single center, we identified all orthotopic heart transplant patients alive at the beginning of the COVID-19 pandemic in March 2020. All patients were followed from the start of the pandemic until their most recent follow up or death. Baseline comorbidities and immediate outcomes data were obtained from the Society for Thoracic Surgery (STS) Adult Cardiac Surgery Database (ACSD). Multiple logistic regression analyzed the association between vaccination status, baseline covariates, and other standard STS outcome measures. Non-parametric tests were used to compare different subgroups.

Results

We included 153 patients, of which 20.9% developed COVID-19 infection (32/153) with 40.6% (13/32) requiring hospitalization and 15.6% of those patients (5/32) dying as a direct result of COVID-19 pneumonia. Kaplan-Meier survival analysis revealed that unvaccinated patients had a significantly higher rate of all-cause mortality as compared to those patients that were fully vaccinated despite similar baseline characteristics (p < 0.001). Patients with previous COVID-19 infection in addition to vaccination had significantly higher IgG titers as compared to those only vaccinated (6568.50 AU/mL vs. 58.05 AU/mL, p = 0.002).

Conclusion

Immunization against COVID-19 is associated with a significant reduction in the mortality of heart transplant patients. IgG titers were variable among heart transplant patients who received the vaccine with the highest titers seen in those patients with a personal history of COVID-19. The implications of IgG levels are still unknown.

303 Mapping the Landscape of Surgical Registries in the United Kingdom

Introduction

Well-designed surgical registries are essential for high-quality patient-centred evaluation of implantable devices and surgical procedures. The importance of registries was highlighted in the recent Cumberlege report that detailed important innovation failures such as the use of vaginal mesh. Many surgical registries exist, but it is currently unclear how different registries are funded; designed; what data are collected; how databases are hosted and if the data can be linked to other datasets. There is therefore a need to understand the characteristics of and variation in existing surgical registries to make recommendations for how these could be improved. The aim of this work is to identify existing surgical registries in the UK and describe and summarise their key characteristics to inform recommendations for how surgical registries may be improved.

Method

Existing surgical registries will be identified using multiple different sources, including society websites; search engine review; a targeted search of Medline and Embase databases and expert knowledge. Details of each registry will be extracted using a standardised data extraction proforma developed by the study team. Characteristics of identified registries will be summarised into a narrative review.

Results

Identification of registries is ongoing. Preliminary data extraction has highlighted marked heterogeneity in the design, content, and structure of existing surgical registries. Data extraction is ongoing, but results will be available for presentation at the ASIT meeting.

Conclusions

There is considerable heterogeneity in existing surgical registries. Further work is needed to establish the extent of this variation and identify areas that can be improved.

Flow vorticity relationships with right ventricular geometry in adult tetralogy of Fallot

Background

Repaired tetralogy of Fallot adults (rToF) undergo right ventricular (RV) remodeling, in part due to volume overload of residual pulmonary regurgitation volume (PRV). Time-resolved phase-contrast cardiac magnetic resonance imaging (4D Flow MRI) enables the qualitative and quantitative measurement of altered blood flow patterns, including vorticity. Cardiac atlases allow for complex three-dimensional heart shapes to be expressed as morphometric scores. Those scores show the extent of geometrical shift and can help explore uncharted relationships between vorticity and architecture.

Purpose

We aimed to quantify vorticity, incorporating deep learning to enhance 4D Flow data, and correlate this with global cardiac parameters and morphometric scores.

Methods

12 Adult rToF patients and 10 age-matched controls underwent 4D flow MRI and cine imaging. RV interventricular vorticity was calculated for outflow and inflow tracts. EDV, ESV and SV were computed from cines which were also used to build three-dimensional shape models.

The biventricular models were projected onto an atlas generated from 95 rToF patients, and twenty-one principal component analysis shape modes were correlated with cardiac metrics and vorticity to identify global shape variations. Association between biventricular shape and vorticity was further analysed using multivariate multiple regression models.

Results

Strong correlation was found between PRV and the right ventricular outflow tract (RVOT) vorticity. PRV and RVOT vorticity both correlated with the same 3 shape modes (r=−0.55, −0.50 and 0.6 (p&lt;0.05) respectively for PR and r=0.63, −0.82 and 0.60 (p&lt;0.05) respectively for vorticity) i.e., the RV dilates with an increase in basal bulging, apical bulging and tricuspid annulus tilting with more severe regurgitation, as well as a smaller LV, and a paradoxical movement of the septum (Figure 1). However, RV vorticity correlated with 2 modes that did not correlate with PRV, (r=−0.62, −0.69, p&lt;0.05). With higher vorticity the RV was longer, increased tilting of the tricuspid annulus and an increased basal bulge around the tricuspid area. The multivariate analysis model demonstrated that higher vorticity was associated with displacement of the pulmonary valve and change in the RVOT length and direction. A septal displacement towards the left ventricle was observed and increased apical flatness of the RV (Figure 1). Qualitatively, vorticity in rToF group was more heterogeneous than controls (Figure 2).

Conclusions

Vorticity is a novel marker based on the influence of blood motion providing new insight into early diagnosis and prognosis of cardiac disease. This is the first study to examine the relationships between vorticity and regional RV shape changes in rToF. Mode associations with vorticity were different to associations with PRV. More longitudinal studies are required for standardization of change in vorticity with the disease process.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): The New Zealand heart foundation Mode variations and morphometric modelVorticity visualization and analysis

1020 Delay to Surgery in Acute Perforated and Ischaemic Gastrointestinal Pathology

Introduction

Patients with acute abdominal pathology requiring emergency laparotomy who experience a delay to theatre have an increased risk of morbidity, mortality, and complications. The timeline between symptom onset and operation is ill-defined with international variance in assessment and management. This systematic review aims to define where delays to surgery occur and assess the evidence for previous interventions.

Method

A systematic review was performed searching MEDLINE and EMBASE databases (January 1st 2005 to May 6th 2020). All studies assessing the impact of time to theatre in patients with acute abdominal pathology requiring emergency laparotomy were considered.

Results

Eighty-five results were assessed to include 19 papers in the analysis. Fifteen unique timepoints were identified in the patient pathway between symptom onset and operation which could be classified into four distinct phases. Time from admission to theatre (1 to 72 hours), and mortality rate (10.6-74.5%) varied greatly between studies. Mean time to surgery was significantly higher in deceased patients compared to survivors. Delays were related to imaging, diagnosis, decision-making, theatre availability and staffing. Four of five interventional studies showed a reduced mortality following introduction of an acute laparotomy pathway.

Conclusions

There is wide variation in the definition and measurement of time delays prior to emergency surgery with few studies exploring interventions. Given the heterogenous nature of the patient population and pathologies, an assessment and management framework from onset of symptoms to operation is proposed. This could be incorporated into national mortality prediction and audit tools and assist in the assessment of interventions.

1289 Gender Representation in The Authorship of Surgical Journals

Introduction

Despite the increase in female doctors graduating from medical schools internationally, gender disparity in surgery remains. This disparity is also evident in academic surgery. This study aims to quantify the extent of gender disparity in the authorship of articles in major surgical journals.

Method

The Top 10 Surgical Journals were identified using SCImago Journal Rank indicator. Authorship details for papers published in 2019 were collected. Authors were assigned as female, male or unknown using Gender API software (Gender API, Germany). For each journal, the percentage of first author, last author, corresponding author and all authors split by gender was interrogated. Gender differences by publication type were also identified.

Results

9 of the 10 journals had full names publicly available. Overall, 2414 manuscripts were interrogated which included 16,277 number of authors. Respectively, females and males accounted for 29.8% [22.9-34.9%] (N = 655) and 62.4% [56.3-70.2%] (N = 1419) of first authors, 20.6% [11.8-27.1%] (N = 453) and 74.2% [65.6-84.1%] (N = 1706) of last authors, 23.9% [14.9-29.6%] (N = 510) and 69.9% [60.5-79.3%] (N = 2341) of corresponding authors and in total 27% [19.4-31.6%] (N = 4298) and 65.5% [58.6-73.4%] (N = 9982) of all authors. The wide range in these results could be a result of various factors.

Conclusions

This study has identified a gender imbalance in authorship positions, with the greatest difference observed in the most senior author position. Whether this is reflective of the current disparity observed in senior academic surgery positions or due to gender discrimination is unclear.

1308 Investigating the Use of a Novel Pre-Hospital Triage Tool for Acute Abdominal Surgical Emergencies – A Two-Phase Single Centre Cohort Study

Background

Despite the recent improvements in mortality in patients undergoing emergency laparotomy(EL) within the UK, delay to theatre continues to be associated with increased mortality. This study aimed to assess if patients requiring urgent surgical intervention for acute abdominal surgical pathology could be identified in the pre-hospital setting.

Method

A two-phase, single-centre, cohort study was performed. Phase 1 retrospectively investigated patients who underwent emergency laparotomy between 01/01/2019-31/12/2019 at Leeds Teaching Hospital Trust (LTHT) through the NELA database. Phase 2 prospectively assessed NEWS2 for all patients presenting to LTHT Surgical Admissions Unit with abdominal pain between 01/01/2020-31/01/2020.

Results

Phase 1: 45 patients were coded through NELA and confirmed through operation note review as undergoing EL for gastrointestinal perforation. 66%(n = 30) were assessed by the ambulance service and 80% (n = 24) had a NEWS2 of 3 or greater. Phase 2: 319 patients were assessed in SAU/ED, of which 69 initially treated by the ambulance service. 30% (n = 21) of these patients had an initial NEWS2 of 3 or above. Sensitivity of a NEWS2 score of &gt;/3 in predicting the need for immediate surgical intervention including EL was 95%(95%CI, 74-99) and specificity was 95% (95%CI, 83-99) with a PPV of 86%(95%CI 67-95) and NPV of 98% (95%CI, 87-99).

Conclusions

A NEWS2 score of &gt;/3 predicts the need for emergency surgical intervention including laparotomy for gastrointestinal perforation with reasonable sensitivity in this cohort. A pre-hospital triage tool for patients presenting with abdominal pain could utilise NEWS2 as an adjunct to decision-making in an acute abdominal pathway.

1423 Quality and Efficacy of Multidisciplinary Team (MDT) Discussion Quality Assessment Tools and Checklists: A Systematic Review

Aim

MDT discussion is the gold standard for cancer care in the UK. With the cancer incidence and complexity of treatments both increasing, demand for MDT discussion is growing. The need for efficiency, whilst maintaining high standards, is therefore clear. Paper-based MDT quality assessment tools and discussion checklists may represent a practical method of monitoring and improving MDT practice. This review aims to describe and appraise these tools, as well as consider their value to quality improvement.

Method

MEDLINE, Embase and PsycInfo were searched using pre-defined terms. PRISMA methodology was followed throughout. Studies were included if they described the development of a relevant tool/checklist, or if an element of the methodology further informed tool quality assessment. To investigate efficacy, studies using a tool as a method of quality improvement in MDT practice were also included. Study quality was appraised using the COSMIN risk of bias checklist or the Newcastle-Ottawa scale, depending on study type.

Results

The search returned 6888 results. 17 studies were included, and 6 different tools were identified. Overall, methodological quality in tool development was adequate to very good for assessed aspects of validity and reliability. Clinician feedback was positive. In one study, the introduction of a discussion checklist improved MDT ability to reach a decision from 82.2% to 92.7%. Improvement was also noted in the quality of information presented and the quality of teamwork.

Conclusions

Several tools for assessing and guiding MDT discussions are available. Although limited, current evidence indicates sufficient rigour in their development and their potential for quality improvement.

1404 NELA Risk Mortality Scores from Admission to Theatre in Emergency Gastrointestinal Perforation – A Retrospective Cohort Study

Background

Patients with acute abdominal pathology requiring emergency laparotomy who experience a delay to theatre have an increased risk of morbidity, mortality and complications. The aim of this study was to assess delay, from symptom onset to theatre in patients with gastrointestinal perforation and its effect on perioperative risk.

Method

A single-centre retrospective study was performed in the Leeds Trust Hospitals, UK investigating the NELA database for patients requiring emergency laparotomy for perforated gastrointestinal viscus who presented to the acute surgical unit or emergency department between 1st February 2018 and 31st January 2020.

Results

101 patients met the inclusion criteria (47% F and 53% M), mean age 59 [21-91]. 37% of patients’ NELA scores worsened from admission to pre-op (median change of + 5.9% IQR 1.3-11.5]), 14% stayed the same and 49% improved (median change of -4.4%[IQR 0.4-9.1]) 3% had their NELA score documented at the time of consent. 18% did not wait for a CT report or went straight to theatre. Mean time from admission to scan report was 9.3 hours (0.9-22.0). Median time from symptom onset to presentation (2 days [IQR 1-13]) was greater in patients with an Index of Multiple Deprivation Decile of 1-5, (n = 64, median 2 days [IQR 1-6]) compared to those in deciles 6-10, (n = 37, median 1 day[IQR 1-3]), p = 0.097.

Conclusions

NELA mortality risk score changes from presentation to surgery in patients with acute gastrointestinal perforation requiring emergency laparotomy. There is suggestion that delay in symptom onset to presentation may correlate with Index of Multiple Deprivation Decile.

Transdermal delivery of carnosine into equine skeletal muscle

The dipeptide carnosine consists of β-alanine and L-histidine. It plays a major role in skeletal muscle metabolism, especially as an intracellular buffer and antioxidant. Increasing intramuscular carnosine has been shown to improve recovery from exercise and increase anaerobic threshold and time-to-exhaustion. Dietary supplementation with carnosine does not effectively increase intramuscular carnosine due to the presence of carnosinase in the blood. However, an effective transdermal delivery process could expediently increase intramuscular concentrations of carnosine. This study’s objective was to examine the efficacy of a transdermal system for delivering carnosine into the skeletal muscle of horses, using a randomised, placebo controlled, crossover study. Carnosine plus a proprietary transdermal delivery agent or the agent alone (placebo) were applied to the middle gluteal muscles of 10 Thoroughbred racehorses, and muscle biopsies were taken before and 30, 60, and 120 min after application. Muscle carnosine concentration was measured using an enzyme-linked immunosorbent assay. A two-way repeated measures analysis of variance was used to test for the main effects of time and treatment (placebo or carnosine) as well as an interaction between time and treatment. Independent F-tests examined the change in intramuscular carnosine levels from baseline to each time point (30, 60, and 120 min). There was a significant main effect of treatment (P=0.004), no significant main effect for time (P=0.18), and a non-significant interaction of treatment with time (P=0.08). Mean intramuscular carnosine concentrations increased from baseline to 120 min. Compared to concentrations following placebo application, carnosine was greater by ~35% at 30 min (P=0.002) and ~46% after 60 min (P=0.044), but not at 120 min (P=0.20). The results indicated that intramuscular carnosine can be increased using a transdermal delivery system within 60 min of application which could have important implications for the health of horses, and their capacity to perform and recover from physical activity.

Automatic segmentation of the aorta on multi-center and multi-vendor phase-contrast enhanced magnetic resonance angiographies and the advantages of transfer learning

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Guala A. received funding from the Spanish Ministry of Science, Innovation and Universities

Background

Phase-contrast (PC) enhanced magnetic resonance (MR) angiography (MRA) is a class of angiogram exploiting velocity data to increase the signal-to-noise ratio, thus avoiding the administration of external contrast agent, normally used to segment 4D flow MR data. To train deep-learning algorithms to segment PC-MRA a large amount of manually annotated data is needed: however, the relatively novelty of the sequence, its rapid evolution and the extensive time needed to manually segment data limit its availability.

Purpose

The aim of this study was to test a deep learning algorithm in the segmentation of multi-center and multi-vendor PC-MRA and to test if transfer learning (TL) improves performance.

Methods

A large dataset (LD) of 262 and a small one (SD) of 22 PC-MRA, acquired without contrast agent at 1.5 T in a General Electric and a Siemens scanner, respectively, were manually annotated and divided into training (232 and 15 cases) and testing (30 and 7) sets. They both included PC-MRA of healthy subjects and patients with aortic diseases (excluding dissections) and native aorta. A convolutional neural networks (CNN) based on nnU-Net framework [1] was trained in the LD and another in the SD. The left ventricle was removed semi-automatically from the DL segmentations of the LD as it was not relevant for this application. Networks were then tested on the test sets of the dataset there were trained and the other dataset to assess generalizability. Finally, a fine-tuning transfer learning approach was applied to LD network and the performance on both test sets were tested. Dice score, Hausdorff distance, Jaccard score and Average Symmetrical Surface Distance were used as segmentation quality metrics.

Results

LD network achieved good performance in LD test set, with a DS of 0.904, ASSD of 1.47, J of 0.827 and HD of 6.35, which further improve after removing the left ventricle in the post-processing to a DS of 0.942, ASSD of 0.93, J of 0.892 and HD of 3.32. SD network results in an average DS of 0.895, ASSD of 0.59, J of 0.812 and HD of 2.05. Once tested on the testing set of the other dataset, LD network resulted in a DS of 0.612 while SD network in DS of 0.375, thus showing limited generalizability. However, the application of transfer learning to LD network resulted in the improvement of the evaluation metrics on the SD from a DS of 0.612 to 0.858, while slightly worsening in the first one without post-processing to 0.882.

Conclusions

nnU-net framework is effective for fast automatic segmentation of the aorta from multi-center and multi-vendor PC-MRA, showing performance comparable with the state of the art. The application of transfer learning allows for increased generalization to data from center not included in the original training. These results unlock the possibility for fully-automatic analysis of multi-vendor multi-center 4D flow MR.

Delay to surgery in acute perforated and ischaemic gastrointestinal pathology: a systematic review

BACKGROUND

Patients with acute abdominal pathology requiring emergency laparotomy who experience a delay to theatre have an increased risk of morbidity, mortality and complications. The timeline between symptom onset and operation is ill defined with international variance in assessment and management. This systematic review aims to define where delays to surgery occur and assess the evidence for interventions trialled across Europe.

METHODS

A systematic review was performed searching MEDLINE and EMBASE databases (1 January 2005 to 6 May 2020). All studies assessing the impact of time to theatre in patients with acute abdominal pathology requiring emergency laparotomy were considered.

RESULTS

Sixteen papers, involving 50 653 patients, were included in the analysis. Fifteen unique timepoints were identified in the patient pathway between symptom onset and operation which are classified into four distinct phases. Time from admission to theatre (1-72 hours) and mortality rate (10.6-74.5 per cent) varied greatly between studies. Mean time to surgery was significantly higher in deceased patients compared with that in survivors. Delays were related to imaging, diagnosis, decision making, theatre availability and staffing. Four of five interventional studies showed a reduced mortality rate following introduction of an acute laparotomy pathway.

CONCLUSION

Given the heterogeneous nature of the patient population and pathologies, an assessment and management framework from onset of symptoms to operation is proposed. This could be incorporated into mortality prediction and audit tools and assist in the assessment of interventions.

Discrimination in the surgical discipline: an international European evaluation (DISDAIN)

Background

Negative workplace experiences (NWPEs), such as gender discrimination, bullying, sexual harassment and ethnic discrimination, are concerns in today’s surgical society. These negative experiences potentially impair surgeons’ performance and might impact patient care or outcomes negatively. This study aimed to assess the experience of NWPEs across the European surgical workforce.

Methods

A prospective online 34-point questionnaire was designed using a combination of Likert scale, multiple-choice and short-answer questions. Invitations were distributed through surgical associations via email/social media between 1 September and 15 November 2019. Data were analysed using non-parametric methods.

Results

Some 840 complete responses were included in the analysis. The distribution across genders and stage of surgical training was even. Of the respondents, 20 per cent (168 respondents) considered quitting their job, 4.5 per cent (38) took time off and 0.5% (4) left surgery due to NWPEs; 12.9 per cent of females and 4.4 per cent of males experienced some form of physical harassment. Females and those in training were significantly more likely to experience or witness gender discrimination and sexual harassment. Just over half of the respondents (448) did not report negative experiences, with most of these (375 respondents) being unaware of whom to report to. Nearly a fifth of respondents felt that NWPEs influenced patient care or outcomes negatively.

Conclusion

NWPEs were frequent, especially among females and those in training. While a substantial proportion of respondents experienced physical harassment, many individuals were unaware of how to raise concerns. Adverse effects on patient outcomes, surgical training and workforce retention indicate a need for urgent action.

POS0495 LARGE JOINT DISEASE IN RHEUMATOID ARTHRITIS AND THE ROLE OF RHEUMATOID FACTOR. RESULTS FROM THE EARLY RHEUMATOID ARTHRITIS STUDY

Background:

Rheumatoid arthritis (RA) is classically described as a symmetric small joint polyarthritis with additional involvement of large joints. There is a paucity of information concerning the time course of damage in large joints, such as shoulder, elbow, hip, knee and ankle, from early to established RA, or of the influence of Rheumatoid Factor (RF) status. There is a historic perception that patients who do not have RF follow a milder less destructive course, which might promote less aggressive treatment strategies in RF-negative patients. The historic nature of the Ealy Rheumatoid Arthritis Study (ERAS) provides a unique opportunity to study RA in the context of less aggressive treatment strategies.

Objectives:

To examine the progression of large joint involvement from early to established RA in terms of range of movement (ROM) and time to joint surgery, according to the presence of RF.

Methods:

ERAS was a multi-centre inception cohort of newly diagnosed RA patients (<2 years disease duration, csDMARD naive), recruited from 1985-2001 with yearly follow-up for up to 25 (median 10) years. First line treatment was csDMARD monotherapy with/without steroids, favouring sulphasalazine for the majority. Outcome data was recorded at baseline, at 12 months and then once yearly. Patients were deemed RF negative if all repeated assessments were negative. ROM of individual shoulder, elbow, wrist, hip, knee, ankle and hindfeet joints was collected at 3, 5, 9 and 12-15 years. The rate of progression from normal to any loss of ROM, from years 3 to 14 was modelled using GEE, adjusting for confounders. Radiographs of wrists taken at years 0, 1, 2, 3, 5, 7, 9 were scored according to the Larsen method. Change in the Larsen wrist damage score was modelled using GEE as a continuous variable, while the erosion score was dichotomised into present/absent. Surgical procedure data were obtained by linking to Hospital Episodes Statistics and the National Joint Registry. Time to joint surgery was analysed using multivariable Cox models.

Results:

A total of 1458 patients from the ERAS cohort were included (66% female, mean age 55 years) and 74% were RF-positive. The prevalence of any loss of ROM, from year 3 through to 14 was highest in the wrist followed by ankle, knee, elbow and hip. The proportion of patients at year 9 with greater than 25% loss of ROM was: wrist 30%, ankle 12%, elbow 7%, knee 7% and hip 5%. Odds of loss of ROM increased over time in all joint regions, at around 7 to 13% per year from year 3 to 14. There was no significant difference between RF-positive and RF-negative patients (see Figure 1). Larsen erosion and damage scores at the wrists progressed in all patients; annual odds of developing any erosions were higher in RF-positives OR 1.28 (95%CI 1.24-1.32) than RF-negatives OR 1.17 (95%CI 1.09-1.26), p 0.013. Time to surgery was similar according to RF-status for the wrist and ankle, but RF-positive cases had a lower hazard of surgery at the elbow (HR 0.37, 0.15-0.90), hip (HR 0.69, 0.48-0.99) and after 10 years at the knee (HR 0.41, 0.25-0.68). Adjustment of the models for Lawrence assessed osteoarthritis of hand and feet radiographs did not influence these results.

Figure 1.

Odds of progression to any loss of ROM (from no loss of ROM) per year in the overall population and stratified by RF status.

Conclusion:

Large joints become progressively involved in RA, most frequently affecting the wrist followed by ankle, which is overlooked in some composite disease activity indices. We confirm a higher burden of erosions and damage at the wrists in RF-positive patients, but have not found RF-negative patients to have a better prognosis over time with respect to involvement of other large joints. In contrast RF-negative patients had more joint surgery at the elbow, hip, and knee after 10 years. There is no justification to adopt a less aggressive treatment strategy for RF-negative RA. High vigilance and treat-to-target approaches should be followed irrespective of RF status.

Disclosure of Interests:

None declared

Routine antiseptic baths and MRSA decolonization: diverse approaches across Singapore's acute-care hospitals

To determine the variation in practices on meticillin-resistant Staphylococcus aureus (MRSA) surveillance and management of MRSA-colonized patients amongst 17 acute healthcare facilities in Singapore, the Ministry of Health convened a sharing session with Infection Prevention and Control Leads. All hospitals practised close to universal MRSA entry swabbing in keeping with national policy. There were, however, major variations in the response to both positive and negative surveillance swabs across facilities including the role of routine antiseptic bathing and MRSA decolonization. Most undertaking decolonization considered its role to be in 'bioburden reduction' rather than longer-term clearance.

Bipolar affective disorder

Abstract Body

Abstract: Biomarkers for diagnosis and treatment of Bipolar Disorder: hope or hype? Professor Allan Young, Centre for Affective Disorders, IoPPN, KCL London, SE5 8AF. allan.young@kcl.ac.uk The use of “biomarkers” (biological markers) in basic and clinical research as well as in clinical practice has become so commonplace in many areas of medicine that their presence as primary endpoints in clinical trials is now widely accepted. In clinical disciplines where specific biomarkers have been well characterized and repeatedly shown to correctly predict relevant clinical outcomes across a variety of treatments and populations, this use is entirely justified and appropriate. However, the validity of biomarkers in most psychiatric disorders continues to be evaluated. This lecture will review the current conceptual status of biomarkers as clinical and diagnostic tools for bipolar disorder and as surrogate endpoints in clinical research in bipolar disorder. The conceptual background in terms of current diagnostic categories and research domain criteria will be discussed and the various approaches with putative value (e.g., brain imaging, genetics, and neuroendocrinology) reviewed (1, 2). The lecture will end with a discussion of approaches to evaluating biomarkers of lithium response (3).

References

Wise et al, Mol Psychiatry. 2016 May 24. doi: 10.1038/mp.2016.72. [Epub ahead of print]; Young AH. Harv Rev Psychiatry. 2014 Nov-Dec;22(6):331–3 Bellivier F, Young AH, et al, Bipolar Disord. 2020 Oct 23. doi: 10.1111/bdi.13023. Online ahead of print.

Disclosure

Paid lectures and advisory boards for the following companies with drugs used in affective and related disorders: Astrazenaca, Eli Lilly, Lundbeck, Sunovion, Servier, Livanova, Janssen, Allegan, Bionomics, Sumitomo Dainippon Pharma, COMPASS Principal Inve

The strain-7 study: multimodal, multivendor, multifield strength, scan:rescan comparison of global longitudinal and circumferential strain in healthy volunteers

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): National Insitute for Health Research

Background

There is clinical and prognostic evidence for global longitudinal strain (GLS) and circumferential strain (GCS). A range of techniques exist: 2-dimensional echocardiography (2Decho), 3-dimensional echocardiography (3Decho) and Cardiovascular Magnetic Resonance (CMR).

Purpose

To investigate inter-study repeatability and inter-method comparison of GLS and GCS techniques.

Methods

Volunteers underwent same day scan

rescan 2Decho, 3Decho, 1.5T Siemens CMR (Cine imaging and Displacement encoding with stimulated echoes [DENSE]), 3T Siemens CMR (Cine Imaging and DENSE) and 3T Philips CMR (Tagging and Fast strain-encoding [fSENC]) imaging. Strain was quantified for 2Decho (EchoPAC), 3Decho (TomTec), Feature tracking (FT) for cine imaging (CircleCVI), CIM (University of Auckland) for DENSE and Tag, and Myostrain (Myocardial solutions) for fSENC.

Results

20(6F) volunteers, mean age 33 ± 7 years, mean LVEF 62 ± 4%. All GLS and GCS methods had excellent inter-study agreement (ICC &gt; 0.75) with coefficient of variation (CoV) between 4-8% (Table 1). Median and IQR are presented in Figure 1.

Friedman’s test revealed statistically significant inter-method differences for GLS (χ2 = 66.4,p &lt; 0.0001) and GCS (χ2 = 50.9,p &lt; 0.0001). Post hoc analysis using Dunn’s test with Bonferroni correction demonstrated significant differences:

-GLS: 2Decho vs DENSE 1.5T (p = 0.001) and Myostrain 3T (p = 0.0116); 3Decho vs FT 3T (p = 0.049) and DENSE 1.5T (p &lt; 0.0001); FT 1.5T vs DENSE 1.5T (p = 0.001) and Myostrain 3T (p = 0.01); FT 3T vs Myostrain 3T (p &lt; 0.0001); DENSE 1.5T vs Tag 3T (p = 0.0008) and Myostrain 3T (p &lt; 0.0001); Tag 3T vs Myostrain (p = 0.02).

-GCS: 3Decho vs DENSE 1.5T (P = 0.0005), FT 1.5T (p &lt; 0.001), FT 3T (P &lt; 0.001) and Myostrain (p = 0.003); FT 1.5T vs Tag 3T (p = 0.001), FT 3T vs Myostrain 3T (p = 0.04).

Conclusion

There is excellent interstudy agreement for GLS and GCS methods. However, there are important inter-method differences in absolute values, that need to be considered for clinical application as a surveillance method and longitudinal studies.

Table 1 Acquisiton Post processing GLS CoV(%) GLS ICC GCS CoV(%) GCS ICC 2DEcho EchoPAC 4.88 0.80 - - 3DEcho TomTec 4.77 0.86 3.97 0.85 Siemens 1.5T cine FT CircleCVI 8.30 0.79 6.00 0.85 Siemens 3T cine FT CircleCVI 6.21 0.89 4.76 0.94 Philips 3T Tag CIM 6.15 0.89 5.86 0.88 Siemens 1.5T DENSE CIM 4.36 0.90 4.65 0.89 Philips 3T fSENC Myostrain 8.45 0.81 4.06 0.90 Interstudy agreement for the different GLS and GCS methods. Abstract Figure 1

Patient-reported experiences of mealtime care and food access in acute and rehabilitation hospital settings: a cross-sectional survey

BACKGROUND

Nutrition and mealtime interventions can improve nutritional intake amongst hospital inpatients; however, patient-reported experience is rarely considered in their development and evaluation. The present study aimed to measure patient-reported food and mealtime experience to evaluate and inform continuous quality improvement of hospital nutrition care.

METHODS

A cross-sectional survey with inpatients in seven acute care and rehabilitation wards was conducted. A 27-item validated questionnaire measured five domains of patient experience: food choices, organisational barriers, feeling hungry, physical barriers to eating and food quality. Responses were summarised descriptively and compared between settings (acute versus rehabilitation), patient demographics (age, gender) and time in hospital.

RESULTS

Responses from 143 participants (mean age 67 years, 57% male, 28% rehabilitation, median 6 days into hospitalisation) showed that 10% or fewer respondents reported difficulties with food choices, feeling hungry or food quality. The most common difficulties were opening packets (36%), insufficient menu information provided (29%), being interrupted by staff when eating (28%), being disturbed when eating (27%), being in an uncomfortable position when eating (24%) and difficulty reaching food (21%). There were no significant differences in domain patterns by sex, age group or time in hospital. Organisational barriers were reported less frequently amongst rehabilitation participants compared to acute care (P = 0.01).

CONCLUSIONS

This survey highlights areas of positive patient-reported experience with nutrition care and suggests that local improvement efforts should focus on physical assistance needs and organisational barriers, especially in acute care wards. The questionnaire may be useful for informing and evaluating systematic nutrition care improvements.