O8: DIRECT MANIPULATION OF THE INTESTINAL MICROBIOME TO INFLUENCE POST-OPERATIVE OUTCOMES

Introduction

Distal feeding (DF) involves intubation of the distal limb of a loop ileostomy to feed with a prebiotic mix. Studies suggest that distally feeding patients following anterior resection prior to ileostomy closure may be beneficial as a form of bowel pre-habilitation. These pilot data examine the adaptive immune response to DF.

Method

Ten healthy controls with an intact GI tract were compared with 10 patients following rectal cancer resection and chemo/radiotherapy, prior to closure of ileostomy over 8 weeks of DF. We examined B and T cell memory responses from peripheral blood using cell proliferation assays. Cells were cultured with dead antigen to reflect the microbiota in the small and large bowel. Two negative and two positive controls were used to assess minimal and maximum cell proliferation.

Result

B cell responses prior to DF were increased in the defunctioned group compared to the normal controls to significance (p=0.0014). After 8 weeks of DF the groups were comparable. T cell responses to bacteria had significant differences in proliferation rate following DF commencement, CD4 week 0 vs 3 p=0.0001, week 3 vs 8 p=0.000034, CD8 week 0 vs 3 p=0.0001, week 3-8 p=0.00024). In individual patients, CD4 responses were shown to shift from responses to facultative aerobic species, to strict anaerobes.

Conclusion

These data suggest that distal feeding fundamentally resets peripheral circulating memory and it may be of use in pre-habilitating the bowel prior to restoration of continuity. Early clinical data suggests that distal feeding improves post-operative outcomes.

Take-home message

distal feeding is an easy pre-operative intervention that has a significant effect on cell proliferation and antigen response, which may contribute to improved post operative outcomes.

Sexual and reproductive health (SRH) needs of women admitted to eileen skellern ward (ES1) psychiatric intensive care unit (PICU)

Introduction

PICU inpatients are likely to be at increased risk of having unmet SRH needs due to barriers to accessing services. Since May 2018, an in-reach SRH assessment has been available to all psychiatric inpatients on ES1 ward, if referred. Analysis of referrals over 15 months identified only 24 had been made during this time.

Objectives

To assess the SRH needs of women admitted to ES1 PICU, the feasibility of providing a SRH in-reach clinic, and the acceptability of delivering a nurse lead referral programme.

Methods

A bi-monthly SRH in-reach clinic and a nurse led SRH referral pathway were implemented on ES1 over a seven-month period. A staff training needs assessment was performed followed by training, a protocol was developed, staff attitudes were explored, and patient engagement was sought.

Results

A total of 41% (32/77) of patients were referred, which was a 29% increase. 53.1% (17/32) of the total referrals had a true SRH need, equating to a 10% increase and 22% (17/77) of all PICU admissions. 90% of referrals were made by nursing staff. A staff focus group (n15) highlighted the acceptability and perceived importance of offering SRH care in PICU, if interventions were appropriately timed and the patient’s individual risk profile was considered.

Conclusions

Results identify that SRH needs for PICU admissions are greater than previously realised. Providing a nurse led referral pathway for an SRH in-reach clinic is acceptable, feasible and beneficial for PICU patients. This project has resulted in service improvements including offering asymptomatic STI testing to all PICU admissions.

Disclosure

No significant relationships.

A103 PIVOTING IN A PANDEMIC: THE IMPACT OF COVID-19 ON THE PROVISION OF CARE FOR PATIENTS WITH INFLAMMATORY BOWEL DISEASE: A PRELIMINARY ANALYSIS

Background

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreak, also known as COVID-19, was declared a worldwide pandemic in March of 2020. Since the onset of the pandemic, the focus of many healthcare systems has shifted toward limiting non-essential visits to hospitals in order to prioritize and allocate resources toward treating those affected by COVID-19, and preventing further exposures. While the effect of COVID-19 has been felt amongst many patient populations, those with inflammatory bowel disease (IBD) have been particularly impacted through delayed appointments and endoscopy, which is critical in disease monitoring.

Aims

We aimed to determine how changes to the provision of IBD care due to the COVID-19 pandemic have affected IBD patients.

Methods

A retrospective cohort study was conducted using administrative data comparing IBD patients admitted to the gastroenterology ward from March 17 to August 31 2019, with IBD patients admitted from March 17 to August 31 2020 at a tertiary care centre in London, Ontario. Patients were reviewed to assess differences in care utilization and IBD-related outcomes such as hospitalization, surgery and length of stay and in-patient drug therapy.

Results

A total of 538 patients (259 in 2019 cohort and 279 in 2020 cohort) were reviewed with 48 and 60 IBD patients meeting the inclusion criteria for 2019 and 2020 respectively. Patient demographics were similar between 2019 and 2020 cohort for age, sex, rurality, disease type, and biologic exposure. A greater proportion of patients were admitted with IBD flares in 2020 (86.7% vs 75%, p=0.03). Furthermore, the 2020 cohort also had a 45% increase in in-patient surgical consultations (p=0.07), a 50% increase in in-patient IBD-related surgeries (p=0.39), a 69% increase in inpatient Remicade prescription (p=0.13) and a 70% increase in infectious complications at presentation to hospital (p=0.21). A shorter median length of stay was reported for patients in the 2020 cohort (4 days IQR 3.95 vs 5.85 IQR 4.65, p=0.09).

Conclusions

Preliminary data suggest that during the COVID-19 pandemic, we have seen more deleterious outcomes in our IBD patients such as increased flares necessitating hospital admission. There was also a non-significant trend toward increased infectious complications as well as in-patient surgeries and need for in-patient Remicade. Though these results cannot be fully interpreted due to the need for further sampling, they suggest that IBD patients may be at-risk for poor outcomes in the current climate of medical care. Completion of this study will help define the full impact of care shifts related to reducing the spread of the novel coronavirus on IBD patients and highlight areas of care that need careful assessment and consideration to protect IBD patient health.

Funding Agencies

None

A113 ANNUAL COLONOSCOPY VOLUME IS NOT PREDICTIVE OF COLONOSCOPY QUALITY - FINDINGS FROM THE SOUTHWEST ONTARIO COLONOSCOPY COHORT

Background

Performing a minimum number of colonoscopies annually has been proposed by some jurisdictions as a requirement for maintaining privileges. However, this practice is supported by limited evidence.

Aims

The objective of this study was to determine if annual colonoscopy volume was associated with colonoscopy quality metrics.

Methods

A population-based study was performed using the Southwest Ontario Colonoscopy cohort, which consists of all adult patients who underwent colonoscopy between April 2017 and Oct 2018 at 21 academic and community hospitals within the health region. Data were collected through a mandatory quality assurance form completed after each procedure and pathology reports were manually reviewed. Physician annualized colonoscopy volumes were compared by correlation analysis to each quality-related outcome, by means of the area under the receiver operating characteristics curve (AUROC), and logistic regression. The prognostic value of colonoscopy volume was also adjusted for case-mix and potential confounders in separate regression analyses for each outcome. The primary outcome was ADR. Secondary outcomes were polyp detection rate (PDR), sessile serrated polyp detection rate (SSPDR), and cecal intubation.

Results

A total of 47,195 colonoscopies were performed by 75 physicians (37.5% by gastroenterologists, 60% by general surgeons, 2.5% others). There were no clear relationships between annual colonoscopy volumes and study outcomes. Colonoscopy volume was not associated with ADR (OR 1.03, 95% CI 0.96–1.10, p=0.48) and corresponded to an AUROC not significantly different from the null (AUROC 0.52, 95% CI 0.43–0.61, p=0.65). Multi-variable regression adjusting for case-mix also demonstrated no predictive value of annual colonoscopy volume for the primary outcome (OR 1.03, 95% CI 0.94–1.12, p=0.55). Similarly, analyses of secondary outcomes failed to find an association between colonoscopy volume and PDR, SSPDR, or cecal intubation (Table 1).

Conclusions

Annual colonoscopy volumes do not predict ADR, PDR, SSPDR, or cecal intubation rate.

Results of unconditional and conditional approaches for examining the predictive value of annual colonoscopy volume for quality related outcomes.

Funding Agencies

None

A152 INVESTIGATING THE ROLE OF NOVEL NUDT15 VARIANT IN AZATHIOPRINE-RELATED MYELOTOXICITY

Background

Azathioprine (AZA), an immunosuppressant, has classically been used to treat patients with inflammatory bowel disease (IBD). AZA inhibits purine synthesis, and its metabolism occurs via a pathway involving thiopurine methyltransferase (TPMT). While standard TPMT genetic screening is conducted for IBD patients initiating AZA treatment to minimize adverse drug effects (ADE), a majority of patients experiencing ADE have wildtype TPMT. Another gene, NUDT15, has been found to be associated with AZA-related myelotoxicity

Aims

In this study we report two novel variants in NUDT15 and aim to evaluate the impact of NUDT15 variation on its gene expression. We hypothesize that the mutations found within novel NUDT15 variant are detrimental either to the gene’s expression levels or its translation process, resulting in a lower amount of NUDT15 product present and hence translating to AZA-related myelotoxicity observed clinically.

Methods

IBD patients experiencing AZA-related myelotoxicity were recruited for this study. Patients were then genotyped and the NUDT15 variants were replicated through site-directed mutagenesis. The NUDT15 variants were subsequently transformed into mammalian cell lines then E. coli cells. DNA products were isolated, and transcription levels were assessed through RT-PCR.

Results

Patient cohort consisted of 27 AZA-exposed IBD patients who developed myelotoxicity despite their TPMT wildtype genotype. Two novel NUDT15 variants were found. The mutation in one of the variants was placed in 3’ UTR, and hence further research was not pursued. Further analysis was conducted for the variant with mutation in coding region. RT-PCR was conducted to assess and compare gene transcription levels between wildtype and variant NUDT15. Wildtype NUDT15 had a relative gene expression level of 0.8x107, whereas variant NUDT15’s relative gene expression level was at 1.1x107. The two groups were not significantly different in terms of gene expression.

Conclusions

Contrary to our initial hypothesis, it appears that the mutation in the start codon for variant NUDT15 gene does not significantly impact its gene expression as compared to the wildtype gene. We are currently pursuing protein expression analysis studies to assess for translational deficits possibly present in the novel NUDT15 variant.

Funding Agencies

SRTP - Schulich School of Medicine

A117 PROPOFOL SEDATION DOES NOT IMPROVE MEASURES OF COLONOSCOPY QUALITY – FINDINGS FROM THE SOUTHWEST ONTARIO COLONOSCOPY COHORT

Background

The use of propofol during colonoscopy has gained increased popularity due to deeper anesthesia compared to conscious sedation. Prior studies examining the use of propofol sedation during colonoscopy have primarily focused on anesthesia outcomes. Whether propofol sedation is associated with improvements in colonoscopy outcomes is uncertain.

Aims

The primary outcome was adenoma detection rate (ADR). Secondary outcomes were the detection of any adenoma (conventional adenoma, sessile serrated polyp, and traditional serrated adenoma), sessile serrated polyp detection rate, polyp detection rate, cecal intubation rate, and perforation rate.

Methods

The Southwest Ontario Colonoscopy cohort consists of all patients who underwent colonoscopy between April 2017 and Oct 2018 at 21 hospitals serving a large geographic area in Southwest Ontario. Procedures performed in patients less than 18 years of age or by endoscopist who perform <50 colonoscopies/year were excluded. Data were collected through a mandatory quality assurance form that was completed by the endoscopist after each procedure. Pathology reports were manually reviewed.

Results

A total of 46,634 colonoscopies were performed by 75 physicians (37.5% by gastroenterologists, 60% by general surgeons, 2.5% others) of which 16,408 (35.2%) received propofol and 30,226 (64.8%) received conscious sedation (e.g. combination of a benzodiazepine and a narcotic). Patients who received propofol were likely to have a screening indication (49.2% vs 45.5%, p<0.0001), not have a trainee endoscopist present and be performed at a non-academic centre (32.2% vs 44.6%, p<0.0001). Compared to conscious sedation, use of propofol was associated with a lower ADR (24.6% vs. 27.0%, p<0.0001) and detection of any adenoma (27.7% vs. 29.8%, p<0.0001); no difference was observed in the detection ofsessile serrated polyps (5.0% vs. 4.7%, p=0.26), polyp detection rate (41.2% vs 41.2%, p=0.978), cecal intubation rate (97.1% vs. 96.8%, p=0.15) or perforation rate (0.04% vs. 0.06%,p=0.45). On multi-variable analysis, the use of propofol was not significantly associated with any improvement in ADR (RR=0.90, 95% CI 0.74–1.10, p=0.30), detection of any adenoma (RR=0.93, 95% CI 0.75–1.14, p=0.47), sessile serrated polyp detection rate (RR=1.20, 95%CI 0.90–1.60, p=0.22), polyp detection rate (RR=1.00, 95% CI 0.90–1.11, p=0.99), or cecal intubation rate (RR=1.00, 95%CI 0.80–1.26, p=0.99).

Conclusions

The use of propofol sedation does not improve colonoscopy quality metrics.

Funding Agencies

None

A12 PRE-TREATMENT HLADQA1-HLADRB1 TESTING FOR THE PREVENTION OF AZATHIOPRINE-INDUCED PANCREATITIS IN INFLAMMATORY BOWEL DISEASE: A PROSPECTIVE COHORT STUDY

Background

Azathioprine (AZA) therapy has a long history of use in IBD. The need to promote its safe use in this population is ensured by governmental health policy requiring IBD patients to fail low cost drugs, such as AZA, prior to approving funding for more potent biologic therapies. AZA-induced pancreatitis is an idiosyncratic and unpredictable response, occurring in up to 7% of AZA-exposed patients that can lead to patient morbidity, hospitalization, delay in effective IBD management, as well as result in substantial additional health-related costs. There are no tools in clinical practice to identify individuals at risk of AZA-induced pancreatitis. Genetic variation in the HLADQA1-HLADRB1*07:01 haplotype is strongly associated with azathioprine (AZA)-induced pancreatitis in inflammatory bowel disease (IBD).

Aims

To evaluate whether HLA DQA1-HLADRB1*07:01A>C pre-treatment genotype testing in an adult IBD population prior to AZA therapy to guide AZA selection would result in a lower incidence of AZA-induced pancreatitis.

Methods

Participants with IBD (n=599) were screened for HLADQA1-HLADRB1*07:01A>C and participants with a variant genotype were excluded from azathioprine treatment (n=271). Wildtype participants (n=328) were started on azathioprine and followed for 3 months. The incidence of pancreatitis was compared to unscreened historical controls (n=373).

Results

The minor allele frequency of HLADQA1-HLADRB1*07:01 was 30.4% and 30.0% in the screened and unscreened populations respectively. Up to 45.2% of participants were excluded from AZA therapy based on genotype in the HLADQA1-HLADRB1*07:01A>C screened cohort. HLADQA1-HLADRB1*07:01A>C screening resulted in an 11-fold reduction in the odds of azathioprine-induced pancreatitis (0.30% versus 3.4%, OR=0.085, 95%CI=0.011–0.651, p=0.002).

Conclusions

HLA DQA1-HLADRB1*07:01A>C screening substantially reduced the risk of pancreatitis during AZA treatment in patients with IBD. However, using this strategy as a tool for guiding the use of AZA therapy in IBD may eliminate a large proportion of patients from being eligible for treatment with AZA. In regions, where there is access to other IBD therapies, and given the short and long term toxicities associated with AZA, HLA DQA1-HLADRB1*07:01A>C screening may be a clinically-relevant strategy for enhancing the safe use of AZA in IBD. Additionally, cost-effectiveness analyses are needed to further solidify the utility of HLA DQA1-HLADRB1*07:01A>C-screening in IBD populations.

Funding Agencies

Academic Medical Organization of Southwestern Ontario Innovation Fund

A156 SERUM TUMOUR NECROSIS FACTOR-α ANTAGONIST DRUG CONCENTRATIONS IN PATIENTS WITH PYODERMA GANGRENOSUM ASSOSCIATED WITH INFLAMMATORY BOWEL DISEASE

Background

The utility of therapeutic drug monitoring for guiding the dosing of tumor necrosis factor-α antagonists (TNFAs) in luminal inflammatory bowel disease (IBD) is well-established and well-accepted. TNFAs, specifically infliximab and adalimumab, have become integral to the management of the rare, neutrophilic dermatosis, pyoderma gangrenosum (PG) in IBD. Little is known regarding the target serum TNFA concentrations to guide dosing to achieve resolution of PG in IBD.

Aims

To describe the serum TNFA concentrations (infliximab or adalimumab) associated with the resolution of PG lesions in patients with IBD.

Methods

Patients with IBD and associated PG treated with one of infliximab or adalimumab (collectively known as TNFAs) seen at two academic hospitals affiliated with Western University were identified. Serum TNFA concentrations were assessed at the time of PG treatment.

Results

Nine patients were identified. All patients had IBD-associated PG. Seven patients were treated with infliximab and 2 patients were treated with adalimumab. All patients received standard dosing. Eight patients had complete resolution of their PG, while one had near complete resolution at the time of last follow-up. A median serum infliximab concentration of 3.00 (IQR, 3.52) µg/ml at week 14 and a median serum adalimumab concentration of 2.02 (IQR, 0.98) µg/ml at week 12 were seen at the time of PG treatment.

Conclusions

Herein, we report low serum TNFA concentrations despite PG healing in a cohort of IBD patients. This is lower than what is in patients for successful TNFA treatment in luminal and fistulising IBD.

Funding Agencies

NoneNone.

A120 NO EVIDENCE OF A FRIDAY EFFECT ON COLONOSCOPY QUALITY OUTCOMES

Background

Colonoscopy quality may be influenced by operator fatigue. Prior studies have shown lower adenoma detection rates for procedures performed at the end of the day. However, it is unknown if colonoscopy quality is impaired at the end of the work week.

Aims

We investigated whether colonoscopy quality-related metrics differ at the end of the work week using the South West Ontario Colonoscopy Cohort.

Methods

Between April 2017 to February 2018, 45,510 consecutive colonoscopies from 20 academic and community hospitals in our health region were captured to form the cohort. In Canada, outpatient endoscopies are generally performed between Monday to Friday, taking Friday, or the last business day, as the last day of the work week compared to the rest of the work week. When a statutory holiday occurred on a Friday, Thursday was designated the last day of the work week. The primary outcome was adenoma detection rate (ADR), and secondary outcomes were sessile serrated polyp detection rate (ssPDR), polyp detection rate (PDR), and failed cecal intubation. Outcomes were presented as unadjusted and adjusted risk ratios derived from modified Poisson regression and adjusting for physician-level clustering, and characteristics of the patient (age, sex, severity), procedure (hospital setting, trainee presence, indication, sedation, bowel preparation quality) and physician (experience and specialty).

Results

During the observation period, 9,132 colonoscopies were performed on the last day of the work week compared to 36,378 procedures during the rest of the work week. No significant difference was observed for ADR (26.4% vs. 26.6%, p=0.75), ssPDR (4.5% vs. 5.0%, p=0.12), PDR (44.1% vs. 43.1%, p=0.081), or failed cecal intubation (2.8% vs. 2.9%, p=0.51) for colonoscopies performed on the last day of the work week compared to the rest of the week, respectively. After adjusting for potential confounders, there were no significant differences in the ADR (RR 1.01, 95% CI [0.88, 1.15], p=0.94), ssPDR (RR 0.90, 95% CI [0.70, 1.14], p=0.38), PDR (RR 1.00, 95% CI [0.92, 1.09], p=0.94), or failed cecal intubation (RR 0.92, 95% CI [0.72, 1.18], p=0.51) for colonoscopies performed on the last day of the work week compared to the rest of week, respectively.

Conclusions

Colonoscopy quality metrics, including ADR, ssPDR, PDR, and failed cecal intubation are not significantly different at the end of the week.

Funding Agencies

None

The FAST-M complex intervention for the detection and management of maternal sepsis in low-resource settings: a multi-site evaluation

OBJECTIVE

To evaluate whether the implementation of the FAST-M complex intervention was feasible and improved the recognition and management of maternal sepsis in a low-resource setting.

DESIGN

A before-and-after design.

SETTING

Fifteen government healthcare facilities in Malawi.

POPULATION

Women suspected of having maternal sepsis.

METHODS

The FAST-M complex intervention consisted of the following components: the FAST-M maternal sepsis treatment bundle and the FAST-M implementation programme. Performance of selected process outcomes was compared between a 2-month baseline phase and 6-month intervention phase with compliance used as a proxy measure of feasibility.

MAIN OUTCOME RESULT

Compliance with vital sign recording and use of the FAST-M maternal sepsis bundle.

RESULTS

Following implementation of the FAST-M intervention, women were more likely to have a complete set of vital signs taken on admission to the wards (0/163 [0%] versus 169/252 [67.1%], P < 0.001). Recognition of suspected maternal sepsis improved with more cases identified following the intervention (12/106 [11.3%] versus 107/166 [64.5%], P < 0.001). Sepsis management improved, with women more likely to receive all components of the FAST-M treatment bundle within 1 hour of recognition (0/12 [0%] versus 21/107 [19.6%], P = 0.091). In particular, women were more likely to receive antibiotics (3/12 [25.0%] versus 72/107 [67.3%], P = 0.004) within 1 hour of recognition of suspected sepsis.

CONCLUSION

Implementation of the FAST-M complex intervention was feasible and led to the improved recognition and management of suspected maternal sepsis in a low-resource setting such as Malawi.

TWEETABLE ABSTRACT

Implementation of a sepsis care bundle for low-resources improved recognition & management of maternal sepsis.

Measurement of the helicity asymmetry E for the reaction γ p → π 0 p : The CBELSA/TAPS Collaboration

A measurement of the double-polarization observable E for the reaction γ p → π 0 p is reported. The data were taken with the CBELSA/TAPS experiment at the ELSA facility in Bonn using the Bonn frozen-spin butanol (C4 H9 OH) target, which provided longitudinally-polarized protons. Circularly-polarized photons were produced via bremsstrahlung of longitudinally-polarized electrons. The data cover the photon energy range fromE γ = 600 to 2310 MeV and nearly the complete angular range. The results are compared to and have been included in recent partial wave analyses.

Prevalence of lower limb venous disease in surgeons: a case study and results of a survey by the BAOMS Reconstruction Surgical Subspecialty Interest Group

We report a case of venous leg ulceration in a reconstructive oral and maxillofacial surgeon. An online survey was created by the British Association of Oral and Maxillofacial Surgeons (BAOMS) Reconstruction Surgical Subspecialty Interest Group (SSIG), primarily to target head and neck surgeons, to investigate the perceived risk and occurrence of venous leg disease. Two respondents had received treatment for lower limb venous disease thus compromising their ability to work, while 13 had symptoms of early venous disease. Our study shows an interesting area of concern for occupational health in surgeons, particularly in those carrying out long operations, as will be the case for members of the Reconstruction SSIG.

The PEARL study: a prospective two-group pilot PrEP promotion intervention for cisgender female sex workers living in Baltimore, MD, U.S

HIV remains elevated among female sex workers (FSW) globally, with a number of structural (e.g., poverty, access to care) factors driving these persistently high rates. Pre-exposure prophylaxis (PrEP), a user-controlled prevention method, is a promising means of empowering vulnerable populations to protect themselves and enhance agency. Yet there is a dearth of PrEP research and interventions targeting cisgender women in the United States, and even fewer aimed to reach FSW. We developed and implemented a multifaceted PrEP pilot intervention, the Promoting Empowerment And Risk Reduction (PEARL) study, to meet this gap. This paper describes the development process and nature of a community-informed intervention for tenofovir/emticitrabine (TDF/FTC) pre-exposure prophylaxis engagement among street-based cisgender FSW in Baltimore, Maryland, U.S. In the course of the study's implementation, structural, programmatic, and medical barriers have already posed significant barriers to full engagement. PEARL implemented a number of strategies in an effort to counter barriers and facilitate increased success of PrEP uptake and maintenance. The study will provide critical insights into the nature of intervention components that could help FSW to initiate PrEP and reduce PrEP care cascade gaps.

Growth patterns of the airway in Crouzon syndrome patients with different types of cranial vault suture synostosis

The severity of obstructive respiratory difficulty varies among affected Crouzon syndrome patients. The aim of this study was to investigate the correlation between the restricted airway volume in Crouzon syndrome and the associated type of cranial vault suture synostosis. Computed tomography scans of 68 unoperated Crouzon syndrome patients and 89 control subjects were subgrouped into four types: type I, bilateral coronal synostosis; type II, sagittal synostosis; type III, pansynostosis; type IV, perpendicular combinations of synostoses. Measurements were made using Mimics software. Of type I Crouzon patients, 42% had a restricted nasal airway (P=0.002), while the pharyngeal airway volume was not significantly reduced. Type II Crouzon patients grew normal segmental airway volumes. Crouzon patients of type III developed simultaneously reduced nasal and pharyngeal airway volumes in infancy, by 38% (P=0.034) and 51% (P=0.014), respectively. However, the nasal airway achieved a normal volume by 2 years of age without any intervention, while the pharyngeal airway remained significantly reduced up to 6 years of age, by 42% (P=0.013), compared to controls. Type IV Crouzon patients developed a reduced nasal airway volume (32%, P=0.048) and a non-significant restricted pharyngeal airway (18%, P=0.325). Airway compromise in Crouzon syndrome is variable when associated with different craniosynostosis fusion patterns. Type II (sagittal synostosis) Crouzon patients grew a normal nasopharyngeal airway volume. Those with types I (bicoronal synostosis) and IV (perpendicular synostoses) had significantly restricted nasal airways and a tendency towards a reduced pharyngeal volume. Type III (pansynostosis) Crouzon infants had the worst restriction of both airways, although there was some improvement with age.

Observation of the pη^{'} Cusp in the New Precise Beam Asymmetry Σ Data for γp→pη

Data on the beam asymmetry Σ in the photoproduction of η mesons off protons are reported for tagged photon energies from 1130 to 1790 MeV (mass range from W=1748  MeV to W=2045  MeV). The data cover the full solid angle that allows for a precise moment analysis. For the first time, a strong cusp effect in a polarization observable has been observed that is an effect of a branch-point singularity at the pη^{'} threshold [E_{γ}=1447  MeV (W=1896  MeV)]. The latest BnGa partial wave analysis includes the new beam asymmetry data and yields a strong indication for the N(1895)1/2^{-} nucleon resonance, demonstrating the importance of including all singularities for a correct determination of partial waves and resonance parameters.

The anesthetist as cardiologist: a case of heart block identified in the peripartum period

We describe a case of undiagnosed heart block which was detected during the postpartum surgical repair of a vaginal tear, and the subsequent investigations that confirmed diagnosis of atrio-ventricular heart block.

Evaluation of sustainability of non-communicable diseases risk factor program in Malaysia

Background

Non-communicable diseases (NCDs) in Malaysia have risen substantially over the last two decades. We aimed to (i) evaluate the sustainability of the existing NCDs risk factor program implemented under the National Strategic Plan and (ii) identify challenges and factors impeding the sustainability of the NCDs program.

Methods

A mixed-method approach using a combination of the Program Sustainability Assessment Tool

with 40-item instrument assessing 8 domains (organizational capacity, program adaptation, program evaluation, communications, strategic planning, funding stability, environmental support and partnerships) and 5 open-ended questions were administered to 80 key managers from district directors of chronic disease programs in Malaysia. The mean score for each of the 8 sustainability domains and the overall mean sustainability score were determined. Data analysis was performed using Statistical Package for the Social Sciences (SPSS) version 25.

Results

Seven domains scored a mean of ≥ 4. The domains of communications (cross-site mean, 4.5 on a scale of 1-7) and organizational capacity (mean, 4.4) had the highest ratings. Funding stability had the lowest rating (mean, 3.8). The overall mean sustainability score was 4.2. Open-ended responses revealed challenges by program leaders, including implementation difficulties, factors impede planning for NCDs sustainability program, lack of financial, staff support and staff training which are largely consistent with the scaled domains.

Conclusions

Capacity issues affecting the sustainability of NCDs program in Malaysia are qualitatively similar to other countries. Future work should aim at improving funding stability and integrating evidence-based public health strategies to sustain implemented NCDs program.

Key messages

Researchers could utilize this tool to assess program design and strategies promoting sustainability during implementation process for long term program sustainment. Investments in leadership support for integrating program evaluation into implementation and greater funding flexibility may enhance sustainability of evidence-based public health program for NCDs.

A-47 Resting-State Functional Connectivity Associated with Contact Level in Female Varsity Athletes

Objective

The effects of participation in contact sports on brain functioning is a growing area of concern in the athlete population. This pilot study examined differences in resting-state functional connectivity (rsFC) associated with level of contact in female varsity student athletes.

Method

Resting-state functional magnetic resonance imaging (fMRI) scans were collected from 29 female university athletes. Level of contact was characterized by active participation in collision sports (n = 13) and contact sports (n = 16). Athletes completed baseline testing including self-reported psychological measures. RsFC was compared between groups using Independent Component Analysis (ICA) within the default mode (DMN), frontoparietal (FPN), dorsal attention (DAN), salience (SN), and sensorimotor (SMN) networks.

Results

Collision sport athletes reported younger age at first sport (M = 4.7, SD = 1.2) and fewer past concussions (Md = 0, Range = 0–3) compared to contact sport athletes (M = 7.5, SD = 3.4; Md = 7.5, Range = 0–6; ps &lt; .05). Collision sport athletes also reported fewer symptoms of depression on the Patient Health Questionnaire-9 (p = 0.03). Collision sport athletes had decreased rsFC between the SMN and the left inferior frontal gyrus (T = −5.6, pFDR = 0.008) compared to the contact sport athletes. This difference in rsFC was not associated with age at first sport or prior concussion history.

Conclusions

Consistent with prior studies of varsity athletes, altered patterns of rsFC were observed in areas supporting somatomotor function in female athletes with suspected greater contact exposure. Further research is necessary to examine whether these neural changes are attributable to greater exposure to sub-concussive hits or other factors, such as differences in visuomotor abilities.

Survival of children and adolescents with intellectual disability following gastrostomy insertion

BACKGROUND

Positive health outcomes have been observed following gastrostomy insertion in children with intellectual disability, which is being increasingly used at younger ages to improve nutritional intake. This study investigated the effect of gastrostomy insertion on survival of children with severe intellectual disability.

METHODS

We used linked disability and health data of children and adolescents who were born in Western Australia between 1983 and 2009 to compare survival of individuals with severe intellectual disability by exposure to gastrostomy status. For those born in 2000-2009, we employed propensity score matching to adjust for confounding by indication. Effect of gastrostomy insertion on survival was compared by pertinent health and sociodemographic risk factors.

RESULTS

Compared with children born in the 1980s-1990s, probability of survival following first gastrostomy insertion for those born in 2000-2009 was higher (2 years: 94% vs. 83%). Mortality risk was higher in cases than that in their matched controls (hazard ratio 2.9, 95% confidence interval 1.1, 7.3). The relative risk of mortality (gastrostomy vs. non-gastrostomy) may have differed by sex, birthweight and time at first gastrostomy insertion. Respiratory conditions were a common immediate or underlying cause of death among all children, particularly among those undergoing gastrostomy insertion.

CONCLUSIONS

Whilst gastrostomy insertion was associated with lower survival rates than children without gastrostomy, survival improved with time, and gastrostomy afforded some protection for the more vulnerable groups, and earlier use appears beneficial to survival. Specific clinical data that may be used to prioritise the need for gastrostomy insertion may be responsible for the survival differences observed.

Scatterometry and diffractometry techniques to monitor surfaces textured by rapid ultra-short pulse laser

The overall aim of the PROMETHEUS project is to develop high power ultra-short pulse lasers and the associated optics to enable the precise periodic texturing of surfaces to impart a range of surface functionalities at unprecedented processing speeds. The project focusses upon the industrial application of ultra-short pulse lasers for manufacturing and on the development of high power ultra-short pulse laser technologies in the range of 700 ps – 10 ns. In summary, new textures will be manufactured to achieve functional surfaces utilising fewer raw materials, less energy and less waste; improve accuracy, power and control over existing technologies; increase achievable precision and minimize heat impact on sensitive materials. This article will provide the outcomes of the first results achieved from the monitoring solutions being used to assess surface textures with micrometer resolution.

Citizens' juries give verdict on whether private practice veterinarians should attend unvaccinated Hendra virus suspect horses

BACKGROUND

Hendra virus (HeV) is endemic in Australian flying foxes, posing a threat to equine and human health. Equine vaccination remains the most effective risk mitigation strategy. Many horses remain unvaccinated - even in higher-risk regions. Debate surrounding the vaccine's use is characterised by conflicting perspectives, misunderstanding and mistrust. Private veterinary practitioners are critical to early identification of public health risk through recognition, sampling and management of suspect-equine-HeV-cases. However, managing such cases can be burdensome, with some veterinarians opting not to attend unvaccinated horses or to abandon equine practice because of risk posed by HeV disease and liability.

OBJECTIVE

Ascertain the perspectives of informed citizens on what obligations (if any) private veterinarians have to attend unvaccinated horses with HeV or HeV-like disease.

METHODS

Three citizens' juries were tasked with considering approaches to managing HeV risk in Australia, including (reported here) roles and obligations of private veterinarians in responding to HeV-suspect-cases.

RESULTS

Jurors acknowledged that HeV management posed an important challenge for private veterinarians. A clear majority (27 of 31 jurors) voted that veterinarians should not be obliged to attend unvaccinated horses. All recognised that greater support for veterinarians should be a priority.

CONCLUSIONS

When informed of HeV risks and strategies for control and management, citizens appreciated the need to support veterinarians performing this critical 'One Health' role for public benefit. The current governance framework within which zoonotic disease recognition and response operates limits the contingency and scope for increasing support and efficacy of these important veterinary public health practices.

A231 UNDERSTANDING THE IMPACT OF TNF-ALPHA ANTAGONISTS ON THE SEVERITY OF NON-MELANOMA SKIN CANCER IN INFLAMMATORY BOWEL DISEASE AND THE CONSEQUENCES FOR THERAPY

Background

Non-melanoma skin cancer (NMSC) accounts for at least 40% of all new cancer diagnoses in Canada annually and presents a significant cost to the health care system due to the volume of cases. The incidence of NMSC in patients with Inflammatory Bowel Disease (IBD) is higher when compared to the general population. Generally, in a non-IBD population, the risk of further NMSC progression is low, however, little data exists that highlights differences in clinical course of patients diagnosed with NMSC who have IBD and are TNF-α antagonist exposed. It is unclear if TNF-α antagonist therapy should be discontinued in this patient population.

Aims

Our goal is to determine whether TNF-α antagonist exposure in IBD is associated with a high risk NMSC presentation at diagnosis, as defined by the National Comprehensive Cancer Network (NCCN) stratification. Our secondary objectives include presence of positive margins following resection, presence of metastatic disease on initial presentation, requirement of additional therapy to treat NMSC, number of patients who had TNF-α antagonist therapy discontinued following diagnosis of NMSC and number of individuals with recurrent NMSC.

Methods

Four hundred and twenty-four IBD patients seen at London Health Sciences Centre were reviewed. We have identified 22 patients who were diagnosed with NMSC. Twelve patients had a pre-NMSC TNF-α antagonist exposure while 10 patients who developed an NMSC and had no TNF-α antagonist exposure prior to NMSC diagnosis.

Results

Preliminary results of the primary outcome demonstrate that fifty-percent (6/12) of patients who have been exposed to TNF antagonist therapy presented with a high risk NMSC lesion at diagnosis compared to 40% (4/10) who were not exposed (OR 5.16, 95%CI 0.47–57.00; p = 0.181). Preliminary results of the secondary outcomes suggest that 25% (3/12) of patients exposed to TNF-α antagonist had positive margins compared with 0% (0/10) of patients who were not exposed. No patients in either group presented with metastatic disease. Twenty-five percent (3/12) of patients in the exposed group received more advanced treatment compared with 0% (0/10) in the non-exposed group. Eight percent (1/12) of patients in the TNF-α antagonist group had their IBD therapy changed from a TNF-α antagonist to an alternative biologic class, and 17% of patients (2/12) in the TNF-α antagonist group had recurrent NMSC lesions.

Conclusions

In conclusion, preliminary results suggest that TNF-α antagonist exposure may be associated with higher risk NMSC lesion at presentation. Further expansion of the sample size is required to explore these hypotheses further.

Funding Agencies

None

A214 GENETIC VARIATION IN THE FARNESOID X RECEPTOR PREDICTS CROHN’S DISEASE SEVERITY IN FEMALE PATIENTS

Background

Crohn’s disease (CD) is an immune-mediated inflammatory bowel disease defined by episodes of intestinal inflammation. There is now an increasing appreciation of the bile acid-sensing nuclear receptor, FXR, as an important regulator of intestinal inflammation, intestinal permeability and response to bacterial overgrowth. Many of these processes are dysregulated in CD. It is unclear how genetic variation in FXR impacts on CD severity. FXR deficiency is rare. Loss of function mutations in FXR as contributors to CD are unlikely; however, partial loss of function of FXR may contribute to CD progression or severity. Our group demonstrated that FXR-1G&gt;T, a SNV adjacent to the ATG start codon, is linked to reduced transactivation of FXR gene targets. We hypothesized that changes in the intestinal barrier as a result of reduced FXR expression among those who harbor the FXR-1T allele are more likely to exhibit a severe CD phenotype compared to G (reference) allele carriers, and thereby experience a more rapid progression to surgery. Alterations in FXR activity may in part be secondary to genetic variation in the FXR gene.

Aims

To evaluate FXR-1G&gt;T as a genomic biomarker of severity in CD and propose a plausible molecular mechanism.

Methods

A retrospective study (n=542) was conducted in a Canadian cohort of CD patients. Blood samples were obtained for genotypic analysis (FXR-1G&gt;T), as well as determination of the FXR downstream product, fibroblast growth factor (FGF) 19. Primary outcomes included risk and time to first CD-related surgery. To better elucidate a potential molecular basis for the observed effect of FXR-1G&gt;T genotype on CD prognosis (more frequent and early surgery) in female CD patients, we explored a connection between the estrogen receptor (ER)-mediated pathway and genetic variation in FXR using a cell-based model. .

Results

The FXR-1GT genotype was associated with the risk of (odds ratio, OR=3.34, 95%CI=1.58–7.05, p=0.002) and early progression to surgery (hazard ratio, HR=3.00, 95%CI=1.86–4.83, p&lt;0.0001) in CD. Female carriers of the FXR-1GT genotype had the greatest risk of surgery (OR=14.87 95%CI=4.22–52.38, p&lt;0.0001) and early progression to surgery (HR=6.28, 95%CI=3.62–10.90, p&lt;0.0001). Furthermore, women carriers of FXR-1GT polymorphism had a nearly three-fold lower FGF19 plasma concentration compared to women with wildtype FXR-1GG genotype (p&lt;0.0001). In HepG2 cells cotransfected with estrogen receptors (ERα and β) and FXR, presence of estradiol further attenuated variant FXR activity.

Conclusions

FXR-1GT is deleterious to women with CD through ER-mediated attenuation of FXR activation. Female CD FXR-1GT carriers should be considered for more aggressive medical management.

Funding Agencies

CAG, CCC, CIHR

A208 HLA-DQA1*05 GENOTYPE PREDICTS ANTI-DRUG ANTIBODY FORMATION AND LOSS OF RESPONSE DURING INFLIXIMAB THERAPY FOR INFLAMMATORY BOWEL DISEASE

Background

The underlying mechanism for immunogenicity in anti-TNFa-exposed patients with inflammatory bowel disease is poorly understood. Anti-drug antibodies are a leading contributor to infliximab loss of response and adverse drug events. Currently, it is not feasible to identify patients at risk of antibody formation prior to initiating infliximab. The genetic variation HLADQA1*05(rs2097432) has been linked to infliximab antibody formation in a cohort of patients with Crohn’s disease.

Aims

Due to the wide variation in the frequency of HLADQA1* 05 across ethnic groups, we aim to independently evaluate the association between HLADQA1*05and infliximab antibody formation, infliximab loss of response, treatment discontinuation and adverse drug events, in a Canadian inflammatory bowel disease cohort.

Methods

In a retrospective cohort study, infliximab-exposed patients with inflammatory bowel disease (n=262) were screened for the genetic variation, HLADQA1*05A&gt;G(rs2097432). The risk of infliximab anti-drug antibody formation, infliximab loss of response, adverse events, and discontinuation were assessed in wild type (GG) and variant-carrying (AG or AA) individuals.

Results

Forty percent of all participants were HLADQA1*05A&gt;Gvariant carriers, with 79% of participants with infliximab antibodies carrying at least one variant allele. The risk of infliximab antibody formation was higher in HLADQA1*05A&gt;Gvariant carriers in an IBD population (adjusted HR=7.29, 95%CI=2.97–17.191, p=1.46x10-5) independent of age, sex, weight, dose and co-immunosuppression with an immunomodulator. Variant carrier status was associated with an increased risk of infliximab loss of response (adjusted HR=2.34, 95%CI=1.41–3.88, p=0.001) and discontinuation (adjusted HR=2.27, 95%CI=1.46–3.43, p=2.53x10-4) though not with infliximab-associated adverse drug events.

Conclusions

HLADQA1*05 is independently associated with a high risk of infliximab antibody formation in addition to infliximab loss of response and treatment discontinuation. As a result, we propose that pre-emptive genetic screening for the HLADQA1* 05A&gt;Gvariant would be useful in order to predict individuals at risk of developing immunogenicity. There may be a role for genotype-guided application of combination therapy in inflammatory bowel disease.

Funding Agencies

NoneWolfe Medical Research Chair in Pharmacogenomics (MOP-89753 to RBK), the Academic Medical Organization of Southwestern Ontario (INN18-005 to RBK and AW; S17-004 to AW), and Lawson Health Research Institute (IRF-05-19 to AW)

Nitrogen oxidation consortia dynamics influence the performance of full-scale rotating biological contactors

Ammonia oxidising microorganisms (AOM) play an important role in ammonia removal in wastewater treatment works (WWTW) including rotating biological contactors (RBCs). Environmental factors within RBCs are known to impact the performance of key AOM, such that only some operational RBCs have shown ability for elevated ammonia removal. In this work, long-term treatment performance of seven full-scale RBC systems along with the structure and abundance of the ammonia oxidising bacteria (AOB) and archaea (AOA) communities within microbial biofilms were examined. Long term data showed the dominance of AOB in most RBCs, although two RBCs had demonstrable shift toward an AOA dominated AOM community. Next Generation Sequencing of the 16S rRNA gene revealed diverse evolutionary ancestry of AOB from RBC biofilms while nitrite-oxidising bacteria (NOBs) were similar to reference databases. AOA were more abundant in the biofilms subject to lower organic loading and higher oxygen concentration found at the distal end of RBC systems. Modelling revealed a distinct nitrogen cycling community present within high performing RBCs, linked to efficient control of RBC process variables (retention time, organic loading and oxygen concentration). We present a novel template for enhancing the resilience of RBC systems through microbial community analysis which can guide future strategies for more effective ammonia removal. To best of the author's knowledge, this is the first comparative study reporting the use of next generation sequencing data on microbial biofilms from RBCs to inform effluent quality of small WWTW.

Development and validation of a risk prediction model to diagnose Barrett's oesophagus (MARK-BE): a case-control machine learning approach

Background

Screening for Barrett's Oesophagus (BE) relies on endoscopy which is invasive and has a low yield. This study aimed to develop and externally validate a simple symptom and risk-factor questionnaire to screen for patients with BE.

Methods

Questionnaires from 1299 patients in the BEST2 case-controlled study were analysed: 880 had BE including 40 with invasive oesophageal adenocarcinoma (OAC) and 419 were controls. This was randomly split into a training cohort of 776 patients and an internal validation cohort of 523 patients. External validation included 398 patients from the BOOST case-controlled study: 198 with BE (23 with OAC) and 200 controls. Identification of independently important diagnostic features was undertaken using machine learning techniques information gain (IG) and correlation based feature selection (CFS). Multiple classification tools were assessed to create a multi-variable risk prediction model. Internal validation was followed by external validation in the independent dataset.

Findings

The BEST2 study included 40 features. Of these, 24 added IG but following CFS, only 8 demonstrated independent diagnostic value including age, gender, smoking, waist circumference, frequency of stomach pain, duration of heartburn and acid taste and taking of acid suppression medicines. Logistic regression offered the highest prediction quality with AUC (area under the receiver operator curve) of 0.87. In the internal validation set, AUC was 0.86. In the BOOST external validation set, AUC was 0.81.

Interpretation

The diagnostic model offers valid predictions of diagnosis of BE in patients with symptomatic gastroesophageal reflux, assisting in identifying who should go forward to invasive testing. Overweight men who have been taking stomach medicines for a long time may merit particular consideration for further testing. The risk prediction tool is quick and simple to administer but will need further calibration and validation in a prospective study in primary care.

Funding

Charles Wolfson Trust and Guts UK.

Development of the FAST-M maternal sepsis bundle for use in low-resource settings: a modified Delphi process

Objective

To develop a sepsis care bundle for the initial management of maternal sepsis in low resource settings.

Design

Modified Delphi process.

Setting

Participants from 34 countries.

Population

Healthcare practitioners working in low resource settings (n = 143; 34 countries), members of an expert panel (n = 11) and consultation with the World Health Organization Global Maternal and Neonatal Sepsis Initiative technical working group.

Methods

We reviewed the literature to identify all potential interventions and practices around the initial management of sepsis that could be bundled together. A modified Delphi process, using an online questionnaire and in‐person meetings, was then undertaken to gain consensus on bundle items. Participants ranked potential bundle items in terms of perceived importance and feasibility, considering their use in both hospitals and health centres. Findings from the healthcare practitioners were then triangulated with those of the experts.

Main outcome measure

Consensus on bundle items.

Results

Consensus was reached after three consultation rounds, with the same items deemed most important and feasible by both the healthcare practitioners and expert panel. Final bundle items selected were: (1) Fluids, (2) Antibiotics, (3) Source identification and control, (4) Transfer (to appropriate higher‐level care) and (5) Monitoring (of both mother and neonate as appropriate). The bundle was given the acronym ‘FAST‐M’.

Conclusion

A clinically relevant maternal sepsis bundle for low resource settings has been developed by international consensus.

Tweetable abstract

A maternal sepsis bundle for low resource settings has been developed by international consensus.

A maternal sepsis bundle for low resource settings has been developed by international consensus.

Exploring the association between ingestion of foods with higher potential salicylate content and symptom exacerbation in chronic rhinosinusitis. Data from the National Chronic Rhinosinusitis Epidemiology Study

INTRODUCTION

Pharmacological salicylates are known to trigger respiratory exacerbations in patients with Non-Steroidal Exacerbated Respiratory Disease (N-ERD), a specific phenotype of Chronic Rhinosinusitis (CRS) and asthma. The impact of dietary sources of salicylates across subgroups of CRS is not well understood. The hypothesis is that in patients with nasal polyps present, there is likely to be a higher incidence of symptom exacerbation due to dietary salicylates regardless of any known response to pharmacological salicylate.

METHODS

The Chronic Rhinosinusitis Epidemiology Study (CRES) was a questionnaire-based case-control study which sought to characterise the UK CRS population in terms of sociological, economic and medical factors. Using specific questions to examine participant responses relating to symptom exacerbation from food groups thought to be high in salicylate content, this analysis of the CRES database sought to compare an estimate of the prevalence of dietary sensitivity due to food with higher potential salicylate content across patients with CRS with (CRSwNPs) and without nasal polyposis (CRSsNPs) and with allergic fungal rhinosinusitis (AFRS).

RESULTS

The CRSwNPs group were significantly more likely than controls to report symptom exacerbation due to ingestion of food groups with higher potential dietary salicylate content. The same trend was observed amongst CRSsNPs participants to a lesser degree. Reported response to the individual specific food groups wine, nuts, spicy foods, fruit and vegetables demonstrated that a statistically significant proportion of CRSwNPs and AFRS participants reported sensitivity to wine.

CONCLUSIONS

This analysis suggests that there is an association between symptom exacerbation in response to food products with higher potential salicylate content, specifically wine, in CRS patients both with and without nasal polyposis when compared to controls, but especially in the CRSwNPs and AFRS phenotypes. Further studies are needed to detail if this relationship represents a causal relationship to dietary salicylate. The data present the possibility that a wider group of CRS patients may elicit salicylate sensitivity than those with known N-ERD.

A multicentre, clinical evaluation of a hydro-responsive wound dressing: the Glasgow experience

OBJECTIVE

Our aim was to assess the effectiveness of hydro-responsive wound dressing (HRWD) in debridement and wound bed preparation of a variety of acute and chronic wounds that presented with devitalised tissue needing removal so that healing may proceed.

METHOD

This was a non-comparative evaluation of acute and chronic wounds that required debridement as part of their normal treatment regimen. Clinicians recorded wound changes including a subjective assessment level of devitalised tissue and wound bed preparation, presence of pain, wound status (e.g., wound size) and periwound skin condition. Data was also collected from clinicians and patients to provide information on clinical performance of the dressing.

RESULTS

We recruited 100 patients with a variety of wound types into the study. Over 90% of the clinicians reported removal of devitalised tissue to enable a healing response in both chronic and acute wounds. Specifically, over the course of the evaluation period, levels of devitalised tissue (necrosis and slough) reduced from 85.5% to 26.3%, and this was accompanied by an increase in wound bed granulation from 12.0% to 33.7%. Correspondingly, there was a 40% reduction in wound area, hence a clinically relevant healing response was seen upon treatment with HRWD. It is also noteworthy that this patient population included a significant proportion of chronic wounds (51.4%) that showed no signs of wound progression within <4 weeks before study inclusion. Of these chronic wounds, 93% demonstrated wound progression upon treatment with HRWD. Despite reported pain levels being low pre- and post-dressing change, overall wound pain improved (reduced) in 48% of patients. Periwound skin condition showed a tendency towards improvement, and the fluid management capabilities of the HRWD was reported as good to excellent in the majority of cases. Wound infections were reduced by at least 60% over the evaluation period. A simple cost-effective analysis demonstrated significant savings using HRWD (£6.33) over current standard practice regimens of a four-step debridement process (£8.05), larval therapy (£306.39) and mechanical pad debridement (£11.46).

CONCLUSION

HRWD was well tolerated and was demonstrated to be an efficient debridement tool providing rapid, effective and pain free debridement in a variety of wound types.

Development and validation of models to predict personal ventilation rate for air pollution research

Air pollution intake represents the amount of pollution inhaled into the body and may be calculated by multiplying an individual's ventilation rate with the concentration of pollutant present in their breathing zone. Ventilation rate is difficult to measure directly, and methods for estimating ventilation rate (and intake) are lacking. Therefore, the goal of this work was to examine how well linear models using heart rate and other basic physiologic data can predict personal ventilation rate. We measured personal ventilation and heart rate among a panel of subjects (n = 36) while they conducted a series of specified routine tasks of varying exertion levels. From these data, 136 candidate models were identified using a series of variable transformation and selection algorithms. A second "free‑living" validation study (n = 26) served as an independent validation dataset for these candidate models. The top‑performing model, which included heart rate (Hr), resting heart rate (Hrest), age, sex, and hip circumference and interactions between sex with Hr, Hrest, age, and hip predicted ventilation rate (Ve) to within 11% and 33% for moderate (Ve = 45 L/min) and low (Ve = 15 L/min) intensity activities, respectively, based on the validation study. Many of the promising candidate models performed substantially worse under independent validation. Our results indicate that while measures of air pollution exposure and intake are highly correlated within tasks for a given individual, this correlation decreases substantially across tasks (i.e., as individuals go about a series of typical daily activities). This discordance between exposure and intake may influence exposure‑response estimates in epidemiological studies. New air pollution studies should consider the trade‑offs between the predictive ability of intake models and the error potentially introduced by not accounting for ventilation rate.

Experience from the selection and nutritional preparation for Expedition ICE MAIDEN: the first successful all-female unassisted Antarctic traverse

INTRODUCTION

Expedition ICE MAIDEN (Ex IM) was the first all-female unsupported crossing of Antarctica. We describe the prerequisite selection and training, comparing those who formed the final team with other participants, and discuss how the expedition diet was established.

METHODS

All women serving in the British Army were invited to participate. Following initial assessments, successful women completed three training/selection ski expeditions. Between expeditions 1 and 2, participants completed 6 months rigorous UK-based training. Weight was measured before and after the 6 months UK-based training, expeditions 2 and 3, and body composition by skinfold before and after expedition 2. Participant feedback, body composition and weight changes were applied to modify the expedition diet and provide weight gain targets prior to Ex IM.

RESULTS

Following 250 applications, 50 women were assessed and 22, 12 and seven women attended training expeditions 1, 2 and 3, respectively. The final team of six women lost more weight than other participants during UK-based training (mean (SD) change -1.3 (1.5) kg vs -0.5 (1.6) kg, respectively, p=0.046) and during training expedition 2 (-2.8 (0.8) kg vs -1.7 (0.4) kg, respectively, p=0.048), when they also gained more lean mass (+2.1 (0.8) kg vs +0.4 (0.7) kg, respectively, p=0.004). The Ex IM diet provided 5000 kCal/day, comprising approximately 45% carbohydrate, 45% fat and 10% protein. Median (range) weight change between expedition 3 and Ex IM was +8.7 (-1.9 to +14.3) kg.

CONCLUSIONS

The selected Ex IM team demonstrated favourable training-associated body composition changes. Training-associated weight loss informed the expeditionary diet design.

Dose intensity in anthracycline-based chemotherapy for metastatic breast cancer: mature results of the randomised clinical trial ANZ 9311

PURPOSE

The separate impacts of dose and dose intensity of chemotherapy for metastatic breast cancer remain uncertain. The primary objective of this trial was to compare a short, high-dose, intensive course of epirubicin and cyclophosphamide (EC) with a longer conventional dose regimen delivering the same total dose of chemotherapy.

METHODS

This open label trial randomised 235 women with metastatic breast cancer to receive either high-dose epirubicin 150 mg/m² and cyclophosphamide 1500 mg/m² with filgrastim support every 3 weeks for 3 cycles (HDEC) or standard dose epirubicin 75 mg/m² and cyclophosphamide 750 mg/m² every 3 weeks for 6 cycles (SDEC). Primary outcomes were time to progression, overall survival and quality of life.

RESULTS

In 118 patients allocated HDEC 90% of the planned dose was delivered, compared to 96% in the 117 participants allocated SDEC. There were no significant differences in the time to disease progression (5.7 vs. 5.8 months, P = 0.19) or overall survival (14.5 vs. 16.5 months, P = 0.29) between HDEC and SDEC, respectively. Patients on HDEC reported worse quality of life during therapy, but scores improved after completion to approximate those reported by patients allocated SDEC. Objective tumour response was recorded in 33 (28%) on HDEC and 42 patients (36%) on SDEC. HDEC produced more haematologic toxicity.

CONCLUSION

For women with metastatic breast cancer, disease progression, survival or quality of life were no better with high-dose intensity compared to standard dose EC chemotherapy. Australian Clinical Trials Registry registration number ACTRN12605000478617.