P–082 Effect of semen hyper viscosity (SHV) on blastocyst formation rate and implantation rate

Study question

Does semen hyper viscosity effects blastocyst formation rate

Summary answer

Hyper viscosity of semen sample later results in poor blastocyst formation rate and lower implantation rate.

What is known already

Normal range of semen hyper viscosity ranges between 12–29%.Highly viscous semen samples impairs the physical and chemical characteristics of seminal fluid and due to which seminal oxidative damage increases which further increases the ROS and reduces the sperm motility there are some factors that can affect the seminal viscosity out of which one is Male accessory gland infection, Hypo function of prostate seminal vesicles and varicoceles. SHV create hindrance in semen preparation.

Study design, size, duration

Retrospective study was conducted from June 2019 to Oct 2020 at IVF unit IKDRC hospital.

Participants/materials, setting, methods

142 patients were enrolled from June 2019 to Oct 2020 in IVF unit IKDRC hospital and divided into two groups. Group A (n = 83) patients with hyper semen viscosity and Group B (n = 69) patients with normal semen viscosity, inclusion and exclusion criteria’s were same for both the groups, only patient with normozoospermia were taken. Semen analysis was done by using WHO manual 2010.

Main results and the role of chance

In group A with hyper semen viscosity fertilization rate was (49.2% vs. 70% p = <0.001) vs in group B with normal semen viscosity which is significantly higher in group B, Blastocyst formation rate ( 18.4% vs 35% p = <0.01) and implantation rate (9.4% vs 20% p = <0.005) both are significantly higher in group B . Which implies fertilization rate , blastocyst formation rate and implantation rate is significantly lower in patients with semen hyper viscosity.

Limitations, reasons for caution

Larger randomized control studies are needed to strengthen these results.

Wider implications of the findings: Our study demonstrates that patients having higher semen viscosity have poor blastocyst formation rate and implantation rate due to oxidative stress.

Trial registration number

Not applicable

P–109 Comparison between the outcome of sperm vitrification protocol and conventional slow freezing protocol for semen cryopreservation

Study question

Does sperm vitrification technique helps in increasing sperm survival and low DNA fragmentation index post warming.

Summary answer

Sperm vitrification protocol results in better motility, high progression and low DNA fragmentation index as compared to slow freezing.

What is known already

Cryopreservation is ceasing and resuming the cell metabolism, which can be achieved by different techniques like slow freezing and vitrification .Vitrification allows solidification of the cells and extracellular milieu into a glass like state without formation of ice which protects intracellular and extracellular ice formation, and further helps in avoiding different types of cryo-injuries and cellular damage. Study design, size, duration: Comparative study from July 2019 to Oct 2020 in IVF unit of IKDRC Hospital. Two hundred and ten patients were randomized by computer generated list and divided into two groups. Group 1 (n = 110) samples cryopreserved by vitrification and Group 2 (n = 100) samples cryopreserved by conventional slow freezing.

Participants/materials, setting, methods

Semen sample were analyzed by WHO 2010 laboratory manual, including all normozoospermic samples , other abnormal samples were excluded from the study . Method of semen preparation before cryopreservation is similar for both the groups, double density gradient method of preparation was used . Semen sample with high viscosity, hypo and hyper-spermia were also excluded. Similar cryovials of 2ml volume were used for both groups.

Main results and the role of chance

In group 1 where samples were cryopreserved by vitrification sperm motility was (54.3% vs 49.2%)vs in group 2 where samples were cryopreserved by slow freezing , non- significant difference were observed , but progressive motility was significantly higher in group 1 as compared to group 2 (36.8%vs17.9%) and DNA fragmentation index is significantly lower in group 1 vitrification than in group 2slow freezing ( 9.7% vs 20%).

Limitations, reasons for caution

Technical proficiency of the operator to avoid human errors and still larger randomized control studies are needed to strengthen these results

Wider implications of the findings: Our study demonstrates that vitrification is better than slow freezing of human sperm, improved survival rates with high progression were found with vitrification and low DNA fragmentation index were also observed in samples cryopreserved with vitrification protocol.

Trial registration number

Not applicable

O41 Quantifying the burden of survivorship associated with infra-renal abdominal aortic aneurysm repair: a systematic review

Introduction

Survivorship encompasses the physical, psychological, social, functional and economic experience of living with a chronic condition for both patients and their caregivers. It comprises 9 distinct domains and remains understudied in non-oncological pathologies, including infra-renal abdominal aortic aneurysmal disease (IRAAA). This review aims to quantify the extent to which existing IRAAA literature addresses the burden of survivorship in patients following surgical intervention.

Method

The databases; MEDLINE, EMBASE and PsychINFO, were searched from 1989 through to July 2020. Randomised controlled trials, observational studies and case series studies were included. Eligible studies had to detail outcomes related to survivorship following IRAAA surgery. Due to heterogeneity between studies and outcomes, no meta-analysis was conducted. Study quality was assessed with specific risk of bias tools.

Result

112 studies were included and only 4 of the 9 domains of survivorship have been previously studied—treatment complications, physical functioning, co-morbidities and caregivers. The available evidence is of variable quality; the majority of studies display a moderate to high risk of bias, are of an observational study design, are based within a limited number of countries and consist of an insufficient follow up period.

Conclusion

This review highlights the absence of robust evidence regarding survivorship following IRAAA surgery, regardless of repair modality. Consequently, contemporary treatment guidelines are reliant upon historic quality of life data that is narrow in scope and non-representative of contemporary clinical practice. As such, there is an urgent need to re-evaluate the scope and methodology associated with this research theme moving forwards.

Take-home Message

There is an urgent need to re-evaluate the scope and methodology associated with traditional quality of life centred IRAAA studies moving forwards in order to better empower patient decision making as well as inform treatment guidelines and health policy initiatives.

Microsponge: A Novel Tool for Topical Drug Delivery of Anti Rheumatoid Drugs

Microsponge is developing field of technology which can achieve goal of site specific as well as controlled drug delivery. Physicochemical properties of microsponge like Particle size, particle size distribution, porosity, surface morphology plays a major role in selection of type of dosage form and route of administration for delivery of drug. Microsponge is also emerged as novel tool for delivering of drug by topical route. Topical route is having added advantage of formulation flexibility, greater patient compliance, improved safety and efficacy of formulation and aesthetic properties. Rheumatoid Arthritis is immunomodulatory disease which requires long term treatment for management of disease. Available oral formulation may cause liver toxicity upon long term use. Topical route can be suitable alternate route for delivery of drug with enhanced stability of drug, reduced side effects, and reduced frequency of administration. Due to porous and spongy structure of Microsponge, it has the capacity to entrap large amount of dose and can modify drug release too.

Safety and feasibility of resuming bariatric surgery under the cloud of COVID-19

INTRODUCTION

Because of the COVID-19 pandemic, numerous bariatric surgical units globally have halted weight loss surgery. Obesity itself has been shown to be a predictor of poor outcome in people infected with the virus. The aim of this study was to report our experience as a high-volume bariatric institution resuming elective weight loss surgery safely amidst emergency admissions of COVID-19-positive patients.

METHODS

A standard operating procedure based on national guidance and altered to accommodate local considerations was initiated across the hospital. Data were collected prospectively for 50 consecutive patients undergoing bariatric surgery following recommencement of elective surgery after the first national lockdown in the UK.

RESULTS

Between 28 June and 5 August 2020, a total of 50 patients underwent bariatric surgery of whom 94% were female. Median age was 41 years and median body mass index was 43.8 (interquartile range 40.0-48.8)kg/m2. Half of the patients (n = 25/50) underwent laparoscopic sleeve gastrectomy and half underwent Roux-en-Y gastric bypass (RYGB). Of these 50 patients, 9 (18%) had revisional bariatric surgery. Overall median length of hospital stay was 1 day, with 96% of the study population being discharged within 24h of surgery. The overall rate of readmission was 6% and one patient (2%) returned to theatre with an obstruction proximal to jejuno-jejunal anastomosis. None of the patients exhibited symptoms or tested positive for COVID-19.

CONCLUSION

With appropriately implemented measures and precautions, resumption of bariatric surgery during the COVID-19 pandemic appears feasible and safe with no increased risk to patients.

Impact of topical budesonide on prevention of esophageal stricture after mucosal resection

BACKGROUND AND AIMS

EMR and endoscopic submucosal dissection (ESD) are treatment modalities for Barrett's esophagus involving high-grade dysplasia or early cancer. Injectional corticosteroid therapy decreases the risk of procedure-related esophageal stricture (ES) formation. Our aim was to assess the efficacy of topical budesonide on the rate of ES formation after EMR or ESD.

METHODS

Patients included prospectively from 3 tertiary endoscopy centers received 3 mg budesonide orally twice a day for 8 weeks after esophageal EMR or ESD of 50% or more of the esophageal circumference between January 1, 2014 and June 30, 2018. These patients were matched (1:3 ratio) retrospectively with a consecutive patient cohort who underwent EMR or ESD of 50% or more of the esophageal circumference without concomitant corticosteroid therapy. The primary endpoint was the presence of ES at the 12-week follow-up.

RESULTS

Twenty-five patients (budesonide) were matched with 75 patients (no budesonide). Most underwent EMR for Barrett's esophagus with biopsy-proven high-grade dysplasia or suspected T1a cancer. Although most baseline characteristics did not differ significantly, patients in the budesonide cohort tended to have a higher proportion of circumferential EMR. The proportion of patients with ES was not significantly lower in the budesonide cohort (16% vs 28%). On logistic regression analysis, budesonide remained associated with a lower incidence of ES (P = .023); however, when controlling for baseline characteristics with a propensity score weighted logistic regression model, there was no significant effect on ES formation (P = .176).

CONCLUSIONS

Topical budesonide might be associated with a reduction of ES after EMR or ESD; however, further studies are needed to verify our results.

Mortality from esophagectomy for esophageal cancer across low, middle, and high-income countries: An international cohort study

BACKGROUND

No evidence currently exists characterising global outcomes following major cancer surgery, including esophageal cancer. Therefore, this study aimed to characterise impact of high income countries (HIC) versus low and middle income countries (LMIC) on the outcomes following esophagectomy for esophageal cancer.

METHOD

This international multi-center prospective study across 137 hospitals in 41 countries included patients who underwent an esophagectomy for esophageal cancer, with 90-day follow-up. The main explanatory variable was country income, defined according to the World Bank Data classification. The primary outcome was 90-day postoperative mortality, and secondary outcomes were composite leaks (anastomotic leak or conduit necrosis) and major complications (Clavien-Dindo Grade III - V). Multivariable generalized estimating equation models were used to produce adjusted odds ratios (ORs) and 95% confidence intervals (CI95%).

RESULTS

Between April 2018 to December 2018, 2247 patients were included. Patients from HIC were more significantly older, with higher ASA grade, and more advanced tumors. Patients from LMIC had almost three-fold increase in 90-day mortality, compared to HIC (9.4% vs 3.7%, p < 0.001). On adjusted analysis, LMIC were independently associated with higher 90-day mortality (OR: 2.31, CI95%: 1.17-4.55, p = 0.015). However, LMIC were not independently associated with higher rates of anastomotic leaks (OR: 1.06, CI95%: 0.57-1.99, p = 0.9) or major complications (OR: 0.85, CI95%: 0.54-1.32, p = 0.5), compared to HIC.

CONCLUSION

Resections in LMIC were independently associated with higher 90-day postoperative mortality, likely reflecting a failure to rescue of these patients following esophagectomy, despite similar composite anastomotic leaks and major complication rates to HIC. These findings warrant further research, to identify potential issues and solutions to improve global outcomes following esophagectomy for cancer.

Increasing adiposity and metabolic dysfunction prolong QTc interval and increase risk of ventricular arrhythmias: results from the UK Biobank

Funding Acknowledgements

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

Background/purpose: Small-scale studies have associated obesity and metabolic ill-health with QTc interval prolongation. Whether these associations are modulated by an underlying genetic predilection and translate into higher risks of ventricular arrhythmias (VA) is unknown.

Methods

 Using the UK Biobank and adjusted multivariate regression analysis, we studied the associations between QTc and clinical measures of adiposity and metabolic ill-health. A polygenic risk score was used to determine whether these associations are modulated by a genetic predilection for QTc prolongation. We compared QTc between four clinical phenotypes defined according to presence (+) or absence (-) of obesity (Ob), and metabolic ill-health (MU). Logistic regression was used to calculate odds ratios (OR) for VA amongst these groups.

Results

 23,683 individuals (11,563 male, mean age 61.0 + 7.5years) had ECG and clinical data available. QTc prolongs with increasing body mass index (0.76ms/kg/m2, 95%CI: 0.68-0.83ms/kg/m2), body fat (0.45ms/%, 95%CI:0.39-0.50ms/%), hip girth (0.35ms/cm, 95%CI:0.31-0.39ms/cm) and waist girth (0.32ms/cm, 95%CI:0.29-0.35ms/cm); all p &lt; 0.001. Genetically determined repolarisation reserve has no significant modulatory effect on the QTc-prolonging effects of increasing adiposity. Referenced to Ob-MU-, Ob + MU- and Ob-MU+ independently prolong QTc to a comparable extent, and Ob + MU+ has an additive effect on QTc prolongation. With reference to Ob-MU-, OR for VA in Ob-MU+ males and females were 5.96 (95%CI:4.70-7.55) and 5.10 (95%CI:3.34-7.80), respectively. OR for Ob + MU+ were 6.99 (95%CI:5.72-8.54) and 3.56 (95%CI:2.66-4.77) in males and females, respectively, (all p &lt; 0.001, see Table).

Conclusion

 Adiposity and metabolic perturbation prolong QTc to a similar extent, and their co-existence exerts an additive effect. These effects are independent of genetically determined repolarisation reserve. Despite their comparable QTc prolonging effects, metabolic ill-health is associated with higher OR for VA than obesity. VA in obesity and metabolic dysfunctionReference phenotypeOb + MU-Ob-MU+Ob + MU+Ob-MU+male1.10(0.87-1.39)ns5.96 (4.70-7.55)***6.99(5.72-8.54)***female0.87(0.64-1.18)ns5.10(3.34-7.80)***3.56(2.66-4.77)***Ob + MU-male--6.01(4.98-7.26)***female--5.61(4.18-7.52)***Ob + MU+male--1.25(1.05-1.49)*female--1.16(0.80-1.68)nsOb, obese; MU, metabolically unhealthy; +, presence; -, absence; ns, non-significant; *p &lt; 0.05; ***p &lt; 0.001. Abstract Figure. QTc in obesity and metabolic dysfunction

TimiRGeN: R/Bioconductor package for time series microRNA-mRNA integration and analysis

Motivation

The analysis of longitudinal datasets and construction of gene regulatory networks (GRNs) provide a valuable means to disentangle the complexity of microRNA (miRNA)–mRNA interactions. However, there are no computational tools that can integrate, conduct functional analysis and generate detailed networks from longitudinal miRNA–mRNA datasets.

Results

We present TimiRGeN, an R package that uses time point-based differential expression results to identify miRNA–mRNA interactions influencing signaling pathways of interest. miRNA–mRNA interactions can be visualized in R or exported to PathVisio or Cytoscape. The output can be used for hypothesis generation and directing in vitro or further in silico work such as GRN construction.

Availability and implementation

TimiRGeN is available for download on Bioconductor (https://bioconductor.org/packages/TimiRGeN) and requires R v4.0.2 or newer and BiocManager v3.12 or newer.

Supplementary information

Supplementary data are available at Bioinformatics online.

A proposed "Radiological Evaluation Score for Bone Tumors" (REST): An objective system for assessment of a radiograph in patients with suspected bone tumor

BACKGROUND

Although radiographs have been widely used in the evaluation of patients with suspected bone tumors, the lack of an objective radiological assessment method leads to a challenge in reaching correct diagnosis. The study aimed to propose a Radiological Evaluation Score for Bone Tumors (REST) which includes eight radiological factors [characteristics, content, cortical breach, distinctiveness, distribution, periosteal reaction, fracture, and soft tissue swelling] to form a single score along with its validation by multidisciplinary observers.

METHODS

We reviewed the radiographs of 100 patients with a primary bone tumor which were selected at random from the database between January 2017 and January 2019 of a tertiary cancer center. Four reviewers (two orthopedic oncologists and two surgical oncologists) independently assessed the radiographs, based on the reporting system of REST. We constituted two groups according to the probable diagnosis of bone tumor (suspected benign tumor and suspected malignant tumor).

RESULTS

The mean score in the suspected benign tumor group was 1.1 (range 0-3, 95% CI 0.8-1.3) and in malignant tumor group was 6.1 (range 2-8, 95% CI 5.8-6.4). A receiver operator characteristic (ROC) curve for REST was with a cutoff of 3.5, with the most diagnostic value area under curve (AUC) of 0.99. The sensitivity was 98% and specificity was 100% with a positive predictive value of 100% and a negative predictive value of 98%. The inter-observer correlation coefficient was 0.985 (p value < 0.05), and Fleiss kappa value for the prediction of the benign or malignant lesion was 0.97 (p value < 0.05). The characteristics and content of tumor, cortical erosion, distinctiveness, distribution, periosteal reaction, and soft tissue mass had a significant correlation with the aggressiveness of bone lesion p value < 0.05.

CONCLUSIONS

The Radiological Evaluation Score for Bone Tumors (REST) is a structured reporting and objective method for the assessment of radiographs in patients with suspected bone tumors. This method is a reliable and helpful tool for clinicians in their outdoor patient department to differentiate a radiograph of a suspected benign tumor from a malignant bone tumor.

Comparison of short-term outcomes from the International Oesophago-Gastric Anastomosis Audit (OGAA), the Esophagectomy Complications Consensus Group (ECCG), and the Dutch Upper Gastrointestinal Cancer Audit (DUCA)

BACKGROUND

The Esophagectomy Complications Consensus Group (ECCG) and the Dutch Upper Gastrointestinal Cancer Audit (DUCA) have set standards in reporting outcomes after oesophagectomy. Reporting outcomes from selected high-volume centres or centralized national cancer programmes may not, however, be reflective of the true global prevalence of complications. This study aimed to compare complication rates after oesophagectomy from these existing sources with those of an unselected international cohort from the Oesophago-Gastric Anastomosis Audit (OGAA).

METHODS

The OGAA was a prospective multicentre cohort study coordinated by the West Midlands Research Collaborative, and included patients undergoing oesophagectomy for oesophageal cancer between April and December 2018, with 90 days of follow-up.

RESULTS

The OGAA study included 2247 oesophagectomies across 137 hospitals in 41 countries. Comparisons with the ECCG and DUCA found differences in baseline demographics between the three cohorts, including age, ASA grade, and rates of chronic pulmonary disease. The OGAA had the lowest rates of neoadjuvant treatment (OGAA 75.1 per cent, ECCG 78.9 per cent, DUCA 93.5 per cent; P < 0.001). DUCA exhibited the highest rates of minimally invasive surgery (OGAA 57.2 per cent, ECCG 47.9 per cent, DUCA 85.8 per cent; P < 0.001). Overall complication rates were similar in the three cohorts (OGAA 63.6 per cent, ECCG 59.0 per cent, DUCA 62.2 per cent), with no statistically significant difference in Clavien-Dindo grades (P = 0.752). However, a significant difference in 30-day mortality was observed, with DUCA reporting the lowest rate (OGAA 3.2 per cent, ECCG 2.4 per cent, DUCA 1.7 per cent; P = 0.013).

CONCLUSION

Despite differences in rates of co-morbidities, oncological treatment strategies, and access to minimal-access surgery, overall complication rates were similar in the three cohorts.

834 What’s The SCORE? Surgeons’ Approach to Treating Symptomatic, Clinically Occult, Radiologically Evident Inguinal Hernias

Introduction

The management of symptomatic, clinically occult, radiologically evident inguinal hernias (SCORE-IH) is challenging. This pathology lacks a validated definition and a standardised treatment paradigm to prevent risks of operative management. This study explores current practice amongst surgeons treating SCORE-IH.

Method

STEER collaborators disseminated a validated online survey amongst their UK consultants. Responses to the survey were collated on a spreadsheet and analysed with basic percentages.

Results

Seventy-three responses were received, including six (8%) international surgeons. UGI and colorectal surgeons were the predominant sub-specialities at 33% and 32%, respectively. Only 26% reported they performed more than 100 IH repairs annually. Less than half of the responders (41%) of surgeons reported more than 50% laparoscopic IH repairs. Nearly two thirds (62%) were unaware of guidelines on the management of SCORE-IH. Imaging chose to manage SCORE-IH included US, MRI, and CT at 71%, 44% and 29%, respectively. Only 14% of surgeons reported they would not consider any imaging. Only 19% would manage conservatively, while 37% would manage operatively.

Conclusions

There is skill diversity when treating IH. A lack of guidance and consensus amongst the surveyed surgeons is evident by the heterogeneity in imaging utilisation and varied treatment pathways offered to SCORE-IH patients.

1005 Antibiotic-Impregnated Calcium Sulfate Beads Are Not Effective in the Primary Prevention of Infection in Open Femur and Tibia Fractures

Introduction

Infection is a major complication of open fractures. Antibiotic-impregnated calcium sulfate (AICS) beads are widely used as an adjuvant to systemic antibiotics. Whilst their efficacy in the secondary prevention of infection is established, we present the first retrospective study evaluating AICS beads in the primary prevention of infection in open fractures.

Method

214 open femur and tibia fractures in 207 patients were reviewed over a seven-year period. 148 fractures received only systemic antibiotic prophylaxis. 66 fractures also received AICS beads. The occurrence of acute infection (wound infection and acute osteomyelitis) was recorded, as well as that of long-term complications (chronic osteomyelitis, non-union and death).

Results

Fractures that received AICS with systemic antibiotics had an overall acute infection rate of 42% (28/66), compared to 43% (63/148) in fractures that received only systemic antibiotics (p &gt; 0.05). There was no significant difference in infection rate even when fractures were stratified by Gustilo-Anderson grade. There was also no significant difference in the rate of long-term complications.

Conclusions

Our results indicate that the adjuvant use of AICS beads is not effective for the primary prevention of acute infection or long-term complications in open leg fractures. Further research is needed to elucidate the factors influencing the outcomes of AICS use.

31 Immediate Post-Operative Phosphodiesterase-5 Inhibitors (PDE5i) Therapy Improves Early Erectile Function Outcomes After Robot Assisted Radical Prostatectomy (RARP)

Introduction

To assess whether the timing of post-RARP PDE5i therapy affects early erectile function, continence, or safety outcomes.

Method

Data from 158 patients treated with PDE5is post-RARP was prospectively collected over two years from a single surgeon at one tertiary centre and retrospectively evaluated. Therapy was started: immediately (day 1-2) in 29%, early (day 3-14) in 37% and late (after day 14) post-op in 34%. EPIC-26 Erectile Function (EF) scores were collected pre-op and post-op after a median 43-day follow-up interval.

Results

Drop in EF scores and percentage return to baseline post unilateral nerve sparing (UNS) compared to bilateral nerve sparing (BNS) RARP was respectively 9 and 11.1% versus 3.5 and 42.9% of immediate therapy, 7 and 14.8% versus 5.5 and 35.5% of early and 9.7 and 9.5% versus 7.3 and 25% of late. Pad free and social continence was achieved in 54% and 37% of those receiving immediate therapy, 60% and 33% for early and 26% and 54% for late.

Conclusions

Immediate post RARP PDE5i therapy may protect EF and should be considered clinically, with more benefits for BNS than UNS patients. Immediate or early, rather than late, PDE5i therapy improved early continence in BNS patients.

879 Establishing the First Eoe Deanery-Wide Trainee Led Virtual Journal Club: Keeping Up Morale by Encouraging Trainee Interaction and Continuous Professional Development During the Hiatus to Teaching Activities Enforced by Coronavirus

Introduction

Over the initial COVID months and with the cancellation of several teaching programs / courses/ conferences; we identified a NEED for trainee interaction and continuous professional development, despite staff redeployments. We since established a deanery-wide trainee led VIRTUAL journal club, run by the Surgical Trainees of East of England Research collaborative (STEER) group.

Method

Following decision in May2020, the STEER group collated curriculum topics and related landmark papers, drafting a programmed-schedule for sessions (45mins – 1hour). CPD accreditation was sought and received from RCSEd prior to some sessions. Sessions were delivered using the Microsoft Teams app (via desktop/tablet/phone). Targeted audience included FYs, CTs, STs, JCFs, SCFs (candidates preparing for MRCS/FRCS or interested in academia). Live polling / feedback forms and attendance certificates were distributed.

Results

Six journal club sessions have been run to-date. A minimum of 15-20 participants attended each session with spread of junior/senior trainees. Sessions were video recorded for repeat playback for those unable to attend. Feedback was overwhelmingly positive, with good engagement from participants.

Conclusions

A deanery wide virtual journal club was positively received by trainees and benefits included: critique and dissemination of evidence (especially recently with COVID-related literature), trainee interaction and keeping up-to-date and understanding and analysing information.

26 COVID-19 Diagnosis in Patients with Acute Abdominal Pain Without Respiratory Symptoms: A UK Emergency General Surgical Unit Experience

Introduction

Evidence has emerged reporting atypical symptoms of the coronavirus (COVID-19). There is a sparsity of existing studies examining COVID-19 related abdominal pain and the role of investigative imaging for the virus in these patients. Study aims were to determine COVID-19 incidence in those with acute abdominal pain in the absence of respiratory symptoms and to assess the performance of Computer Tomography (CT) thoracic imaging.

Method

Retrospective analysis of all patients admitted to our emergency general surgical unit between 1^st March 2020 and 31^st May 2020 was performed. All patients underwent nasal and oro-pharyngeal COVID-19 RT-PCR swabs as well as CT on admission.

Results

From 112 patients admitted with acute abdominal pain in the absence of respiratory symptoms, 16 (14.3%) tested positive for COVID-19 on RT-PCR swab testing. 50% (8/16) of these patients had no intra-abdominal pathology on CT. The sensitivity and specificity of CT thoracic imaging for COVID-19 was 43.8% and 91.7%.

Conclusions

One in seven patients with abdominal pain without any respiratory symptoms tested positive. Half these patients represented COVID-19 manifesting primarily as acute abdominal pain. Combined swab testing and CT imaging should be performed in all abdominal pain presentations due to the varying diagnostic performance of thoracic CT in diagnosing COVID-19.

Dementia patients have greater anti-cholinergic drug burden on discharge from hospital: A multicentre cross-sectional study

Introduction

Anticholinergic medications block cholinergic transmission. The central effects of anticholinergic drugs can be particularly marked in patients with dementia. Furthermore, anticholinergics antagonise the effects of cholinesterase inhibitors, the main dementia treatment.

Objectives

This study aimed to assess anticholinergic drug prescribing among dementia patients before and after admission to UK acute hospitals.

Methods

352 patients with dementia were included from 17 hospitals in the UK. All were admitted to surgical, medical or Care of the Elderly wards in 2019. Information about patients’ prescriptions were recorded on a standardised form. An evidence-based online calculator was used to calculate the anticholinergic drug burden of each patient. The correlation between two subgroups upon admission and discharge was tested with Spearman’s Rank Correlation.

Results

Table 1 shows patient demographics. On admission, 37.8% of patients had an anticholinergic burden score ≥1 and 5.68% ≥3. At discharge, 43.2% of patients had an anticholinergic burden score ≥1 and 9.1% ≥3. The increase was statistically significant (rho 0.688; p=2.2x10-16). The most common group of anticholinergic medications prescribed at discharge were psychotropics (see Figure 1). Among patients prescribed cholinesterase inhibitors, 44.9% were also taking anticholinergic medications.

Conclusions

This multicentre cross-sectional study found that people with dementia are frequently prescribed anticholinergic drugs, even if also taking cholinesterase inhibitors, and are significantly more likely to be discharged with a higher anticholinergic drug burden than on admission to hospital.

Conflict of interest

This project was planned and executed by the authors on behalf of SPARC (Student Psychiatry Audit and Research Collaborative). We thank the National Student Association of Medical Research for allowing us use of the Enketo platform. Judith Harrison was su

Fatigability of the external anal sphincter muscles using a novel strength training resistance exercise device

Exercises involving pelvic floor muscles including repetitive voluntary contractions of external anal sphincter (EAS) musculature have been used to improve fecal incontinence. Muscle fatigue is a prerequisite for successful strength training. However, muscle fatigue induced by these exercises has not been systematically studied. We aimed to assess the fatigability of EAS muscles during various exercise methods. Twelve nulliparous (21 ± 2.7 yr) women were studied. We evaluated fatigue during 40 repetitive 3-s contractions and 30-s long squeeze contractions both with and without an intra-anal compressible resistant load. The sequence of exercises was randomized. This load was provided by the continence muscles Resistance Exerciser Device. Anal canal pressures were recorded by high-resolution manometry. Exercise against a resistive load showed significant decrease in anal contractile integral (CI) and maximum squeeze pressure during repetitive short squeeze contractions compared with exercise without a load. Linear regression analysis showed a significant negative correlation between anal CI and successive contraction against load, suggesting "fatigue." Similar findings were observed for maximum squeeze pressure (slope with load = -4.2, P = 0.0003, vs. without load = -0.9, P = 0.3). Long squeeze contraction against a load was also more susceptible to fatigue than without a load (P < 0.0001). In conclusion, repetitive contractions against a compressible load induce fatigue and thus have the potential to strengthen the anal sphincter contractile function than contractions without a load. Fatigue rate in long squeeze contraction exercises with a load is significantly faster than that without a load, also indicating greater effectiveness in inducing muscle fatigue.NEW & NOTEWORTHY Fecal incontinence is a distressing disorder with a mainstay of treatment being pelvic floor muscle exercises. However, none of these exercises has proven occurrence of fatigability, which is an important prerequisite for successful muscle strengthening in rehabilitative exercises. In this study, we proved that we can fatigue the external anal sphincter muscles more efficiently by providing a resistive load during anal repetitive short squeeze contractions and long squeeze contraction exercise.

A service evaluation of subcutaneous insulin administration at a large hospital

Introduction

One in six adult patients in hospitals have diabetes1. According to the National Diabetes Inpatient Audit (NaDIA)1, around 40% of these patients are treated with insulin, a high-risk drug used to regulate blood glucose levels. Worryingly, 40% of patients treated with insulin experience an insulin error whilst in hospital1. Although the annual NaDIA shows consistent improvement in patient care since 2011, insulin error rates have not reduced significantly. Local data from a large NHS Trust mirrors the national picture2 and this study was part of the Trust’s 2018 NaDIA Quality Improvement Collaborative work to improve patient care specific to subcutaneous (SC) insulin administration. Preliminary work involved the development of a process map of the use of SC insulin with multidisciplinary teams from two wards at the Trust, reflecting how teams think SC insulin is used (work-as-imagined, WAI).

Aims

1) To observe and describe the task of administering SC insulin (work-as-done, WAD), 2) To compare WAI and WAD relating to the task of administering SC insulin.

Methods

Non-participant observation of SC insulin administration took place over a 2-week period (Nov-Dec 2018), during lunch and dinner times, in the same two wards at the Trust where preliminary work took place. A ward pharmacist identified up to 16 opportunities for observations. Data were collected using a piloted observation template. Data from each observation was coded to identify tasks performed, using MS Word. Tasks were further analysed to develop a Hierarchical Task Analysis (HTA). This HTA was compared with the previously developed process map to identify similarities and differences in tasks.

Results

A total of 13 observations were made. The HTA top-level goal was to administer SC insulin, from which there were four sub-goals: 1) time to give insulin, 2) collect equipment, 3) enter ward and 4) administer insulin. More than 50 sub-tasks were represented in the HTA, highlighting the complexity of the overall task of administering SC insulin. There were variations in the way nurses prepared and gave insulin such as the use of workarounds and omissions of tasks. The comparison of the HTA (WAD) and process map (WAI) identified broadly similar tasks in sub-goal “administer insulin”. Differences in the boundaries of analysis in the process map and HTA made further comparisons of tasks difficult. For example, when describing the task of administering SC insulin, teams focused primarily on the final stage of insulin administration and not tasks that took place prior to it.

Conclusion

The administration of SC insulin was a complex process. The observations of SC insulin administration (WAD) largely matched those described by healthcare staff (WAI). Nurses were observed to adapt their work to provide essential patient centred care, The study was limited by the number of observations and differences in the boundary of analysis in the HTA and process map. Future work could investigate and understand the nature and implications of adaptations in SC insulin administration, as a key potential to develop a resilient work system.

References

1. NHS Digital (2018) National Diabetes Inpatient Audit England and Wales, 2017. https://files.digital.nhs.uk/pdf/s/7/nadia-17-rep.pdf Accessed 17/10/2020

2. NHS Digital (2018) National Diabetes Inpatient Audit (NaDIA) – 2017. https://digital.nhs.uk/data-and-information/publications/statistical/national-diabetes-inpatient-audit/national-diabetes-inpatient-audit-nadia-2017#resources Accessed 18/10/2020

Sodium thiosulfate for postoperative cisplatin induced nephrotoxicity following hyperthermic intraperitoneal chemotherapy: A case report

•

Cisplatin induced nephrotoxicity can occur days after administration.

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Hyperthermic intraperitoneal chemotherapy with cisplatin for ovarian cancer is increasing in utilization.

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Sodium thiosulfate can be used following cisplatin induced nephrotoxicity for treatment.

The cloned SPI-1 type 3 secretion system can be functionally expressed outside Salmonella backgrounds

Due to its potential for use in bacterial engineering applications, we previously cloned the SPI-1 type 3 secretion system (T3SS) genes from the genome of Salmonella enterica serovar Typhimurium strain LT2. We have documented that this clone, while functionally expressed in S. Typhimurium strains, displays a severe expression defect in other Gram negative backgrounds including Escherichia coli. To address this issue, we compared SPI-1 DNA sequence across different backgrounds, fully sequenced the original SPI-1 clone, and cloned SPI-1 from other S. Typhimurium strains. In this process, we were able to successfully obtain SPI-1 clones that are functionally expressed in E. coli indicating the first such result for a full-length SP-1 T3SS clone. We discovered that the original cloning technique using a DNA homology-based capture method was the root of the expression defect and that the FRT-Capture technique is preferable over the homology-based method. This result paves the way for future studies and applications using cloned SPI-1 and other T3SS in non-Salmonella bacterial backgrounds.

An automated approach to determine antibody endpoint titers for COVID-19 by an enzyme-linked immunosorbent assay

While a variety of therapeutic options continue to emerge for COVID-19 treatment, convalescent plasma (CP) has been used as a possible treatment option early in the pandemic. One of the most significant challenges with CP therapy, however, both when defining its efficacy and implementing its approach clinically, is accurately and efficiently characterizing an otherwise heterogenous therapeutic treatment. Given current limitations, our goal is to leverage a SARS antibody testing platform with a newly developed automated endpoint titer analysis program to rapidly define SARS-CoV-2 antibody levels in CP donors and hospitalized patients. A newly developed antibody detection platform was used to perform a serial dilution enzyme-linked immunosorbent assay (ELISA) for immunoglobulin (Ig)G, IgM, and IgA SARS-CoV-2 antibodies. Data were then analyzed using commercially available software, GraphPad Prism, or a newly developed program developed in Python called TiterScape, to analyze endpoint titers. Endpoint titer calculations and analysis times were then compared between the two analysis approaches. Serial dilution analysis of SARS-CoV-2 antibody levels revealed a high level of heterogeneity between individuals. Commercial platform analysis required significant time for manual data input and extrapolated endpoint titer values when the last serial dilution was above the endpoint cutoff, occasionally producing erroneously high results. By contrast, TiterScape processed 1008 samples for endpoint titer results in roughly 14 minutes compared with the 8 hours required for the commercial software program analysis. Equally important, results generated by TiterScape and Prism were highly similar, with differences averaging 1.26 ± 0.2 percent (mean ± SD). The pandemic has created unprecedented challenges when seeking to accurately test large numbers of individuals for SARS-CoV-2 antibody levels with a rapid turnaround time. ELISA platforms capable of serial dilution analysis coupled with a highly flexible software interface may provide a useful tool when seeking to define endpoint titers in a high-throughput manner. Immunohematology 2021;37:33-43. While a variety of therapeutic options continue to emerge for COVID-19 treatment, convalescent plasma (CP) has been used as a possible treatment option early in the pandemic. One of the most significant challenges with CP therapy, however, both when defining its efficacy and implementing its approach clinically, is accurately and efficiently characterizing an otherwise heterogenous therapeutic treatment. Given current limitations, our goal is to leverage a SARS antibody testing platform with a newly developed automated endpoint titer analysis program to rapidly define SARS-CoV-2 antibody levels in CP donors and hospitalized patients. A newly developed antibody detection platform was used to perform a serial dilution enzyme-linked immunosorbent assay (ELISA) for immunoglobulin (Ig)G, IgM, and IgA SARS-CoV-2 antibodies. Data were then analyzed using commercially available software, GraphPad Prism, or a newly developed program developed in Python called TiterScape, to analyze endpoint titers. Endpoint titer calculations and analysis times were then compared between the two analysis approaches. Serial dilution analysis of SARS-CoV-2 antibody levels revealed a high level of heterogeneity between individuals. Commercial platform analysis required significant time for manual data input and extrapolated endpoint titer values when the last serial dilution was above the endpoint cutoff, occasionally producing erroneously high results. By contrast, TiterScape processed 1008 samples for endpoint titer results in roughly 14 minutes compared with the 8 hours required for the commercial software program analysis. Equally important, results generated by TiterScape and Prism were highly similar, with differences averaging 1.26 ± 0.2 percent (mean ± SD). The pandemic has created unprecedented challenges when seeking to accurately test large numbers of individuals for SARS-CoV-2 antibody levels with a rapid turnaround time. ELISA platforms capable of serial dilution analysis coupled with a highly flexible software interface may provide a useful tool when seeking to define endpoint titers in a high-throughput manner. Immunohematology 2021;37:33–43.

The novel Mechanical Ventilator Milano for the COVID-19 pandemic

This paper presents the Mechanical Ventilator Milano (MVM), a novel intensive therapy mechanical ventilator designed for rapid, large-scale, low-cost production for the COVID-19 pandemic. Free of moving mechanical parts and requiring only a source of compressed oxygen and medical air to operate, the MVM is designed to support the long-term invasive ventilation often required for COVID-19 patients and operates in pressure-regulated ventilation modes, which minimize the risk of furthering lung trauma. The MVM was extensively tested against ISO standards in the laboratory using a breathing simulator, with good agreement between input and measured breathing parameters and performing correctly in response to fault conditions and stability tests. The MVM has obtained Emergency Use Authorization by U.S. Food and Drug Administration (FDA) for use in healthcare settings during the COVID-19 pandemic and Health Canada Medical Device Authorization for Importation or Sale, under Interim Order for Use in Relation to COVID-19. Following these certifications, mass production is ongoing and distribution is under way in several countries. The MVM was designed, tested, prepared for certification, and mass produced in the space of a few months by a unique collaboration of respiratory healthcare professionals and experimental physicists, working with industrial partners, and is an excellent ventilator candidate for this pandemic anywhere in the world.

AS-amyloidosis. Dual pathology or novel disease? A multimodality, multi-centre assessment across health and disease

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): British Heart Foundation

onbehalf

AS-Amyloidosis consortium

Background

The coexistence of severe aortic stenosis (lone AS) and transthyretin cardiac amyloidosis (lone amyloidosis) is common, but the resultant AS-amyloidosis phenotype is unclear.

Purpose

We characterised AS-amyloidosis, hypothesizing that the dual insult of AS-amyloidosis results is a severe phenotype.

Methods

We compared four cohorts with deep phenotyping: 81 older age controls, 359 lone AS, 36 AS-amyloidosis (Perugini grade 2 and 3) and 107 lone amyloidosis (Perugini grade 2 and 3).

Results

AS-amyloidosis was similar to lone AS with respect to left ventricular mass and LVEF (57 (45, 64)%). It was similar to lone amyloidosis with respect to lateral S" (0.04 (0.03, 0.06) m/s), NT-proBNP (4149 (1449, 6459) ng/L) and troponin T (56 (34, 100) ng/L). Whilst, prevalence of carpal tunnel syndrome (CTS) (17%) and diastolic function (E/A ratio 1.1 (0.8, 2.8)) were intermediate.

Conclusion

AS-amyloidosis is not a double insult from AS and amyloidosis, but a mixed phenotype with features similar to lone amyloidosis (cardiac biomarkers), lone AS (remodelling and LVEF) or intermediate (diastology and CTS).

Characteristics across all 4 groups Variable Older age controls (n = 81) Lone AS (n = 359) AS-amyloidosis (n = 36) Lone amyloidosis (n = 107) P value Age (years) 82 (80, 84)*†‡ 85 (80, 88)§∞ 88 (85, 92)# 80 (75, 84) &lt;0.005 Sex (% male) 69 *‡ 49 ∞ 61 # 94 &lt;0.005 Carpal tunnel syndrome (%) 0 2 § 17 # 38 &lt;0.005 Voltage/mass ratio 0.22 (0.14, 0.27)‡ 0.18 (0.13, 0.28)∞ 0.18 (0.09, 0.21)# 0.07 (0.05, 0.10) &lt;0.005 NT-ProBNP (ng/L) 131 (66, 221)*†‡ 1629 (639, 3941)§∞ 4149 (1449, 6459) 2888 (1755, 5483) &lt;0.005 hsTnT (ng/L) 12 (8, 17)*†‡ 24 (15, 40)§∞ 56 (34, 100) 62 (41, 82) &lt;0.005 Inferolateral wall thickness (cm) 0.9 (0.8, 1.0)*†‡ 1.1 (0.9, 1.3)∞ 1.3 (1.1, 1.5)# 1.7 (1.6, 1.9) &lt;0.005 Anteroseptal wall thickness (cm) 1.0 (0.9, 1.2)*†‡ 1.4 (1.2, 1.6)§∞ 1.5 (1.3, 1.8) 1.7 (1.6, 1.9) &lt;0.005 Indexed LV mass (g/m2) 79 (66, 102)*†‡ 128 (99, 152)∞ 126 (116, 140)# 174 (159, 200) &lt;0.005 LVEF (%) 59 (54, 63)‡ 59 (50, 65)∞ 57 (45, 64)# 39 (31, 48) &lt;0.005 Lateral S" (m/s) 0.08 (0.07, 0.09)*†‡ 0.07 (0.05, 0.08)§∞ 0.05 (0.04, 0.07) 0.05 (0.04, 0.06) &lt;0.005 Septal S" (m/s) 0.06 (0.06, 0.08)*†‡ 0.05 (0.04, 0.06)∞ 0.04 (0.03, 0.06) 0.04 (0.03, 0.05) &lt;0.005 E/A 0.7 (0.6, 0.8)*†‡ 0.8 (0.7, 1.3)§∞ 1.1 (0.8, 2.8)# 2.4 (1.8, 3.3) &lt;0.005 RV Wall thickness (cm) 0.4 (0.3, 0.4)*†‡ 0.4 (0.4, 0.6)∞ 0.6 (0.4, 0.7)# 0.8 (0.7, 1.0) &lt;0.005 TAPSE (cm) 2.4 (2.0, 2.7)*†‡ 2.1 (1.6, 2.5)∞ 1.9 (1.5, 2.1)# 1.4 (1.2, 1.9) &lt;0.005 Classical LFLG AS (%) 9 13 0.472 * p &lt; 0.05, Old age control vs Lone AS † p &lt; 0.05, Old age control vs AS-amyloidosis ‡ p &lt; 0.05, Old age control vs Lone amyloidosis § p &lt; 0.05, Lone AS vs AS-amyloidosis ∞ p &lt; 0.05, Lone AS vs Lone amyloidosis # p &lt; 0.05, AS-amyloidosis vs Lone amyloidosis Abstract Figure. AS-amyloidosis compared to other cohorts

A proposed ''A to Z RAM (Radiograph Assessment Method)'' for triage of patients with a suspected bone tumour

INTRODUCTION

We propose a ''A to Z RAM (Radiograph Assessment Method)'' for evaluation of Radiograph of patients with a suspected bone tumour.

METHODS

In the current study, ten radiological features with letters 'A, B, C, D, E, F and Z' were used and which included the age of the patient, involved part of the bone, characteristics, content, distinctiveness, the exterior of the bone, fracture, and zone of transition. Four independent observers (orthopaedic oncologists and surgical oncologists) evaluated a set of 30 radiographs of bone tumour selected at random from our hospital database based on A to Z RAM. We classified the lesions into two groups according to the traffic signal system; Green (suspected benign lesion) and Red (suspected malignant lesion).

RESULTS

There were 18 (60%) benign bone lesions and 12 (40%) malignant lesions in the current study. 91.6% of malignant tumours and 88.8% of the benign tumours were identified correctly by the four observers. The inter-observer variability with Fleiss kappa was 0.884 (95% CI 0.7-1.03 p-value < 0.05), suggestive of agreement not by chance. These radiographs were again reassessed by the four observers after 3 months. The interobserver variability by Fleiss kappa was 1.0 (95% CI 0.8-1.1) suggesting complete agreement amongst the observers. Both orthopaedic oncologists had intra-observer kappa as 1.0 each and both surgical oncologists had 0.795 and 0.930 respectively.

CONCLUSION

The proposed A to Z RAM is an easy to use and reproducible method for reviewing radiographs in the out-patient department along with clinical findings for better management of patients with suspected bone lesions. The A to Z RAM can be a medical triage tool and subdivide bone lesions into two subgroups i.e. suspected benign lesion with a suggestion of further investigations with MRI and biopsy and suspected malignant lesion with a suggestion of MRI or early referral to a tertiary cancer center with expertise in orthopaedic oncology.

IMPLICATIONS FOR PRACTICE

The A to Z RAM (Radiologic Assessment Method) is a reproducible method for reviewing radiographs in the out-patient department and can be an aid for better management of patients. A to Z RAM is useful as a medical triage system, subdividing patients according to the probable diagnosis into a suspected benign lesion and suspected malignant lesion.

Healthcare staff perceptions and misconceptions regarding antibody testing in the United Kingdom: implications for the next steps for antibody screening

BACKGROUND

Healthcare workers have been at increased risk of exposure, infection and serious complications from COVID-19. Antibody testing has been used to identify staff members who have been previously infected by SARS-CoV-2, and has been rolled out rapidly in the United Kingdom. A number of comment and editorial articles have been published that raise concerns about antibody testing in this context. We present perceptions of National Health Service (NHS) healthcare workers in relation to SARS-CoV-2 antibody testing.

METHODS

An electronic survey regarding perceptions towards SARS-CoV-2 antibody testing was distributed to all healthcare workers at a major NHS tertiary hospital following implementation of antibody testing.

RESULTS

In total, 560 healthcare workers completed the survey (80% female; 25% of Black and Minority Ethnic background; 58% from frontline clinical staff). Exploring whether they previously had COVID-19 was the primary reported reason for choosing to undergo antibody testing (85.2%). In case of a positive antibody test, 72% reported that they would feel relieved, whilst 48% felt that they would be happier to work in a patient-facing area. Moreover, 12% responded that a positive test would mean "social distancing is less important", with 34% of the responders indicating that in this case they would be both less likely to catch COVID-19 and happier to visit friends/relatives.

CONCLUSIONS

NHS staff members primarily seek out SARS-CoV-2 antibody testing for an appropriate reason. Based on our findings and given the lack of definite data regarding the extent of immunity protection from a positive SARS-CoV-2 antibody test, significant concerns may be raised regarding the reported interpretation by healthcare workers of positive antibody test results. This needs to be further explored and addressed to protect NHS staff and patients.

Inhibition of the activin receptor improves cardiac remodelling in the ercc1 mouse model of accelerated ageing

Introduction

In the heart, ageing is associated with pathological remodelling due to an increase of DNA damage, oxidative stress and fibrosis that impairs function, often leading to heart failure. Ageing is also associated with activation of the activin signalling pathway which contributes to cardiac dysfunction. Previous studies have shown that inhibition of the activin signalling pathway preserves cardiac function during aging. However, the beneficial effects of this inhibition in cardiac disorders such as accelerated ageing remain unknown.

Purpose

We hypothesized that inhibition of the activin receptor would be beneficial for the pathological cardiac phenotype of the Ercc1Δ/− mouse model of accelerated ageing.

We aimed to determine the cardiac phenotype of the Ercc1 mouse, and how inhibition of activin signalling affects cardiac remodelling using immunological and biochemical analysis.

Methods

Using immunohistochemical staining, we investigated the cardiac phenotype in 16 week old Ercc1Δ/− progeric and Ercc1+/+ wildtype mice (n=4–6) with or without soluble activin receptor injections from the week 7 (sActRIIB, 10mg/kg). The Ercc1Δ/− mouse displays a deficiency in DNA repair, leading to an accelerated ageing phenotype. Experimentally, injections of the myostatin /activin antagonist called the soluble ActRIIB receptor trap (sActRIIB) can be used to pharmacologically target the activin signalling pathway.

Results

In Ercc1Δ/− mice at 16 weeks there was a 50% decrease in the heart weight in comparison to Ercc1+/+ wildtype mice (175±13 vs 85±4), (p&lt;0.001). Activin inhibition did not have any effect on the heart weight. To determine the extent of DNA damage, cardiac tissue was stained for γH2Ax. γH2Ax accumulates at double stranded DNA breaks where histone 2A becomes phosphorylated. Ercc1Δ/− mice displayed a 20% increase in double stranded DNA breaks in comparison to the Ercc1+/+ wildtype (0.6±0.5 vs 22.5±2.5 vs 15.8±0.7), (p&lt;0.01). Activin inhibition led to a significant 5% decrease (p&lt;0.05). Oxidative stress was determined by dihydroethidium staining. Ercc1Δ/− mice showed a 30% increase in oxidative stress (33.33±3 vs 49.98±3 vs 36.19±3), (p&lt;0.05). Activin inhibition reversed this increase of oxidative stress in Ercc1Δ/− mice (p&lt;0.05). Finally, cardiac fibrosis was assessed using picrosirius red staining. No differences were observed between the Ercc1Δ/− progerics and Ercc1+/+ wildtype mice, while activin inhibition led to a 50% decrease (4.9±0.3 vs 7.7±1.3 vs 2.9±0.1), (p&lt;0.01). Interestingly, Ercc1Δ/− mice display thicker cardiac interstitial collagen I (1.3±0.01 vs 1.4±0.05 vs 1.3±0.01), (p&lt;0.05). Activin inhibition also reversed this increased interstitial collagen (p&lt;0.05).

Conclusion

Inhibition of activin receptor signalling brings beneficial effects to the Ercc1Δ/− cardiac phenotype by attenuating oxidative stress, DNA damage and fibrosis.

Funding Acknowledgement

Type of funding source: None

Catheter ablation for atrial fibrillation in patients with reduced systolic function: a national perspective

Background

Randomized trials have shown improvement in hard clinical end points when catheter ablation (CA) was employed as a management strategy for certain atrial fibrillation (AF) patients with heart failure and reduced ejection fraction (HFrEF). We sought to determine real world data on mortality and complications after utilization of CA in such patients.

Methods and results

Data were derived from National Inpatient Sample from January 2008 to August 2015. Patients were identified using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes. Baseline characteristics and outcomes were compared among AF and HFrEF patients undergoing CA or not. Propensity matching was done to mitigate selection bias and balance confounding variables. Various CA related complications were assessed. Logistic regression was done to determine predictors of mortality in our study cohort. A total of 2,569,919 patients were enrolled and out of these approximately 7773 patients underwent CA. Mortality was significantly better in CA group in both unmatched (1.2% vs. 4.9%, p&lt;0.01) and propensity matched cohorts (1.2% vs. 3.6%, p&lt;0.01). Overall complication rate was 10.2% in CA cohort and were primarily cardiac and neurological in origin. In regression analysis, CA remains a strong predictor of reduced mortality (OR 0.301, 95% CI 0.184–0.494).

Conclusion

CA is associated with improved mortality in admitted AF patients with concomitant HFrEF. Overall complication rate after CA was modest at 10.2%.

Funding Acknowledgement

Type of funding source: None

Detecting national human enteric disease outbreaks linked to animal contact in the United States of America

Enteric pathogens, such as non-typhoidal Salmonella, Campylobacter and Escherichia coli, can reside in the intestinal tract of many animals, including livestock, companion animals, small mammals and reptiles. Often, these animals can appear healthy; nonetheless, humans can become infected after direct or indirect contact, resulting in a substantial illness burden. An estimated 14% of the 3.2 million illnesses that occur in the United States of America (USA) each year from such enteric pathogens are attributable to animal contact. Surveillance for enteric pathogens in the USA includes the compilation and interpretation of both laboratory and epidemiologic data. However, the authors feel that a collaborative, multisectoral and transdisciplinary - or One Health - approach is needed for data collection and analysis, at every level. In addition, they suggest that the future of enteric illness surveillance lies in the development of improved technologies for pathogen detection and characterisation, such as genomic sequencing and metagenomics. In particular, using whole-genome sequencing to compare genetic sequences of enteric pathogens from humans, food, animals and the environment, can help to predict antimicrobial resistance among these pathogens, determine their genetic relatedness and identify outbreaks linked to a common source. In this paper, the authors describe three recent, multi-state human enteric illness outbreaks linked to animal contact in the USA and discuss how integrated disease surveillance was essential to outbreak detection and response. Additional datasharing between public health and animal health laboratories and epidemiologists at the local, national, regional and international level may help to improve surveillance for emerging animal and human health threats and lead to new opportunities for prevention.

Delay in diagnosis of patients with head-and-neck cancer in Canada: impact of patient and provider delay

Background

Head-and-neck cancers (hncs) often present at an advanced stage, leading to poor outcomes. Late presentation might be attributable to patient delays (reluctance to seek treatment, for instance) or provider delays (misdiagnosis, prolonged wait time for consultation, for example). The objective of the present study was to examine the length and cause of such delays in a Canadian universal health care setting.

Methods

Patients presenting for the first time to the hnc multidisciplinary team (mdt) with a biopsy-proven hnc were recruited to this study. Patients completed a survey querying initial symptom presentation, their previous medical appointments, and length of time between appointments. Clinical and demographic data were collected for all patients.

Results

The average time for patients to have their first appointment at the mdt clinic was 15.1 months, consisting of 3.9 months for patients to see a health care provider (hcp) for the first time since symptom onset and 10.7 months from first hcp appointment to the mdt clinic. Patients saw an average of 3 hcps before the mdt clinic visit (range: 1-7). No significant differences in time to presentation were found based on stage at presentation or anatomic site.

Conclusions

At our tertiary care cancer centre, a patient's clinical pathway to being seen at the mdt clinic shows significant delays, particularly in the time from the first hcp visit to mdt referral. Possible methods to mitigate delay include education about hnc for patients and providers alike, and a more streamlined referral system.

Analysis of the frequency of bacteraemia of dental origin implicated in infective endocarditis in patients requiring valve surgery

Understanding the frequency of bacteraemia of dental origin that is implicated in severe infective endocarditis (IE) will further our understanding of the disease's pathoaetiology and help us take steps to reduce its prevalence. A total of 78 patients from the Royal Papworth Hospital, Cambridge, who had valve surgery due to IE (as confirmed by the Modified Duke Criteria) were included. Case notes were retrospectively reviewed for microorganisms that were implicated in the bacteraemia and IE. Associated factors were also recorded to determine whether they were different if a dental or non-dental pathogen was inoculated. A dental pathogen was implicated in 24 of the patients with IE; 20 had non-dental pathogens, and 30 were culture negative. This was not deemed statistically significant (p=0.54). Of the associated factors, only smoking was statistically significant with a greater proportion of non-smokers having bacteraemia of dental origin (p=0.03). No other associated factor was appreciably different based on the aetiology of the microorganism. Our results indicate that dental pathogens are not more likely to cause severe IE. We therefore advocate the stance adopted by the current national guidance on the judicious prescription of antibiotic prophylaxis for IE with regard to dental procedures.

Evaluating the Facilitators, Barriers, and Medical Outcomes Commensurate with the Use of Assistive Technology to Support People with Dementia: A Systematic Review Literature

Background: Assistive technologies (AT) have been used to improve the daily living conditions of people living with dementia (PWD). Research supports the positive impact of the use of AT such as decreased burden on caregivers and behavioral support for people with dementia. Four reviews in the last six years have analyzed AT and PWD, but none have incorporated the dimension of medical outcomes. Objectives: The purpose of this review is to identify the facilitators, barriers, and medical outcomes commensurate with the use of AT with PWD. Method: This review queried The Cumulative Index of Nursing and Allied Health Literature (CINAHL), Web of Science, Science Direct, and PubMed databases for peer-reviewed publications in the last five years for facilitators, barriers, and medical outcomes commensurate with the use of AT with PWD. The study is reported and conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) and the Kruse Protocol for conducting a systematic review. Results: 48 studies were analyzed. Fourteen types of AT, 17 facilitators, 17 barriers, and 16 medical outcomes were identified in the literature. The two most frequently mentioned ATs were cognitive stimulators (9/48, 19%) and social robots (5/48, 10%). The two most frequently mentioned facilitators were caregivers want AT (8/68, 12%) and enables increased independence (7/68, 10%). The top two barriers were cost (8/75, 11%) and PWD reject AT (8/75, 11%). The top medical outcomes were improved cognitive abilities (6/69, 9%), increased activities of daily living (ADLs), and increased autonomy (each at 5/69, 7%): Zero negative outcomes were reported. Conclusion: The systematic review revealed the positive relations that occur when PWD and their caregivers use AT. Although many reservations surrounding the use of AT exist, a majority of the literature shows a positive effect of its use. Research supports a strong support for AT by caregivers due to many positive medical outcomes, but also a reticence to adopt by PWD. If ATs for PWD are a way to reduce stress on caregivers, barriers of cost and complexity need to be addressed through health policy or grants.