A152 FOREIGN BODY INGESTIONS AT A TERTIARY CARE CENTRE - A QUALITY ASSURANCE STUDY

Background

Foreign body ingestion and esophageal food bolus impaction are common emergencies encountered by gastroenterologists. If not treated in a timely fashion these can result in significant morbidity, or even mortality. The mainstay of diagnosis and therapy is endoscopy. Guidelines regarding timing of endoscopy have been published by both the American and European Societies of Gastrointestinal Endoscopy, and both suggest emergent endoscopy, meaning within 2 to 6 hours, for complete esophageal obstructions. There is relatively sparse data regarding the endoscopic techniques used in real world practice.

Aims

This is a quality assurance study looking at the endoscopic practices at an adult tertiary care hospital in Halifax, Nova Scotia with respect to foreign body and food impaction management.

Methods

The hospital records of all patients presenting with ingested foreign bodies or esophageal food bolus impactions between May 2018 and July 2019 were included. Patients were identified by searching the call-back forms used by our department which documents all on-call endoscopy cases. This was then cross-referenced by endoscopy nursing charting which documents every endoscopy performed. Information such as demographics, obstruction type, endoscopic method of removal, complications, time between consultation and endoscopy, underlying pathology, and others were analyzed.

Results

70 cases were identified. Average patient age was 51.3 years old (range 16–96). 18 (25.7%) were female and 52 (74.3%) were male. 64 cases (91.4%) were esophageal food impactions and 6 (8.57%) were foreign body ingestions. Of the food impactions, 39 cases (60.9%) were cleared by the push/slide-by technique only and 10 (16.7%) were relieved using instruments such as snares, forceps, or nets. 15 (23.4%) passed spontaneously prior to scope, of which 7 received glucagon. An overtube was used in 1 case (0.16%). Complications occurred in 5 (7.8%) cases and included 3 mucosal tears, 2 of which required therapeutic interventions, and 2 episodes of oxygen desaturation in which the procedure was aborted. Complete obstructions occurred in 42 (65.6%) cases with average time of consultation to endoscopy of 2.4 hours. However, 3 (7.1%) cases exceeded 6 hours. The most common pathology was eosinophilic esophagitis with 20 cases (31.3%).

Ingested foreign bodies included 2 long objects, 3 sharp objects, and a cylindrical battery, and all but one were in the stomach. 5 (83.3%) cases used an overtube. No complications occurred.

Conclusions

At our institution 67/70 (95.7%) cases were performed within the timelines recommended by society guidelines. No complications occurred in the cases not performed within those time limits. An overtube was used in only one case in which a food bolus was retrieved out of the esophagus. Overall this study suggests that our centre is meeting recommended targets, however there is room for improvement.

Funding Agencies

None

A269 EUS-GUIDED ROSE FNA AND CNB FOR THE DIAGNOSIS OF PANCREATIC CANCER: A COMPARATIVE ANALYSIS

Background

Endoscopic ultrasound-guided fine-needle aspiration with Rapid On Site Evaluation (ROSE EUS-FNA) and endoscopic ultrasound-guided core-needle biopsy (EUS-CNB) are widely used for the diagnosis of pancreatic tumors. There is no known published randomized control trial that compares between the two modalities. Given the aggressive nature of pancreatic cancer, it is crucial to make a prompt diagnosis in order to initiate treatment in a timely fashion.

Aims

This study compares the diagnostic performance of ROSE EUS-FNA and EUS-CNB for diagnosis of pancreatic cancer.

Methods

A retrospective review was performed for patients who underwent ROSE EUS-FNA and/ or EUS-CNB for solid pancreatic lesion. Diagnostic yield (defined as percentage of diagnostic samples), diagnostic accuracy (defined as percentage of correct diagnosis), sensitivity and specificity for malignancy were compared between ROSE EUS- FNA and EUS- CNB. Baseline characteristics for both patients and lesions were also obtained.

Results

A total of 82 patients with solid pancreatic lesions were reviewed. 84 EUS with 61 FNA and 74 CNB were performed. The diagnostic yield was 42/61 (69%) and 59/74 (79.7%) for FNA and CNB respectively (P 0.166). The diagnostic accuracy was 33/61 (54%) and 53/74 (71%) for FNA and CNB respectively (P 0.0326).

50 patients underwent both FNA and CNB during the same EUS. The calculated diagnostic yield among this subgroup was 33/50 (66%) and 39/50 (78%) for FNA and CNB respectively (P 0.265); with diagnostic accuracy of 26/50 (52%) for FNA and 34/50 (68%) for CNB (P 0.152). The diagnostic accuracy after combining both techniques was 40/50 (80%).

The incremental increase in diagnostic yield by combining both methods was 12/50 (24%) and 6/50 (12%) relative to FNA and CNB respectively.

The sensitivity for the diagnosis of malignancy for FNA and CNB was 60.8% and 92.7%, respectively. The specificity was 100% for both methods.

Conclusions

EUS-guided CNB is a superior method of assessing solid pancreatic lesion and pancreatic malignancy with better diagnostic yield and accuracy and higher sensitivity than ROSE EUS-FNA.

Funding Agencies

None

Staff's Perception of the Intensive Care Outreach Nurse Role: A Multisite Cross-sectional Study

BACKGROUND

Rapid Response Systems are emerging internationally to provide a patient-focused approach to prevent potentially avoidable deaths and serious adverse events.

LOCAL PROBLEM

This study focused on ward nurses in the United Arab Emirates (UAE) government hospitals who were perceived to lack the confidence and knowledge to detect and/or respond to deteriorating patients.

METHOD

A cross-sectional study design was used to evaluate the Intensive Care Outreach Nurse (ICON) role from the perspectives of the ICONs, their managers/educators, and ward-based physicians and nurses. ICONs are intensive care experienced nurses with additional education in the role of rapid responder to the deteriorating patient.

INTERVENTIONS

An ICON role was implemented across 4 hospitals to respond to and support clinicians in the recognition and management of the deteriorating patient on general inpatient wards.

RESULTS

ICON skills perceived as most beneficial by respondents included staff education, respiratory therapy, medication administration, and intravenous access.

CONCLUSIONS

The ICON role is able to support recognition and management of the deteriorating patients.

Infectious disease outbreaks in the African region: overview of events reported to the World Health Organization in 2018

The WHO African region is characterised by the largest infectious disease burden in the world. We conducted a retrospective descriptive analysis using records of all infectious disease outbreaks formally reported to the WHO in 2018 by Member States of the African region. We analysed the spatio-temporal distribution, the notification delay as well as the morbidity and mortality associated with these outbreaks. In 2018, 96 new disease outbreaks were reported across 36 of the 47 Member States. The most commonly reported disease outbreak was cholera which accounted for 20.8% (n = 20) of all events, followed by measles (n = 11, 11.5%) and Yellow fever (n = 7, 7.3%). About a quarter of the outbreaks (n = 23) were reported following signals detected through media monitoring conducted at the WHO regional office for Africa. The median delay between the disease onset and WHO notification was 16 days (range: 0-184). A total of 107 167 people were directly affected including 1221 deaths (mean case fatality ratio (CFR): 1.14% (95% confidence interval (CI) 1.07%-1.20%)). The highest CFR was observed for diseases targeted for eradication or elimination: 3.45% (95% CI 0.89%-10.45%). The African region remains prone to outbreaks of infectious diseases. It is therefore critical that Member States improve their capacities to rapidly detect, report and respond to public health events.

Measuring health and well-being with the help of the community

Issue

The Well North Programme is a multi-centre study focused on reducing inequalities in deprived communities through locally-led interventions and activities. As a locally driven project where the local stakeholders were involved in the programme of work, it was important to involve the community when deciding what to measure.

Description

As part of the evaluation there was a need to produce a tool to capture health and wellbeing information that was relevant to the specific communities involved in the project. In order to do this, we established that we needed local people to define what they wanted to measure, and we would use evidence synthesis techniques to identify tools that could be used to measure it within the community.

Results

We formulated the Well North Star, a bespoke spider diagram designed to capture individual level data. The Star is a quantitative tool used to collect individual-level data at an individual, organisational and geographical level. Each arm of the star represents an important theme, selected for measurement by local people. Identified local stakeholders (including residents, voluntary sector, police and councillors) were invited to workshops in order to decide what issues were important locally. After group discussions and thematic analysis, up to seven issues were highlighted as the most important in the community. Two of the main issues highlighted within local communities were aspiration and access to local information. After extensive literature search, tools to measure these were insufficient (e.g. aspiration tools focused on aspiration to become famous) and so bespoke tools needed to be created.

Lessons

When conducting community driven research, it is important to involve representatives from the community in identifying issues that are important to them. There is a gap between what academics and researchers consider important in local communities and what the communities themselves consider important.

First report of infection with Pseudomonas citronellolis: a case of urosepsis

This is the first case report of infection with the environmental bacterium Pseudomonas citronellolis, presented here as a urinary tract and bloodstream infection that occurred shortly after a transrectal ultrasound-guided prostate biopsy.

Propulsion strategy in running in children and adolescents with cerebral palsy

BACKGROUND

Running is a fundamental movement skill important for participation in physical activity. Children with cerebral palsy (CP) who are classified at Gross Motor Function Classification Scale (GMFCS) level I and II are able to run but may be limited by neuromuscular impairments.

RESEARCH QUESTION

To describe the propulsion strategy (PS) during running of children and adolescents with CP.

METHODS

This cross-sectional study used kinematic and kinetic data collected during running from 40 children and adolescents with unilateral or bilateral CP and 21 typically developing (TD) children. Maximum speed, peak ankle power generation (A2), peak hip flexor power generation in swing (H3) and PS (PS = A2/(A2 + H3)) were calculated. Linear mixed models were developed to analyze differences between groups.

RESULTS

Maximum speed, A2 and PS were significantly less in children with CP GMFCS level I than in TD children and significantly less in children in GMFCS level II than level I. For children with CP, A2 and PS were significantly smaller in affected legs than non-affected legs. In affected legs, H3 was significantly larger in children in GMFCS level II than GMFCS level I but not different between TD children and children in GFMCS level II.

SIGNIFICANCE

The contribution of ankle plantarflexor power to forward propulsion in running is reduced in young people with CP and is related to GMFCS level. This deficit appears to be compensated in part by increased hip flexor power generation but limits maximum sprinting speed.

The effect of joint translation constraint on within-participant variability of kinematics and kinetics during running in cerebral palsy

BACKGROUND

Biomechanical data in cerebral palsy are inherently variable but no optimal model of translational joint constraint has been identified. The primary aim of this study was to determine which model of translational joint constraint resulted in the lowest within-participant variability of lower limb joint angles and moments. The secondary aim was to determine which model best distinguished known functional groups in Cerebral Palsy.

METHODS

Three models (three degrees of freedom, six degrees of freedom and six degrees of freedom with specified joint translation constraint) were applied to data from running trials of 40 children with cerebral palsy.

FINDINGS

Joint angle standard deviations were largest using the six degrees of freedom model and smallest using the constrained six degrees of freedom model (p < 0.050). For all joints in all planes of motion, joint moment standard deviations were largest using the six degrees of freedom model and smallest using the constrained six degrees of freedom model; standard deviations using the constrained model were smaller than the three degrees of freedom model by 10-30% of moment magnitude (0.01-0.03 Nm/kg; p < 0.001). The six degrees of freedom models distinguished functional subgroups with larger effect size than the three degrees of freedom model only for hip power generation in swing.

INTERPRETATION

A model with specified joint constraint minimized within-participant variability during running and was useful for detecting differences in functional capacity in cerebral palsy.

Effect of abaloparatide on vertebral, nonvertebral, major osteoporotic, and clinical fractures in a subset of postmenopausal women at increased risk of fracture by FRAX probability

We evaluated the efficacy of abaloparatide in women who were at increased risk for fracture, based on CHMP recommended risk thresholds, at the Abaloparatide Comparator Trial In Vertebral Endpoints (ACTIVE) study baseline. Among patients at high risk based on FRAX probabilities, 18 months of abaloparatide significantly decreased risk for all fracture endpoints compared with placebo.

PURPOSE

Abaloparatide, a novel anabolic agent for the treatment of postmenopausal osteoporosis, significantly reduced the risk of vertebral and nonvertebral fractures in the ACTIVE study compared with placebo. In this post hoc analysis, we evaluated abaloparatide's efficacy in a subset of women in the study at an increased risk of fracture at baseline, based on the Committee for Medicinal Products for Human Use (CHMP) recommended risk thresholds for inclusion in clinical trials.

METHODS

Women with a baseline 10-year risk of major osteoporotic fracture ≥ 10% or hip fracture ≥ 5%, assessed using the FRAX® tool (including femoral neck bone mineral density), were included in the analysis. The proportion with one or more events of new morphometric vertebral fractures was calculated. Event rates for nonvertebral, major osteoporotic, and all clinical fractures were estimated using Kaplan-Meier analysis.

RESULTS

Following 18 months of treatment, abaloparatide significantly reduced incident vertebral fractures compared with placebo (relative risk reduction = 91%; 0.5% versus 5.6%; p < 0.001). Abaloparatide treatment was also associated with significantly fewer nonvertebral, major osteoporotic, and clinical fractures compared with placebo: 2.7% versus 5.8%, p = 0.036; 1.3% versus 6.0%, p < 0.001; and 3.5% versus 8.2%, p = 0.006, respectively. The effect of abaloparatide on major osteoporotic fractures (78% reduction) was significantly greater than that seen with teriparatide (23% reduction, p = 0.007).

CONCLUSION

In a subset of postmenopausal women at increased risk of fracture as judged by CHMP guidance, abaloparatide significantly decreased the risk of all fracture endpoints compared with placebo.

Emergency department models of care in Queensland: a multisite cross-sectional study

Objective The acuity and number of presentations being made to emergency departments (EDs) is increasing. In an effort to safely and efficiently manage this increase and optimise patient outcomes, innovative models of care (MOC) have been implemented. What is not clear is how these MOC reflect the needs of patients or relate to each other or to ED performance. The aim of this study was to describe ED MOC in Queensland, Australia. Methods Situated within a larger mixed-methods study, the present study was a cross-sectional study. In early 2015, leaders (medical directors and nurse managers) from public hospital EDs in Queensland were invited to complete a survey detailing ED activity, staffing profiles, treatment space, MOC and National Emergency Access Target (NEAT) performance. Routinely collected ED information system data was also used. Results Twenty of the 27 EDs invited participated in the study (response rate 74%). An extensive array of MOC were identified that were categorised into those that facilitate input, throughput and output from the ED. There was no consistent evidence as to the relative effectiveness of these MOC in achieving ED performance benchmarks, such as NEAT performance. Conclusion There is considerable variability in the MOC used throughout EDs in Queensland. A more complete analysis of the relative effectiveness of different MOC either in isolation or as part of a comprehensive approach would help inform more consistent MOC in Queensland EDs. What is known about the topic? MOC in any given ED are implemented in response to factors such as the geographical location of the hospital, hospital-specific characteristics and service profile, staffing profile and patient demographic profile. In the era of time-based targets, they may also serve to address a particular aspect of flow in the face of rising ED demand. Although many of the MOC attempt to deal with flow in a linear fashion, target specific phases of the ED journey or address particular patient cohorts, what is clear is that not all EDs are shaped and formed the same. What does this paper add? The study provides a comprehensive description of the varied models of care operating within Queensland public hospital EDs and how they relate to ED performance. A basic taxonomy of contemporary ED MOC is necessary to allow comparison between departments and inform decisions regarding safety, efficiency and cost-effectiveness. What are the implications to practitioners? A contemporary understanding of the presence and profile of ED MOC that currently exist within a network of hospitals and health services is important for managers, clinicians and patients to inform decision-making regarding the safety, clinical effectiveness and cost-effectiveness of these models. This understanding can also inform where and how further improvements in care delivery can progress.