243 Thromboprophylaxis In Elective Arthroplasty Patients: Assessing DVT Rates

Introduction

Deep vein thrombosis (DVT) in elective hip and knee arthroplasty range from 1-25%. The NICE Guidelines for Venous Thromboembolism (VTE) advise offering chemical prophylaxis with anti-embolism stockings (AES) as VTE prophylaxis. The aim of this study was to assess the role of anti-embolism stockings, by analysing the rates of DVT in patients who had chemical VTE prophylaxis in combination with anti-embolism stockings compared to patients who had chemical prophylaxis alone.

Method

Retrospective data analysis of patients who underwent elective primary hip or knee replacements from April 2018 to April 2019. Patient records were reviewed for each patient to identify any subsequent DVT diagnosis.

Results

759 patients were identified. 595 patients had combined chemical VTE prophylaxis and AES. 164 patients did not have AES. 12 patients who received the combined therapy presented to A+E with suspected DVT, which was confirmed in two patients. Of the patients who did not receive AES, there were no cases of DVT.

Conclusions

There was no increase in DVT rates in patients who were not offered anti-embolic stockings. Taking into account the risks associated with AES and the costs incurred, the routine prescription of stockings must be carefully reviewed by orthopaedic departments.

327 Rare Synchronous Volvulus of Sigmoid Colon and Caecum, Management of Two Cases

Colonic volvulus accounts for approximately 5% of cases of large bowel obstruction. Sigmoid volvulus is commonest (75%), followed caecal volvulus (15%). Synchronous volvulus of the caecum and sigmoid is rare, with five reported cases in the literature. We report two cases in a London teaching hospital managed within 6 months. Both male patients (aged 72 and 79 years) had presented to the emergency department on multiple occasions (2-5 times in the preceding 1-8 months), with obstructive symptoms including tender abdominal distension and constipation. On all occasions, sigmoid volvulus was diagnosed based on plain abdominal films and flatus tubes were inserted, with initial clinical resolution. On their final presentation, both patients were admitted for definitive surgery. CT scans of the abdomen and pelvis were consistently reported as showing only sigmoid volvulus. Only intra-operatively was the diagnosis of synchronous caecal and sigmoid volvulus appreciated. Complete symptom resolution was achieved with subtotal colectomy and ileostomy formation. The key learning points from these cases are: 1) synchronous large bowel volvulus is a rare and easily missed diagnosis, 2) conservative management is unlikely to be successful, 3) radiological appearances may only suggest one type of large bowel volvulus and 4) definitive diagnosis is made intra-operatively.

698 A Systematic Review of Smartphone Applications for Enhanced Recovery After Surgery (ERAS) Following Colorectal Surgery

Introduction

Length of stay (LOS) following colorectal surgery has reduced due to enhanced recovery after surgery (ERAS) programs. Telemedicine has shown potential for patients to remotely access support, communicate progress with their medical team and enhance patient empowerment. We conducted a systematic review of smartphone applications for ERAS following colorectal surgery measuring patient outcomes and experience.

Method

The review was performed adhering to PRISMA guidelines, using search terms pertaining to ERAS, colorectal surgery, and mobile applications via electronic databases. All peer-reviewed English articles were assessed for inclusion and quality by two reviewers. A qualitative analysis was conducted to evaluate methodologies, patient experience, and outcomes.

Results

206 abstracts were identified from which 5 articles (2 RCTs and 3 cohorts) were included in the analysis. Studies surveyed patient adherence to ERAS, LOS, readmission, intra and postoperative complications. Four studies recorded patient satisfaction, whilst one assessed quality of life and application validation.

Conclusions

The review highlights paucity in the use of smartphone applications after ERAS in colorectal surgery but demonstrates high patient satisfaction levels. Service delivery in the NHS has increasingly moved to a virtual platform during the coronavirus pandemic. More research and engagement in the development and use of smartphone applications would enhance care for patients.

630 Management and Outcomes of Primary Central Nervous System Lymphoma – Time to Improve the Patient Pathway

Introduction

The clinical and radiological presentation of PCNSL is diverse. Biopsy is required prior to commencing oncological therapy. Steroids administration or inconclusive histopathology may delay diagnosis. This study aimed to assess outcomes of patients managed under clinical oncology and haematology, and investigate factors related to survival.

Method

Retrospective cohort study (2004-2019) of 104 patients. Univariate analysis, using Kaplan Meier curves and multivariate Cox regression analysis were performed.

Results

Median WHO performance status was 1. 12 patients (11.5%) required repeat biopsy. 40 cases were managed under oncology, 25 males (median age 67 years; IQR 60-71). Median time from imaging to diagnosis (TTD) was 18 days (range 8-227). Median time from diagnosis to treatment (TTT) was 19 days (range 3-63). Median overall survival (OS) was 5 months (95% CI 0-15.6). 61 cases were managed under haematology, 32 males (median age 65 years; IQR 54-71). Median TTD was 25 days (range 10-233). Median TTT was 14 days (range 2-96). Median OS was 5 months (95% CI 2.1-7.9). No significant prognostic indicators of OS were identified on multivariate analysis.

Conclusions

PCNSL carries a poor prognosis regardless of treatment team. The wide range in time to treatment suggests that the management pathway needs streamlining to improve outcomes.

P8: A COMPARATIVE EVALUATION OF INTENSIVE OUT-OF-TERM AND CONVENTIONAL TERM-TIME MENTORING SCHEMES IN PREPARING MEDICAL STUDENTS FOR A CAREER IN SURGERY

Introduction

Mentoring schemes have been established to mitigate these concerns and improve interest in surgery among medical students; however, there is a paucity of research on whether conventional term-time (CTT) mentoring or more intensive out-of-term (IOT) mentoring is more meaningful in promoting surgical careers.

Method

Most surgical societies in the UK offer CTT schemes (ca. one-to-three mentoring during the academic year) to their members. In addition to this, a student-led surgical society piloted an IOT scheme (one-to-one mentoring during the summer break). Students completed a ten-point questionnaire at the end of the academic year evaluating the scheme(s) they participated in.

Result

Of the 35 students that completed a questionnaire, 74% participated in either CTT or IOT (1:1), and 26% participated in both. Students that participated in one scheme considered that scheme to be superior in increasing interest in surgery (CTT 69%; IOT 79%), while students that participated in both favoured IOT (78%). With regards to increasing preparedness for surgical careers, IOT was universally preferred. According to previously determined levels of engagement, maximum engagement was achieved by 61.5% of students in a single week of IOT, compared to only 7.7% of students after a full academic year of CTT.

Conclusion

IOT outperforms CTT with regards to boosting interest in surgery and preparedness for surgical careers. This suggests that introduction of IOT schemes nationally may be a valuable advance in the future of surgical mentoring.

Take-home message

Adopting an intensive out-of-term mentoring scheme has shown a positive outcome in terms of both increasing preparedness for, and interest in, surgical careers. This suggests implementing such time intensive schemes nationally could be a sensible future-step in surgical mentoring.

Integrative sequencing discovers an ATF1-motif enriched molecular signature that differentiates hyalinizing clear cell carcinoma from mucoepidemoid carcinoma

OBJECTIVES

Salivary gland tumors are comprised of a diverse group of malignancies with widely varying prognoses. These cancers can be difficult to differentiate, especially in cases with limited potential for immunohistochemistry (IHC)-based characterization. Here, we sought to define the molecular profile of a rare salivary gland cancer called hyalinizing clear cell carcinoma (HCCC), and identify a molecular gene signature capable of distinguishing between HCCC and the histopathologically similar disease, mucoepidermoid carcinoma (MEC).

MATERIALS AND METHODS

We performed the first integrated full characterization of five independent HCCC cases.

RESULTS

We discovered insulin-like growth factor alterations and aberrant IGF2 and/or IGF1R expression in HCCC tumors, suggesting a potential dependence on this pathway. Further, we identified a 354 gene signature that differentiated HCCC from MEC, and was significantly enriched for genes with an ATF1 binding motif in their promoters, supporting a transcriptional pathogenic mechanism of the characteristic EWSR1-ATF1 fusion found in these tumors. Of the differentially expressed genes, IGF1R, SGK1 and SGK3 were found to be elevated in the HCCCs relative to MECs. Finally, analysis of immune checkpoints and subsequent IHC demonstrated that CXCR4 protein was elevated in several of the HCCC cases.

CONCLUSION

Collectively, our data identify an ATF1-motif enriched gene signature that may have clinical utility for molecular differentiation of HCCCs from other salivary gland tumors and discover potential actionable alterations that may benefit the clinical care of recurrent HCCC patients.

Observation of the Exotic Isotope ^{13}F Located Four Neutrons beyond the Proton Drip Line

A ^{13}F resonance was observed following a charge-exchange reaction between a fast ^{13}O beam and a ^{9}Be target. The resonance was found in the invariant-mass distribution of 3p+^{10}C events and probably corresponds to a 5/2^{+} excited state. The ground state was also expected to be populated, but was not resolved from the background. The observed level decays via initial proton emissions to both the ground and first 2^{+} state of ^{12}O, which subsequently undergo 2p decay. In addition, there may also be a significant proton decay branch to the second 2^{+} level in ^{12}O. The wave function associated with the observed level may be collectivized due to coupling to the continuum as is it located just above the threshold for proton decay to the 2_{2}^{+} state of ^{12}O.

Wheat rust epidemics damage Ethiopian wheat production: A decade of field disease surveillance reveals national-scale trends in past outbreaks

Wheat rusts are the key biological constraint to wheat production in Ethiopia-one of Africa's largest wheat producing countries. The fungal diseases cause economic losses and threaten livelihoods of smallholder farmers. While it is known that wheat rust epidemics have occurred in Ethiopia, to date no systematic long-term analysis of past outbreaks has been available. We present results from one of the most comprehensive surveillance campaigns of wheat rusts in Africa. More than 13,000 fields have been surveyed during the last 13 years. Using a combination of spatial data-analysis and visualization, statistical tools, and empirical modelling, we identify trends in the distribution of wheat stem rust (Sr), stripe rust (Yr) and leaf rust (Lr). Results show very high infection levels (mean incidence for Yr: 44%; Sr: 34%; Lr: 18%). These recurrent rust outbreaks lead to substantial economic losses, which we estimate to be of the order of 10s of millions of US-D annually. On the widely adopted wheat variety, Digalu, there is a marked increase in disease prevalence following the incursion of new rust races into Ethiopia, which indicates a pronounced boom-and-bust cycle of major gene resistance. Using spatial analyses, we identify hotspots of disease risk for all three rusts, show a linear correlation between altitude and disease prevalence, and find a pronounced north-south trend in stem rust prevalence. Temporal analyses show a sigmoidal increase in disease levels during the wheat season and strong inter-annual variations. While a simple logistic curve performs satisfactorily in predicting stem rust in some years, it cannot account for the complex outbreak patterns in other years and fails to predict the occurrence of stripe and leaf rust. The empirical insights into wheat rust epidemiology in Ethiopia presented here provide a basis for improving future surveillance and to inform the development of mechanistic models to predict disease spread.

Development and evaluation of a novel pre-operative surgery school and behavioural change intervention for patients undergoing elective major surgery: Fit-4-Surgery School

Group pre-operative education has usually been limited to conditioning expectations and providing education. Prehabilitation has highlighted modifiable lifestyle factors that are amenable to change and may improve clinical outcomes. We instituted a pre-operative 'Fit-4-Surgery School' for patients scheduled for major surgery, to educate and promote healthy behaviour. We evaluated patients' views having attended the school, and after surgery we asked how it had changed their behaviour with a lifestyle questionnaire. The school was launched in May 2016 and was attended by 586/1017 (58%) of invited patients. Patients who did not attend: lived further away, median (IQR [range]) 8 (4-19 [0-123]) miles vs. 5 (3-14 [0-172]) miles, p < 0.001; and were more deprived, Index of Multiple Deprivation Rank decile median (IQR [range]), 6 (4-8 [1-10]) vs. 7 (4-9 [1-10]), p = 0.04. Of the 492/586 (84%) participants who completed an evaluation questionnaire, 462 (94%) would recommend the school to a friend having surgery and 296 (60%) planned lifestyle changes. After surgery, 232/586 (40%) completed a behavioural change questionnaire, 106 (46%) of whom reported changing at least one lifestyle factor, most commonly by increasing exercise. The pre-operative school was acceptable to patients.

Oncological outcomes of salvage radical prostatectomy for recurrent prostate cancer in the contemporary era: A multicenter retrospective study

BACKGROUND

Salvage radical prostatectomy (sRP) historically yields poor functional outcomes and high complication rates. However, recent reports on robotic sRP show improved results. Our objectives were to evaluate sRP oncological outcomes and predictors of positive margins and biochemical recurrence (BCR).

METHODS

We retrospectively collected data of sRP for recurrent prostate cancer after local nonsurgical treatment at 18 tertiary referral centers in United States, Australia and Europe, from 2000 to 2016. SM and BCR were evaluated in a univariate and multivariable analysis. Overall and cancer-specific survival were also assessed.

RESULTS

We included 414 cases, 63.5% of them performed after radiotherapy. Before sRP the majority of patients had biopsy Gleason score (GS) ≤7 (55.5%) and imaging negative or with prostatic bed involvement only (93.3%). Final pathology showed aggressive histology in 39.7% (GS ≥9 27.6%), with 52.9% having ≥pT3 disease and 16% pN+. SM was positive in 29.7%. Five years BCR-Free, cancer-specific survival and OS were 56.7%, 97.7% and 92.1%, respectively. On multivariable analysis pathological T (pT3a odds ratio [OR] 2.939, 95% confidence interval [CI] 1.469-5.879; ≥pT3b OR 2.428-95% CI 1.333-4.423) and N stage (pN1 OR 2.871, 95% CI 1.503-5.897) were independent predictors of positive margins. Pathological T stage ≥T3b (OR 2.348 95% CI 1.338-4.117) and GS (up to OR 7.183, 95% CI 1.906-27.068 for GS >8) were independent predictors for BCR. Limitations include the retrospective nature of the study and limited follow-up.

CONCLUSIONS

In a contemporary series, sRP showed promising oncological control in the medium term despite aggressive pathological features. BCR risk increased in case of locally advanced disease and higher GS. Future studies are needed to confirm our findings.

Microbiome analysis of the skin of sheep that are resistant or susceptible to breech flystrike

Context Breech strike is a serious disease for wool sheep. Skin wrinkle and dags are known predisposing factors for breech strike; however, a large part of the variation among sheep is unknown. Aims We studied the natural diversity and difference in microbial populations in the skin around the breech area in Merino sheep genetically resistant and susceptible to breech strike, by using 16S rRNA gene sequence analysis. Methods The sheep were from the breech strike flocks at the Mount Barker research station in Western Australia and from the CSIRO research station near Armidale in New South Wales. Skin samples were collected from the breech of all 2013-born progeny in both flocks before they were struck. Yearling ewes and rams were then naturally exposed to challenge by Lucilia cuprina blowflies. Breeding values for breech strike were estimated and used with phenotypic data to identify breech strike-resistant and -susceptible sheep. Skin samples of 78 unstruck and 73 struck sheep were selected, their microbiomes were analysed using 16S rRNA meta-barcoding, and operational taxonomic unit counts were analysed. Results The diversity analyses showed that the two flocks in the different environments had different microbiome profiles, but no difference was found between sexes or between breech strike-resistant and -susceptible sheep in either flock. Conclusions The results indicated that microbial differences on the skin of sheep are not associated with differences in susceptibility to breech strike. Implications Microbial differences do not offer opportunities to manage breech strike in Merino sheep.

Cardiac biomarkers of disordered eating as a function of diagnostic subtypes

OBJECTIVE

The purpose of this study was to identify cardiac biomarkers of disordered eating as a function of diagnostic subtype as assessed via self-report inventory.

METHOD

Mean heart rate (HR), systolic and diastolic blood pressure, mean R wave amplitude (mV), mean T wave amplitude (mV), QTc interval (sec), Tpeak-Tend interval prolongation (sec), QTc interval prolongation (sec), QRS prolongation (sec), and spectral indicators of cardiac dysfunction (LF/HF spectral ratio, HF spectral power) were assessed via electrocardiography among women with no eating disorder symptoms (n = 32), subclinical eating disorder symptoms (n = 92), anorexia nervosa (n = 7), bulimia nervosa (n = 89), binge eating disorder (BED: n = 20), and other specified feeding and eating disorders (OSFED: n = 19).

RESULTS

MANOVA results showed statistically significant group differences. Follow-up tests revealed significantly decreased mean R wave amplitude among participants with self-indicated clinical (bulimia nervosa, binge eating disorder) and subclinical forms of disordered eating compared to asymptomatic controls.

DISCUSSION

Results suggest decreased mean R wave amplitude is a promising cardiac biomarker of disordered eating.