Upper gastrointestinal training in the UK and Ireland: a Roux Group Study

INTRODUCTION

Surgical training programmes in the United Kingdom and Ireland (UK&I) are in a state of flux. This study aims to report the contemporary opinions of trainee and consultant surgeons on the current upper gastrointestinal (UGI) training model in the UK&I.

METHODS

A questionnaire was developed and distributed via national UGI societies. Questions pertained to demographics, current training evaluation, perceived requirements and availability.

RESULTS

A total of 241 responses were received with representation from all UK&I postgraduate training regions. The biggest discrepancies between rotation demand and national availability related to advanced/therapeutic endoscopy and robotic surgery, with 91.7% of respondents stating they would welcome greater geographical flexibility in training. The median suggested academic targets were 3-5 publications (trainee vs consultant <3 vs 3-5, p<0.001); <3 presentations (<3 vs 3-5, p=0.002); and 3-5 audits/quality improvement projects (<3 vs 3-5, p<0.001). Current operative requirements were considered achievable (87.6%) but inadequate for day one consultant practice (74.7%). Reassuringly, 76.3% deemed there was role for on-the-job operative training following consultant appointment. Proficiency in diagnostic endoscopy was considered a minimum requirement for Certificate of Completion of Training (CCT) yet the majority regarded therapeutic endoscopy competency as non-essential. The median numbers of index UGI operations suggested were comparable with the current curriculum requirements. Post-CCT fellowships were not considered necessary; however, the majority (73.6%) recognised their advantage.

CONCLUSIONS

Current CCT requirements are largely consistent with the opinions of the UGI community. Areas for improvement include flexibility in geographical working and increasing national provisions for high-quality endoscopy training.

Quantification of the effect of in-utero events on lifetime resilience in dairy cows

Currently, the dairy industry is facing many challenges that could affect its sustainability, including climate change and public perception of the industry. As a result, interest is increasing in the concept of identifying resilient animals, those with a long productive lifespan, good reproductive performance and milk yield. There is much evidence that events in utero, i.e., the Developmental Origins of Health and Disease (DOHaD), alter life-course health of offspring and we hypothesized that these could alter resilience in calves, where resilience is identified using lifetime data. The aim of this study was to quantify lifetime resilience scores (LRS) using an existing scoring system based on longevity with secondary corrections for age at first calving and calving interval and to quantify the effects of in-utero events on the LRS using 2 data sets. The first was a large data set of cattle in 83 farms in Great Britain born from 2006 to 2015 and the second was a smaller, more granular data set of cattle born between 2003 and 2015 in the Langhill research herd at Scotland's Rural College. Events during dam's pregnancy included health events (lameness, mastitis, use of an antibiotic or anti-inflammatory medication), the impact of heat stress as measured by temperature-humidity index and perturbations in milk yield and quality (somatic cell count, percentage fat, percentage protein and fat:protein ratio). Daughters born to dams that experienced higher temperature-humidity indexes while they were in-utero during the first and third trimesters of pregnancy had lower LRS. Daughter LRS scores were also lower where milk yields or median fat percentages in the first trimester were low, and when milk yields were high in the third trimester. Dam LRS was positively associated with LRS of their offspring, however, as parity of the dam increased, LRS of their calves decreased. Similarly, in the Langhill herd, dams of a higher parity produced calves with lower LRS. Additionally, dams which recorded a high max locomotion score in the third trimester of pregnancy were negatively associated with lower calf LRS in the Langhill herd. Our results suggest that events that occur during pregnancy have lifelong consequences for the calf's lifetime performance. However, experience of higher temperature-humidity indexes, higher dam LRS scores and mothers in higher parities explained a relatively small proportion of variation in offspring LRS, which suggests that other factors play a substantial role in determining calf LRS scores. While 'big data' can contain a considerable amount of noise, similar findings between the 2 data sets indicate it is likely these findings are real.

Performance of tumour microenvironment deconvolution methods in breast cancer using single-cell simulated bulk mixtures

Cells within the tumour microenvironment (TME) can impact tumour development and influence treatment response. Computational approaches have been developed to deconvolve the TME from bulk RNA-seq. Using scRNA-seq profiling from breast tumours we simulate thousands of bulk mixtures, representing tumour purities and cell lineages, to compare the performance of nine TME deconvolution methods (BayesPrism, Scaden, CIBERSORTx, MuSiC, DWLS, hspe, CPM, Bisque, and EPIC). Some methods are more robust in deconvolving mixtures with high tumour purity levels. Most methods tend to mis-predict normal epithelial for cancer epithelial as tumour purity increases, a finding that is validated in two independent datasets. The breast cancer molecular subtype influences this mis-prediction. BayesPrism and DWLS have the lowest combined numbers of false positives and false negatives, and have the best performance when deconvolving granular immune lineages. Our findings highlight the need for more single-cell characterisation of rarer cell types, and suggest that tumour cell compositions should be considered when deconvolving the TME.

'How I'm feeling today, I probably won't be feeling tomorrow'. Using I-Poems to explore young people's changing emotions during the Covid-19 pandemic - A qualitative, longitudinal study

Background

Relatively little published qualitative research has explored children and young people's (CYP) prolonged or longitudinal experiences of the pandemic, and their emotional responses to such unreserved change to everyday life. As part of a broader, qualitative longitudinal study, this paper explores change and continuity in young people's emotions over time during the Covid-19 pandemic in North East England.

Methods

I-Poems were curated for each of the 26 young people in this study from serial interview transcripts and diary entries, collected over the course of 16 months. Creation of I-Poems require researchers to focus on sentences made by the interviewee that include the word "I," and without changing the order of those sentences, to present them in poetic stanzas.

Findings

Young people's voices and experiences became more poignant and powerful when their 'I' narrative was centralised, silencing the presence of the researcher. Further, presenting the data in this way allowed us to see how the following emotions shifted over time: grief, sadness, frustration, anger, anxiety, joy, pleasure, excitement. We contend that young people experienced significant rupture and change over the course of our 16 month project, with both positive and negative repercussions for their emotional wellbeing.

Conclusions

Large scale (quantitative and qualitative) studies remain much needed to focus on the long-term impacts of the pandemic on young people's social, emotional and cultural lives. Longitudinal and creative qualitative approaches (such as I-Poems) have the potential to centralise participant voice, break down power dynamics, and allow exploration of shifting experiences and emotions over time.

ROAD: The Road Event Awareness Dataset for Autonomous Driving

Humans drive in a holistic fashion which entails, in particular, understanding dynamic road events and their evolution. Injecting these capabilities in autonomous vehicles can thus take situational awareness and decision making closer to human-level performance. To this purpose, we introduce the ROad event Awareness Dataset (ROAD) for Autonomous Driving, to our knowledge the first of its kind. ROAD is designed to test an autonomous vehicle's ability to detect road events, defined as triplets composed by an active agent, the action(s) it performs and the corresponding scene locations. ROAD comprises videos originally from the Oxford RobotCar Dataset, annotated with bounding boxes showing the location in the image plane of each road event. We benchmark various detection tasks, proposing as a baseline a new incremental algorithm for online road event awareness termed 3D-RetinaNet. We also report the performance on the ROAD tasks of Slowfast and YOLOv5 detectors, as well as that of the winners of the ICCV2021 ROAD challenge, which highlight the challenges faced by situation awareness in autonomous driving. ROAD is designed to allow scholars to investigate exciting tasks such as complex (road) activity detection, future event anticipation and continual learning. The dataset is available at https://github.com/gurkirt/road-dataset; the baseline can be found at https://github.com/gurkirt/3D-RetinaNet.

Assessment of groundwater salinity using principal component analysis (PCA): a case study from Mewat (Nuh), Haryana, India

In the present study, principal component analysis (PCA) is used to investigate the processes controlling groundwater salinity in the Mewat (Nuh) district, Haryana, India. Twenty groundwater samples were collected from salinity-affected areas in the March-April months of years 2018 and 2019 and were analyzed for chemical variables pH, EC, Ca²⁺, Mg²⁺, Na⁺, K⁺, [Formula: see text], Cl^-, SO₄^2-, [Formula: see text], TDS, and total hardness. Three principal components were selected based on the eigen value, which explains 79.58% and 85.08% of the total variation in the years 2018 and 2019, respectively. The first principal component (PC-1) is identified with salinity, the second principal component (PC-2) with alkalinity, and the third principal component (PC-3) described the pollution. When the yearly comparison was made, the samples collected in 2019 were found to have an increased salinity compared to 2018, which shows an increased vulnerability to the aquifer of Mewat on account of the decline in rainfall recharge. It was also evident that declining recharge also triggered the recharge from other sources; thus, the impact of pollution is more pronounced in 2019 compared to 2018.

P-031 AN UNUSUAL CASE OF AN INCARCERATED 5MM PORT SITE HERNIA FOLLOWING LAPAROSCOPIC FUNDOPLICATION

Aim

Port site hernias are a rare, but recognised risk of laparoscopic surgery. Literature supports fascial closure at port sites of 10mm or greater. However, there are few reported cases of herniation through 5mm port sites.

Methods

This case report focuses on a 67-year-old female who underwent an uncomplicated primary laparoscopic Toupet's fundoplication. 11 days post procedure she presented with an incarcerated port site hernia. CT scan demonstrated high grade small bowel obstruction with a transition point at the site of the 5mm right sided port. A laparotomy was performed, the hernia reduced, small bowel was viable, and the port site hernia was closed internally using vicryl sutures.

Results

The incidence of 5mm trocar-site hernias is rare. A recent literature review found only 10 such cases related to general surgery (cholecystectomy:6; appendicectomy: 2; right hemicolectomy: 1; paraesophageal hernia:1). Risk factors for port-site hernias include: high BMI, midline position, size, number and type of trocar tip. The limited current literature identifies excessive trocar manipulation as the major risk factor for developing 5mm port-site hernias, yet routine fascial closure is not supported.

Conclusion

Herniation at 5mm port sites is rare but attention should be paid when patients present with symptoms suggesting its occurrence.

Severity of oEsophageal Anastomotic Leak in patients after oesophagectomy: the SEAL score

Background

Anastomotic leak (AL) is a common but severe complication after oesophagectomy. It is unknown how to determine the severity of AL objectively at diagnosis. Determining leak severity may guide treatment decisions and improve future research. This study aimed to identify leak-related prognostic factors for mortality, and to develop a Severity of oEsophageal Anastomotic Leak (SEAL) score.

Methods

This international, retrospective cohort study in 71 centres worldwide included patients with AL after oesophagectomy between 2011 and 2019. The primary endpoint was 90-day mortality. Leak-related prognostic factors were identified after adjusting for confounders and were included in multivariable logistic regression to develop the SEAL score. Four classes of leak severity (mild, moderate, severe, and critical) were defined based on the risk of 90-day mortality, and the score was validated internally.

Results

Some 1509 patients with AL were included and the 90-day mortality rate was 11.7 per cent. Twelve leak-related prognostic factors were included in the SEAL score. The score showed good calibration and discrimination (c-index 0.77, 95 per cent c.i. 0.73 to 0.81). Higher classes of leak severity graded by the SEAL score were associated with a significant increase in duration of ICU stay, healing time, Comprehensive Complication Index score, and Esophagectomy Complications Consensus Group classification.

Conclusion

The SEAL score grades leak severity into four classes by combining 12 leak-related predictors and can be used to the assess severity of AL after oesophagectomy.

341 Consenting Practices in Plastic Surgery

Introduction

Informed consent is a vital aspect of safe patient care within any surgical specialty, and if not completed thoroughly, may result in misinformation and patient dissatisfaction.

Traditional paper consent forms are notoriously poorly completed by medical professionals, with common issues ranging from ineligible handwriting, to missing key components of the form.

The aim of this audit was to assess our departments’ compliance with standard trust consent forms and compare adherence to local and national consenting policies.

Method

All elective and emergency plastic surgical procedures carried out over a one-week period from 17/05/2021 to 23/05/2021 were identified using eTrauma and Cerner operative records. In total, 40 procedures were identified. Consent forms were then reviewed and assessed for completion in key areas. 4 procedures were excluded due to the consent form not being available for review, and 1 procedure was excluded due to a cancellation.

Results

The risks and benefits of procedures were generally documented to a high standard. Providing written information to patients, confirmation of consent if the procedure was being performed on a different day, and possible additional procedures were poorly completed throughout. 90% of consent forms screened, failed to include confirmation of the surgical site within the specific section of the form.

Conclusions

Overall, the department demonstrated good compliance with completing trust consent forms. Electronic consent forms would likely address the shortcomings identified in this audit and should be adopted. Continued responsibility from the whole team should be highlighted and maintained to ensure a high standard of consenting.

61 Use of Ketamine Sedation for the Treatment of Minor Plastic Surgery Procedures in the Paediatric Emergency Department

Aim

To determine if ketamine sedation is a safe and cost-effective way of treating paediatric patients presenting with minor injuries, requiring plastic surgery procedures, in the emergency department.

Method

A retrospective cohort study was carried out over a 9-month period in children between ages 18 months and 16 years old, presenting to the paediatric emergency department at Chelsea and Westminster Hospital with minor injuries requiring plastic surgery input. The data collected included previously validated co-primary outcome measures of surgical site infection at 7 days and cosmetic appearance summary score at a minimum of 4 months. Parental satisfaction surveys were completed at 4 months to assess perceived quality of treatment. A cost analysis comparison against procedures completed under general anaesthetic was also undertaken.

Results

During the 9-month period of study, 24 minor procedures were performed under ketamine in the paediatric emergency department. There were no serious adverse events recorded. Three cases exceeded the recommended 20-minute maximum procedure duration, but there was no associated adverse outcome. No cases required further procedures under general anaesthesia and there were no cases of surgical site infections at 7 days. Parents reported extremely favourable outcomes using this technique, with an average overall satisfaction score of 9.2 (assessed over a number of parameters, where 10 is complete satisfaction).

Conclusions

Ketamine procedural sedation in the paediatric population is a safe and cost-effective method for the treatment of minor plastic surgery procedures, with low risk for surgical site infection post-operatively, and high parent satisfaction rates

Deep learning in cancer diagnosis, prognosis and treatment selection

Deep learning is a subdiscipline of artificial intelligence that uses a machine learning technique called artificial neural networks to extract patterns and make predictions from large data sets. The increasing adoption of deep learning across healthcare domains together with the availability of highly characterised cancer datasets has accelerated research into the utility of deep learning in the analysis of the complex biology of cancer. While early results are promising, this is a rapidly evolving field with new knowledge emerging in both cancer biology and deep learning. In this review, we provide an overview of emerging deep learning techniques and how they are being applied to oncology. We focus on the deep learning applications for omics data types, including genomic, methylation and transcriptomic data, as well as histopathology-based genomic inference, and provide perspectives on how the different data types can be integrated to develop decision support tools. We provide specific examples of how deep learning may be applied in cancer diagnosis, prognosis and treatment management. We also assess the current limitations and challenges for the application of deep learning in precision oncology, including the lack of phenotypically rich data and the need for more explainable deep learning models. Finally, we conclude with a discussion of how current obstacles can be overcome to enable future clinical utilisation of deep learning.

POS0926 NORMALIZATION OF HIGH SENSITIVITY CRP VERSUS CLINICAL RESPONSE TO IXEKIZUMAB AT WEEK 16 IN PATIENTS WITH RADIOGRAPHIC & NON-RADIOGRAPHIC AXIAL SPONDYLOARTHRITIS: RESULTS FROM THE COAST STUDIES

Background:

C-reactive protein (CRP), an objective marker of inflammation, can be used to monitor treatment response to biologics in patients with axial spondyloarthritis (axSpA) in addition to evaluating signs & symptoms. CRP is not elevated in all patients with active axSpA questioning its validity as a universal biomarker of response. Ixekizumab (IXE) demonstrated efficacy in axSpA treatment irrespective of baseline (BL) CRP levels. However, response to IXE categorized on CRP change from BL is unknown.

Objectives:

To evaluate response to IXE treatment from BL through week (wk) 16 in patients with axSpA categorized according to change in high sensitivity (hs) CRP.

Methods:

COAST-V (NCT 02696785),-W (NCT02696798), & -X (NCT02757352), were phase 3, multicentre, randomized, controlled trials, investigating the efficacy of IXE 80 mg every 4 & 2 wks in patients with: r-axSpA naïve to biologic disease-modifying antirheumatic drugs (bDMARDs; COAST-V); or who were inadequate responders/intolerant to tumour necrosis factor inhibitors (TNFi; COAST-W); or who fulfilled Assessment of SpondyloArthritis International Society (ASAS) criteria for non-radiographic (nr)axSpA (COAST-X).

This post hoc analysis focuses on approved dosing regimens. Depending on BL and wk 16 hsCRP values, patients were categorised as stable low (hsCRP ≤5 mg/L at BL & ≤5 mg/L at wk 16), normalized (hsCRP >5 mg/L at BL & ≤5 mg/L at wk 16) or elevated (hsCRP >5 mg/L at wk 16, irrespective of BL hsCRP). An absolute cutoff of 5 mg/L was used as the stratification factor in all COAST studies. Data were analyzed by treatment arm. Each trial was analyzed separately.

For hsCRP subgroups, patient demographics & other characteristics at BL, as well as trajectory over time for the endpoints ASAS40 & Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) 50 are described. Non-responder imputation was used for missing values.

Results:

In all studies at BL, disease activity & MRI SPARCC score were higher in normalized & elevated subgroups compared to the stable low subgroup - a.

In COAST-V, ASAS40 & BASDAI50 response was observed in IXE-treated patients regardless of hsCRP change status by wk 16 vs placebo. The highest ASAS40 & BASDAI50 response rate was reported in patients with normalized hsCRP - b. Similar findings were observed in COAST-W & -X.

Table 1.

Baseline Patient demographics & other characteristics - ITT population, per CRP subgroup

COAST-V(r-axSpA, bDMARD naive)COAST-W(r-axSpA, inadequate responders /intolerant to TNFi)COAST-X(non-radiographic axSpA, bDMARD naïve)Stable low (n=79)Norma-lized (n=80)Elevated (n=98)Stable low(n=58)Norma-lized (n=34)Elevated (n=126)Stable low (n=78)Norma-lized(n=40)Elevated (n=81)ParameterAge (years)43.7 (12.1)38.9 (10.9)42.7 (12.0)50.4 (13.3)46.1 (13.8)45.7 (12.5)44.0 (12.8)37.2 (14.6)38.7 (12.8)Male gender, n (%)63 (79.7)71.0 (88.8)78 (79.6)39.0 (67.2)30 (88.2)109 (86.5)35 (44.9)23 (57.5)34 (42)Duration of symptoms since axSpA onset (years)17.5 (11.2)14.4 (9.3)16.1 (9.9)21.7 (12.9)16.8 (11.6)18.9 (10.9)12.1 (9.9)10.3 (9.7)9.5 (9.0)HLA-B27 positive, n (%)69 (87.3)75.0 (93.8)89 (90.8)31.0 (91.2)101 (80.2)101 (80.2)48 (61.5)31 (77.5)67 (82.7)BASDAI Total Score6.5 (1.4)6.7 (1.5)7.0 (1.1)7.4 (1.5)7.3 (1.3)7.4 (1.3)6.9 (1.5)7.1 (1.6)7.2 (1.5)ASDAS Total Score3.1 (0.5)3.9 (0.6)4.2 (0.7)3.5 (0.6)4.3 (0.6)4.4 (0.8)3.2 (0.6)4.2 (0.8)4.2 (0.9)Spinal Pain due to AS7.0 (1.5)7.0 (1.5)7.5 (1.3)7.8 (1.5)7.7 (1.5)7.9 (1.4)7.2 (1.7)7.5 (1.7)7.5 (1.6)Patients with peripheral articular manifestations (>=1 TJC or >=1 SJC)47 (59.5)40 (50)62 (63.3)43 (74.1)24 (70.6)86 (68.3)56 (71.8)33 (82.5)66 (81.5)MRI Spine SPARCC ScoreMRI SIJ SPARCC ScoreMRI SPARCC Score6.7 (11.2)21.8 (27.3)20.7 (25.7)1.2 (2.3)7.0 (7.6)10.4 (17.0)5.2 (6.6)6.1 (8.2)6.2 (10.5)

Conclusion:

IXE reduced clinical disease activity in patients with axSpA irrespective of hsCRP change from BL to wk 16. Improvement in hsCRP level was associated with overall response rates.

Acknowledgements:

The authors would like to acknowledge Philana Fernandes, an employee of Eli Lilly and Company, for her for writing and editorial support.

Disclosure of Interests:

Helena Marzo-Ortega Consultant of: Celgene, Janssen, Eli Lilly, Novartis, Pfizer, UCB, Grant/research support from: Janssen, Novartis, Xavier Juanola: None declared, Tadashi Okano Speakers bureau: Asahi Kasei, Astellas, Abbvie, Ayumi, Chugai, Daiichi-Sankyo, Eisai, Eli Lilly, Janssen, Mitsubishi Tanabe, Novartis, Ono, Pfizer, Sanofi and Takeda, Grant/research support from: Asahi Kasei, Abbvie, Chugai, Eisai, Yves Schymura Employee of: Eli Lilly, Andrew Bradley Shareholder of: Eli Lilly, Employee of: Eli Lilly, Jens Gerwien Shareholder of: Eli Lilly, Employee of: Eli Lilly, Brigitte Monsberger Shareholder of: Eli Lilly, Employee of: Eli Lilly, Soyi Liu Leage Employee of: Eli Lilly, Daniel Aletaha Speakers bureau: Abbvie, Amgen, Celgene, Lilly, Medac, Merck, Novartis, Pfizer, Roche, Sandoz, Sanofi/Genzyme, Grant/research support from: Abbvie, Lilly, Novartis, Roche, Mikkel Østergaard Speakers bureau: Abbvie, Celgene, Eli-Lilly, Janssen, Novartis, Pfizer, Roche, Sanofi and UCB, Consultant of: Abbvie, BMS, Boehringer-Ingelheim, Celgene, Eli-Lilly, Hospira, Janssen, Merck, Novartis, Novo, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi and UCB, Grant/research support from: Abbvie, BMS, Merck, Celgene, Novartis

450 Retrospective Analysis of Surgical Clerk-Ins Within the Acute Receiving Unit: A Quality Improvement Project

Introduction

Accurate patient documentation at the ARU is vital to patient safety and ensuring smooth handovers to secondary care services. Because the nature of surgical treatment requires frequent patient handovers, and this increases the risk of miscommunication, we aimed to assess the quality of surgical clerk-ins and identify areas for improvement.

Method

Emergency admissions at the Dumfries Galloway Royal Infirmary were audited, looking at documentation quality under various clerk-in sections. Data was analysed before presentation to clinical governance.

Results

When 46 patient clerk-ins were examined, venous thromboembolism (VTE) prophylaxis plans were performed in only 24% of admissions - less than 1 in 4 patients.

Comparing out-of-hours and in-hours patient documentation, much higher omission rates were identified in the out-of-hours documentation: in systemic enquiry (42 vs 100%) and family history (31% vs 66%).

Conclusions

These results brought to attention the effect of hospital admission timing on patient documentation quality, and the lack of VTE prophylaxis planning. In surgery, these plans are key to minimising risk of avoidable thromboembolic complications.

A departmental meeting was convened to stress the importance of accurate and comprehensive clerk-ins to ARU doctors. Future audits could explore the factors influencing documentation quality for out-of-hours admissions, and ways to address these issues.

Inequity in Access to Transplantation in the United Kingdom

BACKGROUND AND OBJECTIVES

Despite the presence of a universal health care system, it is unclear if there is intercenter variation in access to kidney transplantation in the United Kingdom. This study aims to assess whether equity exists in access to kidney transplantation in the United Kingdom after adjustment for patient-specific factors and center practice patterns.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

In this prospective, observational cohort study including all 71 United Kingdom kidney centers, incident RRT patients recruited between November 2011 and March 2013 as part of the Access to Transplantation and Transplant Outcome Measures study were analyzed to assess preemptive listing (n=2676) and listing within 2 years of starting dialysis (n=1970) by center.

RESULTS

Seven hundred and six participants (26%) were listed preemptively, whereas 585 (30%) were listed within 2 years of commencing dialysis. The interquartile range across centers was 6%-33% for preemptive listing and 25%-40% for listing after starting dialysis. Patient factors, including increasing age, most comorbidities, body mass index >35 kg/m², and lower socioeconomic status, were associated with a lower likelihood of being listed and accounted for 89% and 97% of measured intercenter variation for preemptive listing and listing within 2 years of starting dialysis, respectively. Asian (odds ratio, 0.49; 95% confidence interval, 0.33 to 0.72) and Black (odds ratio, 0.43; 95% confidence interval, 0.26 to 0.71) participants were both associated with reduced access to preemptive listing; however Asian participants were associated with a higher likelihood of being listed after starting dialysis (odds ratio, 1.42; 95% confidence interval, 1.12 to 1.79). As for center factors, being registered at a transplanting center (odds ratio, 3.1; 95% confidence interval, 2.36 to 4.07) and a universal approach to discussing transplantation (odds ratio, 1.4; 95% confidence interval, 1.08 to 1.78) were associated with higher preemptive listing, whereas using a written protocol was associated negatively with listing within 2 years of starting dialysis (odds ratio, 0.7; 95% confidence interval, 0.58 to 0.9).

CONCLUSIONS

Patient case mix accounts for most of the intercenter variation seen in access to transplantation in the United Kingdom, with practice patterns also contributing some variation. Socioeconomic inequity exists despite having a universal health care system.

P264 Burden of disease and relative impact of skin and joint disease on quality of life in PsA: analysis from a UK secondary care cohort

Background

Understanding the impact of psoriatic arthritis (PsA) on an individual and how the disease evolves over time is important when determining a therapeutic strategy. However, little is known about the natural course of arthritis, psoriasis, and enthesitis, their relative impact on quality of life and how disease burden in real world cohorts compares to clinical trial populations. We set out to describe the burden of disease and impact on quality of life in an observational UK secondary care cohort.

Methods

Cross sectional cohorts were selected from the Bath PsA cohort, group one with early disease (within 24 months of diagnosis), groups two and three with established disease (commencing therapy with first or second line biologic Disease Modifying Anti-Rheumatic Drug- bDMARD therapy respectively; assessments both at initiation and 3 months after initiation).

Results

Analyses were undertaken where sufficient data was available on 154 patients eligible for entry into the early PsA cohort (group 1), 240 patients eligible for the biologic initiator cohort (group 2) and 103 for the second line biologics initiator cohort. Cohort characteristics are reported in Table 1. The burden of joint disease was high in all cohorts and approximately comparable to clinical trial populations in group 2 commencing bDMARD (mean tender joints count 22 (SD 14), swollen 7 (SD 5) cDAPSA mean 36 (SD 15)). Mean Body Mass Index (BMI) rose from overweight in early disease to obese in established disease (table 1). There was little enthesitis in any group (LEI mean &lt;1). There was a significant burden of joint disease (cDAPSA), fatigue (FACT) and work disability among those 3 months post commencing bDMARD despite good clinical responses (table 1). The level of skin (PASI) and nail disease (Bath Nail score) was low but remains strongly associated with worse quality of life and the association was stronger in established disease.

Conclusion

We report high levels of residual joint disease, fatigue, obesity and work disability in both early and established PsA cohorts. Despite low absolute levels of residual skin and nail disease both become more strongly associated with worse quality of life in more established disease.

Disclosures

W. Tillett: Honoraria; Eli Lilly, Janssen, Novartis, Pfizer, UCB. Grants/research support; Abbvie, Eli Lilly, Celgene. A. Rambojun: Grants/research support; EPSRC. A. Bradley: Shareholder/stock ownership; Eli Lilly and Company Limited. Other; Employee of Eli Lilly and Company Limited. J. Mount: Shareholder/stock ownership; Eli Lilly and Company Limited. Other; Employee of Eli Lilly and Company Limited. C. Cavill: Grants/research support; Eli Lilly and Company Limited. E. Korendowych: Honoraria; Abbvie, Eli Lilly, Janssen, Novartis. Grants/research support; Eli Lilly and Company Limited. N. McHugh: Consultancies; Abbvie. Grants/research support; Eli Lilly and Company Limited.

Cross-sectional study of the prevalence, causes and management of hospital-onset diarrhoea

BACKGROUND

The National Health Service in England advises hospitals collect data on hospital-onset diarrhoea (HOD). Contemporaneous data on HOD are lacking.

AIM

To investigate prevalence, aetiology and management of HOD on medical, surgical and elderly-care wards.

METHODS

A cross-sectional study in a volunteer sample of UK hospitals, which collected data on one winter and one summer day in 2016. Patients admitted ≥72 h were screened for HOD (definition: ≥2 episodes of Bristol Stool Type 5-7 the day before the study, with diarrhoea onset >48 h after admission). Data on HOD aetiology and management were collected prospectively.

FINDINGS

Data were collected on 141 wards in 32 hospitals (16 acute, 16 teaching). Point-prevalence of HOD was 4.5% (230/5142 patients; 95% confidence interval (CI) 3.9-5.0%). Teaching hospital HOD prevalence (5.9%, 95% CI 5.1-6.9%) was twice that of acute hospitals (2.8%, 95% CI 2.1-3.5%; odds ratio 2.2, 95% CI 1.7-3.0). At least one potential cause was identified in 222/230 patients (97%): 107 (47%) had a relevant underlying condition, 125 (54%) were taking antimicrobials, and 195 (85%) other medication known to cause diarrhoea. Nine of 75 tested patients were Clostridium difficile toxin positive (4%). Eighty (35%) patients had a documented medical assessment of diarrhoea. Documentation of HOD in medical notes correlated with testing for C. difficile (78% of those tested vs 38% not tested, P<0.001). One-hundred and forty-four (63%) patients were not isolated following diarrhoea onset.

CONCLUSION

HOD is a prevalent symptom affecting thousands of patients across the UK health system each day. Most patients had multiple potential causes of HOD, mainly iatrogenic, but only a third had medical assessment. Most were not tested for C. difficile and were not isolated.

Health assessments and screening tools for adults experiencing homelessness: a systematic review

Background

Homelessness is increasing globally. It results in poorer physical and mental health than age matched people living in permanent housing. Better information on the health needs of people experiencing homelessness is needed to inform effective resourcing, planning and service delivery by government and care organisations.

The aim of this review was to identify assessment tools that are valid, reliable and appropriate to measure the health status of people who are homeless.

Methods

Data sources: A systematic literature search was conducted in PubMed (and Medline), PsychInfo, Scopus, CINAHL and ERIC from database inception until September 2018. Key words used were homeless, homelessness, homeless persons, vagrancy, health status, health, health issues, health assessment and health screening. The protocol was registered with PROSPERO. The National Health and Medical Research Council of Australia (NHMRC) hierarchy of evidence was applied; methodological quality of included articles was assessed using the McMaster critical appraisal tools and psychometric properties of the tools were appraised using the International Centre for Allied Health Evidence Ready Reckoner.

Results

Diverse tools and measures (N = 71) were administered within, and across the reviewed studies (N = 37), with the main focus being on general health, oral health and nutrition. Eleven assessment tools in 13 studies had evidence of appropriate psychometric testing for the target population in domains of quality of life and health status, injury, substance use, mental health, psychological and cognitive function. Methodological quality of articles and tools were assessed as moderate to good. No validated tools were identified to assess oral health, chronic conditions, anthropometry, demography, nutrition, continence, functional decline and frailty, or vision and hearing. However, assessments of physical constructs (such as oral health, anthropometry, vision and hearing) could be applied to homeless people on a presumption of validity, because the constructs would be measured with clinical indicators in the same manner as people living in permanent dwellings.

Conclusions

This review highlighted the need to develop consistent and comprehensive health assessment tools validated with, and tailored for, adults experiencing homelessness.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7234-y) contains supplementary material, which is available to authorized users.

Aging phenotype(s) in kidneys of diabetic mice are p66ShcA dependent

The p66ShcA protein controls cellular responses to oxidative stress, senescence, and apoptosis. Here, we test the hypothesis that aging phenotype(s) commonly associated with the broad category of chronic kidney disease are accelerated in diabetic kidneys and linked to the p66ShcA locus. At the organ level, tissue stem cells antagonize senescent phenotypes by replacing old dysfunctional cells. Using established methods, we isolated a highly purified population of stem cell antigen-1-positive mesenchymal stem cells (Sca-1⁺ MSCs) from kidneys of wild-type (WT) and p66 knockout (p66 KO) mice. Cells were plated in culture medium containing normal glucose (NG) or high glucose (HG). Reactive oxygen species (ROS) metabolism was substantially increased in WT MSCs in HG medium in association with increased cell death by apoptosis and acquisition of the senescent phenotype. DNA microarray analysis detected striking differences in the expression profiles of WT and p66 KO-MSCs in HG medium. Unexpectedly, the analysis for p66 KO-MSCs revealed upregulation of Wnt genes implicated in self-renewal and differentiation. To test the in vivo consequences of constitutive p66 expression in diabetic kidneys, we crossed the Akita diabetic mouse with the p66KO mouse. Homozygous mutation at the p66 locus delays or prevents aging phenotype(s) in the kidney that may be precursors to diabetic nephropathy.

Multiple traumatisation and subsequent psychopathology in people with intellectual disabilities and DSM-5 PTSD: a preliminary study

BACKGROUND

Individuals with intellectual disability (ID) are at greater risk of exposure to traumatic life events compared with the non-ID population. Yet no study to date has examined the role of multiple traumatisation and subsequent psychopathology in people with ID. The aim of this study was to explore the association between multiple traumatisation and subsequent mental health.

METHODS

A preliminary cross-sectional study involving 33 participants with DSM-5 post-traumatic stress disorder completed self-report questionnaires on exposure to traumatic life events and post-traumatic stress disorder symptoms, anxiety, depression and general distress.

RESULTS

A proportion of 42.4% of the sample reported multiple traumatisation, including exposure to life events in both childhood and adulthood. Those who reported exposure to life events in childhood and adulthood reported significantly higher risk of harm, depression and general psychological distress compared with those who reported exposure to life events only in adulthood.

CONCLUSIONS

Preliminary results indicate that more severe psychopathology is associated with multiple traumatisation in childhood and adulthood compared with trauma experienced solely in adulthood.

Clinician Attitudes Regarding ICD Deactivation in DNR/DNI Patients

BACKGROUND

Implantable cardioverter-defibrillators (ICDs) offer lifesaving therapies but can become burdensome at the end of life. Many ICD patients choose to implement a do-not-resuscitate/do-not-intubate (DNR/DNI) order. When hospitalized, patients are seen by a range of clinicians whose beliefs about ICD management in DNR/DNI patients may vary.

OBJECTIVE

To assess clinician opinions on managing ICDs in DNR/DNI patients and stratify it by specialty and training level.

METHODS

An online survey was sent to attending physicians, fellows, advanced practice providers (physician assistants and nurse practitioners), and residents in general internal medicine, cardiology, electrophysiology, and geriatrics at an academic medical center. Residents were compared to attending physicians, and attending physicians were additionally stratified by specialty.

RESULTS

The response rate was 32%, yielding 161 complete responses. Among residents (n = 73), 49.3% were comfortable with discussing ICD deactivation and 16.4% asked about it routinely. By contrast, among attending physicians (n = 66), 78.8% were comfortable with discussing deactivation and 34.8% routinely asked. Fewer general internists (19.2% of inpatient internists, 10.5% of outpatient internists) routinely asked about ICD deactivation as compared with 83.3% of geriatricians and 73.3% of cardiologists/electrophysiologists. Twenty-one percent of all respondents felt a DNR/DNI order equated to requesting ICD deactivation; Heart Rhythm Society (HRS) guidelines favor a more nuanced approach.

CONCLUSIONS

Residents are less comfortable discussing ICD deactivation than attending physicians and do so less frequently. General internists discuss deactivation less routinely than cardiologists and geriatricians. Many providers hold opinions about ICD deactivation that differ from HRS guidelines. Additional didactic education could help close these gaps in clinician practice.

Guinea worm infection in northern Nigeria: reflections on a disease approaching eradication

Global eradication of the guinea worm (Dracunculus medinensis) is near, although perhaps delayed a little by the discovery of a transmission cycle in dogs. It is therefore an appropriate time to reflect on the severe impact of this infection on the life of the communities where it was endemic prior to the start of the global eradication programme in 1981. From 1971 to 1974, we conducted a series of unpublished studies on guinea worm in a group of villages in Katsina State, northern Nigeria, where the infection was highly endemic. These studies demonstrated the high rate of infection in affected communities, the frequent recurrence of the infection in some subjects and the long‐standing disability that remained in some infected individuals. Immunological studies showed a high level of immediate hypersensitivity to adult worm and larval antigens but a downregulation of Th1‐type T‐cell responses to worm antigens. Freeing communities such as those described in this article from the scourge of guinea worm infection for good will be an important public health triumph.

Results on the Spin-Dependent Scattering of Weakly Interacting Massive Particles on Nucleons from the Run 3 Data of the LUX Experiment

We present experimental constraints on the spin-dependent WIMP (weakly interacting massive particle)-nucleon elastic cross sections from LUX data acquired in 2013. LUX is a dual-phase xenon time projection chamber operating at the Sanford Underground Research Facility (Lead, South Dakota), which is designed to observe the recoil signature of galactic WIMPs scattering from xenon nuclei. A profile likelihood ratio analysis of 1.4×10^{4}  kg day of fiducial exposure allows 90% C.L. upper limits to be set on the WIMP-neutron (WIMP-proton) cross section of σ_{n}=9.4×10^{-41}  cm^{2} (σ_{p}=2.9×10^{-39}  cm^{2}) at 33  GeV/c^{2}. The spin-dependent WIMP-neutron limit is the most sensitive constraint to date.

Improved Limits on Scattering of Weakly Interacting Massive Particles from Reanalysis of 2013 LUX Data

We present constraints on weakly interacting massive particles (WIMP)-nucleus scattering from the 2013 data of the Large Underground Xenon dark matter experiment, including 1.4×10^{4}  kg day of search exposure. This new analysis incorporates several advances: single-photon calibration at the scintillation wavelength, improved event-reconstruction algorithms, a revised background model including events originating on the detector walls in an enlarged fiducial volume, and new calibrations from decays of an injected tritium β source and from kinematically constrained nuclear recoils down to 1.1 keV. Sensitivity, especially to low-mass WIMPs, is enhanced compared to our previous results which modeled the signal only above a 3 keV minimum energy. Under standard dark matter halo assumptions and in the mass range above 4  GeV c^{-2}, these new results give the most stringent direct limits on the spin-independent WIMP-nucleon cross section. The 90% C.L. upper limit has a minimum of 0.6 zb at 33  GeV c^{-2} WIMP mass.

Effect of Wood Biochar in Manure-Applied Sand Columns on Leachate Quality

Agricultural operations can pose a threat to the quality of nearby water sources particularly from nitrogen (N) and phosphorus (P) losses following land application of manure. Biochar application to soils has the potential to ameliorate degraded soils and reduce nutrient leaching to groundwater. The effects of amending sand soil columns with hybrid poplar biochar ( spp.) made by a slow-pyrolysis process at 450°C at varying rates (0, 1, 2, and 5% by weight) with repeated dairy manure applications over a 56-wk period was examined to evaluate the impact to leachate water quality. Increasing levels of biochar decreased cumulative levels of total N (TN) by 21 to 59%, nitrate (NO-N) by 17 to 46%, and ammonia (NH-N + NH-N) by 46 to 90% in leachate but increased cumulative leaching of total P (TP). Overall leachate pH was increased and peak levels of 5-d biological oxygen demand (BOD) in leachate after manure application were decreased with increasing levels of biochar amendment. The results from this study indicate that biochar amendments could be effective in reducing nitrogen leaching from soils, though further study is needed to determine practical application in a field setting.