Capacity building to address antimicrobial resistance in remote Australia: The inaugural HOT NORTH Antimicrobial Academy

BACKGROUND

Rates of antimicrobial resistance (AMR) for some pathogens in Australia are considerably higher in rural and remote compared to urban regions. The inaugural Hot North Antimicrobial Academy was a 9-month educational programme aimed to build workforce knowledge and capacity in antimicrobial use, audit, stewardship, surveillance and drug resistance in remote primary health care.

METHODS

The Academy was advertised to Aboriginal and Torres Strait Islander, regional and remote healthcare workers. Participants were Aboriginal health practitioners, nurses, pharmacists and doctors from Queensland, Northern Territory, South Australia and Western Australia working in remote primary health care with a focus on Indigenous health. Due to COVID-19 restrictions, the Academy ran virtually from February-November 2021 using Microsoft Teams. The Academy was evaluated using surveys and yarning circles to assess impact and knowledge gain.

RESULTS

Participants and faculty from across Australia attended 19 lectures and mentorship sessions. Eleven participants commenced and eight (73%) completed the Academy. The Academy raised participants awareness of AMR guidelines, governance and generating change; built confidence in advocacy; grew knowledge about drug resistant infections; and created a community of AMR champions in Indigenous health.

CONCLUSION

The evaluation confirmed the Academy met the needs of participants, provided opportunities to move stewardship from tertiary hospitals into Indigenous and remote clinics and developed skills in research, audit, stewardship and advocacy for all involved. All sessions were recorded for future use, with facilitation by the National Aboriginal Community Controlled Health Organisation (NACCHO) in future years.

Coordinating virus research: The Virus Infectious Disease Ontology

The COVID-19 pandemic prompted immense work on the investigation of the SARS-CoV-2 virus. Rapid, accurate, and consistent interpretation of generated data is thereby of fundamental concern. Ontologies-structured, controlled, vocabularies-are designed to support consistency of interpretation, and thereby to prevent the development of data silos. This paper describes how ontologies are serving this purpose in the COVID-19 research domain, by following principles of the Open Biological and Biomedical Ontology (OBO) Foundry and by reusing existing ontologies such as the Infectious Disease Ontology (IDO) Core, which provides terminological content common to investigations of all infectious diseases. We report here on the development of an IDO extension, the Virus Infectious Disease Ontology (VIDO), a reference ontology covering viral infectious diseases. We motivate term and definition choices, showcase reuse of terms from existing OBO ontologies, illustrate how ontological decisions were motivated by relevant life science research, and connect VIDO to the Coronavirus Infectious Disease Ontology (CIDO). We next use terms from these ontologies to annotate selections from life science research on SARS-CoV-2, highlighting how ontologies employing a common upper-level vocabulary may be seamlessly interwoven. Finally, we outline future work, including bacteria and fungus infectious disease reference ontologies currently under development, then cite uses of VIDO and CIDO in host-pathogen data analytics, electronic health record annotation, and ontology conflict-resolution projects.

Evaluation of Metastatic Potential in Esophageal and Gastroesophageal Junction (GEJ) Cancer with Adherence to Elective Nodal Volume Guidelines: A Retrospective Analysis of Elective Nodal Irradiation

PURPOSE/OBJECTIVE(S)

In 2015, expert guidelines on esophageal/GEJ cancer contouring for intensity-modulated radiation therapy (IMRT) were published in IJROBP, which delineate recommended elective nodal basins (celiac, para-aortic, gastrohepatic ligament, supraclavicular) to be irradiated depending on the primary tumor location. We hypothesize that incomplete coverage of these areas increases the risk of the development of distant failures.

MATERIALS/METHODS

Patients treated for non-metastatic esophageal or GEJ cancer with chemoradiotherapy pre-operatively or definitively from 2012 to 2021 were retrospectively identified from a single institution database. Radiation plans of eligible patients were then analyzed by tumor location. Plans were deemed guideline-compliant if radiation dose coverage, between 41.4 to 45 Gy, encompassed nodal basins recommended by the 2015 guidelines. The primary endpoint of this study was the overall rate of distant disease. Other endpoints included locoregional failures, defined as failures within the radiation field but outside of the primary tumor, and local failures within the gross tumor volume. Summary and descriptive statistics were used to define collected variables. Differences were measured using chi-square and Fisher's exact test for categorical variables and two-sided t-tests for continuous measures. Assessment of distant, locoregional, and local failures were assessed using univariate logistic regression with statistical significance at p < 0.05.

RESULTS

With a median follow-up of 25.0 months, 37 patients, with a median age of 66, were included in the study. Most patients were male (94.6%) with cT3 (54.1%), cN0 (43.2%), moderately differentiated (47.1%) adenocarcinoma (75.7%) located at the GEJ (56.8%). The median radiation dose used was 50.4 Gy, with the majority of patients receiving concurrent carboplatin and paclitaxel (83.8%). Four patients received induction chemotherapy and 20 (55.6%) underwent esophagectomy. When examining guideline compliance, 17 (46.0%) radiation plans demonstrated adequate ENI. The most common improperly covered nodal basin was para-aortic (65.0%), followed by gastrohepatic (30.0%). No patients with sufficient ENI coverage (0/17) developed distant failure compared to 45.0% (9/20) with insufficient coverage (p = 0.001). There were inappreciable differences in locoregional or local failure rates between those with and without complete ENI. Patients with complete ENI were more likely to be of larger craniocaudal length (p = 0.007) or have N2 disease (p = 0.003). When examining other tumor characteristics (histologic subtype, location, HER2 status, esophagectomy rate) of patients with and without complete ENI, no further differences were noted.

CONCLUSION

These results suggest that proper coverage of nodal basins, when indicated by expert guidelines, could improve distant metastasis. ENI analysis of previous prospective CRT studies for esophageal cancer could validate these findings.

Improving the Quality and Utility of Electronic Health Record Data through Ontologies

The translational research community, in general, and the Clinical and Translational Science Awards (CTSA) community, in particular, share the vision of repurposing EHRs for research that will improve the quality of clinical practice. Many members of these communities are also aware that electronic health records (EHRs) suffer limitations of data becoming poorly structured, biased, and unusable out of original context. This creates obstacles to the continuity of care, utility, quality improvement, and translational research. Analogous limitations to sharing objective data in other areas of the natural sciences have been successfully overcome by developing and using common ontologies. This White Paper presents the authors' rationale for the use of ontologies with computable semantics for the improvement of clinical data quality and EHR usability formulated for researchers with a stake in clinical and translational science and who are advocates for the use of information technology in medicine but at the same time are concerned by current major shortfalls. This White Paper outlines pitfalls, opportunities, and solutions and recommends increased investment in research and development of ontologies with computable semantics for a new generation of EHRs.

Nanoplasma resonance condition in the middle-infrared spectral range

The resonance-absorption condition in the laser-nanoplasma interactions has been considered to follow the wavelength dependence of the critical plasma density. We experimentally demonstrate that this assumption fails in the middle-infrared spectral range, while it is valid for visible and near-infrared wavelengths. A thorough analysis supported by molecular dynamic (MD) simulations indicates that the observed transition in the resonance condition is caused by the reduction of the electron scattering rate and the associated increase of the cluster outer-ionization contribution. An expression for the nanoplasma resonance density is derived based on experimental results and MD simulations. The findings are important for a broad range of plasma experiments and applications, since the extension of the laser-plasma interaction studies to longer wavelengths has become increasingly topical.

A152 ASSESSING THE USE OF A VALIDATED LYNCH SCREENING QUESTIONNAIRE IN THE OUTPATIENT SETTING AND SUBSEQUENT CHANGES IN PATIENT MANAGEMENT

Background

Colorectal cancer (CRC) is the second most common cause of cancer related deaths in Canada. Approximately 1 in 13 males and 1 in 18 females will develop colorectal cancer in their lifetimes. As many as 10% of CRC may be associated with an inherited syndrome. Lynch Syndrome (LS) is the most common cause of inherited CRC, estimated to account for 3-4% of all CRC cases. . A study by Kastrinos et al. found that a simple, 3 item survey, identified 77% of individuals with known LS. Implementation of this questionnaire at a gastroenterology office may help identify patients at risk for LS.

Purpose

To assess whether implementation of a validated questionnaire to screen for LS is feasible in an outpatient gastroenterology clinic, and if these results would change patient management by gastroenterologists.

Method

Included in this study were all patients 18 years or older, who had been referred to one of the gastroenterologists at Pacific Gastroenterology Associates in Vancouver, British Columbia. Exclusion criteria included those patients less than 18 years of age, and patients previously seen by the HCP.

Each subject was asked the following three questions: (1) Do you have a first-degree relative with CRC or LS-related cancer diagnosed before age 50? (2) Have you had CRC or polyps diagnosed before age 50? (3) Do you have ≥3 relatives with CRC?. Answering yes to any question was considered a positive screen.

Gastroenterologists were initially blinded to the content of the questionnaire and results. After completion of the questionnaire and formal gastroenterology consultation, the patients who screened positive for an increased risk of LS had their results unblinded to their primary gastroenterologist. Gastroenterologists were then asked if the survey results changed their management.

Result(s)

A total of 655 patients were screened, with 33 (5.0%) screening positive for question 1, 71 (10.8%) screening positive for question 2, and 17 (2.6%) screening positive for question 3. In total, 106 (15.9%) of individuals surveyed screened positive indicating higher risk for hereditary colorectal cancer.

Subsequent reassessment by gastroenterologists of patients screening positive with the LS questionnaire (n=51) yielded no change to 47 patients (92%), screening with colonoscopy not originally planned for 1 patient (2%), re-consultation for further risk assessment for 2 patients (4%) and 1 referral to the Hereditary Cancer Program (2%).

Conclusion(s)

Utilization of a simple 3-question survey as part of regular patient intake in a gastroenterology office resulted in an increased number of individuals being identified as being high risk for Lynch syndrome, with a subsequent increase in endoscopic screening not otherwise planned, further assessment for colon cancer risk, and an increased referral to the Hereditary Cancer Program.

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Disclosure of Interest

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Outcomes of laboratory-confirmed SARS-CoV-2 infection during resurgence driven by Omicron lineages BA.4 and BA.5 compared with previous waves in the Western Cape Province, South Africa

OBJECTIVES

We aimed to compare the clinical severity of Omicron BA.4/BA.5 infection with BA.1 and earlier variant infections among laboratory-confirmed SARS-CoV-2 cases in the Western Cape, South Africa, using timing of infection to infer the lineage/variant causing infection.

METHODS

We included public sector patients aged ≥20 years with laboratory-confirmed COVID-19 between May 01-May 21, 2022 (BA.4/BA.5 wave) and equivalent previous wave periods. We compared the risk between waves of (i) death and (ii) severe hospitalization/death (all within 21 days of diagnosis) using Cox regression adjusted for demographics, comorbidities, admission pressure, vaccination, and previous infection.

RESULTS

Among 3793 patients from the BA.4/BA.5 wave and 190,836 patients from previous waves, the risk of severe hospitalization/death was similar in the BA.4/BA.5 and BA.1 waves (adjusted hazard ratio [aHR] 1.12; 95% confidence interval [CI] 0.93; 1.34). Both Omicron waves had a lower risk of severe outcomes than previous waves. Previous infection (aHR 0.29, 95% CI 0.24; 0.36) and vaccination (aHR 0.17; 95% CI 0.07; 0.40 for at least three doses vs no vaccine) were protective.

CONCLUSION

Disease severity was similar among diagnosed COVID-19 cases in the BA.4/BA.5 and BA.1 periods in the context of growing immunity against SARS-CoV-2 due to previous infection and vaccination, both of which were strongly protective.

A new framework for host-pathogen interaction research

COVID-19 often manifests with different outcomes in different patients, highlighting the complexity of the host-pathogen interactions involved in manifestations of the disease at the molecular and cellular levels. In this paper, we propose a set of postulates and a framework for systematically understanding complex molecular host-pathogen interaction networks. Specifically, we first propose four host-pathogen interaction (HPI) postulates as the basis for understanding molecular and cellular host-pathogen interactions and their relations to disease outcomes. These four postulates cover the evolutionary dispositions involved in HPIs, the dynamic nature of HPI outcomes, roles that HPI components may occupy leading to such outcomes, and HPI checkpoints that are critical for specific disease outcomes. Based on these postulates, an HPI Postulate and Ontology (HPIPO) framework is proposed to apply interoperable ontologies to systematically model and represent various granular details and knowledge within the scope of the HPI postulates, in a way that will support AI-ready data standardization, sharing, integration, and analysis. As a demonstration, the HPI postulates and the HPIPO framework were applied to study COVID-19 with the Coronavirus Infectious Disease Ontology (CIDO), leading to a novel approach to rational design of drug/vaccine cocktails aimed at interrupting processes occurring at critical host-coronavirus interaction checkpoints. Furthermore, the host-coronavirus protein-protein interactions (PPIs) relevant to COVID-19 were predicted and evaluated based on prior knowledge of curated PPIs and domain-domain interactions, and how such studies can be further explored with the HPI postulates and the HPIPO framework is discussed.

It doesn’t add up! Calculations in the modern pharmacy technician curriculum

Introduction

Current teaching of calculations to pre-registration pharmacy technicians covers a variety of areas, including dose calculations, conversions, molarity, percentages, displacement values and dilutions. Within the University of East Anglia course these are taught over 2 years with 5 exams spread throughout the course. The extent of how much each calculation is used in practice is unknown. Currently the only educational requirement for pharmacy technicians relating to calculations is to ‘‘Accurately perform pharmaceutical calculations to ensure the safety of people’’ 1. This is open to interpretation and there is no definitive list of what types of calculations pharmacy technicians are expected to carry out and therefore should be taught.

Aim

Identify the types of calculations that pharmacy technicians undertake in practice and compare this to the types of calculation currently taught on the pre-registration training course for pharmacy technicians.

Methods

An online survey was distributed via a gatekeeper (after ethical approval, ref ETH2122-1122) to pre-registration pharmacy technicians enrolled on the UEA training programme in their second year, and their educational supervisors who are registered pharmacy technicians. Consenting responders were asked how often they use a variety of calculations in daily practice ranging from ‘never used’ to ‘use every day’. Calculation examples included quantities and volumes to supply, unit conversions, infusion rates, ingredient amounts (using formulae, percentages and displacement values) and molarity. Data collected were analysed using descriptive statistics via the online JISC survey platform.

Results

51 responses were received: 45% pharmacy technicians and 55% pre-registration pharmacy technicians. Responders were from a variety of pharmacy settings: 52.2 % hospital, 17.4% community and the remaining split between mental health, general practice, health in justice, care homes, education and Primary Care Networks. All calculations had been used in practice but to varying degrees of regularity. More common types were: calculating the quantity to supply (100% having used), calculating a dose by volume of liquid (98.1%) and converting dosage units (98.1%). 16 out of 28 calculation types were ‘never used’ by over 50% of responders. The most rarely used being: calculating the molarity of a solution (9.8%), calculating the amount of ingredient to make a set molarity (6.9%), and using displacement values to calculate the base needed for suppositories (6.9%).

Discussion/Conclusion

The results show that there is disparity between what calculations are taught and what calculations are used by pharmacy technicians in practice. Potential improvements to the curriculum could be to remove some calculations that are less frequently used, focussing more upon commonly used calculations. Removal of any calculations from the curriculum however could result in learners being unable to effectively undertake these if they were to come across the calculation in practice. More research is needed into the importance of learning these calculations, the consequence of removing them from initial curriculums and if there is a need to teach these as further learning for qualified pharmacy technicians.

References

1. General Pharmaceutical Council. Standards for the initial education and training of pharmacy technicians. 2017. Available from: https://www.pharmacyregulation.org/initial-PT

Laparoscopic magnetic sphincter augmentation device placement for patients with medically-refractory gastroesophageal reflux after sleeve gastrectomy

BACKGROUND

The use of the magnetic sphincter augmentation (MSA) in patients with de novo or persistent gastroesophageal reflux disease (GERD) after sleeve gastrectomy has not been thoroughly investigated.

OBJECTIVE

The aim of this study is to evaluate the efficacy of MSA device placement in improving GERD symptoms and reducing anti-reflux medication usage in patients with persistent or de novo GERD after sleeve gastrectomy.

METHODS

This is a retrospective analysis of patients who underwent laparoscopic MSA device placement between January 2018 and July 2020 after sleeve gastrectomy.

RESULTS

A total of twenty-two patients met inclusion criteria. Twenty patients were female (91%) and two patients were male (9%). All patients were taking anti-reflux medications daily to control GERD symptoms prior to MSA device placement. There was a significant improvement in the mean GERD-HRQL survey scores when comparing scores prior to (43.8) and after (16.7) MSA device placement (p < 0.0001). Majority of the patients did well without any post-operative complications (77%). Nearly 82% of patients were no longer taking any anti-acid medications after MSA device placement (p < 0.0485). There were no patients that required MSA device removals. There were no adverse events such as MSA device erosions or device-related mortalities.

CONCLUSIONS

MSA device placement in patients with medically refractory GERD after sleeve gastrectomy is a safe and viable alternative to Roux-en-Y gastric bypass without conferring additional risks. We show an improvement in reflux symptoms after MSA device placement as evidenced by decreased post-operative GERD-HRQL scores, decreased anti-acid medication usage, and overall patient satisfaction with the procedure. Further prospective and comparative studies with longer term follow-up are needed to validate the use of MSA in patients who have undergone sleeve gastrectomy.

188 A REVIEW OF THE REABLEMENT PROGRAM WHICH INCLUDES THERAPY ASSISTANTS WITHIN THE AMBULATORY HUB

Background

The Ambulatory Hub for the older person commenced in May 2021 in line with the Enhanced Community Care Implementation Guidance documents. From a client and carer perspective, the hub provides a single point of access and a co-ordinated approach to the client's care needs with a focus on frailty. The Reablement service is provided alongside the Hub team providing a specialist Occupational Therapy and Physiotherapy geriatric assessment. Depending on the outcome of the assessment and needs identified, the client can avail of the Reablement program. Each patient will have an individualised therapy program which is carried out by the therapy assistants in the client’s home. The Reablement program aims to provide care in line with the “Right Care, Right Place, Right Team, Right Time” ethos.

Methods

The charts of 20 clients who completed the Reablement program were reviewed. The data collected included the number of visits by the Occupational Therapist, Physiotherapist and therapy assistants. Feedback from the client and their family was sought and documented.

Results

The results showed that clients received on average 4 Occupational Therapy and 4 Physiotherapy sessions each. The therapy assistants provided on average 15 visits per client to support the implementation of specialist programs developed by the therapy team. The feedback from clients and family was very positive and the following feedback was received “A program like this is a great initiative”, “ It Improved my confidence”, “I’m able to cook my meals for myself again”

Conclusion

The Reablement program with the support of therapy assistants has led to a patient centred service and co-ordinated approach to the care of the client with increased client compliance. A similar service was not available in the community previously. The Reablement program has reduced the need for inpatient reablement beds which was previously the pathway of care for these clients in the community.

85 QUALITY IMPROVEMENT INITIATIVE TO ASSESS FRAILTY AWARENESS AND USE CLINICAL FRAILTY SCALE AMONGST STAFF IN ACUTE AND PRIMARY CARE SITES

Background

Frailty describes a condition characterized by decreased physiological reserve and a decreased resistance to stressors, leading to an increased vulnerability to adverse outcomes. Identification of frailty can generate greater complexity in treatment choices, care planning, and costs of care.

Methods

30 inpatient, Emergency Department and Ambulatory Hub charts were audited to assess the presence of the word Frailty. The use of the Clinical Frailty Scale or alternative frailty scale was also audited. A staff survey was completed across four sites, a total of 115 staff were surveyed.

Results

Awareness of frailty across all services is very good ranging from 92% to 100%. The use and awareness of the Clinical Frailty Scale varied with 41% Emergency department and 12% of acute staff respectively but only 25% Emergency Department and 12% of acute staff feeling competent to complete the scale. Conversely, there was a 73% awareness of the Clinical Frailty Scale amongst primary care staff, 33% feeling competent in it's use. The Ambulatory Hub had 100% awareness of the scale with 54% of staff feeling competent.

The chart audit showed that 20% of charts in the Emergency Department identified frailty, all by the Frailty Intervention Team. 26% of the inpatient charts identified Frailty by the Frailty Intervention Team's notes and from one visiting consultant. Frailty was identified and measured using the Clinical Frailty Scale in all cases of the Ambulatory Hub notes.

Conclusion

By identifying frailty at the first point of contact, targeted specialist interventions and services can be planned for the service user. Frailty identification on the acute site was mainly linked to the Frailty Intervention Team with the Ambulatory Hub leading out on frailty identification and measurement in the community. Future initiatives aim to increase frailty identification and awareness in acute and primary care sites.

A comprehensive update on CIDO: the community-based coronavirus infectious disease ontology

Background

The current COVID-19 pandemic and the previous SARS/MERS outbreaks of 2003 and 2012 have resulted in a series of major global public health crises. We argue that in the interest of developing effective and safe vaccines and drugs and to better understand coronaviruses and associated disease mechenisms it is necessary to integrate the large and exponentially growing body of heterogeneous coronavirus data. Ontologies play an important role in standard-based knowledge and data representation, integration, sharing, and analysis. Accordingly, we initiated the development of the community-based Coronavirus Infectious Disease Ontology (CIDO) in early 2020.

Results

As an Open Biomedical Ontology (OBO) library ontology, CIDO is open source and interoperable with other existing OBO ontologies. CIDO is aligned with the Basic Formal Ontology and Viral Infectious Disease Ontology. CIDO has imported terms from over 30 OBO ontologies. For example, CIDO imports all SARS-CoV-2 protein terms from the Protein Ontology, COVID-19-related phenotype terms from the Human Phenotype Ontology, and over 100 COVID-19 terms for vaccines (both authorized and in clinical trial) from the Vaccine Ontology. CIDO systematically represents variants of SARS-CoV-2 viruses and over 300 amino acid substitutions therein, along with over 300 diagnostic kits and methods. CIDO also describes hundreds of host-coronavirus protein-protein interactions (PPIs) and the drugs that target proteins in these PPIs. CIDO has been used to model COVID-19 related phenomena in areas such as epidemiology. The scope of CIDO was evaluated by visual analysis supported by a summarization network method. CIDO has been used in various applications such as term standardization, inference, natural language processing (NLP) and clinical data integration. We have applied the amino acid variant knowledge present in CIDO to analyze differences between SARS-CoV-2 Delta and Omicron variants. CIDO's integrative host-coronavirus PPIs and drug-target knowledge has also been used to support drug repurposing for COVID-19 treatment.

Conclusion

CIDO represents entities and relations in the domain of coronavirus diseases with a special focus on COVID-19. It supports shared knowledge representation, data and metadata standardization and integration, and has been used in a range of applications.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13326-022-00279-z.

Concomitant left atrial appendage closure with left ventricular assist device surgery can reduce ischemic cerebrovascular accidents

Background

It remains unknown if concomitant left atrial appendage closure (LAAC) at the time of left ventricular assist device (LVAD) surgery can reduce ischemic cerebrovascular accidents.

Purpose

The purpose of this study is to assess the impact of LAAC at LVAD surgery on the incidence of ischemic cerebrovascular accidents.

Methods

Between January 2012 and November 2021, 310 patients underwent LVAD surgery with HeartMate II or III. Out of 310 patients, 98 patients (31.6%) underwent concomitant LAAC. The cohort was divided into two groups: patients with LAAC (Group A, n=98) and without LAAC (Group B, n=212). To minimize device bias, LVAD surgery with HeartWare HVAD device was excluded. The ischemic cerebrovascular accident was defined as ischemic stroke, hemorrhagic stroke or transient ischemic attack. We reviewed early and long-term clinical outcomes. The incidence of ischemic cerebrovascular accidents was compared between two groups using the Kaplan-Meier method. We also investigated if LAAC was associated with ischemic cerebrovascular accidents by Cox proportional hazards analysis.

Results

There were no significant differences in baseline characteristics between two groups including age (Group A: 55.0±12.3 years old, Group B: 56.9±14.1 years old, p=0.26), preoperative CHADS2 score (Group A: 2.40±1.1, Group B: 2.58±1.1, p=0.19) and history of atrial fibrillation (Group A: 42.9%, Group B: 42.5%, p=0.95). In-hospital mortality was not significantly different between the two groups (Group A: 7.1%, Group B: 12.3%, p=0.16). In terms of postoperative complications, there were no significant differences between two groups in requiring extracorporeal membrane oxygenation, re-exploration for bleeding and newly required hemodialysis. Median follow up period was 474 days. Thirty-five patients (11.2%) developed ischemic cerebrovascular accidents (5 patients in Group A and 30 patients in Group B). The rate of freedom from ischemic cerebrovascular accidents in Group A (94.1% at 500 days and 94.1% at 1500 days) was significantly higher than that in Group B (88.2% at 500 days and 77.4% at 1500 days; log rank=0.024). In a Cox proportional hazards regression analysis including LAAC, age, history of atrial fibrillation, diabetes mellitus and Heartmate 3 device implantation, LAAC was associated with reducing the incidence of ischemic cerebrovascular accidents (hazard ratio 0.37, 95% CI 0.13–0.89, p=0.02).

Conclusion

Concomitant LAAC at the time of LVAD surgery can reduce ischemic cerebrovascular accidents without increasing perioperative mortality and complications.

Funding Acknowledgement

Type of funding sources: None.

Radiographers' experiences and perspectives of forensic imaging in Australia: A qualitative study

INTRODUCTION

Forensic imaging plays a pivotal role regarding medico-legal issues by investigating the cause(s) of injuries to living or deceased individuals. There is currently a gap in the literature on forensic imaging due to limited national and international guidelines, protocols and scope of duties and responsibilities of radiographers undertaking forensic imaging. Thus, this study aimed to investigate the gap by exploring the experiences and perspectives of radiographers on forensic imaging in Australia.

METHODS

A qualitative approach collected data from fifteen purposively sampled qualified Australian radiographers through individual in-depth interviews. The verbatim transcribed data were thematically analysed.

RESULTS

Two themes were identified: 1) Radiographers' experiences of forensic imaging; 2) Radiographers' perceptions of forensic imaging within the job scope of a qualified radiographer.

CONCLUSIONS

Participants' experiences of forensic imaging ranged from anxiety to a positive experience, and others posed ethical and situational dilemmas heightened by the lack of dedicated forensic imaging protocols. While some radiographers expressed that every radiographer should conduct forensic imaging, others felt it was not mandatory.

IMPLICATIONS FOR PRACTICE

Radiographers' shared subjective experiences, thoughts and feelings provided insight into forensic imaging and the need for more significant support from educational and governing bodies.

The influence of anastomotic techniques on postoperative anastomotic complications: Results of the Oesophago-Gastric Anastomosis Audit

BACKGROUND

The optimal anastomotic techniques in esophagectomy to minimize rates of anastomotic leakage and conduit necrosis are not known. The aim of this study was to assess whether the anastomotic technique was associated with anastomotic failure after esophagectomy in the international Oesophago-Gastric Anastomosis Audit cohort.

METHODS

This prospective observational multicenter cohort study included patients undergoing esophagectomy for esophageal cancer over 9 months during 2018. The primary exposure was the anastomotic technique, classified as handsewn, linear stapled, or circular stapled. The primary outcome was anastomotic failure, namely a composite of anastomotic leakage and conduit necrosis, as defined by the Esophageal Complications Consensus Group. Multivariable logistic regression modeling was used to identify the association between anastomotic techniques and anastomotic failure, after adjustment for confounders.

RESULTS

Of the 2238 esophagectomies, the anastomosis was handsewn in 27.1%, linear stapled in 21.0%, and circular stapled in 51.9%. Anastomotic techniques differed significantly by the anastomosis sites (P < .001), with the majority of neck anastomoses being handsewn (69.9%), whereas most chest anastomoses were stapled (66.3% circular stapled and 19.3% linear stapled). Rates of anastomotic failure differed significantly among the anastomotic techniques (P < .001), from 19.3% in handsewn anastomoses, to 14.0% in linear stapled anastomoses, and 12.1% in circular stapled anastomoses. This effect remained significant after adjustment for confounding factors on multivariable analysis, with an odds ratio of 0.63 (95% CI, 0.46-0.86; P = .004) for circular stapled versus handsewn anastomosis. However, subgroup analysis by anastomosis site suggested that this effect was predominantly present in neck anastomoses, with anastomotic failure rates of 23.2% versus 14.6% versus 5.9% for handsewn versus linear stapled anastomoses versus circular stapled neck anastomoses, compared with 13.7% versus 13.8% versus 12.2% for chest anastomoses.

CONCLUSIONS

Handsewn anastomoses appear to be independently associated with higher rates of anastomotic failure compared with stapled anastomoses. However, this effect seems to be largely confined to neck anastomoses, with minimal differences between techniques observed for chest anastomoses. Further research into standardization of anastomotic approach and techniques may further improve outcomes.

Outcomes of laboratory-confirmed SARS-CoV-2 infection during resurgence driven by Omicron lineages BA.4 and BA.5 compared with previous waves in the Western Cape Province, South Africa

Objective

We aimed to compare clinical severity of Omicron BA.4/BA.5 infection with BA.1 and earlier variant infections among laboratory-confirmed SARS-CoV-2 cases in the Western Cape, South Africa, using timing of infection to infer the lineage/variant causing infection.

Methods

We included public sector patients aged ≥20 years with laboratory-confirmed COVID-19 between 1-21 May 2022 (BA.4/BA.5 wave) and equivalent prior wave periods. We compared the risk between waves of (i) death and (ii) severe hospitalization/death (all within 21 days of diagnosis) using Cox regression adjusted for demographics, comorbidities, admission pressure, vaccination and prior infection.

Results

Among 3,793 patients from the BA.4/BA.5 wave and 190,836 patients from previous waves the risk of severe hospitalization/death was similar in the BA.4/BA.5 and BA.1 waves (adjusted hazard ratio [aHR] 1.12; 95% confidence interval [CI] 0.93; 1.34). Both Omicron waves had lower risk of severe outcomes than previous waves. Prior infection (aHR 0.29, 95% CI 0.24; 0.36) and vaccination (aHR 0.17; 95% CI 0.07; 0.40 for boosted vs. no vaccine) were protective.

Conclusion

Disease severity was similar amongst diagnosed COVID-19 cases in the BA.4/BA.5 and BA.1 periods in the context of growing immunity against SARS-CoV-2 due to prior infection and vaccination, both of which were strongly protective.

The Effects of Olfactory Loss and Parosmia on Food and Cooking Habits, Sensory Awareness, and Quality of Life-A Possible Avenue for Regaining Enjoyment of Food

Olfactory dysfunction often has severe consequences on patients’ quality of life. The most common complaint in these patients is their reduced enjoyment of food in both patients with olfactory loss and parosmia. How the different types of olfactory dysfunction differ in relation to food and cooking habits, sensory awareness, and food-related quality of life has not yet received much attention. By applying questionnaires on cooking, food, olfactory function, weight changes, sensory awareness, and food-related quality of life, we investigated how various aspects of eating differ between participants with olfactory loss (n = 271), parosmia (n = 251), and normosmic controls (n = 166). Cooking habits in olfactory dysfunction revealed pronounced differences as compared with normosmic controls. Cooking with olfactory dysfunction was associated with, e.g., a lack of comfort and inspiration for cooking and an inability to make new foods successfully. Significant differences in cooking were also found between olfactory loss and parosmia. Food items were less familiar in participants with olfactory loss and parosmia, while the ratings of liking food items differed between olfactory loss and parosmia, indicating the importance of adapting ingredients in meals separately for olfactory loss and parosmia. Parosmia was associated with a higher incidence of weight loss, but we found no difference in food-related quality of life between participants with olfactory loss and parosmia. While olfactory loss and parosmia have wide-ranging consequences on patients’ cooking and food habits, adapting meals to include ‘safer food items’ and integrating multisensory stimulation may be a possible avenue for improving the enjoyment of food.

Outcomes of laboratory-confirmed SARS-CoV-2 infection in the Omicron-driven fourth wave compared with previous waves in the Western Cape Province, South Africa

OBJECTIVES

The objective was to compare COVID-19 outcomes in the Omicron-driven fourth wave with prior waves in the Western Cape, assess the contribution of undiagnosed prior infection to differences in outcomes in a context of high seroprevalence due to prior infection and determine whether protection against severe disease conferred by prior infection and/or vaccination was maintained.

METHODS

In this cohort study, we included public sector patients aged ≥20 years with a laboratory-confirmed COVID-19 diagnosis between 14 November and 11 December 2021 (wave four) and equivalent prior wave periods. We compared the risk between waves of the following outcomes using Cox regression: death, severe hospitalisation or death and any hospitalisation or death (all ≤14 days after diagnosis) adjusted for age, sex, comorbidities, geography, vaccination and prior infection.

RESULTS

We included 5144 patients from wave four and 11,609 from prior waves. The risk of all outcomes was lower in wave four compared to the Delta-driven wave three (adjusted hazard ratio (aHR) [95% confidence interval (CI)] for death 0.27 [0.19; 0.38]. Risk reduction was lower when adjusting for vaccination and prior diagnosed infection (aHR: 0.41, 95% CI: 0.29; 0.59) and reduced further when accounting for unascertained prior infections (aHR: 0.72). Vaccine protection was maintained in wave four (aHR for outcome of death: 0.24; 95% CI: 0.10; 0.58).

CONCLUSIONS

In the Omicron-driven wave, severe COVID-19 outcomes were reduced mostly due to protection conferred by prior infection and/or vaccination, but intrinsically reduced virulence may account for a modest reduction in risk of severe hospitalisation or death compared to the Delta-driven wave.

Factors influencing decision making for kidney transplantation among Black and Latino patients on dialysis: A qualitative study applying the social ecological model

OBJECTIVES

This qualitative study explored factors that may influence decisions regarding kidney transplantation among African-American and Latino adults on dialysis.

METHODS

Qualitative interviews were audio-recorded and transcribed. Open-coding techniques were used to identify concepts, categories, and themes. The Social Ecological Model (SEM) was used to organize themes and identify potential solutions across multiple levels (individual, interpersonal, community, and policy/health system).

RESULTS

Thirty-six patients were interviewed. Their mean age was 53 SD 12 years; 50% were female; and their duration on dialysis was 4.9 SD 6 years. Five themes emerged and were organized according to the levels of the SEM: 1) Fear about the outcomes of transplantation and 2) faith in God (individual level); 3) Family dynamics and reluctance to involve family in the decision making process (interpersonal level); 4) The experiences of friends and social networks (community level); and 5) Concerns about the social and economic impact of transplantation (policy and health system).

DISCUSSION

The application of a Social Ecological model in this study helped to illuminate the complex and multilevel factors that may influence the decisions for kidney transplantation. Future studies are needed to further explore how family members, social networks, faith communities, and policies/health systems influence the decision making process.

Textbook outcome following oesophagectomy for cancer: international cohort study

Background

Textbook outcome has been proposed as a tool for the assessment of oncological surgical care. However, an international assessment in patients undergoing oesophagectomy for oesophageal cancer has not been reported. This study aimed to assess textbook outcome in an international setting.

Methods

Patients undergoing curative resection for oesophageal cancer were identified from the international Oesophagogastric Anastomosis Audit (OGAA) from April 2018 to December 2018. Textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least 15 lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. A multivariable binary logistic regression model was used to identify factors independently associated with textbook outcome, and results are presented as odds ratio (OR) and 95 per cent confidence intervals (95 per cent c.i.).

Results

Of 2159 patients with oesophageal cancer, 39.7 per cent achieved a textbook outcome. The outcome parameter ‘no major postoperative complication’ had the greatest negative impact on a textbook outcome for patients with oesophageal cancer, compared to other textbook outcome parameters. Multivariable analysis identified male gender and increasing Charlson comorbidity index with a significantly lower likelihood of textbook outcome. Presence of 24-hour on-call rota for oesophageal surgeons (OR 2.05, 95 per cent c.i. 1.30 to 3.22; P = 0.002) and radiology (OR 1.54, 95 per cent c.i. 1.05 to 2.24; P = 0.027), total minimally invasive oesophagectomies (OR 1.63, 95 per cent c.i. 1.27 to 2.08; P &lt; 0.001), and chest anastomosis above azygous (OR 2.17, 95 per cent c.i. 1.58 to 2.98; P &lt; 0.001) were independently associated with a significantly increased likelihood of textbook outcome.

Conclusion

Textbook outcome is achieved in less than 40 per cent of patients having oesophagectomy for cancer. Improvements in centralization, hospital resources, access to minimal access surgery, and adoption of newer techniques for improving lymph node yield could improve textbook outcome.

Textbook outcome following oesophagectomy for cancer: international cohort study

BACKGROUND

Textbook outcome has been proposed as a tool for the assessment of oncological surgical care. However, an international assessment in patients undergoing oesophagectomy for oesophageal cancer has not been reported. This study aimed to assess textbook outcome in an international setting.

METHODS

Patients undergoing curative resection for oesophageal cancer were identified from the international Oesophagogastric Anastomosis Audit (OGAA) from April 2018 to December 2018. Textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least 15 lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. A multivariable binary logistic regression model was used to identify factors independently associated with textbook outcome, and results are presented as odds ratio (OR) and 95 per cent confidence intervals (95 per cent c.i.).

RESULTS

Of 2159 patients with oesophageal cancer, 39.7 per cent achieved a textbook outcome. The outcome parameter 'no major postoperative complication' had the greatest negative impact on a textbook outcome for patients with oesophageal cancer, compared to other textbook outcome parameters. Multivariable analysis identified male gender and increasing Charlson comorbidity index with a significantly lower likelihood of textbook outcome. Presence of 24-hour on-call rota for oesophageal surgeons (OR 2.05, 95 per cent c.i. 1.30 to 3.22; P = 0.002) and radiology (OR 1.54, 95 per cent c.i. 1.05 to 2.24; P = 0.027), total minimally invasive oesophagectomies (OR 1.63, 95 per cent c.i. 1.27 to 2.08; P < 0.001), and chest anastomosis above azygous (OR 2.17, 95 per cent c.i. 1.58 to 2.98; P < 0.001) were independently associated with a significantly increased likelihood of textbook outcome.

CONCLUSION

Textbook outcome is achieved in less than 40 per cent of patients having oesophagectomy for cancer. Improvements in centralization, hospital resources, access to minimal access surgery, and adoption of newer techniques for improving lymph node yield could improve textbook outcome.

SARS-CoV-2 monitoring at three sewersheds of different scales and complexity demonstrates distinctive relationships between wastewater measurements and COVID-19 case data

Wastewater monitoring of SARS-CoV-2 presents a means of tracking COVID-19 community infection dynamics on a broader geographic scale. However, accounting for environmental and sample-processing losses may be necessary for wastewater measurements to readily inform our understanding of infection prevalence. Here, we present measurements of the SARS-CoV-2 N1 and N2 gene targets from weekly wastewater samples at three sites in Hamilton County, Ohio, during an increase and subsequent decline of COVID-19 infections. The concentration of N1 or N2 RNA in wastewater, measured over the course of six months, ranged from below the detection limit to over 10⁴ gene copies/l, and correlated with case data at two wastewater treatment plants, but not at a sub-sewershed-level sampling site. We also evaluated the utility of a broader range of variables than has been reported consistently in previous work, in improving correlations of SARS-CoV-2 concentrations with case data. These include a spiked matrix recovery control (OC43), flow-normalization, and assessment of fecal loading using endogenous fecal markers (HF183, PMMoV, crAssphage). We found that adjusting for recovery, flow, and fecal indicators increased these correlations for samples from a larger sewershed (serving ~488,000 people) with greater industrial and stormwater inputs, but raw N1/N2 concentrations corresponded better with case data at a smaller, residential-oriented sewershed. Our results indicate that the optimal adjustment factors for correlating wastewater and clinical case data moving forward may not be generalizable to all sewersheds.

159 The Role of Proformas in Improving the Documentation of Surgical Ward Rounds

Introduction

Several NHS trusts rely on handwritten notes, including ward round (WR) reviews. These are essential in-patient care and must be completed/documented thoroughly. The General Medical Council and Royal College of Surgeons have both published guidance on WR documentation.

Method

This was a prospective study aiming to review WR documentation within general surgery at Frimley Park Hospital. 17 WR entries were reviewed using an 18-point checklist. A proforma was created based on published guidance and gaps in reviewed documentation. This was introduced for two months before a repeat review was conducted. A third review was conducted after an additional month to monitor for sustained improvement.

Results

Strengths in the baseline included documentation of WR leads (100%) and plans (100%), legible handwriting (95%), and NEWS score (88%). Common weaknesses were documentation of full observations, anticoagulation (both 6%), and relevant bloods and imaging (both 12%). The two months post-proforma review found improvement in all 18 areas of documentation, with five elements scoring 100%. Documentation of anticoagulation improved from 6% to 94%, relevant bloods from 12% to 82%, and full observations from 6% to 76%. Higher scoring WRs were linked to pre-prepared proformas, with lower scores linked to post-take WRs. The review was repeated after an additional month, showing consistently improved results in all areas.

Conclusions

This project has shown significant and sustainable improvement in WR documentation with the proforma. This project would therefore recommend the continued use of the proforma, and an additional review after the junior doctor change over to show continued sustainability.