Review: Opportunities and challenges for the genetic selection of dairy calf disease traits

Interest in dairy cow health continues to grow as we better understand health's relationship with production potential and animal welfare. Over the past decade, efforts have been made to incorporate health traits into national genetic evaluations. However, they have focused on the mature cow, with calf health largely being neglected. Diarrhoea and respiratory disease comprise the main illnesses with regard to calf health. Conventional methods to control calf disease involve early separation of calves from the dam and housing calves individually. However, public concern regarding these methods, and growing evidence that these methods may negatively impact calf development, mean the dairy industry may move away from these practices. Genetic selection may be a promising tool to address these major disease issues. In this review, we examined current literature for enhancing calf health through genetics and discussed alternative approaches to improve calf health via the use of epidemiological modelling approaches, and the potential of indirectly selecting for improved calf health through improving colostrum quality. Heritability estimates on the observed scale for diarrhoea ranged from 0.03 to 0.20, while for respiratory disease, estimates ranged from 0.02 to 0.24. The breadth in these ranges is due, at least in part, to differences in disease prevalence, population structure, data editing and models, as well as data collection practices, which should be all considered when comparing literature values. Incorporation of epidemiological theory into quantitative genetics provides an opportunity to better determine the level of genetic variation in disease traits, as it accounts for disease transmission among contemporaries. Colostrum intake is a major determinant of whether a calf develops either respiratory disease or diarrhoea. Colostrum traits have the advantage of being measured and reported on a continuous scale, which removes the issues classically associated with binary disease traits. Overall, genetic selection for improved calf health is feasible. However, to ensure the maximum response, first steps by any industry members should focus efforts on standardising recording practices and encouragement of uploading information to genetic evaluation centres through herd management software, as high-quality phenotypes are the backbone of any successful breeding programme.

Investigating the potential for genetic selection of dairy calf disease traits using management data

Genetic selection could be a tool to help improve the health and welfare of calves; however, to date, there is limited research on the genetics of calfhood diseases. This study aimed to understand the current impact of calf diseases, by investigating incidence rates, estimating genetic parameters, and providing industry recommendations to improve calf disease recording practices on farms. Available calf disease data composed of 69,695 Holstein calf disease records for respiratory problems (RESP) and diarrhea (DIAR), from 62,361 calves collected on 1,617 Canadian dairy herds from 2006 to 2021. Single- and multiple-trait analysis using both a threshold and linear animal model for each trait were evaluated. Furthermore, each trait was analyzed using 2 scenarios with respect to minimum disease incidence threshold criterion (herd-year incidence of at least 1% and 5%) to highlight the effect of different filtering thresholds on selection potential. Observed scale heritability estimates for RESP and DIAR ranged from 0.02 to 0.07 across analyses, while estimated genetic correlations between the traits ranged from 0.50 to 0.62. Sires were compared based on their estimated breeding value and their diseased daughter incidence rates. On average, calves born to the bottom 10% of sires were 1.8 times more likely to develop RESP and 1.9 times to develop DIAR compared with daughters born to the top 10% of sires. Results from the current study are promising for the inclusion of both DIAR and RESP in Canadian genetic evaluations. However, for effective genetic evaluation, standardized approaches on data collection and industry outreach to highlight the importance of collecting and uploading this information to herd management software is required. In particular, it is important that the herd management software is accessible to the national milk recording system to allow for use in national genetic evaluation.

Multiorgan MRI findings after hospitalisation with COVID-19 in the UK (C-MORE): a prospective, multicentre, observational cohort study

INTRODUCTION

The multiorgan impact of moderate to severe coronavirus infections in the post-acute phase is still poorly understood. We aimed to evaluate the excess burden of multiorgan abnormalities after hospitalisation with COVID-19, evaluate their determinants, and explore associations with patient-related outcome measures.

METHODS

In a prospective, UK-wide, multicentre MRI follow-up study (C-MORE), adults (aged ≥18 years) discharged from hospital following COVID-19 who were included in Tier 2 of the Post-hospitalisation COVID-19 study (PHOSP-COVID) and contemporary controls with no evidence of previous COVID-19 (SARS-CoV-2 nucleocapsid antibody negative) underwent multiorgan MRI (lungs, heart, brain, liver, and kidneys) with quantitative and qualitative assessment of images and clinical adjudication when relevant. Individuals with end-stage renal failure or contraindications to MRI were excluded. Participants also underwent detailed recording of symptoms, and physiological and biochemical tests. The primary outcome was the excess burden of multiorgan abnormalities (two or more organs) relative to controls, with further adjustments for potential confounders. The C-MORE study is ongoing and is registered with ClinicalTrials.gov, NCT04510025.

FINDINGS

Of 2710 participants in Tier 2 of PHOSP-COVID, 531 were recruited across 13 UK-wide C-MORE sites. After exclusions, 259 C-MORE patients (mean age 57 years [SD 12]; 158 [61%] male and 101 [39%] female) who were discharged from hospital with PCR-confirmed or clinically diagnosed COVID-19 between March 1, 2020, and Nov 1, 2021, and 52 non-COVID-19 controls from the community (mean age 49 years [SD 14]; 30 [58%] male and 22 [42%] female) were included in the analysis. Patients were assessed at a median of 5·0 months (IQR 4·2-6·3) after hospital discharge. Compared with non-COVID-19 controls, patients were older, living with more obesity, and had more comorbidities. Multiorgan abnormalities on MRI were more frequent in patients than in controls (157 [61%] of 259 vs 14 [27%] of 52; p<0·0001) and independently associated with COVID-19 status (odds ratio [OR] 2·9 [95% CI 1·5-5·8]; padjusted=0·0023) after adjusting for relevant confounders. Compared with controls, patients were more likely to have MRI evidence of lung abnormalities (p=0·0001; parenchymal abnormalities), brain abnormalities (p<0·0001; more white matter hyperintensities and regional brain volume reduction), and kidney abnormalities (p=0·014; lower medullary T1 and loss of corticomedullary differentiation), whereas cardiac and liver MRI abnormalities were similar between patients and controls. Patients with multiorgan abnormalities were older (difference in mean age 7 years [95% CI 4-10]; mean age of 59·8 years [SD 11·7] with multiorgan abnormalities vs mean age of 52·8 years [11·9] without multiorgan abnormalities; p<0·0001), more likely to have three or more comorbidities (OR 2·47 [1·32-4·82]; padjusted=0·0059), and more likely to have a more severe acute infection (acute CRP >5mg/L, OR 3·55 [1·23-11·88]; padjusted=0·025) than those without multiorgan abnormalities. Presence of lung MRI abnormalities was associated with a two-fold higher risk of chest tightness, and multiorgan MRI abnormalities were associated with severe and very severe persistent physical and mental health impairment (PHOSP-COVID symptom clusters) after hospitalisation.

INTERPRETATION

After hospitalisation for COVID-19, people are at risk of multiorgan abnormalities in the medium term. Our findings emphasise the need for proactive multidisciplinary care pathways, with the potential for imaging to guide surveillance frequency and therapeutic stratification.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Cell free DNA screening for fetal aneuploidy in Ireland: An observational study of outcomes following insufficient fetal fraction

OBJECTIVES

To determine maternal factors associated with low fetal fraction (FF). To determine the proportion of women who receive a result from repeat non-invasive prenatal testing (NIPT) testing. To identify any significant associations between pregnancy interventions or outcomes and low FF.

STUDY DESIGN

Retrospective observational study of 4465 women undergoing antenatal screening by targeted cell free DNA (cfDNA) testing at an Irish tertiary maternity hospital between January 2017 and December 2022. Patients who failed to obtain a result after the first NIPT were analyzed in two cohorts; those who received a result on a repeat sample and those who failed to ever achieve a result despite a second, third or fourth cfDNA test.

RESULTS

Risk of insufficient FF significantly increased with elevated maternal BMI (OR 1.07; 95% CI 1.01-1.13, p = 0.03) and in-vitro fertilization (IVF) (OR 3.4; 95% CI 1.19-9.4, p = 0.02). Women with no result were more likely to have diagnostic invasive testing (p < 0.01), but had no increased risk of aneuploidy. Repeated failed NIPT attempts due to low FF were significantly associated with the subsequent development of hypertensive diseases of pregnancy (p = 0.03). Greater than 70% of patients who were unsuccessful in a first or second attempt at NIPT due to low FF yielded a result following a second or third sample.

CONCLUSIONS

High BMI and IVF conceptions are greater contributors to low FF than fetal aneuploidy. Repeating NIPT yields a result in greater than 70% of cases. WHAT'S ALREADY KNOWN ABOUT THIS TOPIC?: Fetal fraction (FF) in prenatal cfDNA testing is influenced by maternal and pregnancy factors including body mass index (BMI) and IVF. Low FF has been associated with adverse pregnancy outcomes including fetal aneuploidy and hypertensive diseases of pregnancy. WHAT DOES THIS STUDY ADD?: In a large Irish population, increasing maternal BMI and in-vitro fertilization are the most significant contributors to repeated test failures due to low FF. Greater than 70% of patients with test failure due to low FF will receive a result on 2nd and 3rd NIPT attempts. Patients with no result from NIPT were more likely to undergo diagnostic invasive testing but the risk of aneuploidy was not significantly increased.

Can Volume-Based MRI-Guided Planning for Interstitial Gynecologic Brachytherapy Overcome Clinicopathologic Risk Factors for Fistula Formation?

PURPOSE/OBJECTIVE(S)

Tumor and patient factors requiring an interstitial (IS) approach for gynecologic tract brachytherapy (BT) may be associated with high morbidity despite the conformality maximizing effect of ISBT. We reviewed outcomes from a diverse, high-volume center to evaluate the association of clinical features and planning parameters with toxicity, with the hypothesis that MRI-guided volume-based planning mitigates clinicopathologic risk factors associated with treatment related fistula (TRF) after ISBT.

MATERIALS/METHODS

We retrospectively reviewed patients treated with Syed-based ISBT at a single institution from 2014-2019. Fisher's exact was used for group comparison with p<0.05. Kaplan-Meier method was used to estimate local control (LC), overall survival (OS), and fistula-free survival (FFS). Cox regression was used for univariate (UVA) and multivariate analysis (MVA) to estimate hazard ratios (HR). Collinearity was assessed using variable inflation factor and Pearson's correlation.

RESULTS

A total of 54 patients (median age 58 [IQR 46-67], 54% Caucasian, 39% African American, 15% Hispanic) treated with ISBT (89% MRI-guided) with median follow-up 32 months had initial (89%) or recurrent (11%) disease from cervical (70%), vaginal (15%), urethral (6%), and other cancers. At presentation 5.5% had clinically evident fistula. There was radiographic rectal and bladder involvement in 22.0% and 19.2%, respectively. 89% received concurrent chemotherapy and 98% received EBRT prior to ISBT with a cumulative median high-risk CTV (HRCTV) dose 80.8 Gy (IQR 76.8-84.3), bladder D2cc 84.3 Gy (IQR 75.8-89.0), and rectal D2cc 73.8 Gy (IQR 67.7-80.0 Gy). All 7 patients who developed a TRF (rectovaginal in 6/7 and vesicovaginal in 5/7) were former or current smokers, had primary cervical cancer, and received chemotherapy. Management included surgical intervention in 6 (85.7%). LC, OS, and FFS at 2-years was 89.3% (95% CI 75.9-95.4%), 87.8% (95% CI 66.9-89.8%), and 85.2% (95% CI 69.9-93.1%), respectively. On UVA, current smoking (HR 4.60, 95% CI 1.02-20.74), BT bladder D2cc (HR 1.63, 95% CI 1.07-2.47) and BT rectal Dmax (HR 1.30, 95% CI 1.07-1.58) predicted for increased risk of TRF. Most factors were non-significant including Charlson Comorbidity Index, age, BMI, surgical history, extent of vaginal involvement, race, HRCTV volume and number of needles used. No patients with radiographic bladder or rectal invasion developed TRF. On MVA, only smoking status (HR 14.05, 95% CI 1.48-133.1) remained significant. 0% of never (0/26), 20% of former (3/15) and 31% of current (4/13) smokers developed fistulas from toxicities (p<0.05).

CONCLUSION

In patients with locally advanced cancers of the gynecologic tract treated with MRI-guided volume-based ISBT, smoking was the only factor predictive of TRF formation, occurring primarily in cervical cancer patients. This highlights the importance of smoking cessation during treatment and appropriately counseling patients at high risk for this morbidity.

Predictors of Hepatotoxicity in Patients with Metastatic Solid Tumors Treated with Immune Checkpoint Inhibition (ICI) and Liver-Directed SBRT

PURPOSE/OBJECTIVE(S)

Liver-metastasis-directed SBRT (LM-SBRT) alone provides durable local control for liver metastases with low rates of toxicity when adhering to established dose constraints. Whether these constraints are sufficient in the context of concurrent ICI is not established. To determine whether LM-SBRT contributes to hepatotoxic adverse events (HAE) in patients receiving ICI, we analyzed potential predictors of HAE in a prospectively evaluated cohort of clinical trial patients treated with both SBRT and ICI.

MATERIALS/METHODS

Patients with metastatic solid tumors were included from three trials of multi-site SBRT with ICI given concurrently or shortly after SBRT provided they received all study treatments and were monitored for adverse events. ICI agents included pembrolizumab alone or dual agent ICI with nivolumab and either cabiralizumab, urelumab, or ipilimumab. LM-SBRT was delivered to 45 Gy in 3 fr with mean liver dose (MLD) limited to 16 Gy and <700 cc of liver receiving 17.1 Gy. HAE were defined using CTCAE 4.0 as: elevation of AST, ALT, bilirubin or alkaline phosphatase; autoimmune hepatitis; hepatic failure; or cholecystitis. HAE were included if rated at least possibly related to treatment by the trial monitoring committee. Cumulative incidence (CI) of HAE was modeled with death as a competing risk. Competing risks regression was performed using Fine-Gray modeling.

RESULTS

Two hundred thirteen patients were evaluable. Median follow-up was 10 months. Median age was 61, 90 had liver metastases at treatment, 65 received SBRT to a liver lesion, 15 had underlying liver disease (cirrhosis or hepatic steatosis) and 13 patients had a primary liver cancer. Dual agent ICI was given to 97 patients. Table 1 shows CI at 6 months of grades 1-4 HAE in all patients, LM-SBRT patients and non-liver SBRT patients (NL-SBRT). None experienced grade 5 HAE. There was no significant difference in CI of any grade of HAE between LM-SBRT and NL-SBRT patients. This was also true when comparing LM-SBRT patients to NL-SBRT patients with <0.1 Gy MLD. ICI dose reduction or cessation due to HAE occurred in 4 patients, none of whom received LM-SBRT. On univariate analysis, underlying liver disease and dual agent ICI were significantly associated with grade 2+ HAE while age, LM-SBRT, MLD, primary liver cancer and presence of liver metastases at treatment were not. On multivariate analysis, underlying liver disease and dual agent ICI remained significantly associated with grade 2+ HAE (HR: 6.7, 95% CI 2.3 - 19.1; 4.7, 95% CI 1.7 - 13.0). LM-SBRT and MLD were not significant on MVA.

CONCLUSION

LM-SBRT did not significantly increase the risk for hepatotoxicity in patients receiving ICI when respecting the above dose constraints. Risk for hepatotoxicity appears to be driven by dual agent ICI and underlying liver disease.

Concurrent Radiation and Immunotherapy Augments Local Immunity and Improves Survival in Aneuploid NSCLC

PURPOSE/OBJECTIVE(S)

Over 500 clinical trials combining radiation (RT) and immune checkpoint blockade (ICB) have been initiated based on preclinical evidence that RT can augment local immunity and improve the efficacy of ICB. However, many recent clinical trials have not found a benefit of combining RT and ICB, raising questions about whether a synergy exists. We examined whether RT and ICB interact to beneficially stimulate the immune response in patients and identified biomarkers of response to RT and ICB.

MATERIALS/METHODS

We performed a molecular analysis of 1,740 patients from 3 cohorts. The COSINR dataset is a randomized clinical trial of 22 non-small cell lung cancer (NSCLC) patients treated with concurrent or sequential SBRT and ipilimumab/nivolumab. Paired pre- and on-treatment biopsies of an irradiated metastasis underwent whole exome sequencing and RNA-seq. On-treatment biopsies were obtained after SBRT and prior to ICB (sequential) or after SBRT and one cycle of ICB (concurrent). The UC cohort consisted of targeted DNA sequencing of 58 NSCLC patients treated with ICB alone, sequential RT+ICB, or concurrent RT+ICB. The MSKCC dataset is a pan-cancer cohort of targeted DNA sequencing of 1,660 patients treated with ICB. Aneuploidy score (AS) was defined as the fraction of chromosome arms with arm-level copy number alterations. Survival analyses utilized the Kaplan-Meier method and multivariable Cox proportional hazards models.

RESULTS

In the COSINR trial, SBRT+ICB increased, whereas SBRT alone decreased, expression of effector T cell IFN-gamma and adaptive immune signatures (P<0.05). Established biomarkers of ICB response, including IFN-gamma signature, tumor mutational burden (TMB), PD-L1 expression, and neoantigen burden were not associated with survival (P>0.05). However, patients whose tumors exhibited high (≥median) but not low, AS had improved survival when treated with concurrent vs. sequential SBRT+ICB (1-year overall survival [OS] 100% vs. 17%, P = 0.025). Our findings were corroborated in the UC cohort: high AS tumors treated with RT + ICB had superior 1-year OS compared to those treated with ICB alone (59% vs. 31%, P = 0.021). Among those who received RT + ICB, concurrent treatment improved OS relative to sequential (1-year OS 76% vs. 38%). RT did not improve OS in patients with low (

CONCLUSION

Our findings distinguish the genomic and transcriptomic effects of RT versus RT+ICB and challenge the prevailing paradigm that local ablative RT positively stimulates the immune response. We propose the use of tumor aneuploidy as a biomarker in personalizing treatment approaches for patients with various cancers.

Collapse

Key Words Collapse

MESH Headings Collapse

Grants Collapse

Affiliation(s)

L F Spurr University of Chicago, Chicago, IL
C Martinez University of Chicago, Chicago, IL
W Kang University of Chicago, Chicago, IL
M Chen University of Chicago, Chicago, IL
Y Zha University of Chicago, Chicago, IL
R Hseu University of Chicago, Chicago, IL
S Gutiontov Department of Radiation and Cellular Oncology, University of Chicago Medical Center, Chicago, IL
W T Turchan University of Chicago, Chicago, IL
C Lynch Northwestern University Feinberg School of Medicine, Chicago, IL
K B Pointer University of Wisconsin-Madison, Madison, WI
E E Vokes Department of Medicine, Section of Hematology/Oncology, University of Chicago, Chicago, IL
C M Bestvina Department of Hematology Oncology, University of Chicago Medical Center, Chicago, IL
J D Patel Lurie Cancer Center, Northwestern University-Feinberg School of Medicine, Chicago, IL
M Diehn Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA
R R Weichselbaum Department of Radiation and Cellular Oncology, The University of Chicago Medicine, Chicago, IL
S J Chmura Department of Medicine, University of North Carolina, Chapel Hill, NC
S P Pitroda Department of Radiation and Cellular Oncology, University of Chicago Medical Center, Chicago, IL

Collapse

Duplication errors due to brand name confusion; It is not always the name-Short case series

Confusion of drug names has been identified as a leading cause of medication errors and potential iatrogenic harm. Most of these errors occur because of look-alike or sound-alike drugs. This case series gives examples of duplication errors due to brand confusion, where there are no similarities in the names.

Weaning from mechanical ventilation in intensive care units across 50 countries (WEAN SAFE): a multicentre, prospective, observational cohort study

BACKGROUND

Current management practices and outcomes in weaning from invasive mechanical ventilation are poorly understood. We aimed to describe the epidemiology, management, timings, risk for failure, and outcomes of weaning in patients requiring at least 2 days of invasive mechanical ventilation.

METHODS

WEAN SAFE was an international, multicentre, prospective, observational cohort study done in 481 intensive care units in 50 countries. Eligible participants were older than 16 years, admitted to a participating intensive care unit, and receiving mechanical ventilation for 2 calendar days or longer. We defined weaning initiation as the first attempt to separate a patient from the ventilator, successful weaning as no reintubation or death within 7 days of extubation, and weaning eligibility criteria based on positive end-expiratory pressure, fractional concentration of oxygen in inspired air, and vasopressors. The primary outcome was the proportion of patients successfully weaned at 90 days. Key secondary outcomes included weaning duration, timing of weaning events, factors associated with weaning delay and weaning failure, and hospital outcomes. This study is registered with ClinicalTrials.gov, NCT03255109.

FINDINGS

Between Oct 4, 2017, and June 25, 2018, 10 232 patients were screened for eligibility, of whom 5869 were enrolled. 4523 (77·1%) patients underwent at least one separation attempt and 3817 (65·0%) patients were successfully weaned from ventilation at day 90. 237 (4·0%) patients were transferred before any separation attempt, 153 (2·6%) were transferred after at least one separation attempt and not successfully weaned, and 1662 (28·3%) died while invasively ventilated. The median time from fulfilling weaning eligibility criteria to first separation attempt was 1 day (IQR 0-4), and 1013 (22·4%) patients had a delay in initiating first separation of 5 or more days. Of the 4523 (77·1%) patients with separation attempts, 2927 (64·7%) had a short wean (≤1 day), 457 (10·1%) had intermediate weaning (2-6 days), 433 (9·6%) required prolonged weaning (≥7 days), and 706 (15·6%) had weaning failure. Higher sedation scores were independently associated with delayed initiation of weaning. Delayed initiation of weaning and higher sedation scores were independently associated with weaning failure. 1742 (31·8%) of 5479 patients died in the intensive care unit and 2095 (38·3%) of 5465 patients died in hospital.

INTERPRETATION

In critically ill patients receiving at least 2 days of invasive mechanical ventilation, only 65% were weaned at 90 days. A better understanding of factors that delay the weaning process, such as delays in weaning initiation or excessive sedation levels, might improve weaning success rates.

FUNDING

European Society of Intensive Care Medicine, European Respiratory Society.

Implementation evaluation of mhealth interventions in the secondary prevention of coronary artery disease: a supplementary review

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): La Trobe University

Introduction

mHealth technologies have evolved rapidly in recent years and are now widely implemented for the secondary prevention of coronary artery disease (CAD). While there is increasing evidence of their effectiveness, there are significant knowledge gaps concerning their reach, adoption, implementation, and maintenance.

Purpose

This study evaluates internal and external validity dimensions of mHealth-enabled cardiac disease management programs (DMPs) using elements of Glasgow’s RE-AIM (Reach-Effectiveness-Adoption-Implementation-Maintenance) Framework. It is a supplementary review to a systematic review and meta-analysis which evaluated effectiveness.

Methods

From the 27 studies reviewed for the previous systematic review on effectiveness, a citation search was performed to identify additional publications reporting on elements of reach, adoption, implementation, and maintenance. All eligible publications were independently coded by two team members using the 23-item RE-AIM extraction tool and analysed using mixed-methods to ascertain the reporting of these elements.

Results

In total, 35 publications were included in the analysis, 27 from the previous systematic review and 8 supplementary publications. The items for the Reach dimension indicated participant participation rates ranging between 18% to 67%, and used a wide range of exclusion criteria, relating to mental and cognitive impairment (37%), physical impairments (41%) and language issues (26%). Most (44%) interventions were solely home-based with nurses being the main health professionals delivering the intervention (adoption items). The implementation and maintenance items showed intervention duration of between 4-52 weeks (median 24 weeks) with intervention follow-up of between 1-48 months (median 6 months).

Conclusions

This review found great heterogeneity in the duration and follow-up of mHealth-enabled DMPs for patients with CAD, with low participation rates suggesting access barriers. Addressing RE-AIM dimensions in the evaluation of mHealth-enabled cardiac DMPs for patients with CAD is critically important for identifying factors affecting the reach, adoption, implementation, and maintenance of interventions in order to improve translation of research evidence into practice for patients, clinicians and health service organisations.

Clinical characteristics with inflammation profiling of long COVID and association with 1-year recovery following hospitalisation in the UK: a prospective observational study

BACKGROUND

No effective pharmacological or non-pharmacological interventions exist for patients with long COVID. We aimed to describe recovery 1 year after hospital discharge for COVID-19, identify factors associated with patient-perceived recovery, and identify potential therapeutic targets by describing the underlying inflammatory profiles of the previously described recovery clusters at 5 months after hospital discharge.

METHODS

The Post-hospitalisation COVID-19 study (PHOSP-COVID) is a prospective, longitudinal cohort study recruiting adults (aged ≥18 years) discharged from hospital with COVID-19 across the UK. Recovery was assessed using patient-reported outcome measures, physical performance, and organ function at 5 months and 1 year after hospital discharge, and stratified by both patient-perceived recovery and recovery cluster. Hierarchical logistic regression modelling was performed for patient-perceived recovery at 1 year. Cluster analysis was done using the clustering large applications k-medoids approach using clinical outcomes at 5 months. Inflammatory protein profiling was analysed from plasma at the 5-month visit. This study is registered on the ISRCTN Registry, ISRCTN10980107, and recruitment is ongoing.

FINDINGS

2320 participants discharged from hospital between March 7, 2020, and April 18, 2021, were assessed at 5 months after discharge and 807 (32·7%) participants completed both the 5-month and 1-year visits. 279 (35·6%) of these 807 patients were women and 505 (64·4%) were men, with a mean age of 58·7 (SD 12·5) years, and 224 (27·8%) had received invasive mechanical ventilation (WHO class 7-9). The proportion of patients reporting full recovery was unchanged between 5 months (501 [25·5%] of 1965) and 1 year (232 [28·9%] of 804). Factors associated with being less likely to report full recovery at 1 year were female sex (odds ratio 0·68 [95% CI 0·46-0·99]), obesity (0·50 [0·34-0·74]) and invasive mechanical ventilation (0·42 [0·23-0·76]). Cluster analysis (n=1636) corroborated the previously reported four clusters: very severe, severe, moderate with cognitive impairment, and mild, relating to the severity of physical health, mental health, and cognitive impairment at 5 months. We found increased inflammatory mediators of tissue damage and repair in both the very severe and the moderate with cognitive impairment clusters compared with the mild cluster, including IL-6 concentration, which was increased in both comparisons (n=626 participants). We found a substantial deficit in median EQ-5D-5L utility index from before COVID-19 (retrospective assessment; 0·88 [IQR 0·74-1·00]), at 5 months (0·74 [0·64-0·88]) to 1 year (0·75 [0·62-0·88]), with minimal improvements across all outcome measures at 1 year after discharge in the whole cohort and within each of the four clusters.

INTERPRETATION

The sequelae of a hospital admission with COVID-19 were substantial 1 year after discharge across a range of health domains, with the minority in our cohort feeling fully recovered. Patient-perceived health-related quality of life was reduced at 1 year compared with before hospital admission. Systematic inflammation and obesity are potential treatable traits that warrant further investigation in clinical trials.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Brain charts for the human lifespan

Over the past few decades, neuroimaging has become a ubiquitous tool in basic research and clinical studies of the human brain. However, no reference standards currently exist to quantify individual differences in neuroimaging metrics over time, in contrast to growth charts for anthropometric traits such as height and weight1. Here we assemble an interactive open resource to benchmark brain morphology derived from any current or future sample of MRI data ( http://www.brainchart.io/ ). With the goal of basing these reference charts on the largest and most inclusive dataset available, acknowledging limitations due to known biases of MRI studies relative to the diversity of the global population, we aggregated 123,984 MRI scans, across more than 100 primary studies, from 101,457 human participants between 115 days post-conception to 100 years of age. MRI metrics were quantified by centile scores, relative to non-linear trajectories2 of brain structural changes, and rates of change, over the lifespan. Brain charts identified previously unreported neurodevelopmental milestones3, showed high stability of individuals across longitudinal assessments, and demonstrated robustness to technical and methodological differences between primary studies. Centile scores showed increased heritability compared with non-centiled MRI phenotypes, and provided a standardized measure of atypical brain structure that revealed patterns of neuroanatomical variation across neurological and psychiatric disorders. In summary, brain charts are an essential step towards robust quantification of individual variation benchmarked to normative trajectories in multiple, commonly used neuroimaging phenotypes.

Nurse and allied health professional experiences and attitudes toward critical care research: A national questionnaire study

Introduction

The aim of this study was to investigate nurse and allied health professional experiences and attitudes toward critical care research in Wales.

Methods

Data were collected related to demographic characteristics, involvement in and understanding of research, perceived influences and attitudes towards research. We calculated means (ranges) for continuous variable and frequencies (proportions) for discrete variables and performed an exploratory factor analysis.

Results

Response rate was 55% (n = 575). Most respondents (84%) had participated in research less than five times in the previous 12 months, yet 91% believed research led to improved care patients. Only 32% respondents felt they were encouraged by managers to participate in research. Only 25% respondents had undertaken research training. Few respondents (29%) reported receiving adequate information regarding study progress or results (25%). Linear regression models indicate that a higher level of formal education was associated with a more positive view of research across all attitude factors. Promotion of research by colleagues and recognition/ opportunities for involvement in critical care research, were positively associated with the acceptability and experience of research.

Discussion

A number of factors have been identified that could be targeted to improve recruitment to critical care research, including identification of staff to promote research, improved communication of study progress and findings and management encouragement to attend research training. Staff attitudes were positive towards the benefit of research on patient care in Wales.

Clinical outcomes and the impact of prior oral anticoagulant use in patients with coronavirus disease 2019 admitted to hospitals in the UK - a multicentre observational study

Coagulation dysfunction and thrombosis are major complications in patients with coronavirus disease 2019 (COVID-19). Patients on oral anticoagulants (OAC) prior to diagnosis of COVID-19 may therefore have better outcomes. In this multicentre observational study of 5 883 patients (≥18 years) admitted to 26 UK hospitals between 1 April 2020 and 31 July 2020, overall mortality was 29·2%. Incidences of thrombosis, major bleeding (MB) and multiorgan failure (MOF) were 5·4%, 1·7% and 3·3% respectively. The presence of thrombosis, MB, or MOF was associated with a 1·8, 4·5 or 5·9-fold increased risk of dying, respectively. Of the 5 883 patients studied, 83·6% (n = 4 920) were not on OAC and 16·4% (n = 963) were taking OAC at the time of admission. There was no difference in mortality between patients on OAC vs no OAC prior to admission when compared in an adjusted multivariate analysis [hazard ratio (HR) 1·05, 95% confidence interval (CI) 0·93-1·19; P = 0·15] or in an adjusted propensity score analysis (HR 0·92 95% CI 0·58-1·450; P = 0·18). In multivariate and adjusted propensity score analyses, the only significant association of no anticoagulation prior to diagnosis of COVID-19 was admission to the Intensive-Care Unit (ICU) (HR 1·98, 95% CI 1·37-2·85). Thrombosis, MB, and MOF were associated with higher mortality. Our results indicate that patients may have benefit from prior OAC use, especially reduced admission to ICU, without any increase in bleeding.

132 GERIATRIC REHABILITATION IN THE COVID-19 ERA: SERVICE INNOVATION AND PATIENT OUTCOMES

Background

Methods

Results

Conclusion

Effect of synchronized breeding on genetic evaluations of fertility traits in dairy cattle

Estrus detection has become more difficult over the years due to decreases in the estrus expression of high-producing dairy cows, and increased herd sizes and animal density. Through the use of hormonal synchronization protocols, also known as timed artificial insemination (TAI) protocols, it is possible to alleviate some of the challenges associated with estrus detection. However, TAI masks cows' fertility performance, resulting in an unfair comparison of treated animals and innately fertile animals. Consequently, genetically inferior and superior cows show similar phenotypes, making it difficult to distinguish between them. As genetic programs rely on the collection of accurate phenotypic data, phenotypes collected on treated animals likely add bias to genetic evaluations. In this study, to assess the effect of TAI, the rank correlation of bulls for a given trait using only TAI records were compared with the same trait using only heat detection records. A total of 270,434 records from 192,539 animals split across heifers, first and second parity cows were analyzed for the traits: calving to first service, first service to conception, and days open. Results showed large reranking across all traits and parities between bulls compared based on either having only TAI records or only heat detection records, suggesting that a bias does indeed exist. Large reranking was also observed for both the heat detection and TAI groups among the top 100 bulls in the control group, which included all records. Furthermore, breeding method was added to the model to assess its effect on bull ranking. However, there were only minor changes in the rank correlations between scenario groups. Therefore, more complex methods to account for the apparent bias created by TAI should be investigated; for this, the method by which these data are collected needs to be improved through creating a standardized way of recording breeding codes. Though the results of this study suggest the presence of bias within current fertility evaluations, additional research is required to confirm the findings of this study, including looking at high-reliability bulls specifically, to determine if the levels of reranking remain. Future studies should also aim to understand the potential genetic differences between the fertility traits split via management technology, possibly in a multiple-trait analysis.

P–786 Virtual continual professional education programs in ART in time of SARS-CoV–2: do they deliver?

Study question

Can virtual training deliver effective professional education to ART professionals?

Summary answer

Virtual continual professional education programs are an excellent learning platform for ART professionals. The web-based Educational Library is a very useful global scientific resource.

What is known already

Retention levels are the highest when theoretical knowledge sharing is combined with practical hands-on training in a face-to-face training center set up. This is especially the case for training in Assisted Reproductive Techniques, where success depends in part on the ART professional’s skills. Due to the global SARS-CoV–2 pandemic in 2020, hands-on training programs were forced to close, and new educational web-based activities tools like streaming of webinars and journal clubs were developed.

Study design, size, duration

The effectiveness of the Global Education and Webinar Series organised by CooperSurgical (including webinars and journal clubs) streamed in 2020, was evaluated retrospectively by analysing the following: 1) the live attendance rates; 2) viewing rates in the Webinar Series Library; 3) outcomes of the feedback questionnaire focusing on the level of the webinar content, relevance to day-to-day clinical and laboratory work, gaining new knowledge, and pace of the webinar.

Participants/materials, setting, methods

In 2020, 65 webinars and 8 journal clubs were streamed at different timepoints to accommodate a global professional ART audience. The target audience included embryologists, lab technicians, IVF clinicians, counsellors, and scientists. Topics were IVF lab and clinic-based, theoretical but also practical. Lectures were prepared with an evidence-based approach and submitted for scientific review. Post live attendance, viewers were invited to fill in a questionnaire; they obtained a certificate of attendance.

Main results and the role of chance

In 2020, 16,839 viewers attended the 65 live webinars and 8 journal clubs. Live attendance rates dropped by 75% in May, when IVF clinics were re-opening after the first wave of SARS-CoV–2.

On 08.01.2021, a total of 23,258 library viewings were recorded. Library viewings increased significantly after the re-opening of the clinics.

Viewers were located in 129 countries; India, Thailand, and Spain had the highest viewing of all the countries (&gt; 1500 viewings per country). Multiple viewers attended between 10 to 26 of the virtual activities.

The feedback analysis showed that 96% of the viewers found the webinars to be relevant to their day-to-day work; 92% gained knowledge as a result of the webinar; 94% of the viewers found the level appropriate and 91% felt that the pace of the presentations was just right.

These outcomes demonstrate that the need for continual professional education programs in ART in time of SARS-CoV–2 is clearly present globally. Our virtual Global Education and Webinar Series could deliver evidence-based knowledge to viewers globally and assist them in gaining knowledge – even in a distance learning setting. The Library is an excellent resource tool for ART professionals to gain knowledge at their own pace.

Limitations, reasons for caution

Not all ART professionals have access to high-quality internet facilities. Not all the viewers completed the questionnaire

Wider implications of the findings: Web-based virtual activities can be an excellent tool for knowledge sharing. These outcomes will be used to further develop our virtual educational training program.

Trial registration number

Not applicable

P–574 Examination of inter centre variation in PGT-A “no result rate” and efficacy of rebiopsy - Analysis of 22,833 samples 2015–2019

Study question

Are there significant differences in PGT-A “no result” rates and clinical outcomes following rebiopsy between ART clinics, and do rebiopsied embryos perform better than transferring with no result?

Summary answer

There is significant differences between clinics in terms of “no result rate” in PGT-A and utilisation of rebiopsy. What is known already: With any testing platform used in PGT-A, there is always a chance that a sample will not yield a result and rebiopsy may be considered to ascertain an embryos cytogenetic status. Studies have demonstrated rebiopsy yields results and adds to embryos genetically suitable for transfer. Clinical outcome data, however, remains scarce, leading to difficulty for clinics in benchmarking their performance when rebiopsied embryos are transferred.

Study design, size, duration

A retrospective analysis was performed of trophectoderm samples submitted for PGT-A via NGS over a 5yr period, 2015–2019. The no result (NR) rate was calculated per year and per clinic. Clinics were contacted for follow up data on NR embryos in terms of usage and clinical outcomes. Clinical outcomes from rebiopsied embryos were compared with those transferred as NR without rebiopsy.

Participants/materials, setting, methods

Data was collected on 22833 trophectoderm samples, submitted by 30 IVF laboratories. NR rate was analysed by year and by clinic. Clinics were asked if NR embryos had undergone rebiopsy, and if so if they had survived warming and rebiopsy. Clinics were asked if embryos selected for transfer had survived (re)warming, and to provide clinical follow-up including hCG test, clinical pregnancies, miscarriage and livebirth. The two tailed Fishers exact test was used for statistical analysis.

Main results and the role of chance

There was a wide range in sample numbers submitted by clinics over the time period, ranging from 9 samples through to 2633. In tclinics submitting over 500 samples the NR rate ranged from 0.6% to 7.4%, and in the those submitting 100–499 samples it ranged from 1.1% to 5.8%. Both these differences proved to be statistically significant (p &lt; 0.05) between the best and worst performing clinics, and shows that a gap in performance exists between clinics. Less than 50% of NR embryos underwent rebiopsy. While the majority of embryos undergoing rebiopsy yielded a result (92.3%) and 31.4% of these were euploid or mosaic, almost half still remain in storage. The rate of livebirth/ongoing implantation in the rebiopsy group is 35.5% and 17.1% in the non rebiopsy group, illustrating a non significant trend towards a higher chance of implantation and livebirth in the rebiopsy group. Of 58 patients undergoing rebiopsy without any euploids in their initial cycle, 18 had a euploid embryo identified for future use. The additional manipulations involved in rebiopsy do not impact on survival at warming for transfer, but clinical outcomes in rebiopsied embryos appear poorer than those where a result was generated at first biopsy.

Limitations, reasons for caution

Despite starting with 22833 samples, 1115 of which were classified as NR, there were only 31 rebiopsied and 42 NR embryos transferred. It was therefore not possible to analyse transfer data by clinic or by embryo quality.

Wider implications of the findings: Rebiopsy yields genetic results and embryos suitable for patient use, including for patients who produced no other euploid/mosaic embryos in their cycle. However, it is not offered/performed in many cases. Clinical outcome data must continue to be compiled and analysed to confirm performance exceeds transfer of NR embryos.

Trial registration number

Not applicable

Estimated genetic parameters for all genetically evaluated traits in Canadian Holsteins

Genetic improvement is a crucial tool to deal with the increasing demand for high quality, sustainably produced dairy. Breeding programs are based on genetic parameters, such as heritability and genetic correlations, for economically important traits in a population. In this study, we estimated population genetic parameters and genetic trends for 67 traits evaluated on heifers and first-lactation Canadian Holstein cows. The data consisted of approximately 500,000 records with pedigree information collected from 1980 to 2019. Genetic parameters were estimated using bivariate linear animal models under a Bayesian approach. Analyses for the 67 traits resulted in 2,211 bivariate combinations, from which the estimated genetic parameters are reported here. The most highly heritable traits were fat percent (0.66) and protein percent (0.69), followed by stature (0.47). Lowest heritabilities (0.01) were observed for disease-related traits, such as lameness and toe ulcer, and calf survival. The genetic correlations between gestation length, calf size, and calving ease measured on both heifer and cows were close to unity. On the other hand, traits such as body condition score and pin width, cystic ovaries and sole ulcer, rear teat placement, and toe ulcer were genetically unrelated. This study reports genetic parameters that have not been previously published for Canadian Holstein cows, and provides updates of those previously estimated. These estimates are useful for building new indexes, updating existing selection indexes, and for predicting correlated responses due to inclusion of novel traits in the breeding programs.

Recent enhancements in the performance of the Orion high-resolution x-ray spectrometers

During the past few years, the Orion high-resolution x-ray spectrometers have been successful tools for measuring x-ray spectra from plasmas generated in the Orion laser facility. Duplicate spectrometers also operate successfully at the Livermore EBIT-I and SuperEBIT electron beam ion traps for measuring x-ray polarization. We have recently implemented very high-quality, optically bonded, spherically bent quartz crystals to remove the structure in the x-ray image that had been observed in earlier measurements. The structure had been caused by focusing defects and limited the accuracy of our measurements. We present before and after images that show a drastic improvement. We, furthermore, have implemented a spherically bent potassium acid phthalate (KAP) crystal on one of our spectrometers. The KAP crystal was prepared in a similar fashion, and we present measurements of the N Ly-β and Ne Lyβ lines taken in first- and second-order reflections at 600 and 1200 eV, respectively. These measurements confirm that KAP crystals can be produced at a quality suitable for extending the spectral coverage to wavelengths longer than those accessible by different quartz crystals, especially those that cover the astrophysically important lines of iron.

Amalgam Phase-Down Part 1: UK-Based Posterior Restorative Material and Technique Use

Introduction:

A European Union amalgam phase-down has recently been implemented. Publicly funded health care predominates in the United Kingdom with the system favoring amalgam use. The current use of amalgam and its alternatives has not been fully investigated in the United Kingdom.

Objectives:

The study aimed to identify direct posterior restorative techniques, material use, and reported postoperative complication incidence experienced by primary care clinicians and differences between clinician groups.

Methods:

A cross-sectional survey was distributed to primary care clinicians through British dentist and therapist associations (11,092 invitations). The questionnaire sought information on current provision of direct posterior restorations and perceived issues with the different materials. Descriptive statistical and hypothesis testing was performed.

Results:

Dentists’ response rate was 14% and therapists’ estimated minimum response rate was 6% (total N = 1,513). The most commonly used restorative material was amalgam in molar teeth and composite in premolars. When placing a direct posterior mesio-occluso-distal restoration, clinicians booked on average 45% more time and charged 45% more when placing composite compared to amalgam (P < 0.0001). The reported incidences of food packing and sensitivity following the placement of direct restorations were much higher with composite than amalgam (P < 0.0001). Widely recommended techniques, such as sectional metal matrix use for posterior composites, were associated with reduced food packing (P < 0.0001) but increased time booked (P = 0.002).

Conclusion:

Amalgam use is currently high in the publicly funded sector of UK primary care. Composite is the most used alternative, but it takes longer to place and is more costly. Composite also has a higher reported incidence of postoperative complications than amalgam, but time-consuming techniques, such as sectional matrix use, can mitigate against food packing, but their use is low. Therefore, major changes in health service structure and funding and posterior composite education are required in the United Kingdom and other countries where amalgam use is prevalent, as the amalgam phase-down continues.

Knowledge Transfer Statement:

This study presents data on the current provision of amalgam for posterior tooth restoration and its directly placed alternatives by primary care clinicians in the United Kingdom, where publicly funded health care with copayment provision predominates. The information is important to manage and plan the UK phase-down and proposed phase-out of amalgam and will be of interest to other, primarily developing countries where amalgam provision predominates in understanding some of the challenges faced.

Amalgam Phase-Down Part 2: UK-Based Knowledge, Opinions, and Confidence in the Alternatives

Introduction:

Amalgam use has recently been phased down, and the potential for a phase-out is being investigated.

Objectives:

The study aimed to identify knowledge of the phase-down and opinions of a potential phase-out of amalgam by UK primary care clinicians and assess their confidence in using different materials in different situations.

Methods:

An anonymized, prepiloted cross-sectional e-survey was used to assess primary care clinicians’ knowledge and opinions of the amalgam phase-down and potential phase-out and their confidence in using amalgam and the alternatives in different situations. In total, 11,902 invitations were distributed through British dentist and therapist associations. Prior hypotheses were tested alongside descriptive statistics.

Results:

Response rate was 13% (n = 1,513). Knowledge of the amalgam phase-down was low, with just 3% clinicians correctly identifying all patient groups in whom amalgam use should be avoided in the United Kingdom. Postgraduate education on posterior composite placement was high (88%), but a large majority had personal and patient-centered concerns over the suitability of the alternatives and lacked confidence when placing composite in comparison to amalgam in difficult situations (P < 0.0001). Logistic regressions revealed that the best predictors of high confidence in placing mesio-occluso-distal composites and composites in difficult situations were being a private general dentist or being primarily a composite user.

Conclusion:

Primary care clinicians have major personal and patient-centered concerns regarding the amalgam phase-down (of which they have limited knowledge) and potential phase-out. Many lack confidence in using the alternative, composite, to restore posterior teeth in difficult situations, whereas confidence in using amalgam in similar situations is high. Effective education of clinicians and understanding patients’ needs, alongside policy changes, are required to enable a successful amalgam phase-down and potential phase-out.

Knowledge Transfer Statement:

This study shows that UK primary care clinicians are worried about the phase-down of amalgam for themselves and their patients. Many lack confidence in the alternative, composite, when used in difficult situations, which is in stark contrast to amalgam. Knowledge of the phase-down is limited. There is a need for more effective education of clinicians, an understanding of patients’ values, and policy changes to ensure the success of the phase-down and potential phase-out of amalgam.

Prevalence and Outcomes of Acute Hypoxaemic Respiratory Failure in Wales: The PANDORA-WALES Study

BACKGROUND

We aimed to identify the prevalence of acute hypoxaemic respiratory failure (AHRF) in the intensive care unit (ICU) and its associated mortality. The secondary aim was to describe ventilatory management as well as the use of rescue therapies.

METHODS

Multi-centre prospective study in nine hospitals in Wales, UK, over 2-month periods. All patients admitted to an ICU were screened for AHRF and followed-up until discharge from the ICU. Data were collected from patient charts on patient demographics, clinical characteristics, management and outcomes.

RESULTS

Out of 2215 critical care admissions, 886 patients received mechanical ventilation. A total of 197 patients met inclusion criteria and were recruited. Seventy (35.5%) were non-survivors. Non-survivors were significantly older, had higher SOFA scores and received more vasopressor support than survivors. Twenty-five (12.7%) patients who fulfilled the Berlin definition of acute respiratory distress syndrome (ARDS) during the ICU stay without impact on overall survival. Rescue therapies were rarely used. Analysis of ventilation showed that median Vt was 7.1 mL/kg PBW (IQR 5.9-9.1) and 21.3% of patients had optimal ventilation during their ICU stay.

CONCLUSIONS

One in four mechanically ventilated patients have AHRF. Despite advances of care and better, but not optimal, utilisation of low tidal volume ventilation, mortality remains high.

Robotic transanal minimally invasive surgery - technical, oncological and patient outcomes from a single institution

AIM

Robotic transanal minimally invasive surgery (R-TAMIS) is gaining traction around the globe as an alternative to laparoscopic conventional TAMIS for local excision of benign and early malignant rectal lesions. The aim was to analyse patient and oncological outcomes of R-TAMIS for consecutive cases in a single centre.

METHODS

A prospective analysis of consecutive R-TAMIS procedures over a 12-month period was performed. Data were collated from hospital databases and theatre registers.

RESULTS

Eleven patients (six men, five women), mean age 69.81 years (51-92 years), underwent R-TAMIS over 12 months utilizing a da Vinci Xi platform. The mean lesion size was 36 mm (20-60 mm) with a mean distance from the anal verge of 7.5 cm (3-14 cm). Five lesions were posterior in anatomical location, four anterior, one right lateral and one left lateral. All procedures were performed in the lithotomy position using a GelPOINT Path Platform. Mean operative time was 64 min (40-100 min). Complete resection was achieved in 10/11 patients with two patients being upgraded to a diagnosis of adenocarcinoma. Nine patients were diagnosed with dysplastic lesions. Four patients had a false positive diagnosis of an invasive tumour on MRI. Six patients required suturing for full-thickness resections. One patient had a postoperative bleed requiring repeat endoscopy and clipping. One patient (full-thickness resection of T3 tumour) proceeded to a formal resection without difficulty with no residual disease (T0N0, 0/22). One patient with a fully resected T2 tumour is undergoing a surveillance protocol. The mean length of stay was 1 day with two patients having a length of stay of 2 days and one patient of 4 days.

CONCLUSION

R-TAMIS could potentially represent a safe novel approach for local resection of rectal lesions.

COVID-19: how prepared are front-line healthcare workers in England?

National efforts are underway to prepare the UK National Health Service (NHS) for the COVID-19 pandemic; however, the efficacy of these interventions is unknown. In view of this, a cross-sectional survey of front-line healthcare workers (HCWs) at two large acute NHS hospital trusts in England was undertaken to assess their confidence and perceived level of preparedness for the virus. The survey found that there has been moderate success in readying HCWs to manage COVID-19, but that more still needs to be done, particularly in relation to educating HCWs about laboratory diagnostics.

How Much Greater is Obstetric Intervention in Women with Medical Disorders in Pregnancy When Compared to the General Population?

Introduction The purpose of this study was to compare obstetric and neonatal outcomes between women attending a specialised maternal medicine service and the general obstetric population. Methods Women attending from January 2011 to December 2016 were identified from the clinic database. Medical diagnosis, demographics, obstetric and neonatal outcomes were compared with data from hospital annual report 2014. Results 1873 women were compared with 8632 women who delivered at the hospital in 2014. Delivery before 34 weeks [82 (4.5%) vs 189 (2.2%)], induction of labour [761 (40.6%) vs 2664 (30.9%)] and delivery by Caesarean Section (CS) [664 (35%) vs 2479 (29%)] were higher p<0.001; but elective CS [334 (18%) vs 1425 (17%), p=0.18] did not differ between the two groups. Neonatal outcomes were similar. Conclusion Premature delivery, induction of labour and CS rates are higher in women with medical disorders in pregnancy. Encouragingly, 77% of women attempting vaginal birth in this group were successful.

Analgesia, anaesthesia and obstetric outcome in women with inherited bleeding disorders

OBJECTIVE

Vertebral canal haematoma (VCH) complicates 1 in 168,000 obstetric epidurals (Ruppen et al., 2006). This risk is increased in women with inherited bleeding disorders (IBD). The impact of a contraindication to regional anaesthesia on pain management and obstetric outcome in these women is unknown. The purpose of this study was to determine anaesthetic use and obstetric outcomes in a cohort of women with IBD.

STUDY DESIGN

97 women with IBD that delivered 130 babies at the CWIUH from Jan 2011 to Dec 2016 were identified from a maternal medicine database. Multidisciplinary planning of peripartum care was communicated to labour ward staff using a simple checklist. The primary bleeding disorders were: Von Willebrands disease (VWD) Type 1 27 (27.8%); VWD Type 2A 3 (3.8%); Low VWF 3 (3.8%); Bleeding disorder of unknown aetiology (BDUA) 19 (19.6%); deficiency of Factors VII, VIII, IX, X, and XI 13 (13.4%); Carriers of Factor VIII, IX, X, XIII deficiency 17 (17.5%); 5 had combined deficiencies (5.2%) and there was one platelet function defect. 9 had a family history of a bleeding disorder (9.3%). Haemostatic support, analgesia, mode of delivery and maternal and fetal outcomes were compared between pregnancies where regional anaesthesia was permitted and those that were not using the Chi-squared test.

RESULTS

When pregnancies where regional anaesthesia was not recommended (49) were compared with pregnancies where regional anaesthesia was considered safe (81), the women were more likely to see an anaesthetist before labour 46 (94%) vs 46 (61%): p < 0.001; to require prophylactic haemostatic support for delivery 30 (61%) vs 1 (1%): p < 0.001; to use a remifentanil infusion 15 (31%) vs 0: p < 0.001, and have general anaesthesia for Caesarean Section (CS) 10 (20%) vs 1(1%): p < 0.001. Vaginal birth 35 (71%) vs 53(65%): p = 0.4 and CS rates 14 (29%) vs 26 (32%) p = 0.28 were similar. Postpartum haemorrhage (PPH) was more common 11 (24%) vs 9(12%) vs p = 0.07 but not statistically so. There were no cases of neonatal bleeding or VCH.

CONCLUSION

Contraindication to neuraxial blockade in labouring women with IBD does not influence mode of delivery. This information is reassuring to these women who may be anxious about delivery without regional anaesthesia.

Reliability of frailty assessment in the critically ill: a multicentre prospective observational study

Demand for critical care among older patients is increasing in many countries. Assessment of frailty may inform discussions and decision making, but acute illness and reliance on proxies for history-taking pose particular challenges in patients who are critically ill. Our aim was to investigate the inter-rater reliability of the Clinical Frailty Scale for assessing frailty in patients admitted to critical care. We conducted a prospective, multi-centre study comparing assessments of frailty by staff from medical, nursing and physiotherapy backgrounds. Each assessment was made independently by two assessors after review of clinical notes and interview with an individual who maintained close contact with the patient. Frailty was defined as a Clinical Frailty Scale rating > 4. We made 202 assessments in 101 patients (median (IQR [range]) age 69 (65-75 [60-80]) years, median (IQR [range]) Acute Physiology and Chronic Health Evaluation II score 19 (15-23 [7-33])). Fifty-two (51%) of the included patients were able to participate in the interview; 35 patients (35%) were considered frail. Linear weighted kappa was 0.74 (95%CI 0.67-0.80) indicating a good level of agreement between assessors. However, frailty rating differed by at least one category in 47 (47%) cases. Factors independently associated with higher frailty ratings were: female sex; higher Acute Physiology and Chronic Health Evaluation II score; higher category of pre-hospital dependence; and the assessor having a medical background. We identified a good level of agreement in frailty assessment using the Clinical Frailty Scale, supporting its use in clinical care, but identified factors independently associated with higher ratings which could indicate personal bias.

Abstract P4-08-09: DNA methylation markers predict recurrence-free interval in triple-negative breast cancer

BACKGROUND. Chemotherapy remains the treatment mainstay for triple-negative breast cancer (TNBC). Nevertheless, randomized trials have shown that not all TNBC require it, nor does it benefit all patients that receive it. Molecular tools to risk-stratify TNBC are currently lacking. In light of the importance of epigenetic processes modulating gene expression, we performed an array-based genome-wide DNA methylation search in well-documented institutional and clinical trial cohorts of TNBC for markers that can distinguish breast cancers with a favorable natural history from those with a high risk of recurrence.

METHODS. We performed an array-based genome-wide DNA methylation survey of well-documented institutional and clinical trial cohorts of TNBC and conducted molecular marker discovery on institutional TNBCs (115 patient samples; 53 recurrences) treated by locoregional therapy (LRT) alone. The identified hypermethylated gene signatures were then tested in a TNBC cohort (50 patient samples; 16 recurrences) from the no chemotherapy arms of IBCSG trials VIII and IX, and in a separate combined cohort of TNBCs (131 patient samples; 33 recurrences) treated with chemotherapy from an institutional repository and from IBCSG trials VIII and IX. Cross platform validation was conducted using quantitative multiplexed methylation specific PCR (QM-MSP) on hypermethylated markers in samples from both the Discovery Set and IBCSG LRT Test Set.

RESULTS. We identified methylation signatures in the discovery cohort consisting of 100 or 30 CpG probes that discriminated patients who remained recurrence-free from those with recurrent disease. These signatures were then tested in the IBCSG no chemotherapy cohort, and we found that hypermethylation was associated with shorter recurrence-free interval (RFI). A significant association of both 100 CpG (P&lt;0.0001) and 30 CpG (P=0.0021) signatures with shorter RFI was found in the combined institutional and IBCSG chemotherapy cohort. We observed an enrichment of methylation probes residing on chromosome 19, particularly within 19q13.41-43, that significantly correlated with RFI following chemotherapy. QM-MSP results reflected that of the methylation array [Spearman correlation coefficient of r = 0.495 (P = 0.0009)] indicating that the relationship between high methylation and short RFI is detectable independent of analytical platform. We also observed enrichment for Chromosome 19-specific probes within the 100 and 30 probe sets. While only 5% of all CpG markers are located within Chr19, 15% of the 100 CpG set, 37% of the 30 CpG set, and 47% of the 17 CpGs that are statistically significantly correlated with RFI in the chemotherapy group reside on the Chr19, mostly within 19q13.41-43.

CONCLUSIONS. Methylation markers may be of prognostic importance in TNBC and our findings should be validated in additional clinical trial cohorts.

Citation Format: Fackler MJ, Cho SS, Cope LM, Gabrielson E, Wilsbach K, Lynch C, Marks JR, Geradts J, Regan MM, Viale G, Wolff AC, Umbricht CB, Sukumar S. DNA methylation markers predict recurrence-free interval in triple-negative breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-08-09.