Let's Move with Leon-A qualitative evaluation of a UK digital intervention to improve physical activity in people with a musculoskeletal condition

OBJECTIVE

This article presents a qualitative evaluation of a 13-week digital intervention, 'Let's Move with Leon', designed to improve physical activity in people with a musculoskeletal condition.

STUDY DESIGN

A qualitative evaluation embedded within a randomised controlled trial assessing the effectiveness of the intervention at improving self-reported physical activity.

METHODS

A total of 184 participants received the intervention and were asked each week for 13 weeks to provide comment on their use and the usefulness of the digital physical activity behaviour change intervention. In addition, after 13 weeks, 12 participants took part in a semistructured interview to understand their use and the usefulness of the intervention. A thematic analysis was conducted on the combined qualitative data set.

RESULTS

A total of 128 of the 184 intervention participants (70.11%) provided at least one qualitative comment over the course of the evaluation (mean number of comments per participant = 5); in total, 674 comments were received. The thematic analysis identified three themes: (1) dipping in and out, (2) one size does not fit all and (3) monitoring and feedback. The qualitative data suggest that participants used the intervention sporadically, dipping in and out due to other commitments, and competing programmes, their changing physical ability, confidence and motivation. Not getting off to a good start was detrimental to use; many wanted to come back to the programme at a more appropriate time. A 'one size fits' approach catered for some but not all participants. Whilst not a predetermined intervention component the act of monitoring levels of activity as a data collection method seemed to encourage physical activity but may also result in negative social comparisons.

CONCLUSION

Digital physical activity behaviour change interventions are not one-size-fits-all; personalisation is key. Monitoring of activity by a named person can create commitment. Many dip in and out. Digital physical activity behaviour change interventions could complement physiotherapy exercises for people with musculoskeletal conditions. Signposting to local activities should be considered.

A199 BIOFILMS IN THE APPENDIX AND OTHER NON-INFLAMED SECTIONS OF THE COLON IN PEDIATRIC PATIENTS WITH INFLAMMATORY BOWEL DISEASES

Background

Biofilms, aggregated bacteria colonizing the extracellular polymeric substances matrix, are associated with the mucosa of inflammatory bowel diseases (IBD) patients with some studies showing a mean density of the mucosal biofilms 2-fold higher in IBD patients than in controls. The appendix, which is a highly immune organ, seems to be involved in IBD pathogenesis.

Purpose

In this study we aimed to evaluate biofilms in the appendix and other non-inflamed regions of the colon in pediatric IBD patients. We hypothesized that biofilms composed of pathobionts in these sections could drive inflammation in IBD patients.

Method

Tissues from the appendix, peri-appendicular region, cecum, and ascending colon (ASC), collected from the resected colons of 9 pediatric IBD patients and one pediatric non-IBD patient, preserved in methanol Carnoy’s solution were processed and paraffin embedded. Combined fluorescence in situ hybridization (FISH) for biofilms (probe: EUB338) and immunofluorescence (IF) mucin staining (MUC2) identified biofilms and their location. Biofilm formation capacity of culturable bacteria (identified through 16S DNA Sanger sequencing) from these sections was measured. Interleukin (IL)-8 (pro-inflammatory chemokine) and IL-10 (anti-inflammatory cytokine) expressions were assessed by tissue qPCR.

Result(s)

FISH demonstrated biofilms in these sections, in close proximity to epithelial cells. We used a biofilm formation assay to assess the ability of the identified bacteria from these sections to form biofilms, illustrating their potential to colonize and evade host defense and potential antibiotics. We found that Enterococcus avium has a significantly higher ability to form biofilms than the negative control. IL-8 and IL-10 both had the highest expression level in the appendix and peri-appendicular region and the lowest in the ASC among all the patients, suggesting an active immune response. Mechanistic experiments are in progress to investigate the type of bacteria involved in the biofilms and their effects on the gut barrier integrity.

Conclusion(s)

Biofilms adjacent to the epithelium, especially in the appendix and peri-appendix, could interact with or invade epithelial cells. The elevated chemokine transcript level in the appendix could reflect the recruitment of immune cells to this section following bacterial invasion, resulting in the activation of the immune system. Identifying the bacteria involved in the biofilms and clarifying their characteristics will aid us in developing novel microbe-altering treatment strategies or personalized medicine.

Disclosure of Interest

None Declared

Are multiple-use bottles of chlorhexidine solutions at risk of contamination in joint replacement surgery?

INTRODUCTION

Chlorhexidine gluconate 2% w/v in isopropanol 70% solutions in multiple-use bottles is commonly used in surgery as a cost-effective method for skin disinfection. However, multiple-use bottles risk contamination. This study aims to test whether bacterial contamination of multiple-use bottles or their solutions occurs once open and on use between different patients.

METHODS

Consecutive samples were taken each time a chlorhexidine bottle was used over a 7-day study period. Samples were tested using blood culture, agar plate and mass spectrometry.

RESULTS

No growth was observed in 52 samples taken from 18 bottles inoculated into blood culture bottles. Four growths on agar plate culture were determined to be contaminants from the sampling process.

CONCLUSIONS

This study supports the use of multiple-use bottled chlorhexidine solutions as safe and cost-effective in surgical practice.

The reach and benefits of a digital intervention to improve physical activity in people with a musculoskeletal condition delivered during the COVID-19 pandemic in the UK

Aim:

To evaluate a digital intervention to improve physical activity in people in the UK with a musculoskeletal condition delivered during movement restrictions brought about because of the COVID-19 pandemic.

Method:

Service evaluation data collected from 26,041 participants over 5 months was assessed against national datasets to understand the reach and representativeness of the digital physical activity intervention. Measures to restrict the movement and interaction of people were in place during these 5 months. Cross-sectional data from 2752 participants across different stages of the 12-week programme assessed levels of physical activity and the components of behaviour as defined by the COM-B model (Capability, Opportunity, Motivation = Behaviour). Regression analysis investigated the relationship between programme stage and physical activity and the components of behaviour.

Results:

In comparison to the UK population of people with a musculoskeletal condition, the intervention participants were over-represented by females, White, and inactive people. A cross-sectional analysis suggested that the number of participants regularly active increased by programme stage. Scores for the behavioural components of automatic and reflective motivation, physical and psychological capability, and physical opportunity were also improved by programme stage.

Conclusion:

The service evaluation suggests that the digital intervention, designed to improve physical activity in people with a musculoskeletal condition, could be beneficial during measures to restrict movement to slow the spread of infectious disease in those who are already motivated to become or stay active.

A237 VIRULENCE POTENTIAL OF BACTERIA ISOLATED FROM NON-INFLAMED COLON IN PATIENTS WITH INFLAMMATORY BOWEL DISEASES

Background

As inflammation can impact microbes, our lab has focused on non-inflamed bowel sections of patients with inflammatory bowel diseases (IBD) and found bacterial alterations in the terminal ileum. We are also interested in the appendix given the involvement of the peri-appendicular region and effects of appendectomy in ulcerative colitis.

Aims

In this study, we aimed to identify and evaluate microbes from the appendix and non-inflamed regions of the colon in IBD patients. We hypothesized that microbes originating from the non-inflamed sections of the colon or appendix are more invasive and could trigger inflammation in IBD patients.

Methods

16S DNA Sanger sequencing was performed on bacteria, aerobically and anaerobically cultured from tissues of the appendix, peri-appendicular region, cecum, and ascending colon, collected from the resected colons of 5 pediatric IBD patients. The invasive capacity of the identified bacteria was evaluated by gentamicin protection assays on Caco-2 intestinal epithelial cells in vitro. Presence of select invasive or adhesive genes in the bacteria was assessed by PCR.

Results

Escherichia coli was the most frequently cultured species in the aerobic cultures; additional aerobic species included Enterococcus and Klebsiella. Bifidobacterium and Erysipelatoclostridium were identified among the anaerobic cultures. Gentamicin protection assays indicated that Klebsiella isolated from the peri-appendicular region was significantly more invasive (mean ~3000 CFU/ml) than HB101 (~1000 CFU/ml; non-invasive control; P<0.05). Enterococcus avium and Enterococcus faecalis were also more invasive than HB101 in the peri-appendicular region (~10000 CFU/ml) and cecum (~4000 CFU/ml; P<0.05), respectively. E. coli isolated from the appendix showed a higher invasive potential (~3000 CFU/ml) than E. coli isolated from other sections. Additionally, PCR showed that E. coli obtained from different sections, except the ascending colon of one the patients, had the fimH gene while the other types of bacteria did not. None of the isolated bacteria had Hemolysin ( hlyA) or attaching and effacing ( eaeA) genes.

Conclusions

Bacteria, especially E. coli, from non-inflamed bowel in IBD (including the appendix) appear to have increased invasive potential. This suggests that the microenvironment in these regions could be altered, resulting in increased invasion of bacteria or the gut harboring more invasive microbial populations in IBD patients. As a result, inflammation could be triggered or exacerbated through this reservoir of pathobionts.

Funding Agencies

CIHR

Online training resources to aid therapeutic radiographers in engaging in conversations about physical activity and diet: A mixed methods study

INTRODUCTION

This study explored changes in therapeutic radiographers' (TRs) self-reported knowledge and skills to engage in conversations about physical activity and diet with people living with and beyond cancer following completion of publicly available online courses.

METHODS

Participants were randomly assigned to two of five online courses that aim to support health professionals to engage in conversations about physical activity and diet in the oncology setting. Participants rated their agreement with 18 statements related to the COM-B (capability, opportunity and motivation-behaviour) model components following completion of an online course on healthy diet (n = 16) and physical activity (n = 21). Semi-structured telephone interviews (n = 21) were also conducted. Analysis of the interviews was guided by the Theoretical Domains Framework.

RESULTS

Overall, the online courses were acceptable and the TRs in this study self-reported improved COM to deliver advice on physical activity and diet. The inclusion of the evidence and scientific rationale on the benefits of diet and physical activity, and also guidance on how to start conversations with patients were highlighted as important features of the courses. Suggestions for adaptations to the nutrition courses included the need for content that accounts for the side effects cancer patients experience while undergoing treatment. To support the implementation of training and the delivery of advice on these topics, multi-disciplinary working, organisational support and guidance around professional role boundaries were highlighted as important.

CONCLUSION

Current publicly available online courses on physical activity and diet for oncology health professionals can reduce some barriers among TRs to providing advice to those living with and beyond cancer.

IMPLICATIONS FOR PRACTICE

Existing online training courses could be used to support TRs to deliver physical activity and dietary advice in practice. Findings show that these courses can be disseminated within radiotherapy departments. The results also highlight a number of important considerations for the implementation of brief health behaviour advice and online training interventions on physical activity and diet within cancer care.

Search for B^{+}→K^{+}νν[over ¯] Decays Using an Inclusive Tagging Method at Belle II

A search for the flavor-changing neutral-current decay B^{+}→K^{+}νν[over ¯] is performed at the Belle II experiment at the SuperKEKB asymmetric energy electron-positron collider. The data sample corresponds to an integrated luminosity of 63  fb^{-1} collected at the ϒ(4S) resonance and a sample of 9  fb^{-1} collected at an energy 60 MeV below the resonance. Because the measurable decay signature involves only a single charged kaon, a novel measurement approach is used that exploits not only the properties of the B^{+}→K^{+}νν[over ¯] decay, but also the inclusive properties of the other B meson in the ϒ(4S)→BB[over ¯] event, to suppress the background from other B meson decays and light-quark pair production. This inclusive tagging approach offers a higher signal efficiency compared to previous searches. No significant signal is observed. An upper limit on the branching fraction of B^{+}→K^{+}νν[over ¯] of 4.1×10^{-5} is set at the 90% confidence level.

Quality of life after transcatheter aortic valve implantation: Perspectives from a Canadian data base

Funding Acknowledgements

Type of funding sources: None.

Background

We examined changes in quality of life (QOL) of patients after transcatheter aortic valve implantation (TAVI). 

Methods

We conducted an observational cohort study of consecutive patients who had TAVI between 2016-2019 in British Columbia, Canada. QOL was measured at baseline, 30-day and 1-year using the Kansas City Cardiomyopathy Questionnaire (KCCQ-OS). We used linear regression modelling to examine factors associated with 30-day changes in QOL, logistic regression modelling to identify predictors of having a poor outcome, and Cox regression modelling to ascertain risk estimates of the effect of QOL on 1-year mortality. 

Results

The cohort included 1,706 patients [742 women (43.5%)]; median [interquartile range, IQR] age 83 (77,86). Median (IQR) baseline KCCQ-OS was 45 (28.2,67), indicating severe impairment. Patients alive at 1-year (91.3%) reported a mean improvement of 24.1 (95% CI, 22.7-25.6) points in the KCCQ-OS at 30-day, which was sustained at 1-year (25.3; 95% CI, 23.8,26.8). Older age, lower baseline health status, lower aortic valve gradient, lower hemoglobin, atrial fibrillation and non-transfemoral access were associated with worse 30-day QOL. At 1-year, 65% of patients had a favourable outcome; additional risk factors for 1-year mortality (8.7%) were male sex, NYHA Class IV, severe pulmonary and renal disease, diabetes, and in-patient status.  

Conclusions

TAVI is associated with significant early improvement in QOL which is sustained at 1 year in a "real world" registry.  The inclusion of QOL can support treatment decision and the patient-centred evaluation of TAVI

Prevalence of cardiac abnormalities in sickle cell disease identified using cardiac magnetic resonance imaging

Background

Sickle cell disease (SCD) affects thousands of individuals in the United Kingdom causing significant morbidity and mortality. Modern therapies have been successful in increasing life expectancy, however these patients have an increased risk of cardiovascular complications and the extent to which sickle cell disease affects cardiac function is not well understood. Cardiac magnetic resonance imaging (MRI) is the gold standard imaging modality for evaluating myocardial function. It is known that sickle cell patients can present with pulmonary hypertension, left ventricular diastolic dysfunction, and atrial enlargement however the prevalence of other cardiac abnormalities has not been sufficiently investigated with cardiac MRI. In addition, the European Society of Cardiology (ESC) updated their definition of Heart Failure in 2016 and therefore will need to be re-assessed in this population.

Purpose

To evaluate the prevalence of cardiac abnormalities in the sickle cell population using cardiac MRI and based on the recently updated diagnostic criteria.

Methods

We conducted a retrospective review including all patients with sickle cell disease at a large tertiary hospital in London, United Kingdom who had been referred for cardiac MRI between 2011 and 2019. Data was collected data on various measures of cardiac function including: left ventricular ejection fraction (LVEF), left ventricular hypertrophy, left and right atrial enlargement, regional wall motion abnormalities, valvular disease, myocardial scarring, and cardiac iron load.

Results

82 patients and 123 cardiac MRI scans were reviewed in this study. 68% of patients were female and the average age at time of scan was 37 years. The average left ventricular ejection fraction was 57% (n=82). Cardiac abnormalities were identified in 60% of patients. The most common cardiac abnormalities reported were: valvular regurgitation (46%; n=28), left atrial enlargement (28%; n=19), right atrial enlargement (16%; n=11), left ventricular hypertrophy (11%; n=8), regional wall motion abnormalities (10%; n=7), and myocardial scar with late gadolinium enhancement (9%; n=7). 28% of the patients were diagnosed with Heart Failure; 11% of the patients satisfied the diagnostic criteria for HFpEF (Heart failure with preserved ejection fraction, n=9), 10% with HFrEF (Heart Failure with reduced ejection fraction, n=8), and 7% with HFmrEF (Heart Failure with mid-range ejection fraction, n=6).

Conclusion

Sickle cell disease affects cardiac function in the majority of patients resulting in numerous cardiac abnormalities. We have described the overall extent of these effects using data from cardiac MRI scans, which has not been commonly used thus far. This has implications for both the diagnosis and subsequent management of cardiac abnormalities in this population, and it can be used to further investigate and guide the development of targeted treatments for these patients.

Funding Acknowledgement

Type of funding source: None

Six-month and one-year outcomes with the PASCAL transcatheter valve repair system for patients with mitral regurgitation from the multicentre, prospective CLASP study

Background

Transcatheter mitral valve repair has emerged as a viable option for treating mitral regurgitation (MR). We report results from the multicentre, prospective, single arm CLASP study with the PASCAL transcatheter valve repair system.

Methods

109 patients with clinically significant MR deemed candidates for transcatheter repair by the local heart team were treated in the CLASP study. The study evaluated safety, performance, clinical and echocardiographic outcomes and included an independent clinical events committee and echocardiographic core lab. The primary safety endpoint was a composite MAE rate at 30 days of cardiovascular mortality, stroke, MI, new need for renal replacement therapy, severe bleeding, and re-intervention for study device-related complications.

Results

Mean age was 76 years, 54% male, 57% NYHA Class III/IV, 100% MR grade ≥3+ with 62% functional, 31% degenerative, 7% mixed etiology. Successful implantation was achieved in 95% of patients. At 30 days, the MAE rate was 8.3% including one cardiovascular mortality due to cardiogenic shock as a result of severe bleeding at the contralateral arterial access site for hemodynamic monitoring further complicated by disseminated intravascular coagulation, one stroke, and one conversion to mitral valve replacement surgery. In paired analysis, 88% of patients were in NYHA Class I/II (p&lt;0.001), MR grade was ≤1+ in 79% of patients and ≤2+ in 96% of patients. Significant improvements in 6MWD (+27 m, p&lt;0.001) and KCCQ (+16 points, p&lt;0.001) were observed. The six-month data will be available for presentation. In addition, we report one-year follow up of the first 62 patients (ITT): 93% one-year survival rate (Kaplan-Meier estimate), no stroke, no late reintervention, one late MI. In paired analysis, MR grade was ≤1+ in 82% of patients and ≤2+ in 100% of patients. 88% of patients were in NYHA Class I/II (p&lt;0.001), 6MWD improved by 21 m (p=0.124) and KCCQ improved by 13 points (p&lt;0.001).

Conclusions

This study demonstrates the PASCAL transcatheter valve repair system is safe and resulted in robust MR reduction with 100% of patients achieving MR ≤2+, and ∼ 80% MR ≤1+, sustained at one year. Results show high survival and low complication rates, and sustained improvements in functional status, exercise capacity, and quality of life at one year in patients with clinically significant, symptomatic MR. The CLASP IID/IIF pivotal trial is underway.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Edwards Lifesciences (Irvine, CA)

Geometrical predictors of small virtual neoLVOT size in functional mitral regurgitation

Background

LVOT obstruction is a potentially lethal complication of transcatheter mitral valve replacement (TMVR). An anticipated neoLVOT area of &lt;2cm2 is presumed to imply prohibitive risk. Measurement of the anticipated neoLVOT can be time consuming and requires specialist software to facilitate virtual valve implantation.

Purpose

To determine simple geometrical predictors of prohibitive neoLVOT size.

Methods

165 consecutive, non-calcific FMR patients referred to a transcatheter heart valve program were analysed. Segmentation of the mitral annulus and left heart geometry was performed using CT. Suitability for a default D-shaped TMVR was determined by proprietary annular inclusion criteria. Systolic neoLVOT area was determined via virtual valve implantation of the default TMVR.

Results

Sufficient image data for annular and neoLVOT suitability assessment was available in 152 patients. 105 patients (69%) were suitable for TMVR based on annular measurements. Of these, neoLVOT area was &gt;2cm2 in 88 (84%). Overall, compared to patients not suitable for TMVR (n=64), those suitable had larger ventricles with lower LVEF, and larger annuli (table 1). Using binomial logistic regression involving the variables within table 1, LVESD was the sole statistically significant variable to predict neoLVOT area of &lt;2cm2 (p=0.02). LVESD &lt;48mm had 82% sensitivity and 94% specificity for the presence of prohibitive neoLVOT (figure 1).

Conclusion

Smaller LVESD is a strong predictor of small neoLVOT, and hence LVOT obstruction post default D-shaped TMVR implantation. This simple measure may therefore be used to streamline patient selection for advanced pre-procedural imaging analysis.

Predicting NeoLVOT size &lt;2 cm2

Funding Acknowledgement

Type of funding source: None

First-phase ejection fraction predicts response to cardiac resynchronization therapy and adverse outcomes

Background

Cardiac Resynchronization Therapy (CRT) is an important therapeutic treatment for chronic heart failure. However, even in carefully selected cases up to 40% of patient fail to respond. First-phase ejection fraction (EF1), the ejection fraction up to the time of maximal ventricular contraction, is a novel and more sensitive echocardiographic measure of early systolic function.

Purpose

We examined the value of EF1, to predict response to CRT and clinical outcomes after CRT.

Methods

We analysed echocardiograms from 197 patients who underwent CRT between 2009 and 2018 and were followed to determine clinical outcomes.

Results

Volumetric response rate (reduction in end-systolic volume ≥15%) was 92.3% vs. 12.1%, for those with EF1 in the highest vs. lowest tertiles (p&lt;0.001). A cut-off value of 11.9% for EF1 had &gt;85% sensitivity and specificity for prediction of response to CRT; on multivariate logistic regression analysis incorporating previously defined predictors, EF1 was the strongest predictor of response (OR: 1.563, 95% CI: 1.371–1.782, p&lt;0.001) (table 1). EF1 was also the strongest predictor of a clinical composite score (OR: 1.115, 95% CI: 1.044–1.191, p=0.001). Improvement in EF1 at 6 months after CRT implantation (6.5±5.8% vs 1.8±4.3% in responders vs. non-responders, p&lt;0.001) was the best predictor of heart failure re-hospitalization and death after median follow-up of 29.2 months (HR: 0.819, 95% CI:0.765–0.876, p&lt;0.001).

Conclusion

EF1 is a promising marker to identify patients likely to respond to CRT and most likely provides a measure of myocardial viability that determines response.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): British Heart Foundation, Wellcome/EPSRC Centre for Medical Engineering

Search for Axionlike Particles Produced in e^{+}e^{-} Collisions at Belle II

We present a search for the direct production of a light pseudoscalar a decaying into two photons with the Belle II detector at the SuperKEKB collider. We search for the process e^{+}e^{-}→γa, a→γγ in the mass range 0.2<m_{a}<9.7  GeV/c^{2} using data corresponding to an integrated luminosity of (445±3)  pb^{-1}. Light pseudoscalars interacting predominantly with standard model gauge bosons (so-called axionlike particles or ALPs) are frequently postulated in extensions of the standard model. We find no evidence for ALPs and set 95% confidence level upper limits on the coupling strength g_{aγγ} of ALPs to photons at the level of 10^{-3}  GeV^{-1}. The limits are the most restrictive to date for 0.2<m_{a}<1  GeV/c^{2}.

Postmastectomy Radiation Therapy Planning After Immediate Implant-based Reconstruction Using the European Society for Radiotherapy and Oncology-Advisory Committee in Radiation Oncology Practice Consensus Guidelines for Target Volume Delineation

AIMS

To evaluate how common radiation therapy techniques perform in the setting of the new European Society for Radiotherapy and Oncology-Advisory Committee in Radiation Oncology Practice (ESTRO-ACROP) delineation recommendations for immediate breast reconstruction (IBR).

MATERIALS AND METHODS

Seven Danish radiation therapy centres and six international European centres participated in this project. Two breast cancer cases (one left-sided and one right-sided) with a retropectoral implant were chosen for radiation therapy planning using deep-inspiration breath-hold. Target volumes were delineated according to ESTRO-ACROP delineation recommendations. The centres were asked to plan the cases using any radiation therapy technique according to the Danish Breast Cancer Group plan objectives.

RESULTS

In total, 35 treatment plans were collected. Half of the submitted plans, for both the left-sided and the right-sided case, used the field-in-field (FiF) technique (nine for each), a quarter used volumetric arc radiation therapy (VMAT; five for right-sided, four for left-sided) and the remaining quarter was a mix of inverse intensity-modulated radiation therapy (IMRT), helicoidal therapy and hybrid (combined open fields and VMAT) techniques. Mean clinical target volume doses were in the range 99-102% of the prescribed dose. The median FiF mean heart dose (MHD) for right-sided radiation therapy was 1 Gy (range 0.8-3.7) and 5.2 Gy for left-sided radiation therapy (range 2.2-6.5). For right-sided radiation therapy, the median VMAT MHD was 3.42 Gy, for IMRT was 2.3 Gy and for helicoidal therapy was 5.1 Gy. For left-sided radiation therapy, the median VMAT MHD was 6.3 Gy, for IMRT was 7.8 Gy and for helicoidal therapy was 7.3 Gy.

CONCLUSIONS

Different radiation therapy techniques could be used to plan radiation therapy in the setting of IBR. FiF provided good coverage with acceptable organ at risk doses. The best dose distribution results as a trade-off between the objectives of target volume coverage and high-dose organ at risk inclusion. The radiation therapy technique affects the interplay between these objectives.

Investigating alternative materials to EPDM for automatic taps in the context of Pseudomonas aeruginosa and biofilm control

BACKGROUND

Automatic taps use solenoid valves (SVs) which incorporate a rubber (typically EPDM) diaphragm to control water flow. Contaminated SVs can be reservoirs of opportunistic pathogens such as Pseudomonas aeruginosa; an important cause of healthcare-associated infection.

AIMS

To investigate the attachment and biofilm formation of P. aeruginosa on EPDM and relevant alternative rubbers to assess the impact on water hygiene in a laboratory model.

METHODS

Biofilm formation on EPDM, silicone and nitrile rubber coupons was investigated using a CDC biofilm reactor. SVs incorporating EPDM or nitrile rubber diaphragms were installed on to an experimental water distribution system (EWDS) and inoculated with P. aeruginosa. P. aeruginosa water levels were monitored for 12-weeks. SVs incorporating diaphragms (EPDM, silicone or silver ion-impregnated silicone rubber), pre-colonized with P. aeruginosa, were installed and the effect of flushing as a control measure was investigated. The concentration of P. aeruginosa in the water was assessed by culture and biofilm assessed by culture and microscopy.

FINDINGS

Bacterial attachment was significantly higher on nitrile (6.2 × 10⁵ cfu/coupon) and silicone (5.4 × 10⁵ cfu/coupon) rubber than on EPDM (2.9 ×10⁵ cfu/coupon) (P<0.05, N = 17). Results obtained in vitro did not translate to the EWDS where, after 12-weeks in situ, there was no significant difference in P. aeruginosa water levels or biofilm levels. Flushing caused a superficial reduction in bacterial counts after <5 min of stagnation.

CONCLUSION

This study did not provide evidence to support replacement of EPDM with (currently available) alternative rubbers and indicated the first sample of water dispensed from a tap should be avoided for use in healthcare settings.

Search for an Invisibly Decaying Z^{'} Boson at Belle II in e^{+}e^{-}→μ^{+}μ^{-}(e^{±}μ^{∓}) Plus Missing Energy Final States

Theories beyond the standard model often predict the existence of an additional neutral boson, the Z^{'}. Using data collected by the Belle II experiment during 2018 at the SuperKEKB collider, we perform the first searches for the invisible decay of a Z^{'} in the process e^{+}e^{-}→μ^{+}μ^{-}Z^{'} and of a lepton-flavor-violating Z^{'} in e^{+}e^{-}→e^{±}μ^{∓}Z^{'}. We do not find any excess of events and set 90% credibility level upper limits on the cross sections of these processes. We translate the former, in the framework of an L_{μ}-L_{τ} theory, into upper limits on the Z^{'} coupling constant at the level of 5×10^{-2}-1 for M_{Z^{'}}≤6  GeV/c^{2}.

Comparison of Kjeldahl Method for Determination of Crude Protein in Cereal Grains and Oilseeds with Generic Combustion Method: Collaborative Study

Seven laboratories participated in a collaborative study to extend the applicability of the AOAC generic combustion method for determination of crude protein in animal feed (990.03) to include determination in cereal grains and oilseeds. In the study, method 990.03 was compared with the AOAC mercury catalyst Kjeldahl method for determination of protein in grains (979.09) and crude protein in animal feed (954.01). The study also evaluated the effect on the results of fineness of grind. For determination of crude protein in grains and oilseeds by the combustion method, standard deviations for repeatability and reproducibility ranged from 0.10 to 0.37 and from 0.25 to 0.54, respectively, and relative standard deviations for repeatability and reproducibility ranged from 0.77 to 2.57% and from 1.24 to 3.15%, respectively. The combustion method was adopted first action by AOAC International for determination of crude protein in cereal grains and oilseeds containing 0.2- 20% nitrogen.

563 Early systolic function is impaired in patients with heart failure and preserved ejection fraction and is a more important predictor of clinical outcomes than diastolic function

Funding Acknowledgements

British Heart Foundation

Aims

First-phase ejection fraction (EF1), the ejection fraction up to the time of maximal ventricular contraction may be impaired in heart failure with preserved ejection fraction (HFpEF), with homeostatic mechanisms preserving the overall ejection fraction. We examined whether EF1 is impaired and whether it predicts adverse outcomes in patients with HFpEF.

Methods and Results

We examined EF1 in patients with HFpEF diagnosed according to European Society of Cardiology guidelines, in subjects with pre-clinical diastolic dysfunction and in control subjects with no evidence of heart failure. The predictive value of EF1 for a combined end-point of re-hospitalisation for heart failure and death from any cause was compared to that of conventional echocardiographic and other indices. There was a progressive impairment of EF1 in patients with diastolic dysfunction and HFpEF compared to those without evidence of heart failure (P &lt; 0.001). In 180 HFpEF patients followed for a median of 14.7 months, 101 patients reached the primary endpoint (61 deaths and 40 hospitalisations). EF1 was the most powerful predictor of events (table 1). A cut-off value of 19.4% gave hazard ratios (for EF1 &lt; 19.4% compared to ≥19.4%) of 3.04 (figure 1), (95% confidence interval 2.014 – 4.604, P &lt; 0.001) unadjusted, and 2.976 (1.887 – 4.695, P &lt; 0.001) adjusted for age, gender, other echocardiographic indices (including EF, E/e’ ratio, stroke volume and left atrial volume index) and N-terminal pro-brain natriuretic peptide.

Conclusion

Early systolic function is impaired in HFpEF and is a powerful predictor of clinical outcomes. Therapies targeted at improving early systolic function may improve outcomes in HFpEF.

Table 1 HR CI (95%) P value Age 1.020 1.001 - 1.039 0.042 Female Gender 1.989 1.254 - 3.156 0.003 ln NT-proBNP 1.354 1.096 - 1.672 0.005 Haemoglobin 0.992 0.980 - 1.005 0.225 eGFR 0.997 0.988 - 1.006 0.568 Structural Heart Disease 0.748 0.439 - 1.274 0.285 Diastolic Dysfunction 0.694 0.445 - 1.082 0.107 Ejection Fraction 1.031 0.996 - 1.068 0.082 Stroke Volume index 0.963 0.940 - 0.986 0.002 TPAVF 0.995 0.980 - 1.005 0.230 EF1 0.900 0.869 - 0.932 &lt;0.001 Multivariate analysis of predictors of events

Abstract 563 Figure 1 Kaplan-Meier Curve

4291Six-month outcomes from the multicenter, prospective study with the novel PASCAL transcatheter valve repair system for patients with mitral regurgitation in the CLASP study

Background

Severe mitral regurgitation may lead to an impaired prognosis if left untreated. Transcatheter treatment options have emerged as an alternative to surgery and an adjunct to medical therapy. We report the six-month results of the PASCAL transcatheter valve repair system in treating patients with mitral regurgitation enrolled in the multicenter, prospective, single arm CLASP study.

Methods

The PASCAL Transcatheter Valve Repair System is a leaflet repair therapy that uses clasps and paddles to place a woven Nitinol spacer between the native valve leaflets to fill the regurgitant orifice via a transseptal approach. Eligible patients had clinically significant MR despite optimal medical therapy and were deemed candidates for transcatheter mitral repair by the local Heart Team. Safety, performance, and clinical outcomes were prospectively assessed at baseline, discharge, 30 days, and 6 months post-procedure. All major adverse events (MAE) were adjudicated by an independent clinical events committee and echocardiographic images were assessed by a core lab. The MAE rate was the primary safety endpoint, defined as the composite of cardiovascular mortality, stroke, MI, new need for renal replacement therapy, severe bleeding, and re-intervention for study device-related complications.

Results

Between June 2017 and September 2018, 62 patients were enrolled at 14 sites worldwide for transcatheter mitral valve reconstruction using the PASCAL system. The mean age was 76.5 years (62.9% male). All patients had MR grade ≥3+, with 59% functional, 34% degenerative, and 7% mixed etiology, and 51.6% of patients were in NYHA Class III/IV. Successful implantation of the PASCAL device was achieved in 95% of patients. At discharge, 95% of patients had MR grade ≤2+ with 81% grade ≤1+. There was one cardiovascular mortality and the MAE rate was 4.8%. At 30-day follow-up, paired analyses shows that 98% of patients had MR grade ≤2+ with 81% grade ≤1+ and 88% were in NYHA Class I/II (p<0.0001). The 6MWD improved by 38.9 m (p=0.0015) and was accompanied by average improvements in KCCQ and EQ5D scores by 14.1 points (p<0.0001) and 8.3 points (p=0.0028), respectively. The six-month data will be available for presentation.

Conclusions

In this early device experience, the PASCAL transcatheter valve repair system showed an acceptable safety profile and performed as intended in treating patients with mitral regurgitation. The PASCAL device resulted in significant MR grade reduction, which was associated with clinically and statistically significant improvements in functional status, exercise capacity, and quality of life. Continued follow-up is warranted to validate these initial promising results.

Acknowledgement/Funding

Edwards Lifesciences

P6134Understanding non-attendance to an inner city tertiary centre heart failure clinic: a pilot project

Background

Tackling health inequalities is a priority in heart failure (HF). We do not fully understand why some patients do not attend their hospital HF clinic appointments. Currently when a patient DNAs (does not attend) they are offered a repeat appointment often months later or are discharged from the service with a request to the primary care physician to re-refer. Non-attendance represents a missed opportunity to improve patients' health.

Purpose

The purpose of this pilot was to look at the demographics and patient factors that contribute to non-attendance. The aim is to understand and personalise our DNA policy to reduce health inequality, improve outcomes, and reduce inefficiencies in our service.

Methods

The last consecutive 45 patients who DNAd HF clinic were identified and for each, a patient who did attend the same clinic date (Attender), was chosen at random (random.org). The demographics were obtained (age, ethnicity, contact details) and medical notes reviewed (LVEF%, co-morbidities). The patient address was scored for its Index of Multiple Deprivation (IMD) – a UK government dataset measuring relative deprivation by ranking 32,844 neighbourhoods nationally using 37 indicators across 7 domains of deprivation where neighbourhood 1 is the most deprived nationally. Patients were phoned up to three times to establish the patient's mode, duration and cost of their last journey to clinic and, for those patients who DNAd, to ascertain the reason for non-attendance.

Results

Demographic and medical history was obtained for all patients. It was not possible to contact 2/45 of the Attenders, and 13/45 of the DNA patients. There was no significant difference in age, gender, number of comorbidities, LVEF%, travel time, or travel cost between DNAs and attenders. The mean one-way journey time was 53.4 mins (range 15–210 mins) and the mean return journey cost was GBP ≤10.95 (range ≤0–≤80). Common reasons for non-attendance were not receiving appointment details, forgetting appointments, being unwell on the day and difficulties with travel. The IMD score for the patients who DNAd was significantly lower confirming these patients lived in more deprived areas (9436±5863 vs. 15414±7801, p<0.001) with 71% of DNA patient's addresses in the bottom third most deprived neighbourhoods nationally.

Figure 1

Conclusions

There was a significant difference in deprivation score between patients who attended and DNAd their clinics. In addition, we found that all patients were travelling up to an hour each way to attend clinic, and that the cost of travel may be a barrier to attendance, even in a healthcare system that is free at the point of delivery. Despite calling three times, we were unable to speak to 29% of patients who DNAd and 4% of the patients who attended their appointments. Work is ongoing to reduce our DNA rates and personalise our response in this deprived population, with the aim of improving engagement and health inequality.

A mixed methods process evaluation of a print-based intervention supported by internet tools to improve physical activity in UK cancer survivors

OBJECTIVE

A waiting list randomised control trial has shown the Move More Pack, a print-based intervention supported by Internet tools, to improve physical activity levels in cancer survivors; however, one-third of them do not improve from the intervention. The objective of this process evaluation is to understand intervention use, the mechanisms of impact, the perceived benefits and the contextual factors influencing these, identifying for whom it is a useful resource.

METHODS

The process evaluation used mixed methods, based on guidance from the UK Medical Research Council, including 181 questionnaire responses on intervention use and physical activity improvement over 12 weeks, 56 open-text responses and 17 semistructured interviews.

RESULTS

The Move More Pack was suggested to be most useful when delivered towards the start of the cancer journey to those with a positive attitude to fight cancer but with a low level of physical activity, capitalising on a teachable moment. It was suggested that healthcare professionals could support the effective distribution of the Move More Pack. The intervention's printed components were more popular and well used than the Internet tools. Use of the printed intervention components was positively correlated with physical activity improvement but use of the Internet tools was not. Women were more likely to use the intervention's printed components than men. Cancer survivors using the intervention reflected that they had increased confidence and motivation for physical activity and other lifestyle behaviours.

CONCLUSION

The Move More Pack should be offered by healthcare professionals, during cancer treatment, when health is salient, to those with a positive attitude to fight cancer but with low levels of physical activity. Use of the intervention's printed components is more likely to improve physical activity than the Internet tools, and the components are more likely to be used by women. The use of Internet tools to support physical activity improvement in cancer survivors requires further investigation.

A randomised control trial and cost-consequence analysis to examine the effects of a print-based intervention supported by internet tools on the physical activity of UK cancer survivors

OBJECTIVE

The objective of this study was to evaluate the effectiveness of a print-based intervention supported by Internet tools at improving physical activity in cancer survivors compared with a standard letter recommendation. Prediagnosis physical activity and self-efficacy were hypothesised to predict physical activity improvement.

STUDY DESIGN

Waiting list randomised control trial and cost-consequence analysis.

METHODS

Adult cancer survivors who could become physically active without prior medical approval were randomised to receive either a print-based intervention supported by Internet tools (intervention, n = 104) or a standard letter recommendation (control, n = 103). Physical activity was assessed at 12 weeks with maintenance assessed at 24 weeks in the intervention arm. The number needed to treat was calculated, and a cost-consequence analysis completed.

RESULTS

Participants in receipt of a print-based intervention supported by Internet tools improved their physical activity by 36.9% over 12 weeks compared with 9.1% in the control arm. Physical activity was maintained at 24 weeks in the intervention arm. A total of 6.29 cancer survivors needed to receive the intervention for one cancer survivor to improve their physical activity over a standard letter recommendation. Intervention delivery cost £8.19 per person. Prediagnosis physical activity and self-efficacy did not predict physical activity improvement.

CONCLUSION

A print-based intervention supported by Internet tools offers a promising low-cost means to intervene to improve physical activity in cancer survivors. The study was registered with the International Standard Randomised Controlled Trials Number registry (registration number: 66418871), and ethical approval was received from the University of Surrey (reference: UEC/2017/023/FHMS).

Comparison of ammonia emissions related to nitrogen use efficiency of livestock production in Europe

The increasing global demand for food and the environmental effects of reactive nitrogen losses in the food production chain, increase the need for efficient use of nitrogen (N). Of N harvested in agricultural plant products, 80% is used to feed livestock. Because the largest atmospheric loss of reactive nitrogen from livestock production systems is ammonia (NH₃), the focus of this paper is on N lost as NH₃ during the production of animal protein. The focus of this paper is to understand the key factors explaining differences in Nitrogen Use Efficiency (NUE) of animal production among various European countries. Therefore we developed a conceptual framework to describe the NUE defined as the amount of animal-protein N per N in feed and NH₃-N losses in the production of milk, beef, pork, chicken meat and eggs in The Netherlands, Switzerland, United Kingdom, Germany, Austria and Denmark. The framework describes how manure management and animal-related parameters (feed, metabolism) relate to NH₃ emissions and NUE. The results showed that the animal product with the lowest NUE had the largest NH₃ emissions and vice versa, which agrees with the reciprocal relationship between NUE and NH₃ within the conceptual framework. Across animal products for the countries considered, about 20% of the N in feed is lost as NH₃. The significant smallest proportion (12%) of NH₃-N per unit of Nfeed is from chicken production. The proportions for other products are 17%, 19%, 20% and 22% for milk, pork, eggs and beef respectively. These differences were not significantly different due to the differences among countries. For all countries, NUE was lowest for beef and highest for chicken. The production of 1 kg N in beef required about 5 kg N in feed, of which 1 kg N was lost as NH₃-N. For the production of 1 kg N in chicken meat, 2 kg N in feed was required and 0.2 kg was lost as NH₃. The production of 1 kg N in milk required 4 kg N in feed with 0.6 kg NH₃-N loss, the same as pork and eggs, but those needed 3 and 3.5 kg N in feed per kg N in product respectively. Except for beef, the differences among these European countries were mainly caused by differences in manure management practices and their emission factors, rather than by animal-related factors including feed and digestibility influencing the excreted amount of ammoniacal N (TAN). For beef, both aspects caused important differences. Based on the results, we encourage the expression of N losses as per N in feed or per N in product, in addition to per animal place, when comparing production efficiency and NUE. We consider that disaggregating emission factors into a diet/animal effect and a manure management effect would improve the basis for comparing national NH₃ emission inventories.

Cerebral Blood Flow and Marrow Diffusion Alterations in Children with Sickle Cell Anemia after Bone Marrow Transplantation and Transfusion

BACKGROUND AND PURPOSE

Hematopoietic marrow hyperplasia and hyperperfusion are compensatory mechanisms in sickle cell anemia. We have observed marrow diffusion and arterial spin-labeling perfusion changes in sickle cell anemia following bone marrow transplantation. We aimed to compare arterial spin-labeling perfusion and marrow diffusion/ADC values in patients with sickle cell anemia before and after bone marrow transplantation or transfusion.

MATERIALS AND METHODS

We reviewed brain MRIs from patients with sickle cell anemia obtained during 6 consecutive years at a children's hospital. Quantitative marrow diffusion values were procured from the occipital and sphenoid bones. Pseudocontinuous arterial spin-labeling perfusion values (milliliters/100 g of tissue/min) of MCA, anterior cerebral artery, and posterior cerebral artery territories were determined. Territorial CBF, whole-brain average CBF, and marrow ADC values were compared for changes before and after either bone marrow transplantation or transfusion. Bone marrow transplantation and transfusion groups were compared. Two-tailed paired and unpaired Student t tests were used; P < .05 was considered significant.

RESULTS

Fifty-three examinations from 17 patients with bone marrow transplantation and 29 examinations from 9 patients with transfusion were included. ADC values significantly increased in the sphenoid and occipital marrow following bone marrow transplantation in contrast to patients with transfusion (P > .83). Whole-brain mean CBF significantly decreased following bone marrow transplantation (77.39 ± 13.78 to 60.39 ± 13.62 ml/100 g tissue/min; P < .001), without significant change thereafter. CBF did not significantly change following the first (81.11 ± 12.23 to 80.25 ± 8.27 ml/100 g tissue/min; P = .47) or subsequent transfusions. There was no significant difference in mean CBF between groups before intervention (P = .22).

CONCLUSIONS

Improved CBF and marrow diffusion eventuate following bone marrow transplantation in children with sickle cell anemia in contrast to transfusion therapy.

A novel device for preoperative skin preparation to reduce the risk of injury and surgical site infection during lower limb surgery

Surgical site infection (SSI) continues to be a feared complication of surgery but especially orthopaedic surgery where a superficial SSI has been estimated to add nine days to the hospital stay and an average of £2500 to the cost. Despite the efficacy of all skin preparation agents being maximal at around 10 minutes no current system, apart from the double prep method attributed to Sir John Charnley, allows adequate control of bacteria. Current techniques of skin preparation require lifting of the limb with an associated risk of injury to theatre operatives. In order to provide for longer duration of contact, potentially better antisepsis and to remove the dangers inherent in lifting the limb we developed a novel system for limb antisepsis prior to surgery. To demonstrate efficacy we performed a single blind randomised controlled trial powered to demonstrate non-inferiority. We demonstrated a significant benefit of the device in terms of bactericidal effect. Whilst only recently entering full production, we would recommend the system as a significant improvement over current techniques of limb antisepsis.

The impact of hoist sling fabrics on interface pressure whilst sitting in healthy volunteers and wheelchair users: A comparative study

AIM OF THE STUDY

To evaluate the effect of three sling fabrics on gluteal interface pressure whilst sitting in a population of wheelchair users and to compare these to data previously collected in a pilot study with a healthy population.

MATERIALS AND METHODS

A repeated measures experimental design was used with 32 adult wheelchair users (15 women, 17 men). Healthy population pilot study consisted of 61 participants (51 women, 10 men) recruited from staff and students at The University of Salford.

METHODS

Gluteal pressures at six pressure zones were recorded using the X-sensor PX100 pressure sensor at 30 s intervals for 10 min. Data were collected in 4 conditions with participants seated in a standardised chair, followed by the chair with slings made of three different fabrics.

RESULTS

The spacer fabric reduced the mean gluteal pressure more effectively than slipfit and polyester (p = 0.014 and p = 0.01 respectively, 95%CI) and reduced peak pressure at the left ischial tuberosity and coccyx when compared to the slipfit (p = 0.003 and p = 0.005) with the wheelchair users. When comparing data with the pilot study, the mean gluteal pressure and peak pressures at the ischial tuberosities and coccyx were significantly higher in the wheelchair user group (p < 0.005).

CONCLUSION

The fabric identified as the most effective in reducing mean and peak pressures in both groups was the spacer fabric, suggesting that a spacer fabric sling is more likely to reduce the risk of pressure ulcer development. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Contamination of hospital tap water: the survival and persistence of Pseudomonas aeruginosa on conventional and 'antimicrobial' outlet fittings

BACKGROUND

Pseudomonas aeruginosa infections have been linked to contaminated hospital taps, highlighting the potential for tap outlet fittings (OF) to harbour biofilm. P. aeruginosa may be transferred to OFs via contaminated cleaning cloths. Suggested interventions include flushing regimens and alternative OF designs.

AIM

To investigate the transfer of P. aeruginosa from a contaminated cleaning cloth to conventional and 'antimicrobial/antibiofilm' OFs and to determine whether this contamination persists and/or leads to contamination of tap water.

METHODS

Microfibre cloths contaminated with P. aeruginosa (10⁸ cfu/mL) were used to wipe four different types of OF [one of conventional design (OF-A) and three marketed as 'antimicrobial' and/or 'antibiofilm' (OF- B, -C and -D)]. OFs were inserted into an experimental water distribution system for up to 24 h. Survival was assessed by culture. Single and multiple water samples were collected and cultured for P. aeruginosa.

FINDINGS

The median number of P. aeruginosa transferred from cloth to OF was 5.7 × 10⁵ cfu (OF-A), 1.9 × 10⁶ cfu (OF-B), 1.4 × 10⁵ cfu (OF-C) and 2.9 × 10⁶ cfu (OF-D). Numbers declined on all OFs during the 24 h period with log reductions ranging from 3.5 (OF-C) to 5.2 (OF-B; P > 0.05). All water samples delivered immediately after OF contamination contained P. aeruginosa at ≥10 cfu per 100 mL. Contamination of water delivered from OF-A persisted despite continued flushing. Water delivered from OF-B did not contain P. aeruginosa beyond the first flush.

CONCLUSION

Contaminated cleaning cloths may transfer P. aeruginosa to OFs, leading to contamination of tap water. Although not removing the potential for contamination, 'antimicrobial/antibiofilm' OFs may prevent P. aeruginosa from continually contaminating water delivered from the outlet.