Sustaining attention in affective contexts during adolescence: age-related differences and association with elevated symptoms of depression and anxiety

Sustained attention, a key cognitive skill that improves during childhood and adolescence, tends to be worse in some emotional and behavioural disorders. Sustained attention is typically studied in non-affective task contexts; here, we used a novel task to index performance in affective versus neutral contexts across adolescence (N = 465; ages 11-18). We asked whether: (i) performance would be worse in negative versus neutral task contexts; (ii) performance would improve with age; (iii) affective interference would be greater in younger adolescents; (iv) adolescents at risk for depression and higher in anxiety would show overall worse performance; and (v) would show differential performance in negative contexts. Results indicated that participants performed more poorly in negative contexts and showed age-related performance improvements. Those at risk of depression performed more poorly than those at lower risk. However, there was no difference between groups as a result of affective context. For anxiety there was no difference in performance as a function of severity. However, those with higher anxiety showed less variance in their reaction times to negative stimuli than those with lower anxiety. One interpretation is that moderate levels of emotional arousal associated with anxiety make individuals less susceptible to the distracting effects of negative stimuli.

Expectations and outcomes of varying treatment strategies for CML presenting during pregnancy

Diagnosing chronic myeloid leukaemia (CML) during pregnancy is rare. Tyrosine kinase inhibitors (TKIs) have traditionally been contraindicated owing to their teratogenicity. Management decisions should consider the risks to mother and foetus of uncontrolled disease and teratogenic medications. Further cases are required to build upon the paucity of current literature. We report 22 cases of CML diagnosed during pregnancy from 2002 to date. Twenty-one pregnancies resulted in healthy babies and one patient miscarried. Some patients remained untreated throughout pregnancy but the majority received one or both of interferon-α and leucapheresis. One patient was started on imatinib at Week 26, and one on hydroxycarbamide in the third trimester. We report haematological parameters during pregnancy to provide clinicians with realistic expectations of management. There were no fetal abnormalities related to treatment during pregnancy. Seventeen patients achieved at least major molecular response on first-line TKI. A diagnosis of CML during pregnancy can be managed without significant consequences for mother or child. Leucapheresis and interferon-α are generally safe throughout pregnancy. Despite having been avoided previously, there is growing evidence that certain TKIs may be used in particular circumstances during the later stages of pregnancy. Future work should aim to further elucidate this safety profile.

Peritoneal malignancy in the global COVID-19 pandemic: experience of recovery and restoration in a high-volume centre through NHS and independent sector collaboration

INTRODUCTION

Treatment of peritoneal malignancy with cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) requires substantial critical care, theatre and nursing resources. The COVID-19 pandemic caused challenges in providing a high volume, tertiary referral service.

METHODS

We reviewed data on referrals and operations performed in a tertiary referral centre in both NHS and independent sector settings. The impact of COVID-19 on activity was assessed using 2019 as a benchmark.

RESULTS

New patient referrals were similar, with 891 in 2019 compared with 833 in 2020. Delivery of CRS and HIPEC operations were initially impacted by COVID-19. NHS and independent sector collaboration facilitated recovery, with 284 patients treated in 2020 compared with 280 in 2019.

CONCLUSIONS

Close collaboration and structural organisation between the clinical and management teams in the NHS and independent sectors facilitated recovery and restoration of a complex tertiary referral service for peritoneal malignancy during the COVID pandemic.

Impact of an inpatient pharmacist-driven renal dosing policy on order verification time and patient safety

Research regarding pharmacist-driven renal dosing policies has focused on cost savings or prevention of adverse drug events. However, little is known about how these policies influence time from order signature to order verification or how this efficiency may reduce the incidence of adverse outcomes. Objectives: The primary endpoint compared time from prescriber electronic order signature to pharmacist electronic order verification between pre- and post-renal dosing policy implementation. The secondary endpoint evaluated electrocardiogram QTc prolongation attributed to fluconazole accumulation in renal impairment. Methods: This retrospective analysis included adults with a creatine clearance ⩽50 mL/min who received at least two inpatient doses from a 34-medication renal dosing protocol between January-February 2020 and April-May 2020. Results: 502 patients met eligibility for the primary outcome. The pre- and post-policy cohorts shared similar baseline characteristics. Time from order signature to verification was 9 and 8 min in the pre- and post-policy groups, respectively (p = 0.0861). In all, 56 patients met inclusion criteria for the secondary outcome. The QTc interval during fluconazole increased relative to baseline in 3 of 7 (43%) pre-policy and 4 of 5 (80%) post-policy. The QTc interval exceeded 500 ms in two patients, both in the post-policy cohort. Conclusions: There was no difference in order signature to verification time. Post-policy fluconazole renal adjustment did not reduce QTc prolongation.

Outcomes of complex colorectal polyps managed by multi-disciplinary team strategies-a multi-centre observational study

PURPOSE

Team management strategies for complex colorectal polyps are recommended by professional guidelines. Multi-disciplinary meetings are used across the UK with limited information regarding their impact. The aim of this multi-centre observational study was to assess procedures and outcomes of patients managed using these approaches.

METHOD

This was a retrospective, observational study of patients managed by six UK sites. Information was collected regarding procedures and outcomes including length of stay, adverse events, readmissions and cancers.

RESULTS

Two thousand one hundred ninety-two complex polyps in 2109 patients were analysed with increasing referrals annually. Most presented symptomatically and the mean polyp size was 32.1 mm. Primary interventions included endoscopic therapy (75.6%), conservative management (8.3%), colonic resection (8.1%), trans-anal surgery (6.8%) or combined procedures (1.1%). The number of primary colonic resections decreased over the study period without a reciprocal increase in secondary procedures or recurrence. Secondary procedures were required in 7.8%. The median length of stay for endoscopic procedures was 0 days with 77.5% completed as day cases. Median length of stay was 5 days for colonic resections. Overall adverse event and 30-day readmission rates were 9.0% and 3.3% respectively. Malignancy was identified in 8.8%. Benign polyp recurrence occurred in 13.1% with a median follow up of 30.4 months. Screening detected lesions were more likely to undergo bowel resection. Colonic resection was associated with longer stays, higher adverse events and more cancers on final histology.

CONCLUSION

Multi-disciplinary team management of complex polyps is safe and effective. Standardisation of organisation and quality monitoring is needed to continue positive effects on outcomes and services.

The impact of pain management changes to an inpatient general admission electronic order-set

BACKGROUND

Opioids pose many risks, and standardized ordering processes need to be created. In May 2020, our institution implemented pain management changes to the inpatient general admission electronic order-set and increased provider education on pain management prescribing.

OBJECTIVES

This study aimed to investigate the impact of pain management changes to the inpatient general admission electronic order-set on opioid prescribing.

METHODS

Data were collected by retrospective chart review of 376 patients who were admitted using the inpatient general admission electronic order-set at 8 hospital locations within an integrated health system. Two cohorts were identified for comparison: patients admitted pre-electronic order-set change (n = 183; August 2019) and patients admitted post-electronic order-set change (n = 193; August 2020). The primary end points were the amount of intravenous (IV) opioids received measured in morphine milligram equivalents (MME), the quantification of opioids received for pain management, and the oral MME prescribed on discharge.

RESULTS

There was no statistically significant difference in the use of IV opioids. There was, however, a statistically significant difference between the IV MME 24 to 48 hours with median 0 (interquartile range [IQR] 0, 6) and 0 (IQR 0, 0) for pre- and post-electronic order-set implementation, respectively (P = 0.003). Oxycodone was more frequently prescribed in the postimplementation cohort-55 patients (29%) compared with the 31 (17%) in the preimplementation cohort (P = 0.008). Tramadol was prescribed less frequently in the postimplementation cohort (n = 12 [6%]) than in preimplementation cohort (n = 28 [15%]) (P = 0.004). There was no statistically significant difference in the oral MME prescribed on discharge (P = 0.833).

CONCLUSION

Changes to the inpatient general admission electronic order-set had relatively little impact on the prescribing of opioids. Further electronic order-set changes or other methodologies should be explored to affect inpatient opioid use.

Translational challenges and opportunities in biofilm science: a BRIEF for the future

Biofilms are increasingly recognised as a critical global issue in a multitude of industries impacting health, food and water security, marine sector, and industrial processes resulting in estimated economic cost of $5 trillion USD annually. A major barrier to the translation of biofilm science is the gap between industrial practices and academic research across the biofilms field. Therefore, there is an urgent need for biofilm research to notice and react to industrially relevant issues to achieve transferable outputs. Regulatory frameworks necessarily bridge gaps between different players, but require a clear, science-driven non-biased underpinning to successfully translate research. Here we introduce a 2-dimensional framework, termed the Biofilm Research-Industrial Engagement Framework (BRIEF) for classifying existing biofilm technologies according to their level of scientific insight, including the understanding of the underlying biofilm system, and their industrial utility accounting for current industrial practices. We evidence the BRIEF with three case studies of biofilm science across healthcare, food & agriculture, and wastewater sectors highlighting the multifaceted issues around the effective translation of biofilm research. Based on these studies, we introduce some advisory guidelines to enhance the translational impact of future research.

The impact of mindfulness training in early adolescence on affective executive control, and on later mental health during the COVID-19 pandemic: a randomised controlled trial

BACKGROUND

Previous research suggests that mindfulness training (MT) appears effective at improving mental health in young people. MT is proposed to work through improving executive control in affectively laden contexts. However, it is unclear whether MT improves such control in young people. MT appears to mitigate mental health difficulties during periods of stress, but any mitigating effects against COVID-related difficulties remain unexamined.

OBJECTIVE

To evaluate whether MT (intervention) versus psychoeducation (Psy-Ed; control), implemented in after-school classes: (1) Improves affective executive control; and/or (2) Mitigates negative mental health impacts from the COVID-19 pandemic.

METHODS

A parallel randomised controlled trial (RCT) was conducted (Registration: https://osf.io/d6y9q/; Funding: Wellcome (WT104908/Z/14/Z, WT107496/Z/15/Z)). 460 students aged 11-16 years were recruited and randomised 1:1 to either MT (N=235) or Psy-Ed (N=225) and assessed preintervention and postintervention on experimental tasks and self-report inventories of affective executive control. The RCT was then extended to evaluate protective functions of MT on mental health assessed after the first UK COVID-19 lockdown.

FINDINGS

Results provided no evidence that the version of MT used here improved affective executive control after training or mitigated negative consequences on mental health of the COVID-19 pandemic relative to Psy-Ed. No adverse events were reported.

CONCLUSIONS

There is no evidence that MT improves affective control or downstream mental health of young people during stressful periods.

CLINICAL IMPLICATIONS

We need to identify interventions that can enhance affective control and thereby young people's mental health.

Racial Variations in Emergency Department Management of Chest Pain in a Community-based Setting

INTRODUCTION

Chest pain is one of the most common chief presenting complaints occurring in most Emergency Departments. The HEART score is a validated risk stratification tool commonly used to evaluate chest pain. Prior research has demonstrated the existence of complex racial variations in health care, specifically in what tests are ordered (or accepted by patients) during evaluation and treatment of cardiac disease. The authors hypothesized that chest pain management (i.e., disposition to hospital/observation unit and rates of stress testing) patterns and longitudinal outcomes (i.e., death and 30-day readmission) would occur differently in African Americans despite systematic use of the HEART score.

METHODS

Funded by the Statewide Campus System, this study was comprised of a retrospective chart review of a sample of eligible patients presenting with chest pain to the authors' 345-bed community-based Michigan hospital.

RESULTS

Of the 1,412 eligible sample patients, 886 (63%) reported their racial affiliation as White, 473 (33%) African-American, and 53 (4%) "Other". The average HEART score in Whites was 3.92 (SD = 1.89) compared to 3.31 (SD = 1.79) in African-Americans, (p < 0.01, 95% CI: 0.40-0.82). However, White patients' odds of admission to observation or inpatient was 1.49 times higher (95% CI: 1.04 - 2.15), with every unit increase in HEART score increasing the odds ratio of admission by 3.24 times (95% CI: 2.79 - 3.76). White patients were also 2.37 times more likely to receive (or accept) stress tests than African American patients (95% CI: 1.41 - 3.88). Only five (0.01%) of 458 White patients with HEART score between 4 and 6 experienced 30-day readmission or death whereas seven (0.04%) of 193 African-American patients experienced these outcomes (p = 0.04 with OR 3.40, 95% CI: 1.07 - 10.9).

CONCLUSIONS

Although the authors were unable to precisely distinguish the provider (e.g., desire to order testing) and patient-driven (e.g., desire to accept testing) factors likely to contribute to measured differences, these results suggest continued complex racial variations concerning hospital admission and stress testing in chest pain patients. Further studies are needed to analyze potential systems or subject-level factors influencing the multi-dimensional phenomenon of chest pain management across racial affiliation.

The Emirates Mars Mission

The Emirates Mars Mission (EMM) was launched to Mars in the summer of 2020, and is the first interplanetary spacecraft mission undertaken by the United Arab Emirates (UAE). The mission has multiple programmatic and scientific objectives, including the return of scientifically useful information about Mars. Three science instruments on the mission's Hope Probe will make global remote sensing measurements of the Martian atmosphere from a large low-inclination orbit that will advance our understanding of atmospheric variability on daily and seasonal timescales, as well as vertical atmospheric transport and escape. The mission was conceived and developed rapidly starting in 2014, and had aggressive schedule and cost constraints that drove the design and implementation of a new spacecraft bus. A team of Emirati and American engineers worked across two continents to complete a fully functional and tested spacecraft and bring it to the launchpad in the middle of a global pandemic. EMM is being operated from the UAE and the United States (U.S.), and will make its data freely available.

Optimal dynamic incentive scheduling for Hawk-Dove evolutionary games

The Hawk-Dove evolutionary game offers a paradigm of the trade-offs associated with aggressive and passive behaviors. When two (or more) populations of players compete, their success or failure is measured by their frequency in the population, and the system is governed by the replicator dynamics. We develop a time-dependent optimal-adaptive control theory for this dynamical system in which the entries of the payoff matrix are dynamically altered to produce control schedules that minimize and maximize the aggressive population through a finite-time cycle. These schedules provide upper and lower bounds on the outcomes for all possible strategies since they represent two extremizers of the cost function. We then adaptively extend the optimal control schedules over multiple cycles to produce absolute maximizers and minimizers for the system.

The Moondance Bowel Cancer Project schools initiative

BACKGROUND

The 5-year survival rate for bowel cancer in Wales is poor and lags behind the rest of the UK. The aim of the pilot phase of the Moondance Schools Initiative was to develop, deliver and assess a bowel cancer learning module for secondary school students in South Wales. Ultimately, we aim to introduce this programme into the National Curriculum across Wales.

METHODS

Two programmes regarding bowel cancer and screening were designed and delivered to a cohort of secondary school pupils in South Wales. This involved interactive teaching with patients and clinicians, practical sessions and live-streamed videos of bowel cancer surgery. Feedback regarding the events and bowel screening was collected from students and their families.

RESULTS

The programmes were delivered to 185 secondary school students and feedback was extremely positive. The students delivered a live event at the end of the programme to demonstrate their learning to their families and invited guests. Feedback from family members revealed that 100% of respondents were more likely to take a bowel screening test as a result of attending the event.

CONCLUSION

This project established that a pilot to create young bowel screening ambassadors is feasible and was positively received by students, their families and the local community. Future work will disseminate the programme further and correlate changes in bowel screening participation in the local area as a result of these events.

O17 Multidisciplinary decision-making strategies may reduce the need for surgery in complex colonic polyps—a systematic review

Introduction

The recognition of complex colonic polyps is increasing. Management varies considerably and the impact of this on clinical outcomes is unclear. The aim of this systematic review was to assess the impact of group decision-making strategies and defined selection criteria on the treatment outcomes of complex colonic polyps.

Method

A systematic literature review identified studies reporting complex polyp treatment outcomes and describing their decision-making strategies. Databases searched included PubMed, Web of Science, CINAHL and Scopus. Articles were identified by two blinded reviewers using defined inclusion criteria. The review protocol was registered on PROSPERO and performed in line with PRISMA guidelines.

Results

There were 303 identified articles describing treatment outcomes of complex colonic polyps. Only 9 of these fully described the decision-making strategy and met the inclusion criteria. The median adverse event, unsuspected malignancy and secondary surgery rates were 7.7%, 3.8% and 14.4% respectively. Grouping of articles into a hierarchy of decision-making strategies demonstrated a sequential reduction in secondary surgery rates with improving strategies. The secondary surgery rate was significantly lower in studies using group decision-making and defined selection criteria. There was no significant difference in comparisons of adverse event or unsuspected malignancy rates.

Conclusions

There is limited reporting of decision-making strategies in studies describing complex polyp treatment outcomes. The use of group decision-making and defined selection criteria may reduce the need for surgery in complex colonic polyps. This has implications of cost effectiveness for healthcare systems and benefits to patient quality of life.

The effect of ego depletion on challenge and threat evaluations during a potentially stressful public speaking task

It has been well established that challenge and threat evaluations affect the performance of potentially stressful tasks. However, the factors that influence these evaluations have rarely been examined. Objective: This study examined the effects of ego depletion on challenge and threat evaluations during a public speaking task. Method: 262 participants (150 males, 112 females; M_age = 20.5, SD = 4.3) were randomly assigned to either an ego depletion or control group. Participants then completed self-report measures of trait self-control. The ego depletion group performed a written transcription task requiring self-control, while the control group transcribed the text normally. Before the public speaking task, participant's challenge and threat evaluations and subjective ratings of performance were assessed via self-report items. Results: The results of independent t-tests supported the effectiveness of the self-control manipulation. There were no significant differences between the ego depletion and control groups in terms of challenge and threat evaluations or subjective performance. Additional correlation analyses revealed that trait measures of self-control were significantly and negatively related to challenge and threat evaluations and subjective performance. Conclusion: Findings suggest that ego depletion might not influence appraisals of potentially stressful tasks, and thus add to recent evidence questioning the ego-depletion phenomenon.

P26: EVALUATING AND DEVELOPING A TEACHING TOOL ON FAECAL INCONTINENCE IN THE UNDERGRADUATE MEDICAL CURRICULUM

Introduction

To evaluate the medical school undergraduate curriculum on faecal incontinence (FI) and develop an educational tool to improve the teaching on the subject.

Method

Qualitative analysis of literature research and data collected from medical students via emails, questionnaires and focused group discussions.

Result

FI has not been implanted into the undergraduate curriculum 12,13 and there are variations in teaching on the topic in different medical schools. n= 111 medical students at Cardiff University responded to the survey. FI was reported to be overlooked compared to other types of bowel dysfunction. 38 students reported to have teaching on bowel incontinence, whereas 64 and 74 students had teaching on diarrhoea and constipation respectively. 77% of medical students would like more teaching on bowel incontinence. 9 students participated in a focused group discussion. An interactive e-learning module from Xerte was created based on the students' suggestions and were trialed by a separate cohort of students (n=20). All 20 students showed significant improvement of students' confidence in faecal incontinence (p &lt;= 2.132e∧-6) after completing the e-learning module.

Conclusion

We recommend introducing the educational resource into the undergraduate curriculum of Cardiff University medical school, especially targeting the clinical year, a clear guidance for FI should be published by the relevant postgraduate healthcare faculties and consider assessing at which stage of the postgraduate training should FI be taught.

Take-home message

Baseline knowledge of FI is poor. Lack of content in medical school curriculum and E learning modules potentially useful adjuncts.

Factor VIII Inhibitor Bypassing Activity (FEIBA) Reversal for Apixaban and Rivaroxaban in Patients With Acute Intracranial and Nonintracranial Hemorrhage

BACKGROUND

The clinical use of factor VIII inhibitor bypassing activity (FEIBA) for factor Xa (FXa) inhibitor reversal is derived from small studies with notable variation in patient eligibility for use, dosage regimens, concurrent supportive care, and outcome measures. Consequently, additional effectiveness and safety data are warranted to expand the literature evaluating FEIBA for FXa inhibitor reversal.

OBJECTIVE

This study sought to determine the incidence of observed effective hemostasis within 24 hours of post-FEIBA® administration as well as in-hospital and 30-day post-discharge incidences of thromboembolic event (TEE) and mortality between apixaban and rivaroxaban in the intracranial hemorrhage (ICH) and non-ICH populations.

METHODS

This case series evaluated patients between January 1, 2014 through July 1, 2019 who received at least one FEIBA® dose for apixaban or rivaroxaban reversal secondary to acute ICH or non-ICH. Patient demographics, FEIBA® dosages, adjunct treatments, effectiveness, and safety outcomes were retrospectively collected from electronic medical record review. Modified hemostasis outcomes, adapted from criteria previously published by Sarode et al., TEE, and mortality between apixaban and rivaroxaban in the ICH and non-ICH populations were evaluated.

RESULTS

Among the 104 patients evaluated, 62 received apixaban and 42 rivaroxaban. Thirty apixaban and 25 rivaroxaban users experienced ICH, whereas 32 apixaban and 17 rivaroxaban users experienced non-ICH. Among the combined ICH and non-ICH populations, effective hemostasis occurred in 89%, TEE in 8%, and mortality in 13%. No statistically significant differences were observed within ICH and non-ICH populations receiving apixaban or rivaroxaban regarding effective hemostasis, TEE, or mortality.

CONCLUSION AND RELEVANCE

The combined ICH and non-ICH overall rates of effective hemostasis, TEE, and mortality were comparable to preexisting studies of FEIBA for factor Xa inhibitor reversal. The limitations inherent to the study design warrant a randomized controlled trial with an active comparator to confirm these observations.

Incidence of Fever Associated With Dexmedetomidine in the Adult Intensive Care Unit

BACKGROUND

Published literature has described the temporal relationship of dexmedetomidine with elevated temperatures, but there is limited data to quantify the incidence of fever in ICU patients receiving dexmedetomidine.

OBJECTIVE

The primary objective of this study was to estimate the incidence of temperature greater than or equal to 38.5°C in ICU patients receiving dexmedetomidine.

METHODS

This was a retrospective cohort study of ICU patients who received dexmedetomidine with a propensity-matched subgroup analysis comparing dexmedetomidine fever patients to non-fever patients. Patients 18 years of age and older admitted between November 2017 and August 2018 who received continuous dexmedetomidine for 6 or more hours were eligible for inclusion. Included patients with a temperature of great than or equal to 38.5°C while receiving dexmedetomidine were established as having dexmedetomidine-related fever.

RESULTS

Of 882 eligible ICU patients, 404 dexmedetomidine patients were included in the study. Sixty-one patients (15.1%) met the definition for the primary endpoint. Forty-two patients who received dexmedetomidine but experienced no fever were matched for multivariate analysis. The fever group received a higher mean maximum infusion rate (0.98 µg/kg/h ± 0.43 vs. 0.68 µg/kg/h ± 0.42, P < 0.001) and a longer median duration of dexmedetomidine (43.0 hours [range 7-711] vs. 24.3 hours [6-148], P = 0.001) compared to the non-fever group.

CONCLUSION

Fever greater than 38.5°C was observed in 15.1% of ICU patients while receiving dexmedetomidine. Prospective studies are warranted to validate these findings.

Ring patterns generated by an expanding colloidal meniscus

The drop-and-dry is a common technique allowing for creation of periodic nanoparticle (NP) structures for sensing, photonics, catalysis, etc. However, the reproducibility and scalability of this approach for fabrication of NP-based structures faces serious challenges due to the complexity of the simple, at first glance, evaporation process. In this work we study the effect of the spatial confinement on the NP self-assembly under slow solvent evaporation, when the air-liquid-substrate contact line (CL) expands from the center towards the walls of a cylindrical cell, forming a toroid. Using in situ video monitoring of the stick-slip CL motion, we find regular hydrodynamic perturbations in the meniscus, and reveal fine details of the formation of quasiperiodic rings of close packed NP layers. We report that drying of the toroidal NP droplet has a number of important differences from drying of the classical hemispherical colloidal drops. In toroidal drops we observe linear-in-time average meniscus motion, in contrast to the hemispherical drops where the meniscus moves as a square root of time. While both droplet geometries produce NP ring patterns, the ring width for the toroidal drop decreases with increasing ring radius, while it decreases with decreasing the radius of the hemispherical drop. We suggest that free ligands are the main cause of the Marangoni instabilities driving the periodic vorticity in the meniscus. In addition, we show that the usually ignored contact line tension may yield a considerable contribution to the CL pinning causing the CL slip-stick motion and the ring formation.

Susceptibility to prosocial and antisocial influence in adolescence

Introduction

Adolescents are particularly susceptible to social influence and previous studies have shown that this susceptibility decreases with age. The current study used a cross-sectional experimental paradigm to investigate the effect of age and puberty on susceptibility to both prosocial and antisocial influence.

Methods

Participants (N = 520) aged 11–18 from London and Cambridge (United Kingdom) rated how likely they would be to engage in a prosocial (e.g. “help a classmate with their work”) or antisocial (e.g. “make fun of a classmate”) act. They were then shown the average rating (in fact fictitious) that other adolescents had given to the same question, and were then asked to rate the same behaviour again.

Results

Both prosocial and antisocial influence decreased linearly with age, with younger adolescents being more socially influenced when other adolescents’ ratings were more prosocial and less antisocial than their own initial rating. Both antisocial and prosocial influence significantly decreased across puberty for boys but not girls (independent of age).

Conclusions

These findings suggest that social influence declines with increasing maturity across adolescence. However, the exact relationship between social influence and maturity is dependent on the nature of the social influence and gender. Understanding when adolescents are most susceptible to different types of social influence, and how this might influence their social behaviour, has important implications for understanding adolescent social development.

Persistent viral shedding of SARS-CoV-2 in faeces - a rapid review

AIM

In addition to respiratory symptoms, COVID-19 can present with gastrointestinal complaints suggesting possible faeco-oral transmission. The primary aim of this review was to establish the incidence and timing of positive faecal samples for SARS-CoV-2 in patients with COVID-19.

METHODS

A systematic literature review identified studies describing COVID-19 patients tested for faecal virus. Search terms for MEDLINE included 'clinical', 'faeces', 'gastrointestinal secretions', 'stool', 'COVID-19', 'SARS-CoV-2' and '2019-nCoV'. Additional searches were done in the American Journal of Gastroenterology, Gastroenterology, Gut, Lancet Gastroenterology and Hepatology, the World Health Organization Database, the Centre for Evidence-Based Medicine, New England Journal of Medicine, social media and the National Institute for Health and Care Excellence, bioRxiv and medRxiv preprints. Data were extracted concerning the type of test, number and timing of positive samples, incidence of positive faecal tests after negative nasopharyngeal swabs and evidence of viable faecal virus or faeco-oral transmission of the virus.

RESULTS

Twenty-six relevant articles were identified. Combining study results demonstrated that 53.9% of those tested for faecal RNA were positive. The duration of faecal viral shedding ranged from 1 to 33 days after a negative nasopharyngeal swab with one result remaining positive 47 days after onset of symptoms. There is insufficient evidence to suggest that COVID-19 is transmitted via faecally shed virus.

CONCLUSION

There is a high rate of positive polymerase chain reaction tests with persistence of SARS-CoV-2 in faecal samples of patients with COVID-19. Further research is needed to confirm if this virus is viable and the degree of transmission through the faeco-oral route. This may have important implications on isolation, recommended precautions and protective equipment for interventional procedures involving the gastrointestinal tract.

Persistent viral shedding of SARS-CoV-2 in faeces - a rapid review

AIM

In addition to respiratory symptoms, COVID-19 can present with gastrointestinal complaints suggesting possible faeco-oral transmission. The primary aim of this review was to establish the incidence and timing of positive faecal samples for SARS-CoV-2 in patients with COVID-19.

METHODS

A systematic literature review identified studies describing COVID-19 patients tested for faecal virus. Search terms for MEDLINE included 'clinical', 'faeces', 'gastrointestinal secretions', 'stool', 'COVID-19', 'SARS-CoV-2' and '2019-nCoV'. Additional searches were done in the American Journal of Gastroenterology, Gastroenterology, Gut, Lancet Gastroenterology and Hepatology, the World Health Organization Database, the Centre for Evidence-Based Medicine, New England Journal of Medicine, social media and the National Institute for Health and Care Excellence, bioRxiv and medRxiv preprints. Data were extracted concerning the type of test, number and timing of positive samples, incidence of positive faecal tests after negative nasopharyngeal swabs and evidence of viable faecal virus or faeco-oral transmission of the virus.

RESULTS

Twenty-six relevant articles were identified. Combining study results demonstrated that 53.9% of those tested for faecal RNA were positive. The duration of faecal viral shedding ranged from 1 to 33 days after a negative nasopharyngeal swab with one result remaining positive 47 days after onset of symptoms. There is insufficient evidence to suggest that COVID-19 is transmitted via faecally shed virus.

CONCLUSION

There is a high rate of positive polymerase chain reaction tests with persistence of SARS-CoV-2 in faecal samples of patients with COVID-19. Further research is needed to confirm if this virus is viable and the degree of transmission through the faeco-oral route. This may have important implications on isolation, recommended precautions and protective equipment for interventional procedures involving the gastrointestinal tract.

Antimicrobial Resistance in Retail Ground Beef with and Without a “Raised Without Antibiotics” Claim

ObjectivesThe occurrences of human bacterial infections complicated by antimicrobial resistance (AMR) have increased in recent decades. Concerns have been raised that food-animal production practices that incorporate antimicrobials contribute significantly to human AMR exposures since food-animal production accounts for approximately 81% of U.S. antimicrobial consumption by mass. Although empirical studies comparing AMR levels in meat products, including ground beef, are scant ground beef products with Raised without Antibiotics (RWA) label claims are perceived to harbor less AMR than “conventional” (CONV) products with no label claims regarding antimicrobial use. The objective of this research was to determine AMR levels in retail ground beef with and without an RWA label claims.Materials and MethodsRetail ground beef samples were obtained from 6 U.S. cities. Samples were obtained on the following dates: 9/18/2017, 10/30/2017, 11/27/2017. 1/29/2018. 3/5/2018, and 6/11/2018. A total of 599 samples were obtained. Samples with a “Raised without Antibiotics” or USDA Organic claim (N = 299) were assigned to the RWA production system. Samples lacking a “Raised without Antibiotics” claim (N = 300) were assigned to the CONV production system. Each sample was cultured for the detection of five antimicrobial resistant bacteria (ARB). Genomic DNA was isolated from each sample and qPCR was used to determine the abundance of ten antimicrobial resistance genes (ARGs). The impacts of production system and city on ARB detection were assessed by the Likelihood-ratio chi-squared test. The impacts of production system and city on ARG abundance was assessed by two-way ANOVA.ResultsTetracycline-resistant Escherichia coli (CONV = 46.3%; RWA = 34.4%) and erythromycin-resistant Enterococcus (CONV = 48.0%; RWA = 37.5%) were more frequently (P < 0.01) detected in CONV. Detection of third generation cephalosporin-resistant E. coli (CONV = 5.7%; RWA = 1.0%), vancomycin-resistant Enterococcus (CONV = 0.0%; RWA = 0.0%) and methicillin-resistant Staphylococcus aureus (CONV = 1.3%; RWA = 0.7%) did not differ (P = 1.00). The blaCTX-M ARG was more abundant in CONV (2.4 vs. 2.1 log copies/gram, P = 0.01) but the tet(A) (2.4 vs. 2.5 log copies/gram, P = 0.02) and tet(M) (3.6 vs. 3.9 log copies/gram, P < 0.01) ARGs were more abundant in RWA. aadA1, blaCMY-2, mecA, erm(B), and tet(B) abundances did not differ significantly (Fig. 5) (P > 0.05). Abundances of aac (6’)-Ie-aph (2”)-Ia and blaKPC-2 were not analyzed since they were quantified in less than 5% of the samples.ConclusionU.S. retail CONV and RWA ground beef harbor generally similar levels of AMR since only 5 of 15 AMR measurements were statistically different between production systems. Three AMR measurements were higher in CONV, while 2 AMR measurements were higher in RWA. These results are in general agreement with a recently published study authored by our group that examined antimicrobial resistance in CONV and RWA ground beef obtained from U.S. foodservice suppliers (Vikram et al., J. Food Prot. 81:2007–2018. 2018.). Together these studies suggest that antimicrobial use during U.S. cattle production has minimal to no impact on human exposure to AMR via ground beef.Figure 5.

P3522Vagus nerve stimulation for chronic heart failure: differences in therapy delivery and clinical efficacy in ANTHEM-HF, INOVATE-HF, and NECTAR-HF

Background

Vagus Nerve Stimulation (VNS) is meant to deliver Autonomic Regulation Therapy (ART) to neurological targets with sufficient neuromodulation (NM) to ameliorate chronic heart failure (CHF). VNS delivery consists of its intensity (a combination of pulse amplitude, pulse frequency, and pulse duration), polarity, duty cycle (DC; stimulation “on” time and “off” time), and mode (continuous, or intermittent and periodic). In the ANTHEM-HF Pilot Study patients with CHF and reduced ejection fraction (HFrEF), VNS intensity was up-titrated until a change in heart rate (HR) dynamics was objectively confirmed. This did not require any change in GDMT and was associated with significant improvements in LVEF, 6-minute walk distance (6MWD), Minnesota Living with HF (MLWHF) score, and HR variability.

Methods

Qualitative and quantitative analyses used data from peer-reviewed publications and other sources in the public domain to compare VNS delivery in ANTHEM-HF, INOVATE-HF, and NECTAR-HF.

Results (Table): Up-titration of VNS intensity was attempted in all 3 studies. In contrast to ANTHEM-HF, INOVATE-HF aimed only at peripheral neural targets. VNS intensity was delivered at a lower pulse frequency, and had a variable DC as a consequence of R-wave synchronization and only intermittent, periodic stimulation. In NECTAR-HF VNS intensity was delivered at a higher pulse frequency, and this was associated with intolerable adverse off-target effects which restricted VNS up-titration. Significant improvements in EF, 6MWD, MLWHF, and SDNN occurred in ANTHEM-HF relative to the other studies.

ANTHEM-HF (n=60) INOVATE-HF (n=436) NECTAR-HF (n=63) Neural Target Central/Peripheral Peripheral Central/Peripheral Delivery Site Left or right CVN Right CVN Right CVN Delivery Intensity:   Amplitude (milliamperes) 2.0±0.6 3.9±1.0 1.4±0.8   Frequency (Hertz) 10 1–2 20   Duration (microseconds) 250 500 300 Electrode Polarity (Cathode) Caudal Cephalad Caudal Duty Cycle 23% 25% 17% On Time/Off Time (seconds) 18/62 Variable 10/50 Mode of Delivery Cyclic/Continuous Intermittent/Periodic Cyclic/Continuous Clinical Efficacy at 6 Months:   EF 32.4±7.2 to 37.2±10.4 Not available 30.5±6.0 to 32.7±6.4   6MWD 287±66 to 346±78 317±109 to 347±123 Not available   MLWHFS 40±14 to 21±10 Not available 44.2±22.2 to 35.8±20.8   SDNN 94±26 to 111±50 Not available 146±48 to 130±52 Values reported as mean ± standard deviation; CVN = Cervical vagus nerve. *p<0.05 versus NECTAR-HF; **p<0.05 versus INOVATE-HF; ***p<0.025 versus NECTAR-HF; ****p<0.001 versus NECTAR-HF (Analysis using two-sample t-test of the means).

Conclusion

VNS differed in ANTHEM-HF when compared to INOVATE-HF and NECTAR-HF. The neural targets, pulse frequencies for titration, and the DC for NM were different. VNS in ANTHEM-HF was clinically efficacious. The ongoing ANTHEM-HFrEF Pivotal Study uses a similar paradigm.

Acknowledgement/Funding

LivaNova PLC

Abstract P5-04-27: Investigating the incidence of ESR1 gene amplification in breast cancers resistant to multiple endocrine agents

Background: Around 70% of all breast cancers (BCs) are estrogen receptor positive (ER+), but some do not respond to endocrine therapy (ET) and many eventually develop resistance. ESR amplification (ESRA) linked to an increase in ESR1 gene expression is known to occur in some cancers that are endocrine resistant. However, the incidence of ESRA has been the object of debate and its clinical significance remains unclear. This study aimed to investigate the incidence of ESRA in BCs resistant to multiple sequential ETs and optimise a fluorescence in-situ hybridisation (FISH) methodology to robustly detect ESRA.

Methods: Two unique cohorts have been studied:

(A) 20 post-menopausal women with ER+ BC with acquired resistance to letrozole, subsequently treated with up to 4 different lines of ET. Serial RNA and DNA from 3-5 cancer samples per patient (58 samples from 20 patients) were analysed by Ribo0-RNAseq and DNA exome sequencing;

(B) 18 post-menopausal women who developed ER+ BC recurrences on 1st line adjuvant letrozole, then on 2nd line tamoxifen and subsequently on 3rd line exemestane. Tissues were collected at the time of each surgery.

We have optimised a FISH method to assess ESRA in these tissues.

Results: In cohort A, 6/20 patients developed ESR1 gene amplification (ESRA) at some point during treatment. In 5 of these cases, ESRA was only found while on 2nd or 3rd line exemestane but was not present on acquired resistance to previous letrozole or tamoxifen. 1 patient had ESRA at the time of first recurrence on letrozole.

The FISH method showed concordance with the genomic analysis. This suggests that ESRA may be associated with BCs that are treated with and then become resistant to exemestane.

ESRA is also evident in samples from Cohort B, which includes 18 exemestane resistant cases. The complete analysis is ongoing.

Conclusions:

· ESRA can be seen in ER+ recurrent BCs.

· ESRA may be associated with BCs treated with 2nd or 3rd line exemestane.

· The frequency of ESRA in endocrine and exemestane resistance can now be ascertained using an optimised FISH-based method, which is more cost-effective than alternative genomic and biochemical methods.

Citation Format: Turnbull AK, Martinez-Perez C, Mok S, Tanioka M, Fernando A, Renshaw L, Keys J, Wheless A, Garrett A, Parker J, He X, Sims AH, Carey LA, Perou CM, Dixon JM. Investigating the incidence of ESR1 gene amplification in breast cancers resistant to multiple endocrine agents [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 P5-04-27.

Abstract P5-04-14: Tracking ESR1 mutation clonal evolution in breast cancer using in situ mutation detection

Background: Approximately 70% of breast cancers (BCs) are estrogen receptor positive (ER+). Not all ER+ cancers respond to endocrine therapy (ET) and many eventually develop acquired resistance. Next-generation sequencing (NGS) has shown ESR1 mutations (ESRMs) are present in 10-50% of recurrent/metastatic cancers treated with aromatase inhibitors (AIs). Many of these mutations are located in the ligand-binding domain of ER, so they can lead to constitutive activation. This suggests ESRMs are a major mechanism of acquired resistance to endocrine therapy (ET) and numerous studies have shown a link between ESRMs and reduced sensitivity to 2nd line ET. The aim of this project was to investigate the incidence and clonal evolution of common ESRMs in BCs resistant to multiple sequential ETs using NGS, as well as novel PCR and in situ mutation detection methods.

Methods: We have optimised an allele-specific real-time PCR (rtPCR) assay and an in situ mutation detection method (ER-ISMD) for the assessment of ESRMs. Both have been designed to identify a missense gain-of-function D538G mutation with a single nucleotide-resolution in formalin-fixed paraffin-embedded (FFPE) BC tissues.

Two unique cohorts have been studied:

(A) 20 post-menopausal women (PMW) with ER+ BC who acquired resistance to letrozole and were treated with up to 4 subsequent lines of ET. Serial RNA and DNA from 3-5 cancer samples per patient (58 samples from 20 patients) were analysed by Ribo0-RNAseq, DNA exome sequencing, rtPCR and ER-ISMD.

(B) 150 PMW with ER+ BC who developed local (n=79), lymph node (n=59) or distant (n=12) recurrences on 1st line adjuvant letrozole, anastrozole or tamoxifen. Of these, 48 patients developed subsequent recurrences on 2nd line ET. Tissue samples from each recurrence and matched primary BC were collected.

Results: In cohort A, 5/20 patients (20%) had expansion of a D538G ESR1 mutation clone at time of resistance 1st line ET (3:letrozole, 1:anastrozole, 1:tamoxifen). The mutant allele frequency (MAF) increased further in the 4 BCs treated with 2nd line ET (2:tamoxifen, 2:exemestane) and further still in the 1 BC who received 3rd line exemestane. 0/6 patients with ESRM responded to subsequent ET. Allele-specific rtPCR and ER-ISMD have been used to validate these findings and also identified low frequency ESRM clones in the sequential samples prior to the development of clinical resistance, that were not reported by NGS. Both methods have also been applied to screen tissues from patients in cohort B, where ESRMs have also been identified in recurrent samples. Complete analysis is currently ongoing.

Conclusions:

· ESRMs develop and expand in some BCs as a mechanism for acquired resistance to ET and are associated with a lack of response to subsequent standard ETs.

· Allele-specific rtPCR can detect ESRMs and is more cost-effective and easier to use than NGS for ER mutation analysis.

· Some ESRMs predate clinical resistance.

· ER-ISMD is a novel approach that allows for identification and visualisation of the distribution of mutant clones in morphologically intact FFPE tissue.

· ER-ISMD has the potential to become a clinically useful tool to help direct the use of 2nd line ET in routine care.

Citation Format: Martinez-Perez C, Turnbull AK, Tanioka M, Fernando A, Renshaw L, Keys J, Wheless A, Garrett A, Parker J, He X, Sims AH, Carey LA, Perou CM, Dixon JM. Tracking ESR1 mutation clonal evolution in breast cancer using in situ mutation detection [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 P5-04-14.

Abstract P3-07-05: Not presented

This abstract was not presented at the conference.

Citation Format: Hardeman A, Grushko T, Clayton W, Hurley I, Khramtsova G, Parker J, Perou C, Olopade O. Not presented [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 P3-07-05.

Videolaryngoscopy versus direct laryngoscopy for adult patients requiring tracheal intubation: a Cochrane Systematic Review

Difficulties with tracheal intubation commonly arise and impact patient safety. This systematic review evaluates whether videolaryngoscopes reduce intubation failure and complications compared with direct laryngoscopy in adults. We searched CENTRAL, MEDLINE, Embase and clinicaltrials.gov up to February 2015, and conducted forward and backward citation tracking. We included randomized controlled trials that compared adult patients undergoing laryngoscopy with videolaryngoscopy or Macintosh laryngoscopy. We did not primarily intend to compare individual videolaryngoscopes. Sixty-four studies (7044 participants) were included. Moderate quality evidence showed that videolaryngoscopy reduced failed intubations (Odds Ratio (OR) 0.35, 95% Confidence Interval (CI) 0.19-0.65) including in participants with anticipated difficult airways (OR 0.28, 95% CI 0.15-0.55). There was no evidence of reduction in hypoxia or mortality, but few studies reported these outcomes. Videolaryngoscopes reduced laryngeal/airway trauma (OR 0.68, 95% CI 0.48-0.96) and hoarseness (OR 0.57, 95% CI 0.36-0.88). Videolaryngoscopy increased easy laryngeal views (OR 6.77, 95% CI 4.17-10.98) and reduced difficult views (OR 0.18, 95% CI 0.13-0.27) and intubation difficulty, typically using an 'intubation difficulty score' (OR 7.13, 95% CI 3.12-16.31). Failed intubations were reduced with experienced operators (OR 0.32, 95% CI 0.13-0.75) but not with inexperienced users. We identified no difference in number of first attempts and incidence of sore throat. Heterogeneity around time for intubation data prevented meta-analysis. We found evidence of differential performance between different videolaryngoscope designs. Lack of data prevented analysis of impact of obesity or clinical location on failed intubation rates. Videolaryngoscopes may reduce the number of failed intubations, particularly among patients presenting with a difficult airway. They improve the glottic view and may reduce laryngeal/airway trauma. Currently, no evidence indicates that use of a videolaryngoscope reduces the number of intubation attempts or the incidence of hypoxia or respiratory complications, and no evidence indicates that use of a videolaryngoscope affects time required for intubation.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.