Use of multiple pharmacodynamic measures to deconstruct the Nix-TB regimen in a short-course murine model of tuberculosis

A major challenge for tuberculosis (TB) drug development is to prioritize promising combination regimens from a large and growing number of possibilities. This includes demonstrating individual drug contributions to the activity of higher-order combinations. A BALB/c mouse TB infection model was used to evaluate the contributions of each drug and pairwise combination in the clinically relevant Nix-TB regimen [bedaquiline-pretomanid-linezolid (BPaL)] during the first 3 weeks of treatment at human equivalent doses. The rRNA synthesis (RS) ratio, an exploratory pharmacodynamic (PD) marker of ongoing Mycobacterium tuberculosis rRNA synthesis, together with solid culture CFU counts and liquid culture time to positivity (TTP) were used as PD markers of treatment response in lung tissue; and their time-course profiles were mathematically modeled using rate equations with pharmacologically interpretable parameters. Antimicrobial interactions were quantified using Bliss independence and Isserlis formulas. Subadditive (or antagonistic) and additive effects on bacillary load, assessed by CFU and TTP, were found for bedaquiline-pretomanid and linezolid-containing pairs, respectively. In contrast, subadditive and additive effects on rRNA synthesis were found for pretomanid-linezolid and bedaquiline-containing pairs, respectively. Additionally, accurate predictions of the response to BPaL for all three PD markers were made using only the single-drug and pairwise effects together with an assumption of negligible three-way drug interactions. The results represent an experimental and PD modeling approach aimed at reducing combinatorial complexity and improving the cost-effectiveness of in vivo systems for preclinical TB regimen development.

Effect of woodchip bedding during wet conditions on feedlot cattle productivity, behaviour and relative adrenal gland weight

Problems associated with muddy pens have been identified as some of the most serious animal welfare issues related to outdoor feedlot beef production, but there is relatively little work examining the use of woodchip bedding for lot-fed beef cattle under conditions of cold, wet, but non-freezing winters on soil under-bases. This study examined the effects of graded levels of woodchip on the performance and behaviour of feedlot cattle housed in wet pen conditions. Bos taurus steers (n = 300; 379.1 ± 24.1 kg) were blocked by weight and breed and randomly assigned to 30 10-steer feedlot pens provided with either no woodchip bedding (Control, n = 10) manure interface only, or 15 cm depth of woodchip bedding (W15, n = 10) or 30 cm depth of woodchip bedding (W30, n = 10). The steers were housed in these treatment pens for 109 days on a feedlot ration, and the pens were irrigated so that approximately 74 mm of total precipitation (irrigation + natural rainfall) fell onto the pen surface every 30 days. Temperatures were mostly <20 °C maximum and -1 to 5 °C minimum. Steers were weighed on five occasions. Animal position and posture in pen were recorded once a week over an 8-hour day-time period. Carcase characteristics were measured, and adrenal gland weights were recorded. Providing woodchip bedding increased liveweight gain (P < 0.001) and gain:feed (G:F, P = 0.012) after day 28, increased DM intake (DMI) after day 92 (P = 0.049), and increased carcase weight (P = 0.001) and dressing percentage (P = 0.023). There was no additional benefit of W30 over W15 for liveweight gain or DMI, but the benefit of W15 for G:F was lower than that of W30 by the end of the feeding period (P = 0.012). There were no effects of bedding on other carcase quality traits. Steers in Control pens utilised the front of the pen for lying and standing more than the W15 and W30 steers (P < 0.001) suggesting the steers in the Control pens perceived the front of the pen as less aversive, potentially due to increased drainage compared to rest of the pen and proximity to feed bunk. Adrenal gland weight/kg and carcase weight tended to be higher in the Control treatment group than the W30 steers (P = 0.077). This research has demonstrated that for a 109-day feeding period in cold, wet conditions, steer performance and welfare can be improved by providing a minimum of 15 cm woodchip bedding.

Use of Multiple Pharmacodynamic Measures to Deconstruct the Nix-TB Regimen in a Short-Course Murine Model of Tuberculosis

A major challenge for tuberculosis (TB) drug development is to prioritize promising combination regimens from a large and growing number of possibilities. This includes demonstrating individual drug contributions to the activity of higher-order combinations. A BALB/c mouse TB infection model was used to evaluate the contributions of each drug and pairwise combination in the clinically relevant Nix-TB regimen (bedaquiline-pretomanid-linezolid [BPaL]) during the first three weeks of treatment at human equivalent doses. RS ratio, an exploratory pharmacodynamic (PD) marker of ongoing Mycobacterium tuberculosis rRNA synthesis, to-gether with solid culture CFU and liquid culture time to positivity (TTP) were used as PD markers of treatment response in lung tissue; and their time course profiles were mathematically modeled using rate equations with pharmacologically interpretable parameters. Antimicrobial interactions were quantified using Bliss independence and Isserlis formulas. Subadditive (or antagonistic) and additive effects on bacillary load, assessed by CFU and TTP, were found for bedaquiline-pretomanid and linezolid-containing pairs, respectively. In contrast, subadditive and additive effects on rRNA synthesis were found for pretomanid-linezolid and bedaquiline-containing pairs, respectively. Additionally, accurate predictions of the response to BPaL for all three PD markers were made using only the single-drug and pairwise effects together with an assumption of negligible three-way drug interactions. The results represent an experimental and PD modeling approach aimed at reducing combinatorial complexity and improving the cost-effectiveness of in vivo systems for preclinical TB regimen development.

COVID-19 in-hospital mortality during the first two pandemic waves, at Helen Joseph Hospital, South Africa

Introduction

there has been significant global variation in Coronavirus Disease (COVID-19) mortality at different time points in the pandemic. Contributing factors include population demographics, comorbidities, health system capacity, prior infection with COVID-19, vaccinations, and viral variants. The study aims to describe COVID-19-related mortality of inpatients at Helen Joseph Hospital (HJH), over 12 months, during the first two waves of the COVID-19 pandemic in South Africa. The primary objectives were to describe the socio-demographic details, clinical characteristics, and hospital outcomes during the first and second waves of COVID-19. This included an assessment of the in-hospital case fatality ratio (CFR) of patients admitted with COVID-19. The secondary objectives were to compare the socio-demographic details, clinical characteristics, and outcomes between the two waves, and to determine risk factors associated with COVID-19-related mortality.

Methods

this is a retrospective cohort study of all inpatient laboratory-confirmed COVID-19 cases at HJH from 1^st May 2020 to 31^st April 2021. Data were collected by the National Institute for Communicable Diseases (NICD). Bivariate analysis was performed to describe and compare the socio-demographic characteristics, clinical characteristics, and hospital admission outcomes between the two waves. Multivariate logistic regression was used to determine risk factors for COVID-19-related mortality.

Results

overall, 1359 patients were admitted, 595 in wave one, and 764 in wave two. Patients were predominantly male (52.4%), of Black African race (75.1%) with a mean age of 54.6 (standard deviation 15.4) years. The median length of stay was 8 days (interquartile range 5-14 days). In total, 73.2% (995) of patients required oxygen, 5.2% (71) of patients received mechanical ventilation, and 7.1% (96) were admitted to the high care and Intensive Care Unit (ICU). The most common comorbid illnesses were hypertension (36.7%, n=499), diabetes mellitus (26.6%, n=362), Human Immunodeficiency Virus (HIV) (10.8%, n=147), and obesity (11.0%, n=149). The in-hospital CFR during the first wave was 30.4% (181/595) and 25.5% (195/764) (p<0.001) in the second wave, and overall, in-hospital CFR was 27.7% (376/1359). The adjusted odds of death were 79% higher among patients admitted during wave one compared to wave two (aOR=1.79; 95% CI: 1.35-2.38). A one-year increase in age increased the odds of death by 4% (aOR=1.04; 95% CI: 1.03-1.05). The need for oxygen (aOR=2.17, 95%CI: 1.56-3.01) and ventilation (aOR=7.23, 95% CI: 4.02-13.01) were significant risk factors for mortality.

Conclusion

prior to the availability of vaccines, COVID-19-related mortality was high and risk factors for mortality were consistent with national and international findings. This study reflects the impact of the pandemic on the South African public sector with limited resources and minimal ICU capacity.

A248 OUTCOMES OF COVID-19 ILLNESS AND ACCESS TO APPROPRIATE TREATMENT IN LIVER TRANSPLANT RECIPIENTS IN BRITISH COLUMBIA THROUGHOUT THE PANDEMIC

Background

COVID-19 continues to cause significant illness and mortality worldwide. Solid Organ Transplant Recipients (SOTR) have a higher rate of COVID-19 infection and worse outcomes than those who are immunocompetent. Dexamethasone, tocilizumab, and baricitinib have improved inpatient outcomes. Sotrovimab, remdesivir, and nirmatrelvir/ritonavir have recently been approved for used in high risk, minimally symptomatic outpatients. Previous experience has shown that use of monoclonal antibodies and oral antiviral agents have reduced morbidity and mortality of COVID-19 in SOTR.

Purpose

To assess the experiences and outcomes of COVID-19 and access to directed therapy in SOTR in British Columbia (BC).

Method

Data was compiled from patient disclosure to liver transplant clinicians on COVID-19 infection and gathered from patient charts in the SOTR Clinic at Vancouver General Hospital. Inclusion criteria were patients followed at the clinic with a positive COVID-19 test or clinical confirmation of COVID-19 syndrome. This is a retrospective, quality assurance study and did not require ethics review.

Result(s)

158 SOTR reported COVID-19 infections between March 2020 and September 2022. 3 patients died within 30 days of COVID-19 infection, 2 (1.26%) of which the cause of death was directly due to COVID-19, and the other who had cholangitis with severe sepsis and multi-organ system failure. 24 patients required admission to hospital, 7 requiring critical care support.

41 patients did not receive any therapy for COVID-19: there was none available at that time (n=26), it was contraindicated due to a drug interaction (n=2) or medical condition (n=1), was refused (n=1), or the infection was reported too late to qualify (n=10). 83% (92/112) of outpatients received available anti-viral treatment: sotrovimab (n=27), remdesivir (n=63), or nirmatrelvir/ritonavir (n=2). In inpatients (n=24), 13 received corticosteroids, 6 dual treated with tocilizumab (n=4) or baracitinib (n=2). 4 inpatients received remdesivir.

Three patients were treated in hospital after initiating outpatient therapy, one with progression of COVID-19 illness despite starting remdesivir. Two patients had adverse effects of medications provided: one was prescribed nirmatrelvir/ritonavir by a physician outside of the transplant program, which caused tacrolimus toxicity (serum concentration of 69.4 ng/mL) with nausea, vomiting, and diarrhea. Another patient had an episode of hypotension after receiving sotrovimab and sustained an acute kidney injury (AKI). Both patients fully recovered. There were no deaths on antiviral therapy.

Of 145 patients who had laboratory investigations done within 30 days of COVID-19 infection, 16 had a transient rise in liver enzymes, 14 had an AKI and 11required an adjustment in their tacrolimus dose.

Conclusion(s)

Involving the liver transplant team early in the course of COVID-19 illness allows patients to safely access COVID-19 directed therapy to avoid progression of illness, and medication interactions or toxicity.

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Disclosure of Interest

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The impact and experience of cardiac cachexia in advanced heart failure patients and their caregivers

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): Northern Ireland Chest Heart & Stroke

Background

Cardiac cachexia is a multifactorial wasting syndrome, which is characterised by unintentional weight loss, a reduction in skeletal muscle mass, and reduced quality of life. There is a paucity of qualitative research outlining the impact and experience of cardiac cachexia in advanced heart failure patients and their caregivers. Research in this area may promote a better understanding of the syndrome, enhance current treatment strategies, and highlight priorities for patient care.

Purpose

To qualitatively investigate the impact and experience of cardiac cachexia in advanced heart failure patients and their caregivers.

Methods

Semi-structured interviews were performed with advanced heart failure (NYHA functional class III-IV) patients meeting diagnostic criteria for cardiac cachexia (number (n) = 8) and their caregivers (n = 5). Interview questions followed a "laddered style approach", with a focus on determining the experience of cachexia for patients and carers, and its impact on their daily lives. Interviews were digitally recorded and transcribed verbatim. Average interview duration was 43 (15-64) minutes. Data were thematically analysed, using the 6-step approach of Braun & Clarke. Themes were developed and refined by several members of the research team to ensure rigor.

Results

Four key themes were developed from the data. 1) "Changed relationship with food and eating": patients with cachexia referred to eating as something they now ‘make’ themselves do without enjoyment, often just to placate their caregiver. Caregivers noted this change in habit and were concerned about inadequate nutritional intake due to the patient’s lack of interest in food. 2) "Not me in the mirror": patients struggled with their appearance and had a negative perception of themselves, linked to their weight loss. Caregivers were similarly aware of the physical changes in their loved ones and emotionally impacted. 3) "Lack of understanding regarding cachexia": despite the patient and caregivers’ concerns, they had a perception that healthcare professionals were just ‘fobbing you off’. Even though weight loss was noted and distressing to patients and caregivers, there was little clinical recognition of it, nor any advice or support from the clinical team regarding management. 4) "Uncertainty regarding the future": patients and caregivers recognised cachexia as a bad sign, and many expressed concerns about their future health and prognosis.

Conclusion

These novel qualitative findings highlight the severe impact of cardiac cachexia on the daily lives of patients and caregivers, and demonstrate their limited understanding of the syndrome. To improve care, professionals need to recognise and discuss cachexia with heart failure patients and caregivers, supporting them to cope with prognostic implications and develop more effective management strategies.

Optimizing first line treatments for adults with OCD

OCD is characterized by obsessions (recurrent, intrusive, unwanted thoughts, images or impulses and compulsions (repetitive behaviors or mental acts that the individual feels compelled to perform), which can manifest together or separately (Fineberg et al., 2020). NICE guidelines suggest that low intensity psychological treatments (including ERP) is the first line treatment for OCD, and that a "stepped care" treatment approach for OCD reserves combination treatment for adults with OCD with severe functional impairment, and for adults without an adequate response to: 1) treatment with an SSRI alone (12 weeks duration) or 2) CBT (including ERP) alone (NICE, 2005). Existing US treatment guidelines (APA guidelines) suggest that there are three first-line treatments for OCD (SSRI, CBT, SSRI+CBT) and recommends combined treatment for patients with an unsatisfactory response to monotherapy or for patients with severe OCD. Although, systematic review and meta-analysis of studies published in 1993-2014 suggest that combination treatment was not significantly better than CBT plus placebo (Ost et al., 2015), based on data from a recent systematic and meta-analysis which searched the two controlled trials registers maintained by the Cochrane Collaboration Common Mental Disorders group, the combination treatment approach is likely to be more effective than psychotherapeutic interventions alone, at least in severe obsessive-compulsive disorder (Skapinakis et al., 2016a). Based on data from Optimal treatment for OCD study conducted by Fineberg et al., (2018) combined treatment appeared to be the most effective especially when compared to CBT monotherapy, but SSRI monotherapy was found as the most cost effective. In this review we summarize available treatment recommendations.

Magseed localisation of non-palpable breast lesions: experience from a single centre

AIM

To prospectively analyse patients undergoing magnetic seed (Magseed) localisation (MSL) to evaluate the outcome, and to retrospectively compare re-excision rates for MSL with previous wire-guided localisation (WGL) to assess the hypothesis that the introduction of MSL may lead to a lower re-excision rate.

MATERIALS AND METHODS

MSL commenced at University Hospital Crosshouse in December 2017. No other changes were made to radiological or surgical practice during this time. Data were collected prospectively on all patients undergoing MSL between December 2017 and December 2019, in a single breast unit. Data were gathered retrospectively on patients who had undergone localised breast procedures between January 2016 and December 2019 for comparison of re-excision rates.

RESULTS

Two hundred and fifty-five patients underwent MSL surgery between December 2017 and December 2019. Of those, 98% (n=250) patients underwent successful MSL at the first attempt. The Magseed was identified intraoperatively in 100% patients and surgical excision was performed. The re-excision rate reduced from 18.9% in 2016/2017, to 11.6% in 2018/2019 (p=0.098).

CONCLUSION

In conclusion, Magseed localisation has proved to be a safe and effective way of localising breast lesions, with the advantage of high accuracy. The reduction in re-excision rates at University Hospital Crosshouse with the introduction of Magseed® localisation is a potential benefit, which requires further study.

A149 REAL WORLD OUTCOMES OF NON-MEDICAL SWITCHING OF INFLIXIMAB BIOSIMILAR IN BRITISH COLUMBIA FOR THE TREATMENT OF INFLAMMATORY BOWEL DISEASE (IBD)

Background

A mandated non-medical switch to the infliximab biosimilars was launched in British Columbia in 2019. British Columbia was the first province in Canada to mandate the switch from the originator infliximab (RemicadeTM) to one of the 2 approved biosimilars (InflectraTM or RenflexisTM). There is limited data for mandatory non-medical switching in IBD as was undertaken in BC.

Aims

This study aimed to obtain real-world evidence evaluating the clinical outcomes of nonmedical switch from Remicade to the infliximab biosimilars.

Methods

This is a retrospective observational study from the IBD Centre of BC (a tertiary care referral centre in Vancouver, BC). Patients on infliximab at the time of the mandated switch were identified through search of the electronic medical record. The primary outcome was drug continuation at 12 months post switch. Secondary outcomes included flare of disease, adverse events, and number of doctor visits within the first 12 months post switch. A comparison group included patients maintained on originator infliximab.

Results

A total of 235 patients were evaluated; 175 patients in the biosimilar switch group, and 60 patients in the control group. Baseline characteristics of the groups were similar. Discontinuation of infliximab occurred in 22 patients (17 in biosimilar switch group and 5 in the control group. There was no difference in the rate of discontinuation of infliximab between the biosimilar group (9.7%) and the originator molecule group (8.3%); chi squared (1, N=235) = 0.1004, p = .75. The most common reason for discontinuation was flare of disease in 6 patients in the biosimilar group and 4 patients in the control group. An additional 4 patients in the biosimilar group and 3 patients in the control group had a flare of symptoms but were maintained on therapy with an escalation of dosage or course of corticosteroids. Two patients had active disease at the time of switch and discontinued therapy. Adverse events accounted for discontinuation in 5 patients on biosimilar and 1 in the control group. These included joint pain, epigastric symptoms, drug intolerance, drug induced lupus, and drug induced pulmonary nodules in the biosimilar group, and drug induced vasculitis in the control group. Two patients in the biosimilar group discontinued due to antibody formation. Two patients in the biosimilar group discontinued therapy due to preference.

Conclusions

In this small subset of the BC IBD population undergoing a non-medical biosimilar switch of infliximab, there was no difference in the discontinuation rate between the biosimilars or the originator infliximab molecule. These findings are consistent with the existing real-world evidence.

Funding Agencies

None

Can Multi-threaded Flux Tubes in Coronal Arcades Support a Magnetohydrodynamic Avalanche?

Magnetohydrodynamic (MHD) instabilities allow energy to be released from stressed magnetic fields, commonly modelled in cylindrical flux tubes linking parallel planes, but, more recently, also in curved arcades containing flux tubes with both footpoints in the same photospheric plane. Uncurved cylindrical flux tubes containing multiple individual threads have been shown to be capable of sustaining an MHD avalanche, whereby a single unstable thread can destabilise many. We examine the properties of multi-threaded coronal loops, wherein each thread is created by photospheric driving in a realistic, curved coronal arcade structure (with both footpoints of each thread in the same plane). We use three-dimensional MHD simulations to study the evolution of single- and multi-threaded coronal loops, which become unstable and reconnect, while varying the driving velocity of individual threads. Experiments containing a single thread destabilise in a manner indicative of an ideal MHD instability and consistent with previous examples in the literature. The introduction of additional threads modifies this picture, with aspects of the model geometry and relative driving speeds of individual threads affecting the ability of any thread to destabilise others. In both single- and multi-threaded cases, continuous driving of the remnants of disrupted threads produces secondary, aperiodic bursts of energetic release.

Prevalence and effect of cardiac cachexia in advanced heart failure patients living in northern ireland

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): Northern Ireland Chest Heart and Stroke

Background/Introduction: Cardiac cachexia (CC) is a multifactorial wasting syndrome, resulting in significant weight loss and reduction in muscle mass. This is reflected in a detrimental effect on the patients’ physical condition, quality of life and increases the patient’s risk of premature death. Nonetheless, cardiac cachexia remains frequently unrecognised in clinical practice and therefore understudied.

Purpose

To determine the prevalence and effect of cardiac cachexia in 200 patients with advanced heart failure (NYHA class III-IV) living in Northern Ireland.

Methods

A mixed methods cross sectional study of patients recruited from a regional heart failure centre. A total of 200 patients with NYHA class III-IV heart failure were consented, enrolled and detailed data collected from their records. Anthropometric measures were taken (i.e. measures of lean muscle mass and fat tissue) and each individual completed three validated questionnaires - EQ-5D-5L (quality of life), FACIT-Fatigue and FAACT (various wellbeing subscales).

Results

This population was predominately male (65.5%), with an average age of 74.4 years. Of the 200 NYHA class III-IV patients recruited, 30 were identified as cachectic (15%) Physically, cachectic patients were approximately 25 kg lighter than non-cachectic patients (p &lt; 0.01) with an average BMI of 21.8 ± 4.4. The cachectic group showed significant reductions in mid-upper arm circumference (p &lt; 0.01), skinfold thickness (p &lt; 0.01) and upper arm fat area (p &lt; 0.01), in comparison to the non-cachectic group. Measures of muscle mass were reduced, for example upper arm muscle circumference and area (p &lt; 0.01), as well as grip strength (p &lt; 0.01 for both right and left hands). Quality of life results from the EQ-5D-5L [see figure part b)] indicated an overall reduction for the cachectic group (p = 0.047). Of the EQ-5D-5L subscales, mobility and ‘usual activities’ were significantly reduced (p = 0.02 and p &lt; 0.01 respectively), highlighting a significant change in the daily routine and ability of these patients. The FACIT-Fatigue questionnaire showed cachectic patients to be significantly more fatigued (p &lt; 0.01) [see figure part a)], whilst the FAACT demonstrated reduced physical wellbeing (p = 0.02) and greater issues with diet and appetite (p &lt; 0.01).

Conclusions

This is the first prevalence study of cardiac cachexia within Northern Ireland. The 15% prevalence rate shows that the syndrome is relatively common in the advanced heart failure population. Cardiac Cachexia has severe physical consequences, attributed to an individual’s weight loss in both fat and muscle tissue. Such changes may explain the subsequent decrease in mobility and the ability of these patients to conduct their ‘usual activities’. Increased fatigue, reduced physical wellbeing and issues with diet and appetite only intensify these dire physical effects. It is hoped that these results will highlight the impact of this syndrome and promote targeted interventions.

16 Pharmacological Interventions for Sialorrhoea in Parkinson’s Disease: A Systematic Review

Introduction

We looked at patients with Idiopathic Parkinson’s disease and reviewed articles that used any pharmacological therapy to attempt to reduce the volume or burden of sialorrhoea. The control was patients on placebo or receiving usual best care. The primary outcome was symptom burden of sialorrhoea.

Method

The review was registered on Prospero (CRD42016042470.) 7 electronic databases (MEDLINE, EMBASE, CINAHL, PsycINFO, Cochrane Central Register of Controlled Trials (CENTRAL), LILACS) were searched until April 2019 using search terms for sialorrhoea and Parkinson’s disease. We additional searched through the last 6 years of abstracts from the International Movement Disorder Conference, Movement Disorder Society International Congress and World Parkinson’s Congress. Hand searching was performed of published journals from the Movement Disorder Journal of the Movement Disorder Society and Neurology. Inclusion criteria included patients aged over 18; patients with a diagnosis of Idiopathic Parkinson’s disease; patients with the complication of sialorrhoea and any pharmacological therapy aimed at reducing sialorrhoea. All articles were assessed for risk of bias independently by two assessors using the Cochrane risk of bias tool.

Results

7 articles were included from the 1,015 screened citations. 3 studies used Botox B as an intervention with clear objective measures and low risk of bias. These studies did show a significant reduction in sialorrhoea however the largest study showed some reporting bias and the others had small numbers and a short follow up period. 1 study looked at Botox A which showed significant improvement in sialorrhoea but had short follow-up.

Conclusion

Most studies have very small numbers and were followed up for only 1 month. There was significant heterogeneity in outcome measures but little evidence of significant harm from from the treatments studied. Overall, more robust evidence is required in order to achieve a gold standard in the treatment of sialorrhoea.

Endothelin receptor antagonist improves donor lung function in an ex vivo perfusion system

BACKGROUND

A lung transplant is the last resort treatment for many patients with advanced lung disease. The majority of donated lungs come from donors following brain death (BD). The endothelin axis is upregulated in the blood and lung of the donor after BD resulting in systemic inflammation, lung damage and poor lung graft outcomes in the recipient. Tezosentan (endothelin receptor blocker) improves the pulmonary haemodynamic profile; however, it induces adverse effects on other organs at high doses. Application of ex vivo lung perfusion (EVLP) allows the development of organ-specific hormone resuscitation, to maximise and optimise the donor pool. Therefore, we investigate whether the combination of EVLP and tezosentan administration could improve the quality of donor lungs in a clinically relevant 6-h ovine model of brain stem death (BSD).

METHODS

After 6 h of BSD, lungs obtained from 12 sheep were divided into two groups, control and tezosentan-treated group, and cannulated for EVLP. The lungs were monitored for 6 h and lung perfusate and tissue samples were processed and analysed. Blood gas variables were measured in perfusate samples as well as total proteins and pro-inflammatory biomarkers, IL-6 and IL-8. Lung tissues were collected at the end of EVLP experiments for histology analysis and wet-dry weight ratio (a measure of oedema).

RESULTS

Our results showed a significant improvement in gas exchange [elevated partial pressure of oxygen (P = 0.02) and reduced partial pressure of carbon dioxide (P = 0.03)] in tezosentan-treated lungs compared to controls. However, the lungs hematoxylin-eosin staining histology results showed minimum lung injuries and there was no difference between both control and tezosentan-treated lungs. Similarly, IL-6 and IL-8 levels in lung perfusate showed no difference between control and tezosentan-treated lungs throughout the EVLP. Histological and tissue analysis showed a non-significant reduction in wet/dry weight ratio in tezosentan-treated lung tissues (P = 0.09) when compared to control.

CONCLUSIONS

These data indicate that administration of tezosentan could improve pulmonary gas exchange during EVLP.

Understanding the holistic experiences of living with a kidney transplant: an interpretative phenomenological study (protocol)

Background

Currently very little is known about the perceptions and experiences of kidney transplant recipients from a qualitative perspective. As highlighted by the European Kidney Health Alliance recommendations, providing holistic care to kidney patients is important however this is currently an unmet care need in renal disease. It is imperative to understand patient experiences to ensure that they are included in key strategies and future renal service planning. Ignoring these important patient views means that there is a significant risk of inappropriate renal service provision and lack of adequate support impacting on overall health.

Method

A purposive sampling strategy will recruit individuals currently living with a kidney transplant, 6 months to 5 years post-transplant. A maximum of 30 patients will be recruited between two Regional Nephrology units within the United Kingdom via clinical gatekeepers. In-depth interviews will be undertaken with participants living with a kidney transplant across the two sites. Interviews will be digitally-recorded, transcribed verbatim and subjected to interpretative phenomenological analysis.

Discussion

Renal healthcare professionals need to understand more than the biological impact of receiving a kidney transplant. Understanding the holistic and multi-domain experiences that these patients experience will help healthcare professionals to recognize the needs of this group and ensure more responsive care.

Single-stage nasal reconstruction with the islanded forehead flap

BACKGROUND AND PURPOSES

Multi-staged forehead flaps are a well-recognised reconstructive workhorse for subtotal and total nasal defects. It carries the disadvantage of repeated trips to theatre for revisional surgery, which is not suited to all patient cohorts. The single-stage islanded forehead flap eliminates this need. We detail our indications and outcomes of using this flap to highlight the maintained versatility of the technique without significant compromise on reconstructive and patient outcome.

SUBJECTS STUDIED AND METHODS

A prospective surgical database was collated where patients were categorised as partial or total reconstruction. We detail surgical technique and review of rationale of patient selection. Patient demographics, perioperative data and follow-up course were recorded.

MAIN FINDINGS

A total of 22 patients were recorded from both the U.K. and Ethiopia via working with the charity Facing Africa. Defects occurred from a mixture of trauma, Noma and cancer resections. Thirteen were total nasal reconstructions and nine partial. The mean follow-up period was 2.25 years. We experienced two major complications which required minor revision in the theatre and two minor complications, all resolved satisfactorily.

CONCLUSIONS

We demonstrate good outcomes and safety of the procedure in this first report of a varied cohort of nasal reconstructions in a heterogenous cohort of patients. We advocate the use of this flap in the multi-morbid patient where recovery can be expedited or those who have limitations from economical restraints.

The association of pre-operative anaemia with morbidity and mortality after emergency laparotomy

Pre-operative anaemia is associated with poor outcomes after elective surgery but its relationship with outcomes after emergency surgery is unclear. We analysed National Emergency Laparotomy Audit data from 1 December 2013 to 30 November 2017, excluding laparotomy for haemorrhage. Anaemia was classified as 'mild' 129-110 g.l-1; 'moderate' 109-80 g.l-1; or 'severe' ≤ 79 g.l-1. The primary outcome was 90-day mortality. Secondary outcomes were 30-day mortality, return to theatre and postoperative hospital stay. The primary outcome was available for 86,763 patients, of whom 45,306 (52%) were anaemic. There were 12,667 (15%) deaths at 90 postoperative days and 9246 (11%) deaths at 30 postoperative days. Anaemia was associated with increased 90-day and 30-day mortality, odds ratio (95%CI): mild, 1.15 (1.09-1.21); moderate, 1.44 (1.36-1.52); and severe, 1.42 (1.24-1.63), p < 0.001 for all; mild, 1.07 (1.00-1.12), p = 0.030; moderate, 1.30 (1.21-1.38), p < 0.001; and severe, 1.22 (1.05-1.43), p = 0.010, respectively. All categories of anaemia were associated with prolonged hospital stay, adjusted coefficient (95%CI): mild, 1.31 (1.01-1.62); moderate, 3.41 (3.04-3.77); severe, 2.80 (1.83-3.77), p < 0.001 for all. Moderate and severe anaemia were associated with increased risk of return to the operating theatre, odds ratio (95%CI): moderate 1.13 (1.06-1.21), p < 0.001; and severe 1.23 (1.06-1.43), p = 0.006. Pre-operative anaemia is common in patients undergoing emergency laparotomy and is associated with increased postoperative mortality and morbidity.

Obsessive compulsive Personality Disorder and Autism Spectrum Disorder Traits in the Obsessive-compulsive Disorder Clinic

Introduction

Obsessive Compulsive Personality Disorder (OCPD) is a common, highly co-morbid disorder. Subjected to comparatively little research, OCPD shares aspects of phenomenology and neuropsychology with obsessive-compulsive spectrum disorders and neurodevelopmental disorders such as autism spectrum disorder (ASD). A greater understanding of this interrelationship would provide new insights into its diagnostic classification and generate new research and treatment heuristics.

Aims

To investigate the distribution of OCPD traits within a cohort of OCD patients. To evaluate the clinical overlap between traits of OCPD, OCD and ASD, as well as level of insight and treatment resistance.

Method

We interviewed 73 consenting patients from a treatment seeking OCD Specialist Service. We evaluated the severity of OCPD traits (Compulsive Personality Assessment Scale; CPAS), OCD symptoms (Yale–Brown Obsessive Compulsive Scale; Y-BOCS), ASD traits (Adult Autism Spectrum Quotient; AQ) and insight (Brown Assessment of Beliefs Scale; BABS).

Results

Out of 67 patients, 24 (36%) met DSM-IV criteria for OCPD, defined using the CPAS. Using Pearson's test, CPAS scores significantly (P < 0.01) correlated with total AQ and selected AQ domains but not with BABS. Borderline significant correlation was observed with Y-BOCS (P = 0.07). OCPD was not over-represented in a highly resistant OCD subgroup.

Conclusion

Disabling OCPD traits are common in the OCD clinic. They strongly associate with ASD traits, less strongly with OCD severity and do not appear related to poor insight or highly treatment-resistant OCD. The impact of OCPD on OCD treatment outcomes requires further research.

Disclosure of interest

This work did not receive funding from external sources. Over the past few years, Dr. Fineberg has received financial support in various forms from the following: Shire, Otsuka, Lundbeck, Glaxo-SmithKline, Servier, Cephalon, Astra Zeneca, Jazz pharmaceuticals, Bristol Myers Squibb, Novartis, Medical Research Council (UK), National Institute for Health Research (UK), Wellcome Foundation, European College of Neuropsychopharmacology, UK College of Mental Health Pharmacists, British Association for Psychopharmacology, International College of Obsessive-Compulsive Spectrum Disorders, International Society for Behavioural Addiction, World Health Organization, Royal College of Psychiatrists.

Survival analysis of carboplatin added to an anthracycline/taxane-based neoadjuvant chemotherapy and HRD score as predictor of response-final results from GeparSixto

Background

In the neoadjuvant GeparSixto study, adding carboplatin to taxane- and anthracycline-based chemotherapy improved pathological complete response (pCR) rates in patients with triple-negative breast cancer (TNBC). Here, we present survival data and the potential prognostic and predictive role of homologous recombination deficiency (HRD).

Patients and methods

Patients were randomized to paclitaxel plus nonpegylated liposomal doxorubicin (Myocet®) (PM) or PM plus carboplatin (PMCb). The secondary study end points disease-free survival (DFS) and overall survival (OS) were analyzed. Median follow-up was 47.3 months. HRD was among the exploratory analyses in GeparSixto and was successfully measured in formalin-fixed, paraffin-embedded tumor samples of 193/315 (61.3%) participants with TNBC. Homologous recombination (HR) deficiency was defined as HRD score ≥42 and/or presence of tumor BRCA mutations (tmBRCA).

Results

A significantly better DFS (hazard ratio 0.56, 95% CI 0.34-0.93; P = 0.022) was observed in patients with TNBC when treated with PMCb. The improvement of OS with PMCb was not statistically significant. Additional carboplatin did not improve DFS or OS in patients with HER2-positive tumors. HR deficiency was detected in 136 (70.5%) of 193 triple-negative tumors, of which 82 (60.3%) showed high HRD score without tmBRCA. HR deficiency independently predicted pCR (ypT0 ypN0) [odds ratio (OR) 2.60, 95% CI 1.26-5.37, P = 0.008]. Adding carboplatin to PM significantly increased the pCR rate from 33.9% to 63.5% in HR deficient tumors (P = 0.001), but only marginally in HR nondeficient tumors (from 20.0% to 29.6%, P = 0.540; test for interaction P = 0.327). pCR rates with carboplatin were also higher (63.2%) than without carboplatin (31.7%; OR 3.69, 1.46-9.37, P = 0.005) in patients with high HRD score but no tmBRCA. DFS rates were improved with addition of carboplatin, both in HR nondeficient (hazard ratio 0.44, 0.17-1.17, P = 0.086) and HR deficient tumors (hazard ratio 0.49, 0.23-1.04, P = 0.059).

Conclusions

The addition of carboplatin to neoadjuvant PM improved DFS significantly in TNBC. Long-term survival analyses support the neoadjuvant use of carboplatin in TNBC. HR deficiency in TNBC and HRD score in non-tmBRCA TNBC are predictors of response. HRD does not predict for carboplatin benefit.

Increasing person-centred care in paediatrics

Background

Paediatric patients (PPs) often feel that they are not involved in care and treatment decisions. Although training clinicians may help, there is a lack of evaluated training programmes specifically for work with PPs. The aim of this article is to evaluate ‘Me first’, a training programme aimed at improving clinicians’ attitudes and communication skills when working with PPs.

Methods

A total of 69 clinicians attended ‘Me first’ training and completed questionnaires across three time points: (1) prior to attending the training; (2) at the end of the training; and (3) 4–6 weeks later. This included 14 medical staff, 29 nursing staff and 26 allied health staff. Attitude was measured using the Leeds Attitudes to Concordance II (LATCon II) scale, and communication skills were measured using the Effective Listening and Interactive Communication Scale (ELICS).

Results

Overall, clinicians reported that their attitude and communication skills improved after attending ‘Me first’. This was maintained 4–6 weeks later. Subgroup analysis showed that allied health staff did not maintain the improved attitude at the follow‐up conducted 4–6 weeks later.

Conclusions

Findings suggest that ‘Me first’ may be helpful in improving clinician attitudes and communication skills with PPs. Further research should examine whether PPs report higher levels of communication and decision making with clinicians who have attended training.

Overlap of obsessive-compulsive personality disorder and autism spectrum disorder traits among OCD outpatients: an exploratory study

Background: Whereas the phenomenology of obsessive-compulsive personality disorder (OCPD) shows similarities to that of obsessive compulsive and related disorders (OCRDs) as well as with autism spectrum disorder (ASD), the relationship between these disorders is poorly understood.Aims: Within a clinical sample, we aimed to investigate the distribution of OCD, OCPD and ASD symptoms and traits and their interrelationship, as well as to evaluate insight and treatment refractoriness.Methods: Consecutive adult OCD outpatients were assessed for OCPD traits (Compulsive Personality Assessment Scale (CPAS)), OCD symptoms (Yale-Brown Obsessive Compulsive Scale (Y-BOCS)), ASD traits (Autism Spectrum Quotient (AQ)), insight (Brown Assessment of Beliefs Scale (BABS)) and treatment resistance (clinical records). Those scoring highly on the AQ underwent a diagnostic interview for ASD.Results: Sixty-seven consenting individuals completed the CPAS, BABS and AQ, and 65 completed the Y-BOCS. Twenty-four patients (35.8%) were diagnosed with OCPD. Patients with OCPD were less likely to be employed (p=.04). They demonstrated elevated AQ scores (p=.004) and rates of ASD diagnosis (54.2%) (p <.001). OCPD traits (CPAS) showed a highly significant correlation with ASD traits (AQ) (p<.001), and no association with Y-BOCS, BABS or treatment resistance.Conclusions: In an OCD cohort limited by small size, OCPD associated strongly with unemployment and ASD, with implications for diagnosis, treatment and outcome.KEY POINTSClinicians should exercise a high level of vigilance for OCPD and ASD in patients presenting with obsessive compulsive symptoms.The presence of OCPD may indicate a likelihood of disabling ASD traits, including cognitive inflexibility, poor central coherence and poor social communication.These neuropsychological factors may require separate clinical intervention strategies.

The Me first communication model

This article explores communication and decision-making with children and young people in healthcare. Children and young people report that healthcare professionals are good at explaining and helping them to understand what will happen to them, but that they do not feel involved in decision-making about their care or treatment. To improve communication with children and young people, they need to be involved in decision-making about their care and treatment. In partnership with children, young people and healthcare professionals Common Room Consulting, Great Ormond Street Hospital for Children NHS Foundation Trust and Health Education England have co-produced a communication model, Me first, to support decision-making with children and young people in healthcare. This article introduces the Me first model and explores how it can be applied in clinical practice.

Measuring pain in dogs and cats using structured behavioural observation

The contemporary approach to pain measurement in people and animals seeks to measure the affective (emotional) component of the pain experience using structured questionnaires with formal scoring methodology. Chronic pain has wide-ranging impacts which affects the quality of life (QOL) of the individual, whether that is a person or an animal. Accordingly instruments to measure chronic pain are designed to measure its impact on QOL and are called health-related quality of life (HRQL) instruments. In veterinary science instruments to measure pain are based on behavioural observation by the veterinary surgeon/nurse in the case of acute pain and by the owner in the case of chronic pain. The development of HRQL instruments is an expanding field in veterinary science, not just for the measurement of pain, but for other chronic diseases, and it has a wide application in pharmaceutical research and clinical practice to improve patient care. This review highlights the challenges involved in creating such measures for dogs and cats, seeking to provide the reader with an understanding of their development process. It then provides an overview of the current status with regard to acute and chronic pain measurement.

Serum LDH and LDH Isoenzymes in Chronic Renal Failure: Effect of Hemodialysis

Serum levels of several commonly measured enzymes are abnormal in patients with end-stage renal disease (ESRD). In the present study we measured serum total LDH activity and LDH isoenzymes in a group of 25 ESRD patients shortly before, during, and immediately after hemodialysis. Baseline serum total LDH activity in the ESRD group was midly but significantly higher than that found in the normal control group. The observed elevation was associated with an isomorphic pattern. Single passage of blood through the extracorporeal apparatus led to a rise in total LDH, LDH-3, LDH-2 and LDH-4, a pattern consistent with release from the platelets. A steady increase was noted in total LDH, LDH-5 and LDH-1 of arterial blood during hemodialysis. This was thought to be due to ultrafiltration-induced hemoconcentration, enzyme release from the formed elements within the extracorporeal circuit and complement-mediated leukocyte activation and pulmonary leukostasis. These observations should be taken into consideration with regards to interpretation of LDH and LDH isoenzyme values and proper time of blood sampling in ESRD patients.