Precision computerised cognitive behavioural therapy (cCBT) for adolescents with depression: a pilot and feasibility randomised controlled trial protocol for SPARX-UK

BACKGROUND

A serious game called SPARX (Smart, Positive, Active, Realistic, X-factor thoughts), originally developed in New Zealand and incorporating cognitive behavioural therapy (CBT) principles, has been shown to help reduce symptoms of depression and anxiety in adolescents with mild to moderate depression in studies undertaken in Australasia. However, SPARX has never been trialled in the United Kingdom (UK), and there have been issues relating to low engagement when it has been used in a real-world context.

AIMS

To conduct the first pilot and feasibility randomised controlled trial (RCT) in England to explore the use of SPARX in different settings. The trial will explore whether SPARX supported by an e-coach (assistant psychologists) improves adherence and engagement compared with self-directed (i.e. self-help) use. The trial results will be used to inform the optimal mode of delivery (SPARX supported vs. SPARX self-directed), to calculate an appropriate sample size for a full RCT, and to decide which setting is most suitable.

METHODS

Following consultation with young people to ensure study suitability/appropriateness, a total of 120 adolescents (11-19 years) will be recruited for this three-arm study. Adolescents recruited for the study across England will be randomised to receive either SPARX with human support (from an e-coach), self-directed SPARX, or a waitlist control group. Assessments will be conducted online at baseline, week 4, and 8-10-week post-randomisation. The assessments will include measures which capture demographic, depression (Patient Health Questionnaire modified for adolescents [PHQ-A]) and anxiety (Revised Child Anxiety and Depression Scale [RCADS]) symptomatology, and health-related quality-of-life data (EQ-5D-Y and proxy version). Analyses will be primarily descriptive. Qualitative interviews will be undertaken with a proportion of the participants and clinical staff as part of a process evaluation, and the qualitative data gathered will be thematically analysed. Finally, feasibility data will be collected on recruitment details, overall study uptake and engagement with SPARX, participant retention, and youth-reported acceptability of the intervention.

DISCUSSION

The findings will inform the design of a future definitive RCT of SPARX in the UK. If the subsequent definitive RCT demonstrates that SPARX is effective, then an online serious game utilising CBT principles ultimately has the potential to improve the provision of care within the UK's health services if delivered en masse.

TRIAL REGISTRATION

ISRCTN: ISRCTN15124804. Registered on 16 January 2023, https://www.isrctn.com/ISRCTN15124804 .

Studying biodiversity of spiders species in seven different localities of Charsadda District, Khyber Pakhtunkhwa, Pakistan

Abstract The current research work aims to provide knowledge about the diversity of spiders’ fauna and their occurrence throughout the year from District Charsadda Khyber Pakhtunkhwa, Pakistan. Research data were collected from March-2015 to January-2017 from seven different localities of Charsadda District by using the camera, bottle, plastic bags, paraffin films, field book and 70% of ethylene alcohol and 20% of glycerine were used as chemicals. By using special identification keys, spiders were differentiated into families, genera and species. During the study time, a total of 2734 specimens of spiders were collected belonging from 35 genera, 15 families and 44 species were identified. Salticidae was the dominant family according to genera studied plus spiders samples numbers collected with 10 genera and 616 species specimens count. The high occurrence of spiders was studied during July. The result of the current study also shows a reduction of spider’s species in December due to lowering the temperature. The current study shows that Salticidae were the dominant family as capered to other species. The occurrence of spiders species greatly depends on changing the weather condition. The present study also shows great fluctuation in spider’s occurrence with changing of hot climate to colder during the study duration. Moreover, the wet season plays a great role in spiders’ population increase and growth.

Redox mediators boost NOx reduction via trade-off electron charges using a cube-shaped (cMn@rGO) catalyst; mechanism and electrochemical study

Gaseous pollutants like sulfur dioxide and nitrogen oxide(s) (SO2, NOx) have been increasing exponentially for the last two decades, which have had adverse effects on human health, aquatic life, and the environment. Recently, for air pollution taming, manganese/oxide (Mn/MnO) has become a very promising heterogeneous catalyst due to its environment-friendly, low-price, and remarkable catalytic abilities for toxic gases. In this work, cube-shaped Mn nanoparticles (cMn NPs) were decorated on the surface of reduced graphene oxide (rGO) by the solvothermal method. The resulting cMn@rGO composite was employed for electrochemical NOx reduction. However, the microscopic (TEM/HRTEM) and structural analysis were utilised to investigate the morphology and characteristics of the cMn@rGO composite. This electrochemical-based treatment for NOx reduction is employed by using electron shuttle or redox mediators. Here, four distinct redox mediators are used to address electrochemical obstacles, which effectively facilitate electron transportation and promoted NOx reduction on the electrode surface. These mediators not only significantly enhanced the NOx conversion into valuable products, i.e., N2 and N2O, but also made the process smooth with high performance. Among these mediators, neutral red (N.R) exhibited extraordinary potential in enhancing NOx reduction. The obtained results indicated that the remarkable catalytic performance (∼93%) of the cMn@rGO can be attributed to several factors, including the catalyst's three-dimensional architecture structure and abundant active sites. The designed catalyst (cMn@rGO) is not only cost-effective and sustainable but also exhibits excellent potential in effectively reducing NOx, which could be beneficial for large-scale NOx abatement.

Randomised controlled trial of analgesia for the management of acute severe pain from traumatic injury: study protocol for the paramedic analgesia comparing ketamine and morphine in trauma (PACKMaN)

BACKGROUND

Prehospital analgesia is often required after traumatic injury, currently morphine is the strongest parenteral analgesia routinely available for use by paramedics in the United Kingdom (UK) when treating patients with severe pain. This protocol describes a multi-centre, randomised, double blinded trial comparing the clinical and cost-effectiveness of ketamine and morphine for severe pain following acute traumatic injury.

METHODS

A two arm pragmatic, phase III trial working with two large NHS ambulance services, with an internal pilot. Participants will be randomised in equal numbers to either (1) morphine or (2) ketamine by IV/IO injection. We aim to recruit 446 participants over the age of 16 years old, with a self-reported pain score of 7 or above out of 10. Randomised participants will receive a maximum of 20 mg of morphine, or a maximum of 30 mg of ketamine, to manage their pain. The primary outcome will be the sum of pain intensity difference. Secondary outcomes measure the effectiveness of pain relief and overall patient experience from randomisation to arrival at hospital as well as monitoring the adverse events, resource use and cost-effectiveness outcomes.

DISCUSSION

The PACKMAN study is the first UK clinical trial addressing the clinical and cost-effectiveness of ketamine and morphine in treating acute severe pain from traumatic injury treated by NHS paramedics. The findings will inform future clinical practice and provide insights into the effectiveness of ketamine as a prehospital analgesia.

TRIAL REGISTRATION

ISRCTN, ISRCTN14124474. Registered 22 October 2020, https://www.isrctn.com/ISRCTN14124474.

Heavy metals in five commonly consumed fish species from River Swat, Pakistan, and their implications for human health using multiple risk assessment approaches

This study analyzed the levels of heavy metals bioaccumulation in commonly consumed riverine fish species, including G. cavia, T. macrolepis, G. gotyla, S. plagiostomus, and M. armatus from River Swat in Pakistan, and quantify their potential risk to children and adults in general and fisherfolk communities using multiple pollution and risk assessment approaches. The highest metal detected by inductive coupled plasma mass spectrometry (ICP-MS) was Zn, which ranged from 49.61 to 116.83 mg/kg, followed by Fe (19.25-101.33 mg/kg) > Mn (5.25-40.35 mg/kg) > Cr (3.05-14.59 mg/kg) > Ni (4.26-11.80 mg/kg) > Al (1.59-12.25 mg/kg) > Cu (1.24-8.59 mg/kg) > Pb (0.29-1.95 mg/kg) > Co (0.08-0.46 mg/kg) > Cd (0.01-0.29 mg/kg), demonstrating consistent fluctuation with the safe recommendations of global regulatory bodies. The average bioaccumulation factor (BAF) values in the examined fish species were high (BAF > 5000) for Pb, Zn, Mn, Cu, Cr, Ni, and Cd, bioaccumulate (1000 > BAF < 5000) for Co, and probable accumulative (BAF <1000) for Fe, and Al, while the overall ∑heavy metals pollution index (MPI) values were greater than one (MPI > 1) indicating sever heavy metals toxicity in G. cavia, followed by S. plagiostomus, M. armatus, G. gotyla, and T. macrolepis. The multivariate Pearson's correlation analysis identified the correlation coefficients between heavy metal pairs (NiCr, CuCr, PbCr, AlCo, CuNi, and PbNi), the hierarchical cluster analysis (CA) determined the origin by categorizing heavy metal accumulation into Cluster-A, Cluster-B, and Cluster-C, and the principal component analysis (PCA) discerned nearby weathering, mining, industrial, municipal, and agricultural activities as the potential sources of heavy metals bioaccumulation in riverine fish. As per human risk perspective, S.plagiostomus contributed significantly to the estimated daily intake (EDI) of heavy metals, followed by G.cavia > M.armatus > G.gotyla > T.macrolepis in dependent children and adults of the fisherfolk followed by the general population. The non-carcinogenic target hazard quotient (THQ) and hazard index (HI) values for heavy metal intake through fish exposure were < 1, while the carcinogenic risk (CR) for individual metal intake and the total carcinogenic risk (TCR) for cumulative Cr, Cd, and Pb intake were within the risk threshold of 10-6-10-4, suggesting an acceptable to high non-carcinogenic and carcinogenic risk for both children and adults in the fisherfolk, followed by the general population.

Source apportionment and risk assessment of soil heavy metals around a key drinking water source area in northern China: multivariate statistical analysis approach

With the intensive urbanization and industrialization in recent years, lots of products containing heavy metals (HMs) have brought in severe environment problems. Yuqiao Reservoir (YQR) is an important drinking water source area in Tianjin of China, and the soil environmental quality of YQR is vital for human health. The goal of this study was to identify the priority control pollutants and hotspots of HMs contamination of YQR catchment. Thus, an integrated field investigation was conducted to analyze the major elements such as As, Cd, Cr, Cu, Hg, Ni, Pb and Zn in soils around YQR. Geoaccumulation index (Igeo), enrichment factor (EF) and potential ecological risk index (PERI) were employed to assess the contamination status of HMs. The average contents of these elements were given as follows: As 7.97 mg/kg, Cd 0.31 mg/kg, Cr 86.1 mg/kg, Cu 24.7 mg/kg, Hg 0.044 mg/kg, Ni 30.7 mg/kg, Pb 27.3 mg/kg and Zn 76.7 mg/kg. According to geoaccumulation index (I_geo) and enrichment factor (EF) values, Cd, Cr, Pb and As showed a prominent enrichment. The result of multivariate statistics showed that Cd, Cr, Cu, As, Ni, Pb and Zn concentrations were mainly affected by human activities, whereas Hg was mainly from natural release. The anthropogenic activities were the major sources with a contribution of 91.46%, while natural origins only contributed 8.54%. And agricultural fertilization, mining and traffic activities are the most probable sources of these heavy metals in the soil. The PERI values indicated that 65.7% of total HMs were at low risk, 22.5% in moderate risk and 11.8% in considerable risk. To ensure soil environmental quality and human health, cadmium should be listed as a priority control pollutant. Spatial maps of HMs and their integrated PERI provided clear hotspots that indicated lower risk in the region close to YQR but higher risk in the region far from YQR.

Randomised controlled trial of the short-term effects of osmotic-release oral system methylphenidate on symptoms and behavioural outcomes in young male prisoners with attention deficit hyperactivity disorder: CIAO-II study

BACKGROUND

Research has shown that 20-30% of prisoners meet the diagnostic criteria for attention-deficit hyperactivity disorder (ADHD). Methylphenidate reduces ADHD symptoms, but effects in prisoners are uncertain because of comorbid mental health and substance use disorders.

AIMS

To estimate the efficacy of an osmotic-release oral system methylphenidate (OROS-methylphenidate) in reducing ADHD symptoms in young adult prisoners with ADHD.

METHOD

We conducted an 8-week parallel-arm, double-blind, randomised placebo-controlled trial of OROS-methylphenidate versus placebo in male prisoners (aged 16-25 years) meeting the DSM-5 criteria for ADHD. Primary outcome was ADHD symptoms at 8 weeks, using the investigator-rated Connors Adult ADHD Rating Scale (CAARS-O). Thirteen secondary outcomes were measured, including emotional dysregulation, mind wandering, violent attitudes, mental health symptoms, and prison officer and educational staff ratings of behaviour and aggression.

RESULTS

In the OROS-methylphenidate arm, mean CAARS-O score at 8 weeks was estimated to be reduced by 0.57 points relative to the placebo arm (95% CI -2.41 to 3.56), and non-significant. The responder rate, defined as a 20% reduction in CAARS-O score, was 48.3% for the OROS-methylphenidate arm and 47.9% for the placebo arm. No statistically significant trial arm differences were detected for any of the secondary outcomes. Mean final titrated dose was 53.8 mg in the OROS-methylphenidate arm.

CONCLUSIONS

ADHD symptoms did not respond to OROS-methylphenidate in young adult prisoners. The findings do not support routine treatment with OROS-methylphenidate in this population. Further research is needed to evaluate effects of higher average dosing and adherence to treatment, multi-modal treatments and preventative interventions in the community.

An integrated approach towards marble waste management: GIS, SFA, and recycling options

Marble units generate an enormous amount of non-biodegradable waste during the processing operations and are considered one of the environmentally unfriendly industrial sectors. This sector has become a global nuisance due to its multi-dimensional damaging nature. Therefore, a multidimensional approach is needed to geographically describe the pollution sources, their waste load, collection mechanism, and their proper disposal or reuse. This article highlights an integrated approach to sorting out the multidimensional issues associated with the marble sector. More than 150 marble processing units (MPUs) are scattered in the study area pouring waste into the environment in the form of slurry. The produced waste roots environmental issues both for fauna and flora of the terrestrial and aquatic segments of the environment. A geospatial-based attempt has been made through geographic information system (GIS) for the identification and description of the pollution sources, MPUs, in the study area. The quantitative assessment has been made through substance flow analysis (SFA) by taking raw marble as the input source and marble product as output. Furthermore, material characterization has been carried out to confirm the chemical composition of the slurry waste for its potential use. Results confirmed that a major part (> 90%) of marble powder is calcium carbonate (CaCO₃) which has so many potential uses as raw material. The integrated approach of GIS, SFA, and chemical characterization set forth a model that satisfies multi-dimensional queries regarding pollution sources, pollution load, and sustainable solutions to the problem. The output integrated model provides a digital environmental baseline for the monitoring of MPUs, the amount of waste generated by these MPUs, and its potential reuse options. The proposed model can be utilized worldwide as a decision support tool due to its optimum results.

Effects of land use and landscape on the occurrence and distribution of microplastics in soil, China

Microplastic pollution in the soil environment has gathered widespread attention. However, little is known about the effects of land use and landscape patterns on the occurrence and distribution of microplastics in the soil. Herein, the microplastic pollution in different land uses (facility farmland, traditional farmland, orchard, grassland, and woodland) in Yuanmou County, Yunnan Province was investigated. The results showed that the abundance of microplastic ranged from 50.000 to 3450.0 items·kg^-1, with an average abundance of 595.00 ± 740.00 items·kg^-1 and a median of 375.00 items·kg^-1. Microplastics were found to primarily be green-coloured (28.4 %), fragment (72.7 %) in shape, <1 mm (75.7 %) in size, and composed of polypropylene (51.4 %). There were significant differences in the abundance and characteristics of the microplastics between different land use types. Microplastic abundance in facility farmlands, traditional farmlands, and orchard lands was significantly higher than that of grasslands and woodlands (p < 0.05). The main shape of the microplastics in facility farmlands, traditional farmlands, and orchards was fragments and it was fibers in grasslands and woodlands. The median particle size of microplastics in facility farmlands (539.50 μm) and traditional farmlands (574.00 μm), was smaller than those in the orchard (737.60 μm), grasslands (697.60 μm), and woodlands (1239.4 μm). Discrepancies among different land uses may be due to various reasons, such as different pollution sources and the weathering degree of microplastics. The results of the redundancy analysis showed that the microplastic abundance was negatively correlated with the largest patch index. It also showed that microplastic pollution was closely related to human activities. This study provides an important basis for further research on microplastic ecosystem risks that are associated with land use and provides a data basis for formulating effective prevention and control strategies and measures to mitigate soil microplastic pollution.

Intracoronary Imaging in left main stent percutaneous coronary intervention has a clear survival benefit particularly in more complex patients

Background

Left Main Stem Disease (LMS) is prognostically important coronary artery disease that is managed either with coronary artery bypass surgery (CABG) or percutaneous coronary intervention (PCI). Use of intracoronary imaging (ICI) modalities such as intravascular ultrasound (IVUS) and optical coherence tomography (OCT) have been shown to improve outcomes with PCI revascularization.

The primary objective of this study was to evaluate the impact of ICI on outcomes following LMS PCI.

Methods

Retrospective observation study of 498 (5.1% of all PCI cases) patients who had undergone LMS PCI at our tertiary primary PCI centre hospital over a 11-year period between July 2010-July 2021. Data was collected from electronic medical records. Follow-up was also obtained through linkage with the Office of National Statistics.

Results

The mean age at the time of enrolment was 70.7±11.5 years. Majority of the patients were male 351 (70.5%). 353 (70.9%) of cases had acute coronary syndrome (ACS) presentation while the remainder were elective procedures. Mean follow-up duration was 3.75±3.06 years. Survival calculated by Kaplan-Meier was 70%. 87 patients (17.5%) deceased during first year of enrolment. 344 (69.1%) patients had ICI, with IVUS in 316 (63.5%) and OCT in 28 (5.6%) patients. IVUS comprised 91.9% of ICI procedures. Protected LMS (OR 0.175, 95% CI: 0.037–0.833, P-value=0.029) and the use of left ventricular mechanical support device (OR 0.324, 95% CI: 0.122–0.859, P-value=0.024) were associated with decreased odds of undergoing an ICI.

Patients undergoing ICI had significantly better survival compared to those without ICI (HR: 0.54, P&lt;0.001). Moreover, OCT showed significantly better survival compared with IVUS (HR: 0.181, P=0.017). Use of ICI was associated with better survival in patients who had Rotablation (HR: 0.455, 95% CI: 0.232–0.892, P=0.022), ACS (HR: 0.523, 95% CI: 0.383–0.714, P&lt;0.001) or comorbidities of diabetes and stroke (HR: 0.551, 95% CI: 0.337–0.807, P=0.002).

Conclusion

ICI in LMS PCI has a significant survival benefit in our dataset. This is especially the case in patients presenting with ACS, those with comorbidities of Diabetes mellitus and stroke and those undergoing rotablation.

Funding Acknowledgement

Type of funding sources: None.

The 11-year outcome of PCI for treatment of left main stem disease

Background

Left Main Stem Disease (LMS) has historically been treated with coronary artery bypass surgery (CABG). However, not all patents with LMS are candidates for CABG due to co-morbidities. There is limited long-term follow-up of patients undergoing PCI in the real world. The primary objective of this study was to investigate the long-term mortality following LMS PCI.

Methods

We conducted a retrospective study of patients who had undergone PCI for LMS disease at our hospital over a 11-year period between July 2010-July 2021. Data was collected from electronic medical records and analyzed using Kaplain-Meier survival analysis. Follow-up was obtained through linkage with the Office of National Statistics.

Results

498 patients underwent LMS PCI (5.1% of the total PCI cases). The overall survival rate was 70%. Median survival following PCI was 1,196 days (IQR = 1,796). The mean age of the patients was 70.7 years; 70.5% were males. 70.9% of patients underwent PCI for Acute Coronary Syndrome (ACS), and 15.3% had STEMI. 33.7% of patients had a history of diabetes, 8% had stroke, 8.2% had COPD, and 8.8% had PVD. 51 patients went into cardiogenic shock, and 25 died prior to discharge.

Survival of the ACS group was significantly lower than the stable group (67% vs 77%, p&lt;0.01); the STEMI group did not significantly differ from rest of the ACS group (62% vs 66%, p=0.87). Survival in those &lt;60 years of age was significantly higher than in those &gt;60 years (80% vs 68%; p&lt;0.01). The presence of one or more co-morbidities was associated with higher survival compared to zero co-morbidities (74% vs 65%, p&lt;0.01). Patients with a history of diabetes had a significantly lower survival rate than those without diabetes (63% vs 73%, p&lt;0.01). Patients with an LV ejection fraction ≤35% had a significantly lower survival than those with an ejection fraction &gt;35% (22% vs 29%, p&lt;0.01); only 259 patients had data on LV function. Patients who developed cardiogenic shock had a significantly lower survival rate than those who did not develop shock (38% vs 70%; p&lt;0.01). When these patients were excluded from the data set, the overall survival rate increased from 70% to 74%. Lastly, a multinomial analysis showed that the only independent predictors of mortality were age (p&lt;0.01) and cardiogenic shock (p&lt;0.01).

Conclusion

Our results show that the real world 10-year mortality rate following LMS PCI is influenced by multiple factors including age, shock, and LV function. The high mortality rate was potentially due to the significant number of acute cases (70.1%) in non-operable patients. While factors such as age and past medical history are considered in the decision-making process regarding CABG vs PCI, we saw that specific subgroups within these factors may have decreased the effectiveness of PCI as a treatment for LMS disease, suggesting that deeper analysis into these risk factors is required when deciding between CABG and PCI for LMS disease management.

Funding Acknowledgement

Type of funding sources: None.

First report of perfluoroalkyl acids (PFAAs) in the Indus Drainage System: Occurrence, source and environmental risk

Perfluoroalkyl acids (PFAAs) are of global interest due to their persistence in the aquatic environment. This study assessed the occurrence of PFAAs in the Indus Drainage System and discerned their potential sources and environmental risks for the first time in Pakistan. 13 perfluoroalkyl carboxylic acids (PFCAs) and 4 perfluoroalkyl sulfonates (PFSAs) were analyzed to verify the dominant prevalence of short-chain PFAAs in the environment since the phase-out of long-chain perfluorooctanoic acid (PFOA) and perfluorooctane sulfonate (PFOS). A significant variation (p ≤ 0.05) of individual PFAAs between the monitoring sites was confirmed by data normality tests Kolmogorov-Smirnov and Shapiro-Wilk, suggesting that different locations contribute differently to individual PFAAs concentrations. ΣPFAAs concentrations in riverine water and sediments ranged from 2.28 to 221.75 ng/L and 0.78-29.19 ng/g dw, respectively. PFBA, PFPeA, and PFHxA were the most abundant PFAAs, and on average accounted for 14.64, 13.75, and 12.97 ng/L of ∑PFAAs in riverine water and 0.34, 0.64, and 0.79 ng/g dw of ∑PFAAs in sediments. ΣPFAAs mean contamination in the drainage was significantly (p < 0.05) high in River Chenab followed by River Indus > Soan > Ravi > Kabul > Swat with more prevalence of short-chain (C4-C7) PFCAs followed by PFOA, PFBS, PFOS, PFNA, PFDA, PFHxS, PFUnDA, and PFDoDA. The correlation analysis determined the PFAAs' fate and distribution along the drainage, indicating that PFAAs with carbon chains C4-C12, except for PFSAs with carbon chains C6-C8, were most likely contaminated by the same source, the values of Kd and Koc increased linearly with the length of the perfluoroalkyl carbon chain, better understand the transport and partitioning of individual PFAAs between riverine water and sediments, where the HCA and PCA discerned industrial/municipal wastewater discharge, agricultural and surface runoff from nearby fields, and urban localities as potential sources of PFAAs contamination. The collective mass flux of short-chain (C4-C7) PFCAs was 5x higher than that of PFOS + PFOA, suggesting a continuous shift in the production and usage of fluorinated replacements for long-chain PFAAs with short-chain homologs. In terms of risk, individual PFAAs pollution in the drainage was within the world's risk thresholds for human health, with the exception of PFBA, PFPeA, PFHpA, PFHxA, PFOA, PFNA, and PFBS, whereas for ecology, the concentrations of individual PFAAs did not exceed the ecological risk thresholds of the United States of America, Canada, European Union (EU), Italy, Australia, and New Zealand, with the exception of PFSAs, whose detected individual concentrations were significantly higher than the EU, Australian and New Zealander PFSAs guidelines of 0.002 μg/L, 0.00047 μg/L, 0.00065 μg/L, 0.00013 μg/L, and 0.00023 μg/L, respectively, which may pose chronic risks to the regional ecosystem and population.

Heavy metal pollution in the soil of a riverine basin: distribution, source, and potential hazards

Soil pollution with heavy metals (HMs) has become a world environmental problem. This study focuses on surface soil contamination with Cr, Mn, Co, Ni, Cu, Zn, Cd, Hg, Pb, Fe, and Al, their sources, and potential hazards along the basin of River Swat, Pakistan. The average concentrations (mg/kg) of HMs were the most abundant for Al (24,730.19) followed by Fe (22,419.41) > Mn (386.78) > Zn (57.75) > Cr (38.07) > Ni (32.46) > Cu (23.43) > Pb (19.59) > Co (10.77) > Cd (3.18) > Hg (0.12). The concentrations of Cr and Mn in 5.45% each, Co in 10.90%, Zn in 27.27%, Cu in 36.36%, Ni in 41.81%, and Hg in 92.72% of the total soil samples exceeded their respective background values. The geostatistical approaches determined the distribution patterns of HM pollution along the basin, whereas the statistics of principal component analysis exposed the likely sources of HM contamination in the area. Pollution indices evaluated the overall HM distribution and pollution status in the area. Contamination factor showed a high degree of HM contamination in 82% of the total sampling sites, while the geo-accumulation index designated low to moderate contamination with Cr, Mn, Co, Ni, Cu, Zn, Hg, and Pb, and moderate to extreme contamination with Cd, Fe, and Al. The trend of ecological toxicity showed potential ups and downs along with the sites from low to considerable hazard (< 95 < PEHI < 190), whereas the human carcinogenic hazard was within the USEPA acceptable limits (1 × 10^-7-1 × 10^-4), but the non-carcinogenic hazard was higher than the threshold (HI > 1) for children because they are more exposed than adults.

System resilience and neighbourhood action on social determinants of health inequalities: an English Case Study

AIMS

This article seeks to make the case for a new approach to understanding and nurturing resilience as a foundation for effective place-based co-produced local action on social and health inequalities.

METHODS

A narrative review of literature on community resilience from a public health perspective was conducted and a new concept of neighbourhood system resilience was developed. This then shaped the development of a practical programme of action research implemented in nine socio-economically disadvantaged neighbourhoods in North West England between 2014 and 2019. This Neighbourhood Resilience Programme (NRP) was evaluated using a mixed-method design comprising: (1) a longitudinal household survey, conducted in each of the Neighbourhoods For Learning (NFLs) and in nine comparator areas in two waves (2015/2016 and 2018/2019) and completed in each phase by approximately 3000 households; (2) reflexive journals kept by the academic team; and (3) semi-structured interviews on perceptions about the impacts of the programme with 41 participants in 2019.

RESULTS

A difference-in-difference analysis of household survey data showed a statistically significant increase of 7.5% (95% confidence interval (CI), 1.6 to 13.5) in the percentage of residents reporting that they felt able to influence local decision-making in the NFLs relative to the residents in comparator areas, but no effect attributable to the NRP in other evaluative measures. The analysis of participant interviews identified beneficial impacts of the NRP in five resilience domains: social connectivity, cultural coherence, local decision-making, economic activity, and the local environment.

CONCLUSION

Our findings support the need for a shift away from interventions that seek solely to enhance the resilience of lay communities to interventions that recognise resilience as a whole systems phenomenon. Systemic approaches to resilience can provide the underpinning foundation for effective co-produced local action on social and health inequalities, but they require intensive relational work by all participating system players.

A preliminary study of patient-specific differences in induced pluripotent stem cell-derived cardiomyocytes following hypoxia-induced injury

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): Courtois Cardiovascular Signature Program

The increasing rate of cardiovascular disease (CVD) contributes to a worsening morbidity in the general population and a socioeconomic burden on the healthcare system. Newly approved therapies present unforeseen side effects and occasionally entail adverse cardiovascular responses in patients - this issue significantly stalls efficacious pharmacological development. Indeed, modern cardiovascular treatments do not account for the variability of individual patient reactions, due to a lack of a representative in vitro cardiac model. While the use of induced pluripotent stem cell-derived cardiomyocytes (iPSC-CMs) has gained traction as a superior model for drug screening when compared to cardiac biopsies and immortalized cell lines, cardiovascular patient-specific differences remain poorly understood and understudied.

We hypothesized that 1) cardiomyopathic patient-derived iPSC-CMs have differing baselines of beating rate, contractility, viability, metabolic activity and protein expression, when compared to healthy controls, and that 2) cell lines have patient-specific responses to hypoxia-induced injury. As such, the purpose of this preliminary study was two-fold: 1) to perform a characterization of patient iPSC-CM function, and 2) to study patient-specific cellular responses to hypoxia.

First, we generated iPSC-CMs from the peripheral blood of donors (n=6 patients with cardiomyopathies, n=2 healthy donors). We then confirmed the expression of prominent cardiac markers connexin 43 (CXN43), sarcoendoplasmic reticulum Ca2+ ATPase (SERCA2a), GATA4 and cardiac Troponin T, as well as a lack of pluripotency markers Octamer-binding transcription factor 4 (OCT4), Nanog, Stage-specific embryonic antigen-4 (SSEA-4) and TRA-1-60 in the iPSC-CM lines, via immunocytochemistry. Preliminary assessment of iPSC-CMs (days 1-30 post-differentiation) revealed significant baseline differences in beating rate (p&lt;0.01) and contractility amplitude (p&lt;0.01) between iPSC-CMs derived from cardiomyopathic patients and healthy donors.

We then subjected iPSC-CM lines to hypoxic conditions (24 hours), to mimic ischaemic injury. Diseased patient-derived lines had significantly decreased viability and metabolic activity when compared to the controls, under normoxic (p&lt;0.01) and hypoxic conditions (p&lt;0.001). Immunoblotting revealed differential expression of cardiac markers and factors implicated in cardiac function, cardioprotection and pathology. Taken together, these results suggest that the detected differences at the cellular level after hypoxia-induced injury might be translatable to the inter-individual variability currently observed in the CVD patient population. The data gathered will prove to be instrumental in future studies of iPSC-CM responses to treatment. With this preliminary study, we hope to shift the focus towards these patient-specific differences at the cellular level, in the search for tailored therapies and a higher standard of care for CVD patients.

207 An Assessment of Outcome in Patients with Anaemia (Iron Deficient and Non-Iron Deficient) Who Have Colon Cancer - Effect of Treatment with Oral/ IV Iron

Aim

Treatment of iron deficiency anaemia in patients undergoing colon cancer resection improves outcome defined by length of stay, recurrence, and requirement for blood transfusions.

Method

Retrospective analysis of patients with anaemia and colonic cancer between January 2018 - August 2019. Anaemia categorised as – Iron Deficiency Anaemia and non- Iron Deficiency anaemia. IDA was defined as hypochromic microcytic anaemia. Patient demographics, tumour location, pre- and post-operative haemoglobin, length of stay, recurrence and requirement for blood transfusions were collected plus treatment for anaemia. Comparisons made between IDA and non-IDA groups in relation to treatment for anaemia with iron (oral/IV). Non-parametric statistical tests used (median, 2-way ANOVA, Kruskal-Wallis) with significance at P &lt;0.05.

Results

150 patients with colonic cancer identified: 77 in IDA group, 46 treated (42 oral, 4 iv iron). 11 in non- IDA group, 8 treated (oral iron).

IDA oral and IV treatment versus non-IDA:

Median age 74, 80 and 78 years (P = 0.814),

Pre- and post op Hb IDA vs non-IDA: 107, 97; 109, 101 (P 0.007 significant),

Requirement for blood transfusion (units) 0.77, 0.50;0.90 (P 0.596)

Length of Stay (days) 6, 5; 7 (P 0.113),

Tumour location: mean of right colon and transverse colon 24.33, 3.667 (P &gt;0.1), and

Recurrence P &gt;0.1.

Conclusions

In our series, iron treatment does not influence recurrence, length of stay, requirement for blood transfusions. Tumour location is not significantly different between IDA and non-IDA group. Patients treated with oral iron therapy are seen to have a larger drop in haemoglobin post operatively than the other groups.

Heavy metals contamination, potential pathways and risks along the Indus Drainage System of Pakistan

Riverine water exposed to heavy metals (HMs) pollution is a major concern in the world because of its serious effects on ecosystem and human health. This study assessed the pollution status, sources, diffusion and potential risks of Mn, Co, Cu, Zn, Cr, Ni, Cd, Hg and Pb for the first time along the entire Indus Drainage System of Pakistan. The concentrations of nine HMs in the riverine water ranged from 5.05-101.59 μg/L with a mean value of 41.51 μg/L. The overall metals quantification along the drainage was significantly high (27% of the total) in River Chenab followed by River Indus (26%) > Soan (20%) > Ravi (19%) > Kabul (5%) > Swat (3%). The potential sources of contamination were identified to be the surrounding geogenic activities, industrial/municipal wastewater discharges, agricultural and surface runoffs by using multivariate statistics including metals correlation analysis, hierarchical cluster analysis and principal component analysis. The average mass flux of ∑HMs in the entire drainage was approximately 10.24 tons/year, to which the River Indus contributed 84% of the total, Chenab 11%, Ravi 3%, Kabul 1%, and Soan 1% with more prevalence of biological essential (Zn&Mn) and non-essential (Ni&Cr) metals. In terms of ecological risk, the riverine water metals contamination (1.59 to 57.06) was within the risk threshold (ERI < 110), while the risks of ∑carcinogenic metals for exposed children and adults along the basin were significantly influenced between acceptable to high cancer risk by Cd, Co, Ni, Cr and Pb.

OUP accepted manuscript

Current methods for tuberculosis treatment monitoring are suboptimal. We evaluated plasma matrix metalloproteinase (MMP) and procollagen III N-terminal propeptide concentrations before and during tuberculosis treatment as biomarkers. Plasma MMP-1, MMP-8, and MMP-10 concentrations significantly decreased during treatment. Plasma MMP-8 was increased in sputum Mycobacterium tuberculosis culture–positive relative to culture-negative participants, before (median, 4993 pg/mL [interquartile range, 2542–9188] vs 698 [218–4060] pg/mL, respectively; P = .004) and after (3650 [1214–3888] vs 720 [551–1321] pg/mL; P = .008) 6 months of tuberculosis treatment. Consequently, plasma MMP-8 is a potential biomarker to enhance tuberculosis treatment monitoring and screen for possible culture positivity.

What data is currently collected on social prescribing outcomes?Case studies of two sites in England

Whilst a considerable amount of social prescribing activity is taking place across the North West of England, little is known about how different models are being implemented, how data is being collected to support evidence of impact and outcomes, and how these models could be positively or negatively influencing health inequalities. Our study aims to investigate the reach and impact of two social prescribing services by using a mixed-methods approach which will include analysing secondary data from social prescribing management databases held by participating organisations, workshops, focus groups and interviews. Participants will include professionals involved in commissioning, delivery and monitoring and evaluation roles related to social prescribing link workers and members of the public who have accessed social prescribing services. Observational data will also be collected during meetings and informal conversations with those involved in the project. The findings will be reviewed with participants to support the development of a larger research project to explore the effects of social prescribing on health inequalities in ways that are meaningful to stakeholders. In this presentation the findings will be presented and discussed loosely around the following questions: 1. What routinely collected outcome data is currently available to social prescribing researchers (locally, nationally and internationally)?; 2.What is missing from that data regarding meaningful outcomes in relation to health inequalities?; 3. How might social prescribing reduce or exacerbate health inequalities?

Statin induced myalgia on high intensity statin in patients with Acute Coronary Syndrome

Background

High intensity statins are recommended in patients with acute coronary syndrome. Statins inhibit atherosclerotic plaque formation in the coronary arteries and reducing the burden of ischemic heart disease, therefore decreasing the morbidity and mortality. Muscle symptoms are most common adverse effect of statins. Hence, the aim of this study is to determine the statin induced myalgia by the statin myalgia clinical score.

Purpose

To monitor the Statin induced myalgia on high intensity statin in patients with Acute Coronary Syndrome

Methods

This was an prospective observational study comprised of 418 patients with acute coronary syndrome who were commenced on high intensity statins (Rosuvastatin 20–40mg & Atorvastatin 40–80). These patients were followed at 4 weeks, 8 weeks and 12 weeks subsequently and the clinical myalgia score (SAMS-CI) was calculated at each visit to determine the statin induced myalgia. SAMS-CI was categorized as unlikely (2–6), possible (7–8) and probable (9–11)

Results

From 418 patients, 327 were males and 91 were females. Mean age was 55.6±11.14. Only 19 (7.63±1.8) patients developed muscle symptoms on high intensity statins (Rosuvastatin 20 mg and Atorvastatin 40 mg) on SAMS-CI Score. 5 patients were unlikely to develop myalgia on SAMS-CI and continued with the same dosage without any new symptoms. 6 patients were possible on SAMS-CI, therefore the dosage of these patients were decreased to moderate intensity statin (Rosuvastatin 10mg, Atorvastatin 20 mg), their symptoms were resolved and continued with the moderate intensity statins. Furthermore, Statin was hold in 8 patients in the probable category for 4 weeks until the resolution of symptoms followed by moderate intensity statins.

Conclusion

Statin induced myalgia is more reported in old aged and female patients. Most of the patients can better tolerate the lower range of high intensity statins with the similar benefits and should be prescribed in every patient

Funding Acknowledgement

Type of funding sources: None.

An evaluation of patient outcomes following transcatheter pulmonary valve implantation: a meta-analysis

Background

Transcatheter pulmonary valve implantation has emerged as an effective alternative to surgery in patients with congenital Right Ventricular Outflow Tract Dysfunction (RVOT). There is demonstrable evidence that Percutaneous Pulmonary Valve Implantation (PPVI) effectively restores conduit graft viability with a consequent improvement in right ventricular pressures.

Aim

The objective of this study was to perform a meta-analysis of all previously published studies examining the outcome of PPVI and the associated early and late peri-procedural factors in patients with RVOT dysfunction. Data from procedures performed within our own centre have also been included.

Methodology

We performed a meta-analysis of all observational studies investigating early and late outcomes following PPVI. Risk ratios and risk differences were pooled in a random-effects model. The I2 statistic was used to quantify heterogeneity between studies. We searched EMBASE, MEDLINE, CINAHL, PsychInfo and Cochrane databases from their inception until 2021. Studies were included if they reported any comparative data regarding study endpoints. Primary endpoint was mean RVOT gradient. Secondary end points include pulmonary regurgitation fraction, left and right ventricular end-diastolic and systolic volume indexes, and left ventricular ejection fraction. Complication rates were considered a safety endpoint.

Results

A total of 23 studies with 1501 participants enrolled were included in the final meta-analysis. The RVOT gradient decreased significantly [weighted mean difference (WMD) = −20.32 mmHg; 95% confidence interval (CI): −22.15, −19.11; p&lt;0.001]. Mean right ventricular (RV) systolic pressures fell significantly [(WMD)= −18.4 mmHg; 95% CI: −16.4, −20.2; p&lt;0.001) and RV diastolic pressures decreased significantly [(WMD) = −6.3 mmHg, 95% CI: −4.3, −8.9; p&lt;0.001). Pulmonary regurgitation fraction (PRF) also decreased notably (WMD = −24.38%, 95% CI: −28.27, −17.32; p&lt;0.001).The incidence of infective endocarditis was 1.8% (95% CI: 0.7–3.8).

Conclusion

PPVI is an effective and safe strategy in relieving right ventricular remodelling and improving haemodynamic and clinical outcomes in patients with RVOT dysfunction. Multi-centre collaborations are essential to further determine the long-term effects of PPVI on cardiac function, exercise tolerance and quality of life in RVOT dysfunction.

Funding Acknowledgement

Type of funding sources: None.

1133 Long Term Survival After Standard EVAR: Have We Started to Treat The EVAR-2 Patient?

Aim

Abdominal aortic aneurysm repair was traditionally preformed with open surgical repair (OSR). Recently endovascular aneurysm repair (EVAR) has increased in popularity due to its less invasive nature particularly in those deemed unfit for OSR. The EVAR-2 trial found no significant difference between BMT and EVAR in the 30 days all-cause mortality. This questioned whether EVAR was the best option in those medically unfit for OSR.

Method

Elective EVAR procedures from the 1st April 2012 to 1st September 2017 were analysed with Kaplan-Meier graphs. The patient data was stratified by year, age group and EVAR risk scoring.

Results

The all-cause mortality at 30 days was 1.8%, at 6 months it was 7%, and at 4 years it was 19.8%. There was no significant difference with log rank analysis of the year of EVAR operation and consultant (P &gt; 0.05). The log rank analysis found a significant difference between the stratified age groups (P &lt; 0.001) and the EVAR scoring (P = 0.032). At all time-points the RLUH EVAR patients had a lower all-cause mortality compared to the EVAR-2. At the 4-year time point, the RLUH EVAR group had lower all- cause mortality than both EVAR-1 and EVAR-2 trials.

Conclusions

The retrospective audit data from 2012-2017, suggest the RLUH EVAR treatment practice is not falling into the EVAR-2 trial findings. At all time-points the RLUH EVAR patients had a lower all-cause mortality compared to the EVAR-2. Therefore, it can be concluded the RLUH is not treating EVAR-2 patients.

1034 A Survey to Assess the Confidence and Knowledge of Foundation Year One Doctors to Perform A Digital Rectal Examination

Aim

Digital Rectal Examination (DRE) is an essential component of comprehensive assessment of a surgical patient, both in acute and elective settings. Due to the intimate nature of the examination, this important examination is often not well taught. This study aims to assess the confidence and knowledge of the Foundation Year 1 (FY1) doctors in performing DRE.

Method

FY1 doctors were invited for online voluntary anonymous survey via Google forms. The survey consisted of 16 questions on the indications, findings, and interpretation of DRE. The purpose and aims of the study were explained in an invitation email and participants provided a declaration of consent, giving permission for their anonymous results to be used in the study.

Results

There were 24 responses, 79% had performed DRE (including on mannequins and simulations) less than 10 times. Two thirds of DRE were performed during the FY1 rotation and two thirds in the elective wards. Majority of respondents (83%) were moderately confident in performing and appreciating DRE findings. 63% respondents though that a chaperone is not mandatory if the gender of the doctor and patient was same. 58% respondents thought that hematuria is not an indication to preform DRE. Interpretation of DRE findings - approximately 80% respondents correctly interpreted the findings, however only 45% could formulate the correct initial management plan.

Conclusions

This study illustrates that FY1 doctors receive inadequate exposure to performing and interpreting DRE. Their teaching should be enhanced by providing them with more opportunities through simulation and dedicated teaching sessions.

964 Stage Migration in Newly Diagnosed Oesophago-Gastric Cancer During the First Wave Of COVID-19 Pandemic

Aim

Covid-19 has significantly disrupted elective and emergency health care provision including cancer care within the UK. The aim of the study was to investigate the impact of the pandemic on the staging of oesophago-gastric cancers at presentation, determine the time delay in performing gastroscopy and the multidisciplinary team (MDT) treatment outcomes.

Method

A retrospective cohort study of all newly diagnosed oesophago-gastric cancers (adenocarcinoma and squamous cell carcinoma) in a single regional MDT was performed between 1st October 2019 and 30th September 2020. Electronic records were interrogated and patients dichotomised into two groups with those presenting before the introduction of the UK national lockdown of 23rd March 2020 compared to those presenting post-lockdown.

Results

349 new oesophago-gastric cancer patients were discussed in the MDT (192 pre-lockdown versus 157 post-lockdown). Demographics were evenly matched between the two groups. More patients presented as an emergency admission post-lockdown (28.0% vs 12.5%, p &lt; 0.001). Median waiting time for gastroscopy was longer post-lockdown (23 vs 14 days, p = 0.035). Metastatic disease at presentation was more frequent post-lockdown (47.8% vs 33.3%, p = 0.008). Overall, more patients had a palliative rather than curative treatment intent post-lockdown (71.3% vs 57.8%, p = 0.005).

Conclusions

The Covid-19 pandemic has had a significant negative effect on the stage of oesophago-gastric cancers at presentation. This has translated into more patients receiving palliative treatment and ultimately having a poorer prognosis. This study highlights the importance of maintaining cancer services during Covid-19 pandemic.

1120 Clinical Applications of Local Field Potentials in Deep Brain Stimulation

Aim

Local field potentials (LFP) are gathered when deep brain stimulation (DBS) electrodes are inserted into subcortical structures; however, the clinical application of these findings are unclear.

Method

A literature search was conducted using PRISMA guidelines, 231 papers were analysed for the literature review.

Results

The lack of dopamine in Parkinson’s disease (PD), is thought to increase the sensitivity of the basal ganglia-thalamo-cortical network to rhythmic oscillatory inputs causing pathological oscillations. Beta band frequency oscillations have been strongly linked to bradykinesia and rigidity in Parkinson’s disease patients. Whereas gamma oscillations were found to be prokinetic and possibly related to normal physiology. There has been varying views on LFP findings and tremor pathology, recent research has suggested a link between the ratio of slow and fast oscillations increasing resulting in a tremor. Studies found contradicting results with pathological oscillations, reasons for the variation include the time of the LFP recordings and the placement of the electrodes. The use of LFP presents a promising new technology namely adaptive deep brain stimulation (aDBS). aDBS has not been tested long-term in human patients, the safety and effectiveness long-term is unknown.

Conclusions

aDBS provide an exciting new technology however, the current evidence base provides a proof-of- principle, there are still many issues which need to be addressed before this can become an established treatment. With technological advances aDBS could revolutionise PD treatment and if perfected could potentially abolish patient’s symptoms completely.

973 Why Are Curative Treatment Rates So Low for Stage I/II Oesophago-Gastric Cancer in The West of Scotland?

Aim

Over the last decade, quality performance indicators (QPIs) have been used to drive improvements in cancer care in Scotland. QPI-11 targets curative treatment rates for oesophago-gastric (OG) cancer and this target has been consistently missed. This study aimed to investigate why patients with potentially curable Stage I and II OG cancer did not receive curative treatment in the West of Scotland.

Method

The West of Scotland MCN database was interrogated for patients with newly diagnosed stage I and II OG cancer between January 2018 and December 2019 to identify those patients who did not have curative treatment. Electronic records were then analysed.

Results

81 patients (mean age of 79.3 ± 8.9 years; 41 (50.6%) female) were identified. Median Scottish Index of Multiple Deprivation was 3 (IQR 1-7). There were 46 (56.8%) oesophageal cancers, 49 (60.5%) adenocarcinomas and 63 (77.8%) were Stage II cancers. Formal CPEX fitness was assessed in only 6 patients (7.4%). Reasons for curative treatment not being received were as follows: not clinically fit (n = 69 (85.2%)); patient declined curative treatment (n = 7 (8.6%)); disease progression (n = 3 (3.7%)) and identification of synchronous cancers (n = 2 (2.5%)). 61 patients (75.3%) are deceased at the time of analysis, with a median time from MDT discussion to death of 6 (IQR 2-11.5) months.

Conclusions

Lack of fitness for radical treatment is the predominant reason for Stage I and II OG cancer patients in the West of Scotland not being treated with curative intent. This may be related to the previously described “West of Scotland” effect on health comorbidities.

377 Expanding the Use of Wide-Awake Local Anaesthesia Non-Tourniquet (WALANT) Technique in The Management of Hand Trauma Patients During the COVID 19 Pandemic

Aim

COVID19 produced a unique challenge to the management of hand trauma. There was reduced theatre capacity and inpatient beds as staff and resources were lost to make way for the critically unwell¹, however the burden of patients (albeit reduced) requiring emergency procedures remained². During 1^stUK peak we adopted a one-stop hand trauma clinic where patients were assessed by senior surgeons and immediately operated on under local anaesthesia with Adrenalin, a model mirrored by other units across the UK during this time^3,4. Subsequent to surgery they were either seen on the same day for advice with a hand therapist or booked for immediate hand therapy follow up.

Method

A retrospective review of 158 cases operated on over a 4-month COVID19 period compared to the same 4-month period 1 year previously. Indications for surgery and type of anaesthesia were recorded. Follow up and complication rates were reviewed for the COVID19 patients.

Results

There were similarities in the demographic of patients across both cohorts and in mechanism of injury, with trauma the highest indication for surgery. The comparable data sets showed only 21% of patients treated used WALANT pre-COVID19 versus 100% of patient during COVID19.

Conclusions

WALANT is a viable model by which to perform emergency hand trauma surgery in a low cost and low resource setting. Previously this model was not utilised to full effect in our hospital. The results demonstrate the adaptability of WALANT in an adverse and dynamic situation, such as COVID19, thus highlighting benefits to patient care and service provision.

1385 “Pre-Op Fasting Times Audit in Colorectal Surgery at A University Teaching Hospital”

Aim

Hull University teaching hospitals NHS trust has guidelines for patient fasting times prior to major elective surgery. We aimed to assess the compliance of pre-op fasting times for patients undergoing elective colorectal surgery.

Method

An initial and later re-audit was undertaken, prospectively, of 20 consecutive patients admitted for elective colorectal surgery at Castle Hill Hospital. Data was collected on a structured proforma and was completed following patient’s interview, ORMIS (operation room system) and Lorenzo (hospital intranet).

Results

Initial audit demonstrated 10% (2 out of 20) and 5% (1 out of 20) compliance with liquid and solid fasting times, respectively. Following implementation of changes, re-audit demonstrated 60% (12 out of 20) and 0% (0 out of 20) compliance with liquid and solid fasting times respectively

Conclusions

We concluded that liquid fasting times can be improved further by communication between theatre staff and ward. Whilst solid fasting times can be improved but at an expense of losing a theatre space. A further re-audit [planned in a month period.

1282 Evaluation of the Basket in Catheter Technique for Transcystic Bile Duct Exploration and Suspected Ductal Stones

Aim

The ‘Basket-in-catheter’ (BIC) technique facilitates laparoscopic transcystic ductal exploration (LTCE) and increases its success rate, being easier and safer than inserting the basket alone. This study evaluates the benefits in confirmed and suspected ductal stones.

Method

Prospective preoperative, operative and postoperative data on consecutive single session ductal explorations was collected over 28 years and analysed. BIC became our default technique for the transcystic approach to confirmed or suspected bile duct stones.

Results

741 of 1225 (60.5%) attempted LTCE were performed using retrieval baskets without dilating the cystic duct (CD). BIC was used in 646 (87.2%). Of 386 (52.1%) patients undergoing successful stone retrieval 62.7% had clinical and radiological risk factors for ductal stones and 92.0% had positive intraoperative cholangiography. 355 (47.9%) patients had preoperative or operative risk factors for CBD stones and equivocal cholangiography in 25%. Basket trawling was negative and repeat cholangiography confirmed resolution of abnormalities. Choledochoscopy was utilised in 484/1225 (39.5%), either primarily or when blind trawling failed to extract stones. Retained stones occurred in 7 patients, six requiring ERCP. Bile leakage occurred in 6 patients. There were two open conversions, no biliary injuries and no mortality. Post-operative pancreatitis occurred in 7 and recurrent stones in 8 patients.

Conclusions

The BIC technique achieves successful LTCE without CD dilatation in 40%, reducing the need for choledochoscopy and choledochotomy. It facilitates safe and speedy CBD trawling when stones are suspected due to preoperative or operative risk factors or equivocal cholangiography and helps surgeons acquire and consolidate ductal exploration skills.

982 Higher General Surgical Trainee preferences for Annual Review of Competency Progression during COVID-19 Pandemic

Aim

The COVID-19 pandemic has caused significant disruption in surgical training. We aim to explore the preferences of higher general surgical trainees for Annual Review of Competency Progression (ARCP) also compare the responses across different training grades.

Method

All higher general surgical trainee in a single deanery were invited to participate in an online voluntary anonymous survey. The respondents were divided in two groups: junior (ST3-ST5) and senior higher surgical trainees (ST6-ST8) and responses compared.

Results

Sixty-four of 88 trainees responded. Thirty-three (51.6%) were ST3–ST5, 24 (37.5%) were ST6–ST8 and 7 (10.9%) were out-of-training. More trainees in ST3–ST5 group preferred to defer the next rotation for 12 months (18.2% vs 0%, p = 0.034), repeat current sub-specialty (33.3% vs 4.2%, p = 0.009), or add 12 months to training and delay predicted CCT date by 12 months (18.2% vs 0%, p = 0.034). Most trainees in both groups preferred the option of prolonging training should be offered to all trainees with an option to decline extension if ARCP competencies met (66.7% vs 50.0%, p = 0.276).

Conclusions

The preference for ARCP and length of training was different between two training groups, hence the need of trainees should be considered by training committees when addressing the impact of COVID-19.

Sero-epidemiology and risk factor analysis of human brucellosis in Punjab, Pakistan: a cross sectional study

Human brucellosis is a neglected zoonotic problem worldwide with a high degree of morbidity in humans and is mostly overlooked due to other febrile conditions. The aim of this study was to evaluate the sero-prevalence and risk factors of human brucellosis among subjects living in Punjab, Pakistan. In this cross-sectional study, human blood samples were collected from seven districts of Punjab, Pakistan. Information regarding personal data, demographic data and potential risk factors was collected through a structured questionnaire. Detection of anti-Brucella antibodies was done through Rose Bengal Plate Test (RBPT) and Enzyme Linked Immunosorbent Assay (ELISA). Descriptive analysis, Chi square test and Odds ratio was applied using STATA software version 12. The sero-prevalence of human brucellosis was 13.13% with significantly higher percentage in males 17.23% and age group 25-40 years 16.50% (P=< 0.001). The demographic factors positively associated with human brucellosis were lack of education (P = 0.003; OR = 1.85) and farming as an occupation (P =<0.001; OR = 2.50) Similarly, among the risk factors studied, keeping animals at home (P =<0.001; OR = 2.03), slaughtering of animals (P =<0.001; OR = 15.87) and consuming raw milk (P =<0.001; OR = 5.42) were the factors strongly connected with human brucellosis. A massive awareness should be given to livestock farmers and individuals directly linked to animals regarding risk factors and transmission of brucellosis. Consumption of unpasteurized milk and its products should be condemned to curtail this neglected disease.

Antioxidant enzymes and association of CAT SNP-21 A/T (rs7943316) with male infertility

Infertility is a multifactorial and polygenic disease. A vast majority of infertility is still unexplained despite modern diagnostic techniques. Oxidative stress is considered a factor for male infertility but etiology in terms of functional gene polymorphism and experimental studies on human subjects is scarcely reported. The aim of the study was to investigate the status of three antioxidant enzymes; catalase, superoxide dismutase (SOD), and glutathione reduced (GSH) in clinically diagnosed infertile males and find the potential association of CAT gene variant in the promoter region -21 A/T (rs7943316). The study consisted of 55 clinically diagnosed infertile males and 50 non-infertile volunteers. The activity of antioxidant enzymes was measured through a spectrophotometer. Polymerase chain reaction-restriction fragment length polymorphism was performed for genotyping of single-nucleotide polymorphism. Catalase enzyme activity was significantly decreased while SOD and GSH were substantially increased (p ≤ 0.01) in infertile men in comparison to non-infertile. CAT gene variant rs7943316 had shown significant association in dominant, recessive model and allelic frequencies. The study concludes that rs7943316 has a substantial role in male infertility. The outcome of the study may help in resolving idiopathic infertility cases and may help in evolving novel diagnostic and therapeutic approaches. Other variants of CAT and antioxidant genes are suggested to ascertain further insight.