A preliminary investigation of epigenome-wide DNA methylation and temperament during infancy

This study provides preliminary evidence for an epigenetic architecture of infant temperament. At 12 months of age, blood was collected and assayed for DNA methylation and maternally reported infant temperament was assessed using the Infant Behavior Questionnaire in 67 mother-infant dyads. Epigenome-wide analyses showed that the higher order temperament dimensions Surgency and Negative Affect were associated with DNA methylation. The epigenetic signatures of Surgency and Negative Affect were situated at genes involved in synaptic signaling and plasticity. Although replication is required, these results are consistent with a biologically based model of temperament, create new avenues for hypothesis-driven research into epigenetic pathways that underlie individual differences in temperament, and demonstrate that infant temperament has a widespread epigenetic signature in the methylome.

Implementing psychological interventions delivered by respiratory professionals for people with COPD. A stakeholder interview study

Implementing psychological interventions in healthcare services requires an understanding of the organisational context. We conducted an interview study with UK National Health Service stakeholders to understand the barriers and facilitators for implementing psychological interventions for people with chronic obstructive pulmonary disorder (COPD). We used TANDEM as an exemplar intervention; a psychological intervention recently evaluated in a randomised controlled trial. Twenty participants providing care and/or services to people with COPD were purposively sampled from NHS primary/secondary care, and commissioning organisations. Participants were recruited via professional networks and referrals. Verbatim transcripts of semi-structured interviews were analysed using thematic analysis. Four themes were identified: (1) Living with COPD and emotional distress affects engagement with physical and psychological services; (2) Resource limitations affects service provision in COPD; (3) Provision of integrated care is important for patient well-being; and (4) Healthcare communication can be an enabler or a barrier to patient engagement. People need support with physical and psychological symptoms inherent with COPD and healthcare should be provided holistically. Respiratory healthcare professionals are considered able to provide psychologically informed approaches, but resources must be available for training, staff supervision and service integration. Communication between professionals is vital for clear understanding of an intervention's aims and content, to facilitate referrals and uptake. There was widespread commitment to integrating psychological and physical care, and support of respiratory healthcare professionals' role in delivering psychological interventions but significant barriers to implementation due to concerns around resources and cost efficiency. The current study informs future intervention development and implementation.

Multiple staging investigations may not change management in patients with high-grade dysplasia or early esophageal adenocarcinoma

The clinical value of multiple staging investigations for high-grade dysplasia or early adenocarcinoma of the esophagus is unclear. A single-center prospective cohort of patients treated for early esophageal cancer between 2000 and 2019 was analyzed. This coincided with a transition period from esophagectomy to endoscopic mucosal resection (EMR) as the treatment of choice. Patients were staged with computed tomography (CT), endoscopic ultrasound (EUS) and 2-deoxy-2-[18F]fluoro-d-glucose (FDG) positron emission tomography(PET)/CT. The aim of this study was to assess their accuracy and impact on clinical management. 297 patients with high-grade dysplasia or early adenocarcinoma were included (endoscopic therapy/EMR n = 184; esophagectomy n = 113 [of which a 'combined' group had surgery preceded by endoscopic therapy n = 23]). Staging accuracy was low (accurate staging EMR: CT 40.1%, EUS 29.6%, FDG-PET/CT 11.0%; Esophagectomy: CT 43.3%, EUS 59.7%, FDG-PET/CT 29.6%; Combined: CT 28.6%, EUS46.2%, FDG-PET/CT 30.0%). Staging inaccuracies across all groups that could have changed management by missing T2 disease were CT 12%, EUS 12% and FDG-PET/CT 1.6%. The sensitivity of all techniques for detecting nodal disease was low (CT 12.5%, EUS 12.5%, FDG-PET/CT0.0%). Overall, FDG-PET/CT and EUS changed decision-making in only 3.2% of patients with an early cancer on CT and low-risk histology. The accuracy of staging with EUS, CT and FDG-PET/CT in patients with high-grade dysplasia or early adenocarcinoma of the esophagus is low. EUS and FDG-PET/CT added relevant staging information over standard CT in very few cases, and therefore, these investigations should be used selectively. Factors predicting the need for esophagectomy are predominantly obtained from EMR histology rather than staging investigations.

Consensus Quality Measures and Dose Constraints for Lung Cancer From the Veterans Affairs Radiation Oncology Quality Surveillance Program and ASTRO Expert Panel

PURPOSE

For patients with lung cancer, it is critical to provide evidence-based radiation therapy to ensure high-quality care. The US Department of Veterans Affairs (VA) National Radiation Oncology Program partnered with the American Society for Radiation Oncology (ASTRO) as part of the VA Radiation Oncology Quality Surveillance to develop lung cancer quality metrics and assess quality of care as a pilot program in 2016. This article presents recently updated consensus quality measures and dose-volume histogram (DVH) constraints.

METHODS AND MATERIALS

A series of measures and performance standards were reviewed and developed by a Blue-Ribbon Panel of lung cancer experts in conjunction with ASTRO in 2022. As part of this initiative, quality, surveillance, and aspirational metrics were developed for (1) initial consultation and workup; (2) simulation, treatment planning, and treatment delivery; and (3) follow-up. The DVH metrics for target and organ-at-risk treatment planning dose constraints were also reviewed and defined.

RESULTS

Altogether, a total of 19 lung cancer quality metrics were developed. There were 121 DVH constraints developed for various fractionation regimens, including ultrahypofractionated (1, 3, 4, or 5 fractions), hypofractionated (10 and 15 fractionations), and conventional fractionation (30-35 fractions).

CONCLUSIONS

The devised measures will be implemented for quality surveillance for veterans both inside and outside of the VA system and will provide a resource for lung cancer-specific quality metrics. The recommended DVH constraints serve as a unique, comprehensive resource for evidence- and expert consensus-based constraints across multiple fractionation schemas.

Consensus Quality Measures and Dose Constraints for Prostate Cancer From the Veterans Affairs Radiation Oncology Quality Surveillance Program and American Society for Radiation Oncology Expert Panel

PURPOSE

There are no agreed upon measures to comprehensively determine the quality of radiation oncology (RO) care delivered for prostate cancer. Consequently, it is difficult to assess the implementation of scientific advances and adherence to best practices in routine clinical practice. To address this need, the US Department of Veterans Affairs (VA) National Radiation Oncology Program established the VA Radiation Oncology Quality Surveillance (VA ROQS) Program to develop clinical quality measures to assess the quality of RO care delivered to Veterans with cancer. This article reports the prostate cancer consensus measures.

METHODS AND MATERIALS

The VA ROQS Program contracted with the American Society for Radiation Oncology to commission a Blue Ribbon Panel of prostate cancer experts to develop a set of evidence-based measures and performance expectations. From February to June 2021, the panel developed quality, aspirational, and surveillance measures for (1) initial consultation and workup, (2) simulation, treatment planning, and delivery, and (3) follow-up. Dose-volume histogram (DVH) constraints to be used as quality measures for definitive and post-prostatectomy radiation therapy were selected. The panel also identified the optimal Common Terminology Criteria for Adverse Events, version 5.0 (CTCAE V5.0), toxicity terms to assess in follow-up.

RESULTS

Eighteen prostate-specific measures were developed (13 quality, 2 aspirational, and 3 surveillance). DVH metrics tailored to conventional, moderately hypofractionated, and ultrahypofractionated regimens were identified. Decision trees to determine performance for each measure were developed. Eighteen CTCAE V5.0 terms were selected in the sexual, urinary, and gastrointestinal domains as highest priority for assessment during follow-up.

CONCLUSIONS

This set of measures and DVH constraints serves as a tool for assessing the comprehensive quality of RO care for prostate cancer. These measures will be used for ongoing quality surveillance and improvement among veterans receiving care across VA and community sites. These measures can also be applied to clinical settings outside of those serving veterans.

Zero-Gap Electrochemical CO2 Reduction Cells: Challenges and Operational Strategies for Prevention of Salt Precipitation

Salt precipitation is a problem in electrochemical CO₂ reduction electrolyzers that limits their long-term durability and industrial applicability by reducing the active area, causing flooding and hindering gas transport. Salt crystals form when hydroxide generation from electrochemical reactions interacts homogeneously with CO₂ to generate substantial quantities of carbonate. In the presence of sufficient electrolyte cations, the solubility limits of these species are reached, resulting in "salting out" conditions in cathode compartments. Detrimental salt precipitation is regularly observed in zero-gap membrane electrode assemblies, especially when operated at high current densities. This Perspective briefly discusses the mechanisms for salt formation, and recently reported strategies for preventing or reversing salt formation in zero-gap CO₂ reduction membrane electrode assemblies. We link these approaches to the solubility limit of potassium carbonate within the electrolyzer and describe how each strategy separately manipulates water, potassium, and carbonate concentrations to prevent (or mitigate) salt formation.

Ophthalmia nodosa secondary to intraocular, white-marked tussock caterpillar setae (Orgyia leucostigma) in a 15-year-old

A 15-year-old female presented to the emergency department with a 1-day history of pain and swelling of her right eye following ocular contact with a caterpillar. Caterpillars of the white-marked tussock moth and other related species possess hairlike structures called setae, with angled barbs along their length, allowing them to travel linearly upon penetration of an enemy, resisting backward movement and becoming very difficult to extract once imbedded. When these fine, pointed hairs contact the surface of the eye, they can easily migrate in, eliciting movement of the globe, blinking, and rubbing of the eye in an attempt to remove the offending agent, potentially leading to ophthalmia nodosa. One of the most important aspects of ophthalmia nodosa diagnosis is a thorough history and prompt slit-lamp examination to identify the presence of foreign bodies and where they are located; this will help guide clinical management decisions. This case demonstrates that, depending on the number and location, more than one attempt may be required to remove all of the barbed setae. If ophthalmia nodosa is suspected, it is important to promptly refer to ophthalmology for a thorough eye exam, keep the eye clean, prescribe prophylactic topical antibiotics and/or steroids to reduce the potential for infection and inflammation, and emphasize the importance of keeping the eye protected during the healing process with an eye shield.

Leadership Insights From a Pathology Peer-to-Peer Learning Collaborative in Immuno-oncology

Introduction/Objective

As the use of immuno-oncology (IO) expands into more cancers, there is a growing need for pathologists and laboratory professionals to demonstrate leadership and guide biomarker testing processes and procedures at their own institutions. To educate and empower its members, the American Society for Clinical Pathology worked in collaboration with Q Synthesis to develop a peer-to-peer learning collaborative. This project was supported by an educational grant from Bristol Myers Squibb.

Methods/Case Report

18 pathologists and laboratory professionals participated in a 10-month program: IO ChangeMakers. Learners completed online modules covering scientific updates on IO biomarker testing. Through small-group, case-based discussions, learners reviewed operational challenges and opportunities to refine biomarker testing. They applied this knowledge to lead IO improvement projects at their own institutions.

Results (if a Case Study enter NA)

The learners identified the following leadership insights around IO biomarker testing: Reflex testing: Develop or refine reflex biomarker testing processes to ensure that tissue is sent for PD-L1 testing at the time of cancer diagnosis. Establish testing criteria with oncologists and implement steps to reduce delays in testing. Interobserver concordance: Evaluate interobserver concordance among pathologists scoring PD-L1, especially in upper GI cancers where the combined positive score (CPS) is used. Scoring upper GI cancers is challenging because of the spatial distribution of PD-L1 within a tumor. Tissue handling: Identify ways to improve tissue processing and handling to preserve small amounts of tissue for biomarker testing. If quantity is not sufficient, prioritize PD-L1 testing and contact the oncologist to order a liquid biopsy. Confusion around different PD-L1 antibody clones: Pathologists and clinicians are often confused about the use of different PD-L1 antibody clones (eg, 22C3, SP142, etc.) and scoring criteria (eg, TPS ≥ 1%, CPS ≥ 10, TC ≥ 25%, etc.). Develop education and reference guides to ensure the right PD-L1 test is ordered based on the type of tumor and intended treatment. Test ordering to reporting: In many cancer centers, biopsy samples are being sent out for PD-L1 testing. Refine electronic test ordering, tracking status, and reporting results.

Conclusion

Pathologists have numerous opportunities to lead improvement efforts in IO biomarker testing. As the use of IO expands into more cancers, there will be a growing need for pathologists to demonstrate leadership in this area.

Education to Improve Ki67 Testing in Hormone Receptor-Positive/HER2-Negative Early-Stage Breast Cancer (HR+ EBC)

Introduction/Objective

Ki67 is a marker of active cellular proliferation with prognostic utility in EBC. However, clinical use has been limited due to variability in assay protocols and interpretation. Recently, a Ki67 companion diagnostic received FDA approval for assessing recurrence risk and guiding therapy decision-making for high-risk HR+ EBC. We report a comprehensive program to understand current clinical use of Ki67 and identify and address educational needs of healthcare professionals regarding Ki67 testing to improve patient care.

Methods/Case Report

The multimodal program included a baseline survey to explore gaps in knowledge, skills, and clinical confidence in Ki67 assessment; a live, virtual webinar featuring a pathologist and an oncologist discussing practice-changing developments; and an interactive on-demand webcast developed from the webinar.

Results (if a Case Study enter NA)

Of the 653 survey respondents (227 self-identified a role in medical oncology and 261 in pathology), 77% indicated that they currently test for Ki67 in patients with HR+ EBC, and 64% indicated they were very or moderately knowledgeable on how to use Ki67 as a diagnostic assay. However, only 46% indicated they were very or moderately knowledgeable about the strengths and limitations of Ki67 testing methods or identifying patients who would likely benefit from CDK4/6 inhibition. At the end of the webinar, 67% to 83% of the evaluation respondents (92 – 115) indicated that the education increased their knowledge and/or confidence around how to use and test for Ki67 and identify eligible patients. There were also statistically significant gains from the webcast, including knowledge of strengths/limitations of Ki67 testing methods and confidence in the ability to identify patients for targeted therapies or clinical trials.

Conclusion

These data suggest some challenges in integrating Ki67 as a biomarker for clinical practice, but education can enhance knowledge and confidence on this topic. A detailed analysis of the survey and outcomes from the linked education are presented.

Engaging Pathologists in a Peer-to-Peer Learning Collaborative on HER2-Low Breast Cancer

Introduction/Objective

Recent advances in research have shown clinical effectiveness when targeting the lower range of HER2 expression (ie, HER2-low) in patients with metastatic breast cancer. American Society for Clinical Pathology worked in collaboration with Q Synthesis to develop a peer-to-peer learning collaborative to proactively prepare pathologists for HER2-low. This CME project was supported by an educational grant from AstraZeneca Pharmaceuticals LP and Daiichi Sankyo Inc.

Methods/Case Report

38 pathologists participated in the ASCP HER2 Breast Trailblazers. For foundational knowledge, learners completed online modules covering scientific updates on HER2-low. Through small-group, case- based discussions, learners reviewed operational challenges and opportunities to prepare for HER2-low. They applied this knowledge to lead projects at their own institutions focusing on the anticipated changes around HER2-low.

Results (if a Case Study enter NA)

The learners identified the following challenges and opportunities: Defining HER2-low: Several learners had heard misconceptions around the definition of HER2-low. Recent studies have defined HER2-low as IHC 1+ or IHC 2+ with ISH-negative. Interobserver concordance with IHC 0 vs 1+: Several learners discussed the challenges around interpreting IHC 0 vs 1+. They felt that some pathologists may need guided feedback to improve their diagnostic skills. Use of IHC vs. ISH: Several learners only performed ISH for HER2 testing on all breast cancer samples. If HER2-low emerges as a third category, they would need to return to IHC. Implications for non-metastatic breast cancer: Recent HER2-low studies have focused on patients with metastatic breast cancer. If HER2-low emerges as a third category, it is unclear whether this designation will also be used in patients who have early-stage breast cancer.

Leadership

As pathologists prepare for HER2-low, they have opportunities to lead projects to assess and improve IHC interobserver concordance, coach others on IHC interpretation, increase operational efficiency, strength communication skills, and build up the team by proactively anticipating challenges around HER2-low.

Conclusion

HER2-low breast cancer may be emerging as a new category. Through a peer-to-peer learning collaborative, pathologists identified ways to proactively prepare and demonstrate leadership so that cancer centers and laboratories may be ready to embrace a new paradigm of HER2 classification in breast cancer.

Patient experiences of hospital care during the COVID-19 pandemic in Ireland

Introduction

The COVID-19 pandemic has greatly impacted healthcare service delivery. This study explored patient experiences of hospital care during the COVID-19 pandemic in Ireland, using National Inpatient Experience Survey (NIES) 2021 data.

Methods

NIES is a repeat cross-sectional survey of inpatient experiences in all public acute hospitals in Ireland. Patients who spent 24+ hours in hospital and were discharged in September 2021 were eligible to participate. 7 questions addressed experiences specific to the pandemic. Comparisons between 2019 and 2021 were conducted using t-tests. Effect sizes (d) are reported. Qualitative data were thematically analysed.

Results

10,743 patients participated (42% response rate). While 68% did not feel at risk of catching COVID-19, 9% felt at risk. 35% reported that staff always helped them to keep in touch with family. There were small, statistically significant differences between 2019 and 2021 ratings, with questions on opportunity for family to talk to a doctor (d=-.328), provision of information to family (d=-.136), and being able to find staff to talk to about worries and fears (d=-.167) recording the biggest decreases. Scores for cleanliness of wards (d = 0.063) and bathrooms (d=.075), and privacy during examination or treatment in the ED (d = 0.085) improved significantly. Patients commented on their appreciation of staff, but missed having visitors, with restrictions posing challenges for those with sensory or physical impairments.

Conclusions

Given the unique challenges experienced by acute healthcare services during the COVID-19 pandemic, comparisons with pre-pandemic patient experiences should be interpreted with caution. Continuing to gather patient feedback during a pandemic presents a unique opportunity to understand the resilience of healthcare systems as they continue to operate under unprecedented pressure, with the potential to inform responses and delivery of care during future pandemics or other emergencies.

Key messages

• Visiting restrictions posed many challenges for patients and affected communication both between patients and their family members, as well as between healthcare staff and patients’ family.

• Gathering patient feedback during a pandemic presents a unique opportunity to inform responses and delivery of care during future pandemics or other emergencies.

Consensus Quality Measures and Dose Constraints for Breast Cancer from the Veterans Affairs Radiation Oncology Quality Surveillance Program and American Society for Radiation Oncology (ASTRO) Expert Panel

INTRODUCTION

Using evidence-based radiation therapy to direct care for patients with breast cancer is critical to standardizing practice, improving safety, and optimizing outcomes. To address this need, the Veterans Affairs (VA) National Radiation Oncology Program (NROP) established the VA Radiation Oncology Quality Surveillance Program (VAROQS) to develop clinical quality measures (QM). The VA NROP contracted with the American Society for Radiation Oncology (ASTRO) to commission five Blue-Ribbon Panels for breast, lung, prostate, rectal, and head & neck cancers.

METHODS

The Breast Cancer Blue-Ribbon Panel experts worked collaboratively with NROP to develop consensus QM for use throughout the VA system. establishing a set of quality measures for patients in several areas including: 1) consultation and work up, 2) simulation, treatment planning and treatment, and 3) follow up care. As part of this initiative, consensus dose volume histogram (DVH) constraints were outlined.

RESULTS

In total, 36 quality measures were established. Herein we review the process utilized to develop QM and final consensus QM pertaining to all aspects of radiation patient care as well as DVH constraints.

CONCLUSIONS

The QM and expert consensus DVH constraints are intended for ongoing quality surveillance within the VA system, centers providing community care for Veterans, and also available for use by the greater non-VA community measures of quality care for breast cancer patients receiving radiation.

The influence of anastomotic techniques on postoperative anastomotic complications: Results of the Oesophago-Gastric Anastomosis Audit

BACKGROUND

The optimal anastomotic techniques in esophagectomy to minimize rates of anastomotic leakage and conduit necrosis are not known. The aim of this study was to assess whether the anastomotic technique was associated with anastomotic failure after esophagectomy in the international Oesophago-Gastric Anastomosis Audit cohort.

METHODS

This prospective observational multicenter cohort study included patients undergoing esophagectomy for esophageal cancer over 9 months during 2018. The primary exposure was the anastomotic technique, classified as handsewn, linear stapled, or circular stapled. The primary outcome was anastomotic failure, namely a composite of anastomotic leakage and conduit necrosis, as defined by the Esophageal Complications Consensus Group. Multivariable logistic regression modeling was used to identify the association between anastomotic techniques and anastomotic failure, after adjustment for confounders.

RESULTS

Of the 2238 esophagectomies, the anastomosis was handsewn in 27.1%, linear stapled in 21.0%, and circular stapled in 51.9%. Anastomotic techniques differed significantly by the anastomosis sites (P < .001), with the majority of neck anastomoses being handsewn (69.9%), whereas most chest anastomoses were stapled (66.3% circular stapled and 19.3% linear stapled). Rates of anastomotic failure differed significantly among the anastomotic techniques (P < .001), from 19.3% in handsewn anastomoses, to 14.0% in linear stapled anastomoses, and 12.1% in circular stapled anastomoses. This effect remained significant after adjustment for confounding factors on multivariable analysis, with an odds ratio of 0.63 (95% CI, 0.46-0.86; P = .004) for circular stapled versus handsewn anastomosis. However, subgroup analysis by anastomosis site suggested that this effect was predominantly present in neck anastomoses, with anastomotic failure rates of 23.2% versus 14.6% versus 5.9% for handsewn versus linear stapled anastomoses versus circular stapled neck anastomoses, compared with 13.7% versus 13.8% versus 12.2% for chest anastomoses.

CONCLUSIONS

Handsewn anastomoses appear to be independently associated with higher rates of anastomotic failure compared with stapled anastomoses. However, this effect seems to be largely confined to neck anastomoses, with minimal differences between techniques observed for chest anastomoses. Further research into standardization of anastomotic approach and techniques may further improve outcomes.

Consensus Quality Measures and Dose Constraints for Head and Neck Cancer with an emphasis on Oropharyngeal and Laryngeal Cancer from the Veterans Affairs Radiation Oncology Quality Surveillance Program and American Society for Radiation Oncology Expert Panel

PURPOSE

Safeguarding high-quality care using evidence-based radiation therapy for patients with head and neck cancer is crucial to improving oncologic outcomes, including survival and quality of life.

METHODS AND MATERIALS

The Veterans Administration (VA) National Radiation Oncology Program established the VA Radiation Oncology Quality Surveillance Program (VAROQS) to develop clinical quality measures (QM) in head and neck cancer. As part of the development of QM, the VA commissioned, along with the American Society for Radiation Oncology, a blue-ribbon panel comprising experts in head and neck cancer, to develop QM.

RESULTS

We describe the methods used to develop QM and the final consensus QM, as well as aspirational and surveillance QM, which capture all aspects of the continuum of patient care from initial patient work-up, radiation treatment planning and delivery, and follow-up care, as well as dose volume constraints.

CONCLUSION

These QM are intended for use as part of ongoing quality surveillance for veterans receiving radiation therapy throughout the VA as well as outside the VA. They may also be used by the non-VA community as a basic measure of quality care for head and neck cancer patients receiving radiation.

Increasing the use of perioperative risk scoring in emergency laparotomy: nationwide quality improvement programme

Background

Emergency laparotomy is associated with high morbidity and mortality. The early identification of high-risk patients allows for timely perioperative care and appropriate resource allocation. The aim of this study was to develop a nationwide surgical trainee-led quality improvement (QI) programme to increase the use of perioperative risk scoring in emergency laparotomy.

Methods

The programme was structured using the active implementation framework in 15 state-funded Irish hospitals to guide the staged implementation of perioperative risk scoring. The primary outcome was a recorded preoperative risk score for patients undergoing an emergency laparotomy at each site.

Results

The rate of patients undergoing emergency laparotomy receiving a perioperative risk score increased from 0–11 per cent during the exploratory phase to 35–100 per cent during the full implementation phase. Crucial factors for implementing changes included an experienced central team providing implementation support, collaborator engagement, and effective communication and social relationships.

Conclusions

A trainee-led QI programme increased the use of perioperative risk assessment in patients undergoing emergency laparotomy, with the potential to improve patient outcomes and care delivery.

Severity of oEsophageal Anastomotic Leak in patients after oesophagectomy: the SEAL score

Background

Anastomotic leak (AL) is a common but severe complication after oesophagectomy. It is unknown how to determine the severity of AL objectively at diagnosis. Determining leak severity may guide treatment decisions and improve future research. This study aimed to identify leak-related prognostic factors for mortality, and to develop a Severity of oEsophageal Anastomotic Leak (SEAL) score.

Methods

This international, retrospective cohort study in 71 centres worldwide included patients with AL after oesophagectomy between 2011 and 2019. The primary endpoint was 90-day mortality. Leak-related prognostic factors were identified after adjusting for confounders and were included in multivariable logistic regression to develop the SEAL score. Four classes of leak severity (mild, moderate, severe, and critical) were defined based on the risk of 90-day mortality, and the score was validated internally.

Results

Some 1509 patients with AL were included and the 90-day mortality rate was 11.7 per cent. Twelve leak-related prognostic factors were included in the SEAL score. The score showed good calibration and discrimination (c-index 0.77, 95 per cent c.i. 0.73 to 0.81). Higher classes of leak severity graded by the SEAL score were associated with a significant increase in duration of ICU stay, healing time, Comprehensive Complication Index score, and Esophagectomy Complications Consensus Group classification.

Conclusion

The SEAL score grades leak severity into four classes by combining 12 leak-related predictors and can be used to the assess severity of AL after oesophagectomy.

Textbook outcome following oesophagectomy for cancer: international cohort study

Background

Textbook outcome has been proposed as a tool for the assessment of oncological surgical care. However, an international assessment in patients undergoing oesophagectomy for oesophageal cancer has not been reported. This study aimed to assess textbook outcome in an international setting.

Methods

Patients undergoing curative resection for oesophageal cancer were identified from the international Oesophagogastric Anastomosis Audit (OGAA) from April 2018 to December 2018. Textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least 15 lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. A multivariable binary logistic regression model was used to identify factors independently associated with textbook outcome, and results are presented as odds ratio (OR) and 95 per cent confidence intervals (95 per cent c.i.).

Results

Of 2159 patients with oesophageal cancer, 39.7 per cent achieved a textbook outcome. The outcome parameter ‘no major postoperative complication’ had the greatest negative impact on a textbook outcome for patients with oesophageal cancer, compared to other textbook outcome parameters. Multivariable analysis identified male gender and increasing Charlson comorbidity index with a significantly lower likelihood of textbook outcome. Presence of 24-hour on-call rota for oesophageal surgeons (OR 2.05, 95 per cent c.i. 1.30 to 3.22; P = 0.002) and radiology (OR 1.54, 95 per cent c.i. 1.05 to 2.24; P = 0.027), total minimally invasive oesophagectomies (OR 1.63, 95 per cent c.i. 1.27 to 2.08; P &lt; 0.001), and chest anastomosis above azygous (OR 2.17, 95 per cent c.i. 1.58 to 2.98; P &lt; 0.001) were independently associated with a significantly increased likelihood of textbook outcome.

Conclusion

Textbook outcome is achieved in less than 40 per cent of patients having oesophagectomy for cancer. Improvements in centralization, hospital resources, access to minimal access surgery, and adoption of newer techniques for improving lymph node yield could improve textbook outcome.

Textbook outcome following oesophagectomy for cancer: international cohort study

BACKGROUND

Textbook outcome has been proposed as a tool for the assessment of oncological surgical care. However, an international assessment in patients undergoing oesophagectomy for oesophageal cancer has not been reported. This study aimed to assess textbook outcome in an international setting.

METHODS

Patients undergoing curative resection for oesophageal cancer were identified from the international Oesophagogastric Anastomosis Audit (OGAA) from April 2018 to December 2018. Textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least 15 lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. A multivariable binary logistic regression model was used to identify factors independently associated with textbook outcome, and results are presented as odds ratio (OR) and 95 per cent confidence intervals (95 per cent c.i.).

RESULTS

Of 2159 patients with oesophageal cancer, 39.7 per cent achieved a textbook outcome. The outcome parameter 'no major postoperative complication' had the greatest negative impact on a textbook outcome for patients with oesophageal cancer, compared to other textbook outcome parameters. Multivariable analysis identified male gender and increasing Charlson comorbidity index with a significantly lower likelihood of textbook outcome. Presence of 24-hour on-call rota for oesophageal surgeons (OR 2.05, 95 per cent c.i. 1.30 to 3.22; P = 0.002) and radiology (OR 1.54, 95 per cent c.i. 1.05 to 2.24; P = 0.027), total minimally invasive oesophagectomies (OR 1.63, 95 per cent c.i. 1.27 to 2.08; P < 0.001), and chest anastomosis above azygous (OR 2.17, 95 per cent c.i. 1.58 to 2.98; P < 0.001) were independently associated with a significantly increased likelihood of textbook outcome.

CONCLUSION

Textbook outcome is achieved in less than 40 per cent of patients having oesophagectomy for cancer. Improvements in centralization, hospital resources, access to minimal access surgery, and adoption of newer techniques for improving lymph node yield could improve textbook outcome.

805 UPPER LIMB FRACTURE PATHWAYS IN FRAILTY ENABLE EARLIER RETURN TO FUNCTION WITH ASSOCIATED REDUCED LENGTH OF HOSPITAL STAY

Introduction

Upper limb fractures are the second most common fracture requiring admission to hospital after hip fracture [Jennison, 2019]. At 1-year 20.5% have died, compared to 29.5% in hip fracture [Wiedl, 2021]. Local Problems: At North Bristol Trust most patients with upper limb fractures and a Clinical Frailty Score ≥ 5 are managed non-operatively on medical wards. Local service evaluation identified a long length of stay of 23 days. Case note review revealed: • Delayed transfers of care (DTOCs) had been managed non-weight bearing in slings for 4–6 weeks. • Non-weight bearing status resulted in DTOC due to declined access to social care and rehabilitation due to perceived health needs. • A high rate of hospital-acquired complications and failure to rehabilitate. • Breakdown in interdisciplinary communication and ownership across the pathway.

Methods

A multidisciplinary QI project was commenced. Using local data through business analytics, clinician and patient feedback, a new Trust guideline was developed for older people with frailty and upper limb fractures. Data collected determined average length of stay before and after implementation of the service change. A standard process control chart was created monitoring the effect of the changes in the pathway. The multidisciplinary team met regularly to make alterations during implementation. The resulting intervention included: • Removal of functional restrictions; allow free use of limb as comfort permits. • Simplified slings and minimised light weight casts. • Proactive integration of orthopaedic plan into CGA documentation. • Proactive interdisciplinary communication across pathways. • Patient information leaflets.

Results

Pre-intervention average length of stay was 23 days. Post-intervention was 14 days.

Conclusion

Proactive, structured management of upper limb fractures in people with frailty is associated with significant reduction in acute hospital length of stay. Next steps include a business case for a frailty trauma specialist therapist embedded into medicine.

Reliability of transcutaneous hemoglobin measurements in an outpatient pediatric clinic

OBJECTIVE

Our study assessed the reliability of a transcutaneous hemoglobin (tcHgb) measurement as compared to a standard capillary hemoglobin (cHgb) measurement in screening for iron deficiency anemia in a single university-based pediatric outpatient clinic.

METHODS

Study participants included all pediatric patients requiring a hemoglobin (Hgb) assessment from July 2019 to June 2020. A tcHgb measurement was attempted on all children who received a cHgb measurement. Additional variables evaluated were age, visit type, gender, insurance type, weight, BMI percentile and presence of comorbid conditions.

RESULTS

Of 777 attempts, both cHgb and tcHgb were obtained in 196 children aged 9 months to 21 years. Attempts were most successful in children > 2 years of age due to finger size and ability to remain still for one to two minutes. The mean cHgb was 12.5 ± 1.5 g/dL, mean tcHgb value 13.1 ± 2.1 g/dL, and the mean difference was 0.6 ± 2.1 g/dL (tcHgb-cHgb). An intraclass correlation coefficient was 0.29. There were no differences with regards to age, visit type, gender, insurance type, weight, BMI percentile and presence of comorbid conditions. Bland-Altman analysis displayed a lack of agreement between the tcHgb and cHgb measurements and tcHgb tended to over-estimate Hgb values when the cHgb was low.

CONCLUSIONS

The measurement of a transcutaneous Hgb is less invasive for pediatric patients but has significant limitations. Smaller children (probe specifications) and movement limited the ability to obtain a tcHgb measurement in ~75% of children tested. Falsely normal tcHgb values occurred due to overestimation of hemoglobin when compared to the traditional cHgb device. The suboptimal sensitivity of the tcHgb device may cause providers to miss a diagnosis of anemia. Future research should compare both methods of Hgb assessment to the gold standard laboratory-analyzed complete blood count and use a smaller probe for children under 2, once available.

The Emirates Mars Mission

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

Clinical Relevance of the Tumor Location-Modified Laurén Classification System for Gastric Cancer in a Western Population

Background

The Tumor Location-Modified Laurén Classification (MLC) system combines Laurén histologic subtype and anatomic tumor location. It divides gastric tumors into proximal non-diffuse (PND), distal non-diffuse (DND), and diffuse (D) types. The optimum classification of patients with Laurén mixed tumors in this system is not clear due to its grouping with both diffuse and non-diffuse types in previous studies. The clinical relevance of the MLC in a Western population has not been examined.

Methods

A cohort study investigated 404 patients who underwent gastrectomy for gastric adenocarcinoma between 2005 and 2020. The classification of Laurén mixed tumors was evaluated using receiver operating characteristic (ROC) curve analysis and comparison of clinicopathologic characteristics (chi-square). Survival analysis was performed using multivariable Cox regression.

Results

The ROC curve analysis demonstrated a slightly higher area under the curve value for predicting survival when Laurén mixed tumors were grouped with intestinal-type rather than diffuse-type tumors (0.58 vs 0.57). Survival, tumor recurrence, and resection margin positivity in mixed tumors also was more similar to intestinal type. Distal non-diffuse tumors had the best 5-year survival (DND 64.7 % vs PND 56.1 % vs diffuse 45.1 %; p = 0.006) and were least likely to have recurrence (DND 27.0 % vs PND 34.3 % vs diffuse 48.3 %; p = 0.001). Multivariable analysis demonstrated that MLC was an independent prognostic factor for survival (PND: hazard ratio [HR], 1.64; 95 % confidence interval [CI], 1.16–2.32 vs diffuse: HR, 2.20; 95 % CI, 1.56–3.09)

Conclusions

The MLC was an independent prognostic marker in this Western cohort of patients with gastric adenocarcinoma. The patients with PND and D tumors had worse survival than those with DND tumors.

Supplementary Information

The online version contains supplementary material available at 10.1245/s10434-021-11252-y.

Preparing for Pediatrics: Experiential Learning Helps Medical Students Prepare for Their Clinical Placement

Despite the importance of effective communication skills in pediatrics, clinical placements may inadequately prepare undergraduate students to communicate with children. The integration of non-clinical interactions with healthy children within a pediatric curriculum has the potential to enhance learning. We designed and implemented a novel course involving experiential learning, including video-recorded consultations with simulated parents (SPs), team-based scenarios with a pediatric mannequin, interactions with healthy children through a pre-school visit and medical student led health workshops for primary school children. Medical students at the RCSI University of Medicine and Health Sciences took part in the course. We used a mixed methods approach to assess the impact of the course. We investigated medical students' perspectives through a pre- and post-intervention questionnaire and post-intervention focus group discussions (FGDs). We assessed participating children's health literacy at the start of the course. 144/279 (51.6%) of the fourth year medical student cohort on their pediatric rotation, consented to participate in the study. All 144 (100%) of consenting students completed the pre-intervention questionnaire. 59/144 (40.1%) of consenting students completed the post-intervention questionnaire. Results showed a statistically significant improvement in ratings (p < 0.05) for items related to managing a confrontational situation involving family members, completing a psychosocial assessment with an adolescent and effectiveness using evidence-based medicine (EBM) when motivating patients. There was a statistically significant decrease in how students rated their comfort at using EBM when motivating patients. Four themes relating to how students experienced the intervention were identified from eight FGDs (n = 35 students): Shaping Student Learning; Supporting Student Learning; Developing New Skills and Feeling More Prepared. 39/49 (79.6%) children completed a health literacy assessment. All questions had a high percentage of positive responses. Question 7, understanding your doctor, had the highest proportion of negative responses (27%). Ours is one of the first studies to design an educational intervention to enhance pediatrics teaching by combining interactions with healthy children outside of a clinical setting with more traditional simulation-based approaches. We conclude that this type of intervention supports students' learning of pediatric communication skills and enhances students' perceived preparation for clinical placement.

147 ‘CHAMPIONING CONTINENCE’—ESTABLISHMENT OF A MULTIDISCIPLINARY CONTINENCE PROMOTION WORKING GROUP IN AN ACUTE TEACHING HOSPITAL

Background

In line with the National Frailty Programme1, patients over the age of 75 admitted to hospital should have a comprehensive geriatric assessment including the assessment of current continence status and any history of incontinence. Up to 39% of adults are reported to develop new onset urinary incontinence during admission to hospital2,3, however studies show that is it a problem not always identified by staff members,4. In response to these observations within an acute teaching hospital, a continence working party was formed involving members of nursing, physiotherapy and occupational therapy colleagues to explore the current practice and culture relating to continence management.

Methods

The group established key objectives which were broken into four strands;

1. Audit of documentation of baseline continence on admission (therapy and nursing).

2. Obtaining access to additional types of continence wear.

3. Staff education.

4. Pre and post education survey.

Results

1. Audit of documentation demonstrated poor standards of documentation of baseline continence. This led to an amendment to questioning prompts on therapy initial assessment forms and a plan to further evaluate the nursing documentation.

2. A wider array of continence wear has been made available on the wards providing greater options for patients.

3. Staff education session was compiled by a specialist physiotherapist and is widely available for staff to access on the hospitals online training portal.

4. Pre-education surveys have been completed with a view to re-administering following education roll-out.

Conclusion

The aim of this multidisciplinary working group is to equip staff with the correct resources, knowledge, and confidence to ensure best practice promotion of continence on the targeted wards. This project is the first strand of a wider culture changed that is needed around continence promotion for older adults in the acute setting.

216 IMPROVING INPATIENT INFLUENZA VACCINATION RATES—THE VALUE OF AN ELECTRONIC PATIENT RECORD REMINDER SYSTEM

Background

Influenza vaccination, particularly for vulnerable, older adults, will have added importance this winter given the possibility of further waves of COVID-19 pandemic. Previous interventions at the study site noted poor awareness on the need for inpatient Influenza vaccination¹. This study examines a vaccination reminder process using an electronic patient record (EPR) to identify high-priority eligible inpatients.

Methods

The study site is a 900-bed university teaching hospital with all clinical notes accessed via an EPR.

We included a convenience sample of 750 adults aged≥50 years (mean age 75.9 +/− 0.4 years, 48% female) and high-priority for influenza vaccination (Age > 65 years and/or length of stay (LOS) >30 days) from October 1^st 2020 to January 12^th 2021.

A live electronic dashboard identified eligible inpatients for vaccination, prompting vaccination reminders to the clinical teams via the antimicrobial pharmacist.

Data was collected retrospectively. Logistic regression models reporting odds ratios were used to assess the association of these reminders with vaccine uptake.

Results

Over one third (35%, 264/750) of high-priority patients received the Influenza vaccine while inpatients, including 40% aged ≥80 years.

The reminder was sent on 41% (305/750) of patients and was associated with an almost 50% higher likelihood of vaccination after adjusting for other covariates (Odds Ratio 1.48 (95% CI 1.00–2.20); p = 0.048).

Other factors independently associated with vaccination were advancing age (Odds Ratio 2.69 (95% CI 1.12–6.47) for age ≥ 80 years); LOS (4% higher likelihood of vaccination for every additional day in hospital) and admission under geriatric medicine (Odds Ratio 3.71 (95% CI 2.45–5.62) when compared to other specialities).

Conclusion

Our study shows relatively low uptake of inpatient Influenza vaccination and strategies to improve uptake are required. Reminders sent to clinical teams using the EPR appear to be an effective means of increasing Influenza vaccination and should be considered as part of this year’s inpatient vaccination drive.

Postoperative outcomes in oesophagectomy with trainee involvement

BACKGROUND

The complexity of oesophageal surgery and the significant risk of morbidity necessitates that oesophagectomy is predominantly performed by a consultant surgeon, or a senior trainee under their supervision. The aim of this study was to determine the impact of trainee involvement in oesophagectomy on postoperative outcomes in an international multicentre setting.

METHODS

Data from the multicentre Oesophago-Gastric Anastomosis Study Group (OGAA) cohort study were analysed, which comprised prospectively collected data from patients undergoing oesophagectomy for oesophageal cancer between April 2018 and December 2018. Procedures were grouped by the level of trainee involvement, and univariable and multivariable analyses were performed to compare patient outcomes across groups.

RESULTS

Of 2232 oesophagectomies from 137 centres in 41 countries, trainees were involved in 29.1 per cent of them (n = 650), performing only the abdominal phase in 230, only the chest and/or neck phases in 130, and all phases in 315 procedures. For procedures with a chest anastomosis, those with trainee involvement had similar 90-day mortality, complication and reoperation rates to consultant-performed oesophagectomies (P = 0.451, P = 0.318, and P = 0.382, respectively), while anastomotic leak rates were significantly lower in the trainee groups (P = 0.030). Procedures with a neck anastomosis had equivalent complication, anastomotic leak, and reoperation rates (P = 0.150, P = 0.430, and P = 0.632, respectively) in trainee-involved versus consultant-performed oesophagectomies, with significantly lower 90-day mortality in the trainee groups (P = 0.005).

CONCLUSION

Trainee involvement was not found to be associated with significantly inferior postoperative outcomes for selected patients undergoing oesophagectomy. The results support continued supervised trainee involvement in oesophageal cancer surgery.

E-learning versus face-to-face training: Comparison of two learning methods for Lyme borreliosis

OBJECTIVES

To compare two learning methods for Lyme disease (e-learning versus face-to-face training) to assess knowledge and know-how.

METHODS

The study population was volunteer general medicine residents and family physicians (FP). Face-to-face training on Lyme disease was offered to each group. E-learning training was then offered to those who had not attended the face-to-face training. Theoretical knowledge was assessed by an identical pre- and post-test questionnaire and know-how by a script concordance test.

RESULTS

Seventy learners (47 FPs and 23 general medicine residents) were included in the face-to-face training group and 61 (33 FPs and 28 general medicine residents) in the e-learning group. The pre- and post-test scores were significantly improved in the FP group (difference of 29.3±1.9 [P<0.0001] out of 100) as well as in the general medicine resident group (difference of 38.2±2.7 [P<0.0001] out of 100). E-learning was more effective than face-to-face training, particularly among general medicine residents (progression of mean difference of 44.3±3.4/100 vs. 30.9±4.0/100; P=0.0138) and to a lesser extent among FPs (progression of 25.3±2.3/100 vs. 31.9±2.7/100; P=0.0757). Forty-six script concordance tests were completed by FPs and 20 by general medicine residents. Script concordance test results did not seem significant between the subgroups.

CONCLUSIONS

E-learning seems to be a good alternative to face-to-face training for Lyme disease. It seems to be more effective than face-to-face training for the acquisition of theoretical knowledge. The script concordance test evaluation of know-how did not show any difference between the two learning methods.

1301 Early MRI in the Diagnosis of Suspected Scaphoid Fractures – An Audit of a Redesigned Diagnostic Pathway

Introduction

MRI is the gold standard for investigation of suspected scaphoid fractures, which can be missed on initial x-rays. This full cycle audit reports the impact of our new patient pathway, which changes repeat x-rays at 2 weeks to urgent limited sequence scaphoid MRI for those with normal initial x-rays, but clinical suspicion of fracture at initial clinic visit.

Method

A second cycle audited MRI requests for suspected scaphoid fractures at Southmead hospital following implementation of the new pathway in October 2020. We collected wait times from request to scan, and radiologist reports. Results were compared to our first cycle, 6-month time period.

Results

he results for 24 limited sequence MRIs via our new pathway were compared to 134 full wrist MRIs of the first cycle. Two scans (9.1%) were positive for scaphoid fracture versus 12% in the first cycle. 19 scans (86%) identified alternate pathology including sprain (6), bone bruise (5), non-scaphoid fractures (4) and degenerative change (3). 1 scan (4.5%) was reported as normal. 73% of MRIs were performed within 14 days, compared to 63% in previous cohort.

Conclusions

Our new pathway using limited sequence MRI identified similar rates of scaphoid fractures. Reduced time to MRI was observed compared to the previous cohort due to shorter scan durations and resulted in earlier diagnosis and fewer outpatient follow-up appointments. Our new pathway has benefits to patient experience and also reduces footfall in hospital, during a time of global Covid-19 pandemic, with no increase in costs.

578 Insights into Patient Satisfaction with Telephone Fracture Clinic Consultations During COVID-19

Aim

The COVID-19 pandemic led to an unusually fast pace of change in clinical practice in the UK. An early requirement to reduce outpatient attendances to a pminimum meant that this Trust adopted remote consultations for fracture clinics whenever possible. This study aimed to evaluate patient satisfaction with the new system of telephone consultations to assess its acceptability and guide future decisions.

Method

299 patients who received remote telephone consultations for fracture clinic appointments at North Bristol NHS Trust during the COVID-19 pandemic in early 2020 were retrospectively identified and sent a postal survey. Satisfaction levels were assessed through degree of agreement with statements (9 items), yes/no answers (4 questions) and space for comments. Data was analysed with Excel pivot tables and Chi-squared tests.

Results

131 survey responses were included (43.8% response rate). The majority of patients were satisfied overall with the care they received (82%) and preferred a telephone consultation to a face-to-face appointment during the pandemic (78%). However, only 22% maintained this preference in ‘normal’ (pre-COVID-19) times.

Conclusions

The positive responses to the survey reassure us that telephone consultations for fracture clinic consultations are acceptable to the majority of patients during a pandemic. The results as well as free text comments will help us ameliorate the fracture clinic service to minimise infection risk without compromising on quality of care.

Integrin-mediated interactions with a laminin-presenting substrate modulate biosynthesis and phenotypic expression for cells of the human nucleus pulposus

With aging and pathology, cells of the nucleus pulposus (NP) de-differentiate towards a fibroblast-like phenotype, a change that contributes to degeneration of the intervertebral disc (IVD). Laminin isoforms are a component of the NP extracellular matrix during development but largely disappear in the adult NP tissue. Exposing human adult NP cells to hydrogels made from PEGylated-laminin-111 (PEGLM) has been shown to regulate NP cell behaviors and promote cells to assume a biosynthetically active state with gene/protein expression and morphology consistent with those observed in juvenile NP cells. However, the mechanism regulating this effect has remained unknown. In the present study, the integrin subunits that promote adult degenerative NP cell interactions with laminin-111 are identified by performing integrin blocking studies along with assays of intracellular signaling and cell phenotype. The findings indicate that integrin α3 is a primary regulator of cell attachment to laminin and is associated with phosphorylation of signaling molecules downstream of integrin engagement (ERK 1/2 and GSK3β). Sustained effects of blocking integrin α3 were also demonstrated including decreased expression of phenotypic markers, reduced biosynthesis, and altered cytoskeletal organization. Furthermore, blocking both integrin α3 and additional integrin subunits elicited changes in cell clustering, but did not alter the phenotype of single cells. These findings reveal that integrin- mediated interactions through integrin α3 are critical in the process by which NP cells sense and alter phenotype in response to culture upon laminin and further suggest that targeting integrin α3 has potential for reversing or slowing degenerative changes to the NP cell.

Mortality from esophagectomy for esophageal cancer across low, middle, and high-income countries: An international cohort study

BACKGROUND

No evidence currently exists characterising global outcomes following major cancer surgery, including esophageal cancer. Therefore, this study aimed to characterise impact of high income countries (HIC) versus low and middle income countries (LMIC) on the outcomes following esophagectomy for esophageal cancer.

METHOD

This international multi-center prospective study across 137 hospitals in 41 countries included patients who underwent an esophagectomy for esophageal cancer, with 90-day follow-up. The main explanatory variable was country income, defined according to the World Bank Data classification. The primary outcome was 90-day postoperative mortality, and secondary outcomes were composite leaks (anastomotic leak or conduit necrosis) and major complications (Clavien-Dindo Grade III - V). Multivariable generalized estimating equation models were used to produce adjusted odds ratios (ORs) and 95% confidence intervals (CI95%).

RESULTS

Between April 2018 to December 2018, 2247 patients were included. Patients from HIC were more significantly older, with higher ASA grade, and more advanced tumors. Patients from LMIC had almost three-fold increase in 90-day mortality, compared to HIC (9.4% vs 3.7%, p < 0.001). On adjusted analysis, LMIC were independently associated with higher 90-day mortality (OR: 2.31, CI95%: 1.17-4.55, p = 0.015). However, LMIC were not independently associated with higher rates of anastomotic leaks (OR: 1.06, CI95%: 0.57-1.99, p = 0.9) or major complications (OR: 0.85, CI95%: 0.54-1.32, p = 0.5), compared to HIC.

CONCLUSION

Resections in LMIC were independently associated with higher 90-day postoperative mortality, likely reflecting a failure to rescue of these patients following esophagectomy, despite similar composite anastomotic leaks and major complication rates to HIC. These findings warrant further research, to identify potential issues and solutions to improve global outcomes following esophagectomy for cancer.

Using administrative health data for palliative and end of life care research in Ireland: potential and challenges

Background: This study aims to examine the potential of currently available administrative health and social care data for palliative and end-of-life care (PEoLC) research in Ireland. Objectives include to i) identify data sources for PEoLC research ii) describe the challenges and opportunities of using these and iii) evaluate the impact of recent health system reforms and changes to data protection laws.

Methods: The 2017 Health Information and Quality Authority catalogue of health and social care datasets was cross-referenced with a recognised list of diseases with associated palliative care needs. Criteria to assess the datasets included population coverage, data collected, data dictionary and data model availability, and mechanisms for data access.

Results: Nine datasets with potential for PEoLC research were identified, including death certificate data, hospital episode data, pharmacy claims data,  one national survey, four disease registries (cancer, cystic fibrosis, motor neurone and interstitial lung disease) and a national renal transplant registry.  The ad hoc development of the health system in Ireland has resulted in i) a fragmented information infrastructure resulting in gaps in data collections particularly in the primary and community care sector where much palliative care is delivered, ii) ill-defined data governance arrangements across service providers, many of whom are not part of the publically funded health service and iii) systemic and temporal issues that affect data quality. Initiatives to improve data collections include introduction of i) patient unique identifiers, ii) health entity identifiers and iii) integration of the Eircode postcodes. Recently enacted general data protection and health research regulations will clarify legal and ethical requirements for data use.

Conclusions: Ongoing reform initiatives and recent changes to data privacy laws combined with detailed knowledge of the datasets, appropriate permissions, and good study design will facilitate future use of administrative health and social care data for PEoLC research in Ireland.

Comparison of short-term outcomes from the International Oesophago-Gastric Anastomosis Audit (OGAA), the Esophagectomy Complications Consensus Group (ECCG), and the Dutch Upper Gastrointestinal Cancer Audit (DUCA)

BACKGROUND

The Esophagectomy Complications Consensus Group (ECCG) and the Dutch Upper Gastrointestinal Cancer Audit (DUCA) have set standards in reporting outcomes after oesophagectomy. Reporting outcomes from selected high-volume centres or centralized national cancer programmes may not, however, be reflective of the true global prevalence of complications. This study aimed to compare complication rates after oesophagectomy from these existing sources with those of an unselected international cohort from the Oesophago-Gastric Anastomosis Audit (OGAA).

METHODS

The OGAA was a prospective multicentre cohort study coordinated by the West Midlands Research Collaborative, and included patients undergoing oesophagectomy for oesophageal cancer between April and December 2018, with 90 days of follow-up.

RESULTS

The OGAA study included 2247 oesophagectomies across 137 hospitals in 41 countries. Comparisons with the ECCG and DUCA found differences in baseline demographics between the three cohorts, including age, ASA grade, and rates of chronic pulmonary disease. The OGAA had the lowest rates of neoadjuvant treatment (OGAA 75.1 per cent, ECCG 78.9 per cent, DUCA 93.5 per cent; P < 0.001). DUCA exhibited the highest rates of minimally invasive surgery (OGAA 57.2 per cent, ECCG 47.9 per cent, DUCA 85.8 per cent; P < 0.001). Overall complication rates were similar in the three cohorts (OGAA 63.6 per cent, ECCG 59.0 per cent, DUCA 62.2 per cent), with no statistically significant difference in Clavien-Dindo grades (P = 0.752). However, a significant difference in 30-day mortality was observed, with DUCA reporting the lowest rate (OGAA 3.2 per cent, ECCG 2.4 per cent, DUCA 1.7 per cent; P = 0.013).

CONCLUSION

Despite differences in rates of co-morbidities, oncological treatment strategies, and access to minimal-access surgery, overall complication rates were similar in the three cohorts.

959 Undertaking Core Surgical Training Less Than Full Time: A Qualitative Study of Experiences

Introduction

The Royal College of Surgeons identifies Less Than Full Time Training (LTFT) as a key factor in attracting excellent candidates at Core level. Previous evaluations of LTFT have, however, focused on ST3 and beyond. This study focuses on Core Surgical Training (CST), to determine how well it is delivering for LTFT trainees.

Method

Participants undertaking any part of CST LTFT were eligible. An electronic, self-administered questionnaire was accessed by participants.

Results

There were 11 participants. The majority (55%) rated the information available, which often related to more senior trainees, as poor. A third reported it ‘very difficult’ to arrange a LTFT training post. A significant proportion felt their access to operative experience was decreased and 45% reported feeling less confident. Positive aspects were improved work-life balance and being able to maintain a surgical career with a family. Suggestions for improvements included normalising LTFT in surgery to reduce stigma, having dedicated LTFT TPDs, clear pathways, and longer rotations.

Conclusions

Training LTFT offers many benefits – not least, increasing workforce diversity. However, for many, training LTFT at Core level produces additional stress, work and stigma. If the surgical community is serious about maintaining an excellent, diverse workforce, these issues should be tackled sooner rather than later.

71 Electronic Prescribing Promotes Antimicrobial Stewardship In Surgery: A Closed-Loop Audit

Introduction

Antimicrobial resistance is increasing globally. Surgical inpatients are more likely to receive inappropriately broad-spectrum and prolonged antimicrobial treatment, against local policy. Electronic prescribing (e-prescribing) has the potential to promote antimicrobial stewardship. We conducted a closed-loop audit to assess the impact of e-prescribing on surgical inpatient prescriptions.

Method

Audit standards (from Public Health England) included: (1) documentation of allergy status, prescriber contact information, antimicrobial indication and review/stop dates; and (2) prescription of appropriate antimicrobials for appropriate durations (IV and total). Prospective data collection occurred over 1-week. The interventions included an educational session, a once weekly microbiology round of surgical inpatients and the introduction of e-prescribing (Cerner©).

Results

Compliance improved significantly between cycle 1 (n = 54 prescriptions) and 2 (n = 59 prescriptions), for: documentation of prescriber contact details (69 vs 100%) and appropriate antimicrobial review/stop dates (17 vs 100%), indications (78 vs 96%), selection (76 vs 90%) and IV and total antibiotic duration (63 vs 93% and 87 vs 100%, respectively); p &lt; 0.05 throughout.

Conclusions

Audit compliance improved significantly, partly because Cerner© prompts clinicians to input contact details, review dates and indications before prescribing. E-prescribing in combination with appropriate education is likely to promote antimicrobial stewardship and should be considered by other Trusts using paper prescriptions.

Use of Video Consultation in Irish General Practice:The Views of General Practitioners

Introduction Video consultation involves the live interaction between the doctor and the patient remotely. Prior to the Covid-19 pandemic, the majority of video consultations in primary care were provided by GPs who were not the individual's own GP, which presented safety and continuity issues. This study aims to determine GPs' attitudes to the use of video consultation for their own patients. Methods This was a qualitative study involving semi-structured interviews. Participants were purposively recruited through use of a GP tutor as a key informant and guided by a sampling framework to include those with and without previous video consultation experience. Braun and Clarke thematic analysis was used. Results Participants included eight GPs, half of whom had previously worked with video consultation. Four themes emerged: impact on the consultation, the potential role, and the potential threat to current practice and technology and logistics. There were optimistic and cautious observations within all themes. Conclusion With the increased use of video consultation, Irish General Practice is in a unique position to frame the future its use. The provision of this modality to one's own patients may provide benefit while mitigating some of the pitfalls but would not entirely avoid the potential dangers of video consultation.

Gender and health literacy: men's health beliefs and behaviour in Trinidad

Gender variations in health literacy have implications for engagement in preventive behaviours and the uptake of health services, especially in areas such as the Caribbean where there are marked disparities in life expectancy and health service utilization. A self-reported questionnaire was used to examine men's concepts of health, their help-seeking behaviours and their functional and interactive health literacy. Two hundred and forty-eight men across the life course participated at three sites in Trinidad. Data were analysed using descriptive statistics, with free-text responses analysed thematically. Men were concerned about, and accepted responsibility for their own health but social norms concerning sickness and masculinity were barriers to accessing health services. Almost one-third (31.5%) sought advice from a healthcare service when they were last sick because they were prompted to do so by their wife/partner or family. Levels of functional and interactive health literacy were not high among older men, who were reliant on healthcare professionals to communicate health messages. There was an age divide in e-health literacy. There is little published evidence on men's health literacy, particularly from Caribbean countries such as Trinidad and Tobago. This study highlights the importance of the design and implementation of specific policies focusing on men's health. A major challenge is to engage with men who do not access health services.

Using linked administrative health data for palliative and end of life care research in Ireland: potential and challenges

Background: This study aims to examine the potential of currently available administrative health data for palliative and end-of-life care (PEoLC) research in Ireland. Objectives include to i) identify administrative health data sources for PEoLC research ii) describe the challenges and opportunities of using these and iii) estimate  the impact of recent health system reforms and changes to data protection laws.  Methods: The 2017 Health Information and Quality Authority catalogue of health and social care datasets was cross-referenced with a recognised list of diseases with associated palliative care needs. Criteria to assess the datasets included population coverage, data collected, data dictionary and data model availability and mechanisms for data access. Results: Eight datasets with potential for PEoLC research were identified, including four disease registries, (cancer, cystic fibrosis, motor neurone and interstitial lung disease), death certificate data, hospital episode data, community prescription data and one national survey. The ad hoc development of the health system in Ireland has resulted in i) a fragmented information infrastructure resulting in gaps in data collections particularly in the primary and community care sector where much palliative care is delivered, ii) ill-defined data governance arrangements across service providers, many of whom are not part of the publically funded health service and iii) systemic and temporal issues that affect data quality. Initiatives to improve data collections include introduction of i) patient unique identifiers, ii) health entity identifiers and iii) integration of the eircode postcodes. Recently enacted general data protection and health research regulations will clarify legal and ethical requirements for data  use. Conclusions: With appropriate permissions, detailed knowledge of the datasets and good study design currently available administrative health data can be used for PEoLC research. Ongoing reform initiatives and recent changes to data privacy laws will facilitate future use of administrative health data for PEoLC research.

Recruitment and Consent in an observational study

OBJECTIVE

The study sought to explore the consent rate and associated potential bias across a cohort in a large longitudinal population based study.

RESEARCH DESIGN

Data were taken from a study designed to examine the effects of the reintroduction of community water fluoridation on children's oral health over a five-year period. Children were recruited from a fluoridated and non-fluoridated area in Cumbria, referred to as Group 1 and Group 2.

RESULTS

Data were available for 3138 individuals. The consent rate was 12.91 percentage points lower in Group 2 than Group 1 (95% CI -16.27 to -9.56, p⟨0.001). The population in Group 2 was more deprived (higher Index of Multiple Deprivation (IMD)) than Group 1 before consent was taken. Consent was not associated with deprivation in either group.

CONCLUSION

The cohort appeared to be unaffected by IMD-related non-consent. However there was a difference in consent rate between the two groups. With the population in Group 1 being more deprived than Group 2, it will be important to incorporate these differences into the analysis at the end of this longitudinal study.

Predictors and burden of injury mortality in the Thai cohort study 2005-2015

BACKGROUND

Thailand is a high injury burden setting. In 2015 it had the world's second highest rate of road traffic fatalities. In order to develop strategies to reduce this burden an accurate understanding of the development of injury risk over the life course is essential.

METHODS

A national cohort of adult Thais was recruited in 2005 (n = 87,151). Participants completed a health questionnaire covering geodemographic, behavioural, health and injury data. Citizen ID numbers were matched with death registration records, identifying deaths from any injury. Adjusted logistic regression models were used to measure associations between baseline exposures and injury deaths between 2005 and 2015.

RESULTS

Injury mortality comprised 363 individuals, the majority (36%) from traffic injuries. Predictors of all-injury mortality were being male (AOR 3.55, 95% CI 2.57-4.89), Southern Thai (AOR 1.52, 95% CI 1.07-2.16), smoking (AOR 1.55, 95% CI 1.16-2.17), depression (AOR 1.78, 95% CI 1.07-2.96), previous injury (AOR 1.37, 95% CI 1.03-1.81) and drink driving history (AOR 1.37, 95%CI 1.02-1.85). Age and region of residence were stronger predictors for men, while anxiety/depression was a stronger predictor for women. Among males in the far south, assault caused the largest proportion of injury mortality, elsewhere traffic injury was most common.

CONCLUSIONS

This study identifies that a history of drink driving, but not regular alcohol consumption, increased injury risk. The associations between smoking and depression, and injury mortality also need further consideration.

Efficacy of temporomandibular joint arthroplasty and insertion of a Matthews device as treatment for ankylosis of the joint: a case series

Temporomandibular joint (TMJ) ankylosis is a condition in which bony or fibrous adhesion of the anatomical joint components results in loss of function. This is particularly distressing and debilitating for patients who struggle to maintain good oral hygiene, which results in additional pain, oral disease, and ultimately, a poor aesthetic profile. A retrospective chart review was carried out to document the cases of three patients who attended a single centre for the management of ankylosis of the TMJ. Consent for chart review and use of photographs was gained from each one. Charts were obtained, records reviewed, and each of the cases written up for presentation in a case series. All three underwent arthroplasty of the TMJ and insertion of Matthews devices (two patients unilateral, one bilateral). All were followed up postoperatively. They experienced significant improvements in vertical mouth opening which have been maintained to the present. The Matthews device allows movement and physiotherapy postoperatively whilst maintaining the surgically created space. This prevents impingement on the tissues placed between the glenoid fossa and mandible, and appears to prevent relapse and further ankylosis. To our knowledge, few studies to date have documented the use of the Matthews device following interpositional arthroplasty of the TMJ.

Adjuvant therapy following oesophagectomy for adenocarcinoma in patients with a positive resection margin

BACKGROUND

The role of adjuvant therapy in patients with oesophagogastric adenocarcinoma treated by neoadjuvant chemotherapy is contentious. In UK practice, surgical resection margin status is often used to classify patients for receiving adjuvant treatment. The aim of this study was to assess the survival benefit of adjuvant therapy in patients with positive (R1) resection margins.

METHODS

Two prospectively collected UK institutional databases were combined to identify eligible patients. Adjusted Cox regression analyses were used to compare overall and recurrence-free survival according to adjuvant treatment. Recurrence patterns were assessed as a secondary outcome. Propensity score-matched analysis was also performed.

RESULTS

Of 616 patients included in the combined database, 242 patients who had an R1 resection were included in the study. Of these, 112 patients (46·3 per cent) received adjuvant chemoradiotherapy, 46 (19·0 per cent) were treated with adjuvant chemotherapy and 84 (34·7 per cent) had no adjuvant treatment. In adjusted analysis, adjuvant chemoradiotherapy improved recurrence-free survival (hazard ratio (HR) 0·59, 95 per cent c.i. 0·38 to 0·94; P = 0·026), with a benefit in terms of both local (HR 0·48, 0·24 to 0·99; P = 0·047) and systemic (HR 0·56, 0·33 to 0·94; P = 0·027) recurrence. In analyses stratified by tumour response to neoadjuvant chemotherapy, non-responders (Mandard tumour regression grade 4-5) treated with adjuvant chemoradiotherapy had an overall survival benefit (HR 0·61, 0·38 to 0·97; P = 0·037). In propensity score-matched analysis, an overall survival benefit (HR 0·62, 0·39 to 0·98; P = 0·042) and recurrence-free survival benefit (HR 0·51, 0·30 to 0·87; P = 0·004) were observed for adjuvant chemoradiotherapy versus no adjuvant treatment.

CONCLUSION

Adjuvant therapy may improve overall survival and recurrence-free survival after margin-positive resection. This pattern seems most pronounced with adjuvant chemoradiotherapy in non-responders to neoadjuvant chemotherapy.

Specialist palliative cancer care in acute hospitals and place of death: a population study

OBJECTIVE

This study compares the characteristics and place of death of patients with cancer receiving specialist palliative care in acute hospitals with those who do not.

METHODS

All patients with incident invasive cancer in Ireland (1994-2016 inclusive), excluding non-melanoma skin cancer, who attended a cancer centre and died in 2016 were identified from cancer registry data. Patients were categorised based on a diagnosis code 'Encounter for palliative care' from linked hospital episode data. Place of death was categorised from death certificate data. Data were analysed using descriptive statistics, χ² tests and logistic regression.

RESULTS

Of n=4103 decedents identified, 62% had a hospital-based palliative care encounter in the year preceding death. Age (p<0.001), marital status (p=0.017), deprivation index (p<0.001) and health board region (p=0.008) were independent predictors of having a palliative care encounter. Place of death differed by palliative care encounter group: 45% of those with an encounter died in hospital versus 50% without an encounter, 33% vs 16% died in a hospice and 18% vs 28% died at home (p<0.001).

CONCLUSION

Almost two-thirds of patients with cancer who attended a cancer centre and died in 2016 had a palliative care encounter. They were younger, less likely to be married and more likely to be from deprived areas. Having accounted for sociodemographic factors, there was evidence of regional variation in receiving care. Demographic and clinical factors and the provision of health services in a region need to be considered together when assessing end-of-life care.