ART history prior to conception: trends and association with postpartum disengagement from HIV care in Khayelitsha, South Africa (2013-2019): a retrospective cohort study

INTRODUCTION

In recent years, the expansion of HIV treatment eligibility has resulted in an increase in people with antiretroviral therapy (ART) experience prior to pregnancy but little is known about postpartum engagement in care in this population. We examined differences in disengagement from HIV care after delivery by maternal ART history before conception.

METHODS

We analysed data from people living with HIV (aged 15-49) in Khayelitsha, South Africa, with ≥1 live birth between April 2013 and March 2019. We described trends over time in ART history prior to estimated conception, classifying ART history groups as: (A) on ART with no disengagement (>270 days with no evidence of HIV care); (B) returned before pregnancy following disengagement; (C) restarted ART in pregnancy after disengagement; and (D) ART new start in pregnancy. We used Kaplan-Meier curves and proportional-hazards models (adjusted for maternal age, number of pregnancy records and year of delivery) to examine the time to disengagement from delivery to 2 years postpartum.

RESULTS

Among 7309 pregnancies (in 6680 individuals), the proportion on ART (A) increased from 19% in 2013 to 41% in 2019. The proportions of those who returned (B) and restarted (C) increased from 2% to 13% and from 2% to 10%, respectively. There was a corresponding decline in the proportion of new starts (D) from 77% in 2013 to 36% in 2019. In the first recorded pregnancy per person in the study period, 26% (95% CI 25-27%) had disengaged from care by 1 year and 34% (95% CI 33-36%) by 2 years postpartum. Individuals who returned (B: aHR 2.10, 95% CI 1.70-2.60), restarted (C: aHR 3.32, 95% CI 2.70-4.09) and newly started ART (D: aHR 2.41, 95% CI 2.12-2.74) had increased hazards of postpartum disengagement compared to those on ART (A).

CONCLUSIONS

There is a growing population of people with ART experience prior to conception and postpartum disengagement varies substantially by ART history. Antenatal care presents an important opportunity to understand prior ART experiences and an entry into interventions for strengthened engagement in HIV care.

Systematic review of survival following liver or lung metastasectomy for metastatic anal squamous cell carcinoma

INTRODUCTION

Metastatic anal squamous cell carcinoma (SCC) carries a poor prognosis and the evidence base for surgical resection of metastases remains limited. The aim of this study was to establish the survival outcomes for patients undergoing metastasectomy for anal SCC.

METHODS

A systematic review was performed using the MEDLINE®, Embase®, Cochrane and PubMed® databases. Studies were considered for inclusion in the review if they involved patients aged >18 years with a diagnosis of stage IV anal SCC who underwent metastasectomy for liver and/or lung metastases. The primary outcome measure was overall survival. Secondary outcome measures were disease free survival, early morbidity according to the Clavien-Dindo classification and quality of life, measured using a validated scoring tool. Risk of bias was assessed with the ROBINS-I (Risk Of Bias In Non-randomised Studies - of Interventions) tool.

RESULTS

There were 10 studies with a total of 98 patients. There was heterogeneity in results reporting, with recurrence free survival the most reported outcome. For all studies reporting on liver metastasectomy, the one-year overall survival rate was 87%. In studies with adequate follow-up reported, the three and five-year overall survival rates were 53% and 38% respectively. Only one study reported on lung metastasectomy patients; the overall median survival was 24 months. None of the studies reported on quality of life measures. The ROBINS-I tool identified a critical risk of bias in six studies, a serious risk in one study and a moderate risk in three studies.

CONCLUSIONS

The evidence base for metastasectomy in metastatic anal SCC is limited. Further information is required to inform future treatment methods and use of a standardised outcomes reporting method is needed to support this.

The empty pelvis syndrome: a core data set from the PelvEx collaborative

BACKGROUND

Empty pelvis syndrome (EPS) is a significant source of morbidity following pelvic exenteration (PE), but is undefined. EPS outcome reporting and descriptors of radicality of PE are inconsistent; therefore, the best approaches for prevention are unknown. To facilitate future research into EPS, the aim of this study is to define a measurable core outcome set, core descriptor set and written definition for EPS. Consensus on strategies to mitigate EPS was also explored.

METHOD

Three-stage consensus methodology was used: longlisting with systematic review, healthcare professional event, patient engagement, and Delphi-piloting; shortlisting with two rounds of modified Delphi; and a confirmatory stage using a modified nominal group technique. This included a selection of measurement instruments, and iterative generation of a written EPS definition.

RESULTS

One hundred and three and 119 participants took part in the modified Delphi and consensus meetings, respectively. This encompassed international patient and healthcare professional representation with multidisciplinary input. Seventy statements were longlisted, seven core outcomes (bowel obstruction, enteroperineal fistula, chronic perineal sinus, infected pelvic collection, bowel obstruction, morbidity from reconstruction, re-intervention, and quality of life), and four core descriptors (magnitude of surgery, radiotherapy-induced damage, methods of reconstruction, and changes in volume of pelvic dead space) reached consensus-where applicable, measurement of these outcomes and descriptors was defined. A written definition for EPS was agreed.

CONCLUSIONS

EPS is an area of unmet research and clinical need. This study provides an agreed definition and core data set for EPS to facilitate further research.

Factors associated with vertical transmission of HIV in the Western Cape, South Africa: a retrospective cohort analysis

INTRODUCTION

Monitoring mother-infant pairs with HIV exposure is needed to assess the effectiveness of vertical transmission (VT) prevention programmes and progress towards VT elimination.

METHODS

We used routinely collected data on infants with HIV exposure, born May 2018-April 2021 in the Western Cape, South Africa, with follow-up through mid-2022. We assessed the proportion of infants diagnosed with HIV at birth (≤7 days), 10 weeks (>1 to 14 weeks) and >14 weeks as proxies for intrauterine, intrapartum/early breastfeeding and late breastfeeding transmission, respectively. We used mixed-effects Poisson regression to assess factors associated with VT in mothers known with HIV by delivery.

RESULTS

We included 50,461 infants born to mothers known with HIV by delivery. HIV was diagnosed in 894 (1.8%) infants. Among mothers, 51% started antiretroviral treatment (ART) before and 27% during pregnancy; 17% restarted during pregnancy after ≥6 months interruption; and 6% had no recorded ART during pregnancy. Most pregnancy ART regimens included non-nucleoside reverse transcriptase inhibitors (83%). Of mothers with available results (90% with viral load [VL]; 70% with CD4), VL nearest delivery was <100 copies/ml in 78% and CD4 count ≥350 cells/μl in 62%. HIV-PCR results were available for 86%, 67% and 48% of eligible infants at birth, 10 weeks and >14 weeks. Among these infants, 0.9%, 0.4% and 1.5% were diagnosed positive at birth, 10 weeks and >14 weeks, respectively. Among infants diagnosed with HIV, 43%, 16% and 41% were diagnosed at these respective time periods. Among mothers with VL<100, 100-999, 1000-99,000 and ≥100,000 copies/ml nearest delivery, infant HIV diagnosis incidence was 0.4%, 2.3%, 6.6% and 18.4%, respectively. Increased VT was strongly associated with recent elevated maternal VL with a seven-fold increased rate with even modestly elevated VL (100-999 vs. <100 copies/ml). VT was also associated with unknown/low maternal CD4, maternal age <20 years, no antenatal ART, later maternal ART start/restart in pregnancy and ART gaps.

CONCLUSIONS

Despite high maternal ART coverage and routine postnatal prophylaxis, ongoing VT remains a concern. Timing of infant HIV diagnoses suggests intrapartum and/or breastfeeding transmission in nearly 60%. Interventions to ensure retention on ART and sustained maternal viral suppression are needed to reduce VT.

Change in HIV-related characteristics of children hospitalised with infectious diseases in Western Cape, South Africa, 2008-2021: a time trend analysis

INTRODUCTION

With the scaling up of vertical HIV transmission prevention programmes, the HIV-related population profile of children in South Africa has shifted. We described temporal changes in HIV-related characteristics of children, aged ≤3 years (up to the third birthday), with infectious disease hospitalisations across the Western Cape province.

METHODS

We used routinely collected electronic data to identify children born in the Western Cape with infectious disease hospital records for lower respiratory tract infections, diarrhoea, meningitis and tuberculous meningitis, from 2008 to 2021. Linked maternal and child unique identifiers were used to extract pregnancy, HIV-related, laboratory, pharmacy and hospitalisation data. We described temporal changes in child HIV exposure and acquisition status, timing of maternal HIV diagnosis and antiretroviral therapy (ART) start, infant exposure to maternal ART and timing thereof, and maternal CD4 and HIV viral load closest to delivery. We used logistic and multinomial regression to assess changes in characteristics between the Pre-Option B+ (2008-2013), Option B+ (2013-2016) and Universal ART periods (2016-2021).

RESULTS

Among 52,811 children aged ≤3 years with hospitalisations, the proportion living with HIV dreased from 7.0% (2008) to 1.1% (2021), while those exposed to HIV and uninfected increased from 14.0% (2008) to 16.1% (2021) with a peak of 18.3% in 2017. Among mothers with HIV (n = 9873), the proportion diagnosed with HIV and starting ART before pregnancy increased from 20.2% to 69.2% and 5.8% to 59.0%, respectively, between 2008 and 2021. Children hospitalised during the Universal ART period had eight times higher odds (Odds Ratio: 8.41; 95% CI: 7.36-9.61) of exposure to maternal ART versus children admitted Pre-Option B+. Among mothers of children exposed to HIV and uninfected with CD4 records (n = 7523), the proportion with CD4 <350 cells/μl decreased from 90.6% (2008) to 27.8% (2021).

CONCLUSIONS

In recent years, among children hospitalised with infectious diseases, there were fewer children with perinatally acquired HIV, while an increased proportion of those without HIV acquisition are exposed to maternal HIV and ART. There is a need to look beyond paediatric HIV prevalence and consider child exposure to HIV and ART among children without HIV, when assessing the HIV epidemic's impact on child health services.

COVID-19 among adults living with HIV: correlates of mortality among public sector healthcare users in Western Cape, South Africa

INTRODUCTION

While a large proportion of people with HIV (PWH) have experienced SARS-CoV-2 infections, there is uncertainty about the role of HIV disease severity on COVID-19 outcomes, especially in lower-income settings. We studied the association of mortality with characteristics of HIV severity and management, and vaccination, among adult PWH.

METHODS

We analysed observational cohort data on all PWH aged ≥15 years experiencing a diagnosed SARS-CoV-2 infection (until March 2022), who accessed public sector healthcare in the Western Cape province of South Africa. Logistic regression was used to study the association of mortality with evidence of antiretroviral therapy (ART) collection, time since first HIV evidence, CD4 cell count, viral load (among those with evidence of ART collection) and COVID-19 vaccination, adjusting for demographic characteristics, comorbidities, admission pressure, location and time period.

RESULTS

Mortality occurred in 5.7% (95% CI: 5.3,6.0) of 17,831 first-diagnosed infections. Higher mortality was associated with lower recent CD4, no evidence of ART collection, high or unknown recent viral load and recent first HIV evidence, differentially by age. Vaccination was protective. The burden of comorbidities was high, and tuberculosis (especially more recent episodes of tuberculosis), chronic kidney disease, diabetes and hypertension were associated with higher mortality, more strongly in younger adults.

CONCLUSIONS

Mortality was strongly associated with suboptimal HIV control, and the prevalence of these risk factors increased in later COVID-19 waves. It remains a public health priority to ensure PWH are on suppressive ART and vaccinated, and manage any disruptions in care that occurred during the pandemic. The diagnosis and management of comorbidities, including for tuberculosis, should be optimized.

Peritoneal dialysis outcomes in a tertiary-level state hospital in Johannesburg, South Africa: Ethnicity and HIV co-infection do not increase risk of peritonitis or discontinuation

BACKGROUND

Peritoneal dialysis (PD) is a valuable means to increase access to kidney replacement therapy in South Africa (SA). An increased rate of modality discontinuation related to an increased risk of peritonitis in patients of black African ethnicity, in those with diabetes and in those living with HIV has previously been suggested, which may lead to hesitancy in adoption of 'PD first' programmes.

OBJECTIVES

To analyse the safety of a PD-first programme in terms of 5-year peritonitis risk and patient and modality survival at the outpatient PD unit at Helen Joseph Hospital, Johannesburg.

METHODS

After exclusions, clinical data from 120 patients were extracted for analysis. The effects of patient age at PD initiation, ethnicity, gender, diabetes mellitus and HIV infection on patient and modality survival and peritonitis risk were analysed using Cox proportional hazards modelling and logistic regression analysis. Five-year technique and patient Kaplan-Meier survival curves for peritonitis and comorbidity groups were compared using the Cox-Mantel test. The Mann-Whitney U-test and Fisher's exact test were used to compare continuous and categorical variables where appropriate.

RESULTS

Five-year patient survival was 49.9%. Black African ethnicity was associated with reduced mortality hazard (hazard ratio (HR) 0.33; 95% confidence interval (CI) 0.15 - 0.71; p=0.004), and patients with diabetes had poorer 5-year survival (19.1%; p=0.097). Modality survival at 5 years was 48.1%. Neither Black African ethnicity nor HIV infection increased the risk of PD discontinuation. Peritonitis was associated with increased modality failure (HR 2.99; 95% CI 1.31 - 6.87; p=0.009). Black African ethnicity did not increase the risk of peritonitis. HIV was not independently associated with an increased risk of peritonitis. Patient and PD survival were generally similar to other contemporaneous cohorts, and the peritonitis rate in this study was within the International Society for Peritoneal Dialysis acceptable range.

CONCLUSION

PD is a safe and appropriate therapy in a low socioeconomic setting with a high prevalence of HIV infection. Consideration of home circumstances and training in sterile technique reduce peritonitis risk and improve PD modality survival. Patients with diabetes may be at risk of poorer outcomes on PD.

Prevalence of undiagnosed HIV among children in South Africa, Côte d'Ivoire and Zimbabwe: a model-based analysis to inform paediatric HIV screening programmes

INTRODUCTION

To improve the diagnosis and survival of children living with HIV (CLWH), the World Health Organization recommends testing approaches beyond traditional infant HIV testing programmes. Information about undiagnosed HIV prevalence among children of varying ages in the general population is needed to guide innovative national/subnational case-finding and testing approaches.

METHODS

We used the Cost-Effectiveness of Preventing AIDS Complications (CEPAC)-Pediatric model to estimate the prevalence of undiagnosed HIV in 2-, 5- and 10-year-old children in South Africa, Côte d'Ivoire and Zimbabwe in 2018. We simulated cohorts of children born in 2008 (10-year-olds), 2013 (5-year-olds) and 2016 (2-year-olds). Country-/year-specific inputs for pregnant/breastfeeding women included: HIV prevalence (4.2-32.3%), HIV incidence (0.03-0.24%/month), knowledge of HIV status (27-89%) and antiretroviral drug coverage (36-95%). Paediatric inputs included early infant testing coverage (6-95%) and breastfeeding duration (0-20 months). We projected the proportion of surviving CLWH in whom HIV remained undiagnosed and the undiagnosed HIV prevalence among surviving children of each age in the general population. For children born in 2016, we projected survival and diagnosis of all CLWH through 2026. We conducted sensitivity analyses on model parameters.

RESULTS

In 2018, the projected proportion of surviving CLWH whose HIV remained undiagnosed in South Africa/Côte d'Ivoire/Zimbabwe was 44.2%/55.8%/52.9% among 2-year-old CLWH; 29.0%/37.8%/33.2% among 5-year-old CLWH; and 18.3%/25.4%/23.1% among 10-year-old CLWH. Projected general population undiagnosed HIV prevalence in South Africa/Côte d'Ivoire/Zimbabwe was 0.44%/0.32%/0.68% among 2-year-olds; 0.25%/0.17%/0.41% among 5-year-olds; and 0.24%/0.14%/0.38% among 10-year-olds. Among all CLWH born in 2016, 50-54% were projected to die without HIV diagnosis (and subsequently without treatment) within 10 years after birth; 80-85% of these deaths occurred in the first 2 years.

CONCLUSIONS

Projected population-level undiagnosed HIV prevalence is low and sharply decreases after age 2, with more CLWH dying than being diagnosed. Despite low undiagnosed prevalence in the general population of older children, we project that a large proportion of CLWH remain undiagnosed, suggesting that innovative strategies targeting untested children of all ages outside of health facility settings should be prioritized. Programmes could consider routine testing of the general population of children below 2 in all settings and children of all ages in high-prevalence settings.

The household economic burden of drug-susceptible TB diagnosis and treatment in The Gambia

OBJECTIVE: To determine the costs and catastrophic costs incurred by drug-susceptible (DS) pulmonary TB patients in The Gambia.METHODS: This observational study collected cost and socio-economic data using a micro-costing approach from the household perspective from 244 adult DS-TB patients with pulmonary TB receiving treatment through the national treatment programme in The Gambia. We used data collected between 2017 and 2020 using an adapted version of the WHO generic patient cost survey instrument to estimate costs and the proportion of patients experiencing catastrophic costs (≥20% of household income).RESULTS: The mean total cost of the TB episode was $104.11 (2018 USD). Direct costs were highest before treatment ($22.93). Indirect costs accounted for over 50% of the entire episode costs. Using different income estimation approaches and catastrophic cost thresholds, 0.4-75% of participants encountered catastrophic costs, showing the variability of results given the different assumptions we utilised.CONCLUSIONS: We show that despite the benefits of free TB care and treatment, DS-TB patients still incur substantial direct and indirect costs, and cases of impoverishing expenditure varied vastly depending on the income estimation approaches used.

Minimum standards of pelvic exenterative practice: PelvEx Collaborative guideline

This document outlines the important aspects of caring for patients who have been diagnosed with advanced pelvic cancer. It is primarily aimed at those who are establishing a service that adequately caters to this patient group. The relevant literature has been summarized and an attempt made to simplify the approach to management of these complex cases.

Age and the anaesthetist: considerations for the individual anaesthetist and workforce planning: Guidelines about the ageing anaesthetic workforce from the Association of Anaesthetists: Guidelines for the ageing anaesthetic workforce from the Association of Anaesthetists

There is clear evidence of a growing workforce gap and this is compounded by demographic data that show the current workforce is ageing. Within the current workforce, more doctors are taking voluntary early retirement and the loss of these experienced clinicians from departments can have wide-ranging effects. Older doctors are at risk of age-related health problems (e.g. sight, musculoskeletal, menopause) and are more susceptible to the effects of fatigue, which may increase the risk of error and or complaint. The purpose of this working party and advocacy campaign was to address concerns over the number of consultants retiring at the earliest opportunity and whether a different approach could extend the working career of consultant anaesthetists and SAS doctors. This could be viewed as 'pacing your career'. The earlier this is considered in a clinician's career the greater the potential mitigation on individuals.

Incisional hernia following colorectal cancer surgery according to suture technique: Hughes Abdominal Repair Randomized Trial (HART)

BACKGROUND

Incisional hernias cause morbidity and may require further surgery. HART (Hughes Abdominal Repair Trial) assessed the effect of an alternative suture method on the incidence of incisional hernia following colorectal cancer surgery.

METHODS

A pragmatic multicentre single-blind RCT allocated patients undergoing midline incision for colorectal cancer to either Hughes closure (double far-near-near-far sutures of 1 nylon suture at 2-cm intervals along the fascia combined with conventional mass closure) or the surgeon's standard closure. The primary outcome was the incidence of incisional hernia at 1 year assessed by clinical examination. An intention-to-treat analysis was performed.

RESULTS

Between August 2014 and February 2018, 802 patients were randomized to either Hughes closure (401) or the standard mass closure group (401). At 1 year after surgery, 672 patients (83.7 per cent) were included in the primary outcome analysis; 50 of 339 patients (14.8 per cent) in the Hughes group and 57 of 333 (17.1 per cent) in the standard closure group had incisional hernia (OR 0.84, 95 per cent c.i. 0.55 to 1.27; P = 0.402). At 2 years, 78 patients (28.7 per cent) in the Hughes repair group and 84 (31.8 per cent) in the standard closure group had incisional hernia (OR 0.86, 0.59 to 1.25; P = 0.429). Adverse events were similar in the two groups, apart from the rate of surgical-site infection, which was higher in the Hughes group (13.2 versus 7.7 per cent; OR 1.82, 1.14 to 2.91; P = 0.011).

CONCLUSION

The incidence of incisional hernia after colorectal cancer surgery is high. There was no statistical difference in incidence between Hughes closure and mass closure at 1 or 2 years.

REGISTRATION NUMBER

ISRCTN25616490 (http://www.controlled-trials.com).

Outcomes of laboratory-confirmed SARS-CoV-2 infection in the Omicron-driven fourth wave compared with previous waves in the Western Cape Province, South Africa

OBJECTIVES

The objective was to compare COVID-19 outcomes in the Omicron-driven fourth wave with prior waves in the Western Cape, assess the contribution of undiagnosed prior infection to differences in outcomes in a context of high seroprevalence due to prior infection and determine whether protection against severe disease conferred by prior infection and/or vaccination was maintained.

METHODS

In this cohort study, we included public sector patients aged ≥20 years with a laboratory-confirmed COVID-19 diagnosis between 14 November and 11 December 2021 (wave four) and equivalent prior wave periods. We compared the risk between waves of the following outcomes using Cox regression: death, severe hospitalisation or death and any hospitalisation or death (all ≤14 days after diagnosis) adjusted for age, sex, comorbidities, geography, vaccination and prior infection.

RESULTS

We included 5144 patients from wave four and 11,609 from prior waves. The risk of all outcomes was lower in wave four compared to the Delta-driven wave three (adjusted hazard ratio (aHR) [95% confidence interval (CI)] for death 0.27 [0.19; 0.38]. Risk reduction was lower when adjusting for vaccination and prior diagnosed infection (aHR: 0.41, 95% CI: 0.29; 0.59) and reduced further when accounting for unascertained prior infections (aHR: 0.72). Vaccine protection was maintained in wave four (aHR for outcome of death: 0.24; 95% CI: 0.10; 0.58).

CONCLUSIONS

In the Omicron-driven wave, severe COVID-19 outcomes were reduced mostly due to protection conferred by prior infection and/or vaccination, but intrinsically reduced virulence may account for a modest reduction in risk of severe hospitalisation or death compared to the Delta-driven wave.

Growth and CD4 patterns of adolescents living with perinatally acquired HIV worldwide, a CIPHER cohort collaboration analysis

INTRODUCTION

Adolescents living with HIV are subject to multiple co-morbidities, including growth retardation and immunodeficiency. We describe growth and CD4 evolution during adolescence using data from the Collaborative Initiative for Paediatric HIV Education and Research (CIPHER) global project.

METHODS

Data were collected between 1994 and 2015 from 11 CIPHER networks worldwide. Adolescents with perinatally acquired HIV infection (APH) who initiated antiretroviral therapy (ART) before age 10 years, with at least one height or CD4 count measurement while aged 10-17 years, were included. Growth was measured using height-for-age Z-scores (HAZ, stunting if <-2 SD, WHO growth charts). Linear mixed-effects models were used to study the evolution of each outcome between ages 10 and 17. For growth, sex-specific models with fractional polynomials were used to model non-linear relationships for age at ART initiation, HAZ at age 10 and time, defined as current age from 10 to 17 years of age.

RESULTS

A total of 20,939 and 19,557 APH were included for the growth and CD4 analyses, respectively. Half were females, two-thirds lived in East and Southern Africa, and median age at ART initiation ranged from <3 years in North America and Europe to >7 years in sub-Saharan African regions. At age 10, stunting ranged from 6% in North America and Europe to 39% in the Asia-Pacific; 19% overall had CD4 counts <500 cells/mm3 . Across adolescence, higher HAZ was observed in females and among those in high-income countries. APH with stunting at age 10 and those with late ART initiation (after age 5) had the largest HAZ gains during adolescence, but these gains were insufficient to catch-up with non-stunted, early ART-treated adolescents. From age 10 to 16 years, mean CD4 counts declined from 768 to 607 cells/mm3 . This decline was observed across all regions, in males and females.

CONCLUSIONS

Growth patterns during adolescence differed substantially by sex and region, while CD4 patterns were similar, with an observed CD4 decline that needs further investigation. Early diagnosis and timely initiation of treatment in early childhood to prevent growth retardation and immunodeficiency are critical to improving APH growth and CD4 outcomes by the time they reach adulthood.

Risk-Reducing Salpingo-Oophorectomy and the Use of Hormone Replacement Therapy Below the Age of Natural Menopause: Scientific Impact Paper No. 66 October 2021: Scientific Impact Paper No. 66

This paper deals with the use of hormone replacement therapy (HRT) after the removal of fallopian tubes and ovaries to prevent ovarian cancer in premenopausal high risk women. Some women have an alteration in their genetic code, which makes them more likely to develop ovarian cancer. Two well-known genes which can carry an alteration are the BRCA1 and BRCA2 genes. Examples of other genes associated with an increased risk of ovarian cancer include RAD51C, RAD51D, BRIP1, PALB2 and Lynch syndrome genes. Women with a strong family history of ovarian cancer and/or breast cancer, may also be at increased risk of developing ovarian cancer. Women at increased risk can choose to have an operation to remove the fallopian tubes and ovaries, which is the most effective way to prevent ovarian cancer. This is done after a woman has completed her family. However, removal of ovaries causes early menopause and leads to hot flushes, sweats, mood changes and bone thinning. It can also cause memory problems and increases the risk of heart disease. It may reduce libido or impair sexual function. Guidance on how to care for women following preventative surgery who are experiencing early menopause is needed. HRT is usually advisable for women up to 51 years of age (average age of menopause for women in the UK) who are undergoing early menopause and have not had breast cancer, to minimise the health risks linked to early menopause. For women with a womb, HRT should include estrogen coupled with progestogen to protect against thickening of the lining of the womb (called endometrial hyperplasia). For women without a womb, only estrogen is given. Research suggests that, unlike in older women, HRT for women in early menopause does not increase breast cancer risk, including in those who are BRCA1 and BRCA2 carriers and have preventative surgery. For women with a history of receptor-negative breast cancer, the gynaecologist will liaise with an oncology doctor on a case-by-case basis to help to decide if HRT is safe to use. Women with a history of estrogen receptor-positive breast cancer are not normally offered HRT. A range of other therapies can be used if a woman is unable to take HRT. These include behavioural therapy and non-hormonal medicines. However, these are less effective than HRT. Regular exercise, healthy lifestyle and avoiding symptom triggers are also advised. Whether to undergo surgery to reduce risk or not and its timing can be a complex decision-making process. Women need to be carefully counselled on the pros and cons of both preventative surgery and HRT use so they can make informed decisions and choices.

356 An Unfortunate Case of Spinal Injury and Bladder Dysfunction During the Covid-19 Pandemic

There is no doubt that COVID-19 has had a profound impact on every medical and surgical speciality. In the height of the pandemic many non-emergency services were shut down, including dental services, with unexpected consequences. We present a case which highlights the unexpected and indirect consequences of a national lockdown on a Urology patient and discuss learning points.

A 54-year-old male, previously fit and well suffered with a small dental abscess, media outlets were reporting that dental surgeries were closed, and he therefore attempted to drain the abscess himself. The infection spread to his epidural space, causing compression via a collection at L2 and consequently spinal cord injury. This was managed with urgent lumbar decompression and antibiotics.

A specialist functional urology team were involved after his transfer to the tertiary spinal unit 3 months after his first presentation. He was catheterised but suffered with recurrent catheter blockages. Video urodynamics demonstrated a stable bladder with a low-pressure leak point, managed with urethral catheterisation. A repeat video urodynamics demonstrated a loss of compliance and stress incontinence. Unclear as to whether he would regain function rehabilitation techniques are currently being attempted prior for definitive operative management with an artificial sphincter.

This case highlights the indirect impact of COVID-19 on UK urology services, and this has not been widely reported.

965 Complication Rates in Operatively Managed Ankle Fracture/Dislocations - The Effect of Pre-Reduction Imaging and Compliance with BOAST 12 Guidance

Aim

The BOAST-12 guidelines for the management of ankle fractures aims to optimise functional recovery and reduce complications. They advise against having radiographs prior to urgent reduction of clinically deformed ankles as it could cause an unacceptable delay to subsequent management. Our study aimed to assess the effect of time to acceptable reduction on the risk of complications and time to definitive reduction.

Method

This was a retrospective observational study of patients with ankle fracture-dislocations between 2013 to 2017 at the Northern General Hospital’s Emergency Department (ED). Information collected from 2 patient groups (with and without pre-reduction radiographs), included patient demographics, time to accepted reduction, number of manipulations, operations, and subsequent complications.

Results

242 patients were identified. Time from arrival in ED to acceptable reduction was significantly longer in patients with pre-reduction radiographs versus patients without (184.5 vs 82 minutes, p &lt; 0.00), but did not increase the overall risk of complications (p = 0.62). Pre-reduction radiographs were associated with insignificantly higher rates of post-traumatic osteoarthritis (p = 0.17) and slightly longer wait time for definitive intervention (1 vs 2 days, p = 0.72). However, this had no relationship with the number of manipulations (p = 0.53).

Conclusions

The use of pre-reduction radiographs significantly increased time to acceptable reduction of ankle fracture-dislocations. However, this was not associated with increased risk of complications or time to definitive management.

Global HIV mortality trends among children on antiretroviral treatment corrected for under-reported deaths: an updated analysis of the International epidemiology Databases to Evaluate AIDS collaboration

INTRODUCTION

The Joint United Nations Programme on HIV/AIDS (UNAIDS) projections of paediatric HIV prevalence and deaths rely on the International epidemiology Databases to Evaluate AIDS (IeDEA) consortium for mortality estimates among children living with HIV (CHIV) receiving antiretroviral therapy (ART). Previous estimates, based on data through 2014, may no longer be accurate due to expanded paediatric HIV care and treatment eligibility, and the possibility of unreported deaths in CHIV considered lost to follow-up (LTFU). We therefore estimated all-cause mortality and its trends in CHIV (<15 years old) on ART using extended and new IeDEA data.

METHODS

We analysed (i) IeDEA observational data from CHIV in routine care globally, and (ii) novel data from an IeDEA tracing study that determined outcomes in a sample of CHIV after being LTFU in southern Africa. We included 45,711 CHIV on ART during 2004 to 2017 at 72 programmes in Africa, Asia-Pacific and Latin America. We used mixed effects Poisson regression to estimate mortality by age, sex, CD4 at ART start, time on ART, region and calendar year. For Africa, in an adjusted analysis that accounts for unreported deaths among those LTFU, we first modified the routine data by simulating mortality outcomes within six months after LTFU, based on a Gompertz survival model fitted to the tracing data (n = 221).

RESULTS

Observed mortality rates were 1.8 (95% CI: 1.7 to 1.9) and 9.4 (6.3 to 13.4) deaths per 100 person-years in the routine and tracing data, respectively. We found strong evidence of higher mortality at shorter ART durations, lower CD4 values, and in infancy. Averaging over covariate patterns, the adjusted mortality rate was 54% higher than the unadjusted rate. In unadjusted analyses, mortality reduced by an average 60% and 73% from 2005 to 2017, within and outside of Africa, respectively. In the adjusted analysis for Africa, this temporal reduction was 42%.

CONCLUSIONS

Mortality rates among CHIV have decreased substantially over time. However, when accounting for worse outcomes among those LTFU, mortality estimates increased and temporal improvements were slightly reduced, suggesting caution in interpreting analyses based only on programme data. The improved and updated IeDEA estimates on mortality among CHIV on ART support UNAIDS efforts to accurately model global HIV statistics.

P–712 Ovulation induction in type 1 anovulation: a comparative study using gonadotrophins and the GnRH pump

Study question

Is there a difference in treatment outcome between gonadotrophin releasing hormone (GnRH) pump or hMG for women with Type 1 anovulation undergoing ovulation induction?

Summary answer

Treatment with GnRH was more efficient compared to hMG, with fewer number of cycles to pregnancy, fewer days of stimulation and fewer cycle cancellations.

What is known already

Whilst there is a lot of information on ovulation induction in WHO type II anovulation (PCOS), type 1 anovulation is under-represented in research. WHO type 1 anovulation is characterised by low pituitary gonadotrophins and oestradiol. Treatment options used to include induction of ovulation using gonadotrophins (hMG) or the Gonadotrophin hormone releasing hormone (GnRH) pump delivering pulsatile GnRH. Since the withdrawal of GnRH pump, options have become limited. One study reveals that monofollicular cycles are lower and cycle cancellation higher in women with Type 1 anovulation women treated with gonadotrophins. Study design, size, duration: This is a single centre retrospective cohort study. All women with a diagnosis of WHO type 1 anovulation attending the Reproductive Medicine Unit at the University College London Hospital who received ovulation induction treatment using either hMG or GnRH pump between 1993 and 2020 were included in the study

Participants/materials, setting, methods

147 women with WHO type 1 anovulation were included in the study. Diagnosis was based on the presence of primary or secondary amenorrhoea in combination with low gonadotrophins and oestradiol. Demographic and clinical data were obtained by reviewing medical records stored within an electronic database. A total of 599 treatment cycles were identified. Statistical analysis between the groups was performed using the independent T test and chi squared test.

Main results and the role of chance

147 women with WHO type 1 anovulation underwent ovulation induction. hMG was used in 500 cycles (83.5%) and the GnRH pump in 99 cycles (16.5%). Per cycle started the pregnancy rate in the hMG cycles was 107/500 (21.4%) and in the GnRH pump cycles was 19/99 (19.2%) p = 0.36. Cycle cancellation was significantly greater in hMG than GnRH pump cycles (hMG 137/ 500 27.4% vs GnRH pump 17/99 17.2% p = 0.02). Over response was more common in hMG cycles than GnRH pump cycles (66/130 50.8% vs 3/16 18.8% p = 0.01). A total of 363/500 (72.5%) cycles in the hMG and 82/99 (82.8%) cycles in the GnRH pump group reached ovulation. There was no difference in the pregnancy rate after ovulation (hMG 107/363 29.5% vs GnRH pump 19/82 23.2% p = 0.15). The mean number of treatment cycles to achieve pregnancy was significantly fewer with the GnRH pump compared to hMG (1.8 (min 1 – max 3) vs 2.4 ( min 1 – max 8) p = 0.03).The mean days of stimulation required to reach ovulation was also significantly less with the GnRH pump compared to hMG (16.7 (min 8 – max 34) vs 23.4 (min 7 – max 72) p = &lt;0.001).

Limitations, reasons for caution

This is a retrospective cohort study and is reliant on the quality and quantity of the data entry at the time of clinical treatment.

Wider implications of the findings: Ovulation induction for women with type 1 anovulation is now restricted to a single treatment, namely hMG. hMG is not as effective or optimal as GnRH. Reinstating GnRH in routine clinical practice should be promoted to allow more individualised treatment options and prevent the premature need for in vitro fertilisation..

Trial registration number

NA

P–384 First trimester pregnancy outcomes after confirmed SARS-CoV–2 infection in the community; a nationwide prospective longitudinal study of 10,000 pregnant women from the COVID–19 pandemic

Study question

Are pregnant women in the community with confirmed diagnosis of SARS-CoV–2 infection, at increased risk of an early miscarriage?

Summary answer

Women diagnosed with COVID–19 in their first trimester were not at increased risk of an early miscarriage. What is known already: In the earliest stages of the pandemic, the Human Fertilisation and Embryology Authority and the European Society of Human Reproduction and Embryology, independently advised against starting assisted reproductive treatments. At the time of this recommendation, among other reasons, there were concerns about the complications of SARS-CoV–2 during pregnancy and the potential for vertical transmission.

We now having growing evidence that pregnant women are at an increased risk of severe illness along with higher rates of preterm births in those with severe acute respiratory syndrome. However, data on the impact of community infections of SARS-CoV–2 in early pregnancy has been sparse.

Study design, size, duration

This is an online survey study undertaken in the UK between May and November 2020. Pregnant women at any stage in their pregnancy were invited to participate in the study. Study participants were asked to complete online surveys at the end of each trimester. 10, 430 women were recruited to take part in the study. Participants/materials, setting, methods: We analysed pregnancy outcomes from women who were under 13 weeks gestation at the time of registration. We compared miscarriage rates among women with a confirmed diagnosis of SARS-CoV–2 infection to healthy controls. Those in the control group had not been diagnosed with or had symptoms of SARS-CoV–2 infection nor did they have any household contacts that were diagnosed with or had symptoms of SARS-CoV–2 infection.

Main results and the role of chance

10, 430 pregnant women were recruited to participate in the study. 2934 were under 13 weeks gestation at the time of registration. The median age was 32.6 [IQR 29.8–35.6]. The median gestational age at registration was 8 weeks [IQR [6–10]. 246 women reported a miscarriage before 13 weeks of gestation. The overall miscarriage rate before 13 weeks of gestation was 8.4% (95% CI 7.3%–9.4%).

68 women reported a confirmed diagnosis of SARS-CoV–2 infection in their first trimester. The overall rate of confirmed SARS-CoV–2 infections in the first trimester was 2.3% (95% CI 1.8–2.9%). 3/68 (4.4%) were asymptomatic. Among those reporting symptoms, the commonest symptoms were fatigue (82%), headache (69%) and loss of smell/taste (69%). Only 38% of those with a confirmed diagnosis reported a fever. None of the 68 women with confirmed diagnosis of SARS-CoV–2 infection were hospitalised.

The rate of miscarriage before 13 weeks of gestation in women who were diagnosed with SARS-CoV–2 infections was not significantly higher compared to healthy controls (11.8% versus 9.3%, p = 0.35). A further 35 women had household contacts with confirmed SARS-CoV–2 infection although they themselves had not been diagnosed. No miscarriages were reported in this group.

Limitations, reasons for caution

None of the 68 patients diagnosed with SARS-CoV–2 were hospitalised. We do not know whether the rate of miscarriage among hospitalised women with SARS-CoV–2 infection is the same as those with community infections.

Wider implications of the findings: The overall rate of miscarriage during the pandemic was not higher than rates occurring outside of the pandemic. The rate of miscarriage among women diagnosed with SARS-CoV–2 infection was not significantly higher compared to healthy controls. This data can be used to counsel women planning a pregnancy during this pandemic

Trial registration number

Not applicable

P–592 Safety and effectiveness of follitropin alfa biosimilar to originator follitropin alfa in real-world clinical practice: A Multinational Comparative, Prospective Cohort Study

Study question

Are safety and effectiveness of Ovaleap® (follitropin alfa), and Gonal-f®, comparable in one treatment cycle of ART in routine clinical practice?

Summary answer

Safety in terms of incidence proportions of OHSS and OHSS severity, as well as pregnancy and live birth rates, were similar between Ovaleap® and Gonal-f®.

What is known already

Ovaleap® (Theramex), a r-hFSH, is a biosimilar medicinal product to Gonal-f® (Merck). As a biosimilar, it went through a rigorous series of physio-chemical, in vitro, in vivo tests and confirmatory Phase I and III studies, to demonstrate similarity/equivalence in quality, safety and efficacy to the reference medicinal product, per the European Medicines Agency (EMA) guidelines. Ovaleap® was approved by the EMA in 2013 for use at the same dose and for the same therapeutic indications as Gonal-f®. Further outcome data from a broader patient population on safety and live birth outcomes provides clinically important insights on newly introduced FSH medicines.

Study design, size, duration

SOFIA (Safety of Ovaleap® Follitropin alfa in Infertile women undergoing superovulation for Assisted reproductive technologies) was a multi-national, comparative, non-interventional, prospective cohort study. The study was performed at 56 centers specializing in ART from six European countries, (Belgium, France, Germany, Italy, Spain, and the United Kingdom) from January 2017 to September 2019 and comprised of 817 infertile women undergoing controlled ovarian hyperstimulation in one treatment cycle for ART

Participants/materials, setting, methods

The study population comprised of infertile women undergoing controlled ovarian hyperstimulation for ART, who were administered Ovaleap® or Gonal-f® and were naïve to any FSH containing products. Eligible patients were enrolled at a ratio of approximately 1:1, both within and between countries. They were followed up to 30 days after the last FSH dose administration. Women who had a confirmed clinical pregnancy were followed until the end of the pregnancy or until delivery.

Main results and the role of chance

A total of 408 and 409 women who were administered Ovaleap® or Gonal-f®, respectively, were eligible for analysis. A total of 382 patients (94%) in the Ovaleap® and 390 patients (95%) in the Gonal-f® cohort completed FSH treatment (up to oocyte maturation triggering), respectively. The two cohorts were generally similar with regard to demographic and baseline characteristics. The incidence proportion of OHSS was 5.1% (95% CI: 3.4, 7.7) in the Ovaleap® and 3.2% (95% CI: 1.9, 5.4) in the Gonal-f® cohort. This difference in OHSS incidence proportion between the two cohorts was not statistically significant neither before (p = 0.159) nor after univariate adjustment for each potential confounder (p &gt; 0.05). The incidence proportion of OHSS severity grades was similar in the two treatment groups (3.4% versus 2.0% for Grade I, 1.2% versus 1.0% Grade II, and 0.5% versus 0.2% Grade III, in the Ovaleap® and Gonal-f® cohorts, respectively) and without a significant statistical difference (p = 0.865, for each grade). Among patients who had embryo transfer, clinical pregnancy rates were 33% and 31%, live birth rates 27% and 26% in the Ovaleap® and Gonal-f® cohorts, respectively.

Limitations, reasons for caution

Since treatment was non-randomised, the study may have been susceptible to selection bias. This was addressed at both the design stage, by balancing recruitment to a 1:1 ratio for Ovaleap® and Gonal-f® treatments, and also at the analysis stage in which, a univariate analysis was performed.

Wider implications of the findings: Findings from this first large European prospective comparative real-world SOFIA study demonstrated that effectiveness (pregnancy and delivery rates) and safety (risk and severity of OHSS), were similar between Ovaleap®and Gonal-f® treatments. Ovaleap, a biosimilar r-hFSH is therefore a suitable option for follicular stimulation in routine clinical practice.

Trial registration number

EUPAS17328

Trends in 30-day readmissions following hospitalisation for heart failure by sex, socioeconomic status and ethnicity

BACKGROUND

Reducing the high patient and economic burden of early readmissions after hospitalisation for heart failure (HF) has become a health policy priority of recent years.

METHODS

An observational study linking Hospital Episode Statistics to socioeconomic and death data in England (2002-2018). All first hospitalisations with a primary discharge code for HF were identified. Quasi-poisson models were used to investigate trends in 30-day readmissions by age, sex, socioeconomic status and ethnicity.

FINDINGS

There were 698,983 HF admissions, median age 81 years [IQR 14].In-hospital deaths reduced by 0.7% per annum (pa), whilst additional deaths at 30-days remained stable at 5%. Age adjusted 30-day readmissions (21% overall), increased by 1.4% pa (95% CI 1.3-1.5). Readmissions for HF (6%) and 'other cardiovascular disease (CVD)' (3%) remained stable, but readmissions for non-CVD causes (12%) increased at a rate of 2.6% (2.4-2.7) pa. Proportions were similar by sex but trends diverged by ethnicity. Black groups experienced an increase in readmissions for HF (1.8% pa, interaction-p 0.03) and South Asian groups had more rapidly increasing readmission rates for non-CVD causes (interaction-p 0.04). Non-CVD readmissions were also more prominent in the least (15%; 15-15) compared to the most affluent group (12%; 12-12). Strongest predictors for HF readmission were Black ethnicity and chronic kidney disease, whilst cardiac procedures were protective. For non-CVD readmissions, strongest predictors were non-CVD comorbidities, whilst cardiologist care was protective.

INTERPRETATION

In HF, despite readmission reduction policies, 30-day readmissions have increased, impacting the least affluent and ethnic minority groups the most.

FUNDING

NIHR.

A system dynamics-based scenario analysis of residential solid waste management in Kisumu, Kenya

The problem of solid waste management presents an issue of increasing importance in many low-income settings, including the progressively urbanised context of Kenya. Kisumu County is one such setting with an estimated 500 t of waste generated per day and with less than half of it regularly collected. The open burning and natural decay of solid waste is an important source of greenhouse gas (GHG) emissions and atmospheric pollutants with adverse health consequences. In this paper, we use system dynamics modelling to investigate the expected impact on GHG and PM_2.5 emissions of (i) a waste-to-biogas initiative and (ii) a regulatory ban on the open burning of waste in landfill. We use life tables to estimate the impact on mortality of the reduction in PM_2.5 exposure. Our results indicate that combining these two interventions can generate over 1.1 million tonnes of cumulative savings in GHG emissions by 2035, of which the largest contribution (42%) results from the biogas produced replacing unclean fuels in household cooking. Combining the two interventions is expected to reduce PM_2.5 emissions from the waste and residential sectors by over 30% compared to our baseline scenario by 2035, resulting in at least around 1150 cumulative life years saved over 2021–2035. The contribution and novelty of this study lies in the quantification of a potential waste-to-biogas scenario and its environmental and health impact in Kisumu for the first time.

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We present a system dynamics study of solid waste management in Kisumu, Kenya.

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Scenarios involve a waste-to-biogas initiative and a ban on open burning in landfill.

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Combined scenario generates 1.1m tonnes cumulative GHG savings by 2035.

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Largest contribution (42%) is from biogas substituting traditional cooking fuels.

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Combined scenario may save 1,150 cumulative life years by 2035, plus ~220 more p.a.

Home Energy Efficiency and Subjective Health in Greater London

The UK has introduced legislation that requires net-zero greenhouse gas emissions to be achieved by 2050. Improving the energy efficiency of homes is a key objective to help reach this target, and the UK government's Clean Growth Strategy aims to get many homes up to an Energy Performance Certificate (EPC) Band of C by 2035. The relationship between home energy-efficiency and occupant health and wellbeing remains an area of ongoing research. This paper explores the nexus between home energy efficiency, energy consumption and self-reported health-an indicator of the general health and wellbeing of the population. We focus on Greater London through secondary data analysis. Energy-efficiency ratings and air infiltration rates of dwellings, derived from EPCs, were aggregated and matched to local area self-reported health and energy consumption data obtained from the Greater London Authority's (GLA) Lower Layer Super Output Area (LSOA) Atlas database. Our regression model indicates that improving the energy efficiency (SAP) rating by 10 points for a typical home may reduce household gas consumption by around 7% (95% CIs: 2%, 14%). Beta regression finds a positive, but not statistically significant association between median SAP rating and the proportion of the population reporting 'good or very good' health when considering all Greater London LSOAs (z score = 0.60, p value = 0.55). A statistically significant positive association is observed however when repeating the analysis for the lowest income quartile LSOAs (z score = 2.03, p value = 0.04). This indicates that the least well-off may benefit most from home energy efficiency programs. A statistically significant positive association is also observed for the relationship between self-reported health and air infiltration rates (z score = 2.62, p value = 0.01). The findings support existing evidence for the predominantly naturally ventilated UK housing stock, suggesting that home energy efficiency measures provide a co-benefit for occupant health provided that adequate air exchange is maintained.

Links between the amount of antipsychotic medication prescribed per population at general practice level, local demographic factors and medication selection

BACKGROUND

Antipsychotic medications are the first-line pharmacological intervention for severe mental illnesses (SMI) such as schizophrenia and other psychoses, while also being used to relieve distress and treat neuropsychiatric symptoms in dementia. Our aim was to examine the factors relating to antipsychotic prescribing in general practices across England and how cost changes in recent years have impacted on antipsychotic prescribing.

METHODS

The study examined over time the prescribing volume and prices paid for antipsychotic medication by agent in primary care. Monthly prescribing in primary care was consolidated over 5 years (2013-2018) and DDD amount from WHO/ATC for each agent was used to convert the amount to total DDD/practice. The defined Daily Dose (DDD is the assumed average maintenance dose per day for a drug used for its main indication in adults.

RESULTS

We included 5750 general practices with practice population > 3000 and with > 30 people on their SMI register. In 2018/19 there were 10,360,865 prescriptions containing 136 million DDD with costs of £110 million at an average cost of £0.81/DDD issued in primary care. In 2017/18 there was a sharp increase in overall prices and they had not reduced to expected levels by the end of the 2018/19 evaluation year. There was a gradual increase in antipsychotic prescribing over 2013-2019 which was not perturbed by the increase in drug price in 2017/18. The strongest positive relation to increased prescribing of antipsychotics came from higher social disadvantage, higher population density (urban), and comorbidities e.g. chronic obstructive pulmonary disease (COPD). Higher % younger and % older populations, northerliness and non-white (Black and Minority Ethnic(BAME)) ethnicity were all independently associated with less antipsychotic prescribing. Higher DDD/general practice population was linked with higher proportion(%) injectable, higher %liquid, higher doses/prescription and higher %zuclopenthixol depot. Less DDD/population was linked with general practices using higher % risperidone and higher spending/dose of antipsychotic.

CONCLUSIONS

The levels of antipsychotic prescribing at general practice level are driven by social factors/comorbidities. We found a link between depot prescriptions with higher antipsychotic DDD and risperidone prescriptions with lower antipsychotic DDD. It is important that all prescribers are aware of these drivers / links.

Exploring the perceptions of emotional distress among couples living with Type 2 diabetes and among diabetes healthcare providers, and consideration of support needs

AIMS

To compare the emotional distress experienced by people with Type 2 diabetes with the perceptions of their partners, and to explore the perceptions of healthcare providers and how these differ from the perceptions and experiences of couples living with Type 2 diabetes regarding their support needs.

METHODS

A purposive sample of people with Type 2 diabetes and their partners was recruited through Diabetes UK media outlets and support groups, while healthcare providers were recruited through hospital and diabetes education teams. Inductive thematic analysis was conducted.

RESULTS

Seven people with Type 2 diabetes and six partners took part in separate semi-structured interviews and seven healthcare providers took part in focus groups. Themes emerged regarding unique psychological struggles for people with Type 2 diabetes: 'sense of restriction'; 'disempowerment'; and 'acceptance of diabetes'. For partners the themes of 'feeling responsible' and 'need for greater involvement' emerged. Common themes arising from people with Type 2 diabetes, partners and healthcare providers highlighted diabetes-related stresses: 'self-care struggles' and 'perceived need for appropriate psychological support'. A key theme drawn from healthcare providers was 'perceived professional barriers to psychological support', which captures concerns related to providing emotional support in clinical practice.

CONCLUSIONS

People with Type 2 diabetes, partners, and healthcare providers share a common understanding of the emotional stresses of living with Type 2 diabetes, but also experience diabetes differently depending on their role and responsibilities. All face barriers that need to be considered to ensure that emotional support in diabetes is meaningful and feasible in routine practice.

Simultaneous pelvic exenteration and liver resection for primary rectal cancer with synchronous liver metastases: results from the PelvEx Collaborative

AIM

At presentation, 15-20% of patients with rectal cancer already have synchronous liver metastases. The aim of this study was to determine the surgical and survival outcomes in patients with advanced rectal cancer who underwent combined pelvic exenteration and liver (oligometastatic) resection.

METHOD

Data from 20 international institutions that performed simultaneous pelvic exenteration and liver resection between 2007 and 2017 were accumulated. Primarily, we examined perioperative outcomes, morbidity and mortality. We also assessed the impact that margin status had on survival.

RESULTS

Of 128 patients, 72 (56.2%) were men with a median age of 60 years [interquartile range (IQR) 15 years]. The median size of the liver oligometastatic deposits was 2 cm (IQR 1.8 cm). The median duration of surgery was 406 min (IQR 240 min), with a median blood loss of 1090 ml (IQR 2010 ml). A negative resection margin (R0 resection) was achieved in 73.5% of pelvic exenterations and 66.4% of liver resections. The 30-day mortality rate was 1.6%, and 32% of patients had a major postoperative complication. The 5-year overall survival for patients in whom an R0 resection of both primary and metastatic disease was achieved was 54.6% compared with 20% for those with an R1/R2 resection (P = 0.006).

CONCLUSION

Simultaneous pelvic exenteration and liver resection is feasible, with acceptable morbidity and mortality. Simultaneous resection should only be performed where an R0 resection of both pelvic and hepatic disease is anticipated.