Kidney Outcomes Following Utilization of Molecular Adsorbent Recirculating System

Introduction

Molecular adsorbent recirculating system (MARS) is an extracorporeal system combining conventional veno-venous hemodiafiltration and adsorption to provide rescue support in fulminant hepatic failure. Acute kidney injury (AKI) is common in patients with hepatic failure warranting continuous kidney replacement therapy (CKRT). Our primary aim was to characterize a cohort of patients who received MARS therapy and examine kidney events given the current paucity of available data.

Methods

Patients initiating MARS in a tertiary care setting from January 2014 through December 2020 were assessed for treatment indications, transplantation, CKRT, kidney recovery, and death. Data was collected using the REDCAP software.

Results

A total of 49 patients (67% female; 75% White) received MARS therapy with 29 patients (59%) requiring concomitant CKRT. Hepatic encephalopathy (HE) was the most common indication for MARS initiation (55%). In-hospital mortality was 41% (12/29) among patients who received CKRT versus 10% (2/20) among those not requiring CKRT (relative risk [RR] 4.15, 95% confidence interval [CI] 1.04 to 16.52, P = 0.044); this persisted following adjustment for prespecified patient characteristics (all RR ≥ 3.76, all P ≤ 0.060). One-year mortality post-MARS initiation was high overall but highest among the CKRT group (59% [17/29] vs. 25% [5/20] unadjusted RR 2.92, 95% CI 1.08 to 7.94, P = 0.035). Liver transplant after MARS occurred in 41% of patients (20/49). After CKRT, 39% of patients (9/29) recovered kidney function prior to hospital discharge.

Conclusions

Patients requiring MARS frequently have AKI warranting the use of concomitant CKRT, which is associated with a high rate of in-hospital and 1-year mortality.

Provision of smoking cessation support for patients following a diagnosis of cancer in Ireland

There is growing evidence that smoking cessation (SC) improves outcomes following diagnosis of cancer. Notwithstanding adverse outcomes, a significant number of those diagnosed with cancer continue to smoke. Our objective was to document the SC services provided for patients with cancer by specialist adult cancer hospitals across Ireland, a country with a stated tobacco endgame goal. A cross-sectional survey based on recent national clinical guidelines was used to determine SC care delivery across eight adult cancer specialist hospitals, and one specialist radiotherapy centre. Qualtrics was used. The response rate was 88.9% with data reported from seven cancer hospitals and one specialist radiotherapy centre, all indicating they had some SC related provision (100%). Stop smoking medications were provided to cancer inpatients in two hospitals, at outpatients and attending day ward services in one hospital. Smokers with cancer were referred automatically to the SC service in two hospitals at diagnosis. While stop smoking medications were available 24 h a day in five hospitals, most did not stock all three (Nicotine Replacement Therapy, Bupropion, Varenicline). One hospital advised they had data on uptake of SC services for smokers with cancer but were unable to provide detail. There is considerable variation in SC information and services provided to cancer patients across adult cancer specialist centres in Ireland, reflecting the suboptimal practice of smoking cessation for patients with cancer found in the limited international audits. Such audits are essential to demonstrate service gaps and provide a baseline for service improvement.

Challenges faced by parents of screen-detected children with Cystic Fibrosis: The ICOS study

Background

Informal care is an essential component of overall care for patients, particularly those with chronic illnesses such as Cystic Fibrosis (CF). This study aims to assess the level of caregiving burden faced by parents/caregivers of children with CF (CwCF) recruited to the Irish Comparative Outcomes Study of CF (ICOS), a historical cohort study of CwCF. In July 2011, a new-born screening programme began in Ireland.

Methods

The study population includes the parents of screen-detected CwCF born between July 2011-2021. The Challenge of Living with CF-Short Form is a new, validated 15-item tool that evaluates the caregiving burden faced by parents from the child’s diagnosis until early adolescence. Comparisons based on the age of screen-detected CwCF were conducted. SPSS was used for analysis.

Results

69 parents of screen-detected CwCF responded. Fifty percent of parents of older children (aged 4-12+ years) and 35% of the parents of toddlers (0-3 years) faced moderate-high level difficulties in managing the extra expenses required for the care of their CwCF, despite all children receiving free clinical care, prescriptions and medications. A significantly greater proportion of the parents of older children than younger children experienced constant problems in managing daily oral medication routines (37% vs 13%; P = 0.039), nebulised medication routines (67.5% vs 21.4%; P = 0.003), and physiotherapy routines (57.8% vs 31.8%; P = 0.046)

Conclusions

Using the novel Challenge of living with Cystic Fibrosis-Short Form questionnaire, our findings suggest that the caregiving burden is higher for parents of older CwCF. Expenses incurred by parents of a child with a serious chronic medical condition go beyond medical care and treatment expenses.

Key messages

• The challenge of living with Cystic Fibrosis-Short Form is being used for the first time in a population setting.

• The caregiving burden was more pronounced in the parents of older CwCF.

Impact of community outreach programme on improving cancer related preventive health behaviour

 

Cancer services were negatively affected due to the Covid-19 pandemic and will have likely delayed early detection and diagnosis. The Irish Cancer Society (ICS) planned and delivered a number of cancer roadshow events in 4 deprived regions in Ireland to address improvements in awareness of cancer signs, importance of screening, positive lifestyle changes and encourage medical care-seeking behaviour. Health checks (blood pressure, BMI & CO2 monitoring) and motivational interviews were carried out by ICS nurses and trained ICS volunteers. Data was collected via anonymous questionnaire from participants and volunteers. SPSS was used for analysis. 98 people (54 male, 44 female) participated; 87.7% found the information provided useful, 84.7% approved of the health check and 72.5% stated that they would likely make changes to their current lifestyle to reduce their cancer risk. Moderate/high understanding of cancer signs and symptoms and moderate/high awareness of cancer risk factors both rose post event (from 62.2% to 81.6% (p < 0.001) and from 49% to 61.2% (p < 0.001) respectively). If symptomatic for cancer 77.6% of participants would likely visit their GP and 73.5% would likely contact ICS. Younger people (aged ≤40 years) were more likely to consider consulting a healthcare professional if symptomatic (p = 0.027) and to contact the ICS (p = 0.007) for more information. High numbers of participants (98.9%) and volunteers (95.2%) recommended a nationwide roll out. Volunteers reported moderate/high levels of public engagement; the most common topics discussed were own treatment experience, cancer screening, information on making lifestyle changes and ICS services. Volunteers reported the need for more training and improvements to some organisational aspects. More rigorous cancer health promotion programmes are required to counter disrupted cancer services. Our results suggest such cancer roadshow events are both feasible and beneficial at this time post pandemic.

Key messages

• Health literacy is continuous process to achieve positive health outcomes.

• Reaching out to people in different setting is acceptable and potentially effective.

Smoking cessation for cancer patients through the lens of cancer specialists: challenges & solutions

Background

The benefits of smoking cessation (SC) for cancer patients are widely recognised. However, there has been a limited emphasis on SC in this context and it continues to be a challenge for cancer patients. As part of a larger feasibility study aiming to develop a structured SC pathway for cancer patients in Ireland, this qualitative study explored the SC practices, experiences and opinions of oncology healthcare professionals (HCPs).

Methods

Semi-structured interviews were conducted with 18 HCPs from lung, breast, cervical, head and neck and general oncology, across 4 specialist adult cancer hospitals in Ireland. Interview transcripts were analysed using thematic analysis.

Results

Four key themes emerged:

(1) Frequently ask and advise but infrequently assist: most HCPs ask about smoking and many advise about available supports, but few refer patients to SC services. Where offered, referrals were to hospital SC services and/or nicotine replacement therapy was prescribed; no HCP prescribed varenicline or bupropion. Barriers included lack of time, ill-defined referral pathways and lack of knowledge.

(2) Increased willingness but differing ability to quit: most patients were interested in quitting post diagnosis and had varying support needs, linked to cancer stage, social circumstances and stress levels.

(3) Need for an integrated or parallel service: all HCPs suggested that a structured and defined referral pathway will facilitate SC.

(4) Motivational counselling and pharmacotherapy combination: many HCPs suggested face to face as the best mode of intervention initially, with regular follow ups and ongoing support virtually, started pre-treatment, with an empathetic and empowering approach with provision of both motivational counselling and SC pharmacotherapy.

Conclusions

Smoking post cancer diagnosis has serious implications for cancer treatment and prognosis but is frequently overlooked. These findings will inform the design of a SC pathway for cancer patients.

Key messages

• Despite increased willingness to quit, there is inadequate and inconsistent SC support provision for cancer patients.

• Tailored SC support should be an integral part of comprehensive cancer care.

Breastfeeding and allergic disease at age nine in Ireland: An Irish prospective cohort study

Background

Despite well-recognised benefits, Irish breastfeeding rates remain suboptimal. Although associations between breastfeeding and allergic disease are well-researched in younger children, evidence for continued effect in older children is sparse. This Irish prospective cohort study investigated associations between breastfeeding and allergic disease at age nine.

Methods

The study sample included all nine-year-old children enrolled in the Growing Up in Ireland Infant Cohort Study whose mothers had participated in both Wave 1 and Wave 5. Mothers self-reported infant feeding practices at nine months and allergic diseases at nine years. Multiple logistic regression was used to generate adjusted odds ratios (aOR) for associations between breastfeeding and allergic diseases; re-weighting was applied to enhance generalisability.

Results

Response rate was 72% (N = 8,006). Most mothers (53%) had ever-breastfed their child; younger mothers, smokers and those of lower socioeconomic status were significantly less likely to have ever-breastfed. Compared to never-breastfeeding, ever-breastfeeding was protective against asthma (aOR 0.74, 95%CI 0.62-0.87) and eczema (aOR 0.72, 95%CI 0.55-0.93) at age nine. Ever-breastfeeding increased the risk of atopic rhinitis (aOR 1.44, 95%CI 1.07-1.94); the association with food allergy was inconclusive (aOR 1.17, 95%CI 0.83-1.64). Breastfeeding ≥6 months was protective against asthma (aOR 0.57, 95%CI 0.39-0.82) and any allergic disease (aOR 0.72, 95%CI 0.55-0.96). Exclusive breastfeeding (3-5 months) was protective against asthma (aOR 0.67, 95%CI 0.50-0.89) and eczema (aOR 0.54, 95%CI 0.34-0.86).

Conclusions

This study provides new evidence suggesting breastfeeding may be protective against asthma and eczema but may increase the risk of atopic rhinitis in older Irish children. Results must be considered in light of high Irish allergic disease prevalence and action in support of breastfeeding prior to and following birth prioritised accordingly.

Key messages

Rapid systematic review of smoking cessation interventions for people who smoke and have cancer

Background

Higher rates of cancer are reported in smokers compared to non-smokers, and continued smoking following a cancer diagnosis is associated with reduced health outcomes and survival. Despite international evidence of increased risks, a substantial percentage of people with a cancer diagnosis continue to smoke. Patients may be unaware of the additional risks associated with continued smoking, and health care professionals may not engage with quit supports. As part of a larger feasibility study to develop a smoking cessation pathway in cancer services in Ireland, a rapid review of the evidence was completed.

Methods

Systematic searches of PubMed, Embase, and CINAHL 2015 to December 2020 were conducted; with studies restricted to adults with a cancer diagnosis [lung, breast, cervical, head and neck] and published in English. No restriction was placed on study designs. 6404 studies were identified and uploaded into COVIDENCE platform, Cochrane's systematic review methods were adopted throughout, PRISMA reporting guidelines were used, and narrative data synthesis was completed (CRD 42020214204).

Results

The twenty-three-studies report evidence from USA, Canada, England, Lebanon, and Australia. The setting for all interventions was hospitals and cancer clinics. Evidence identifies high dropout rates, inconsistencies in approaches and duration of smoking cessation interventions with varied outcomes. A wide-ranging number of critical components emerged associated with optimal quit support- including the timing of and frequency of quit conversations, use of electronic records, in-person support meetings, provision of nicotine replacement therapy and extended use of Varenicline, smoking cessation services embedded in oncology depts, and engaging with families wanting to quit at the same time.

Conclusions

Developing tailored smoking cessation interventions are needed for smokers diagnosed with cancer to enable engagement.

Key messages

• Continued smoking following a cancer diagnosis is associated with reduced health outcomes.

• Smoking cessation programmes for cancer patient should be tailored to meet needs.

Implementation of student experiential learning in health & wellbeing in a large university setting

Background

Healthy UCD is a health promotion initiative in University College Dublin (UCD). Working together with university academic staff, we have provided opportunities for graded experiential learning for students in health and wellbeing-related courses. This abstract presents how experiential learning was implemented in the 2020/21 academic year.

Objectives

The first objective was to provide a public health nutrition learning opportunity to MSc in Clinical Nutrition & Dietetics students through the design, implementation and evaluation of UCD Healthy Eating Week in Autumn 2020. Secondly, we aimed to facilitate the running of a wellbeing event by BSc Sport & Exercise Management students with Healthy UCD as their client in Spring 2021. The students had the additional challenge this year of delivering the content online.

Results

MSc Clinical Nutrition & Dietetics students utilised Healthy UCD's website and social media channels to deliver a virtual Healthy Eating Week. Infographics, videos, articles and podcasts were produced which generated 1,000 website visits and reached over 3,000 on social media. Most students involved agreed that the event was successful (95%) and that they were sufficiently supported by Healthy UCD and their tutors (65%). BSc Sport & Exercise Management students devised and delivered a week-long event titled “Wellbeing Your Way”, creating wellbeing seminars and live exercise classes with each receiving an average of 460 views. The students reported gaining valuable experience of the responsibilities of running a professional event and operating as a team.

Conclusions

These examples of experiential learning for credit demonstrate how university campus health promotion teams can facilitate student learning and simultaneously reap the benefit for university faculty and students. The key requirements are committed academic engagement and supported students.

Key messages

University campus health promotion provides excellent opportunities for experiential learning. Health promotion practical experience can have benefits both for students and for the university.

Breast self-examination among older women in Ireland: The Irish Longitudinal Study on Ageing -TILDA

Background

Regular breast self-examination (BSE) is a simple, cost-effective way of early breast cancer detection, particularly for women outside eligible screening age and for interval cancers. Although mammographic screening is the current most effective breast screening tool, the importance of regular BSE and breast awareness may be overlooked. The study aimed to identify socio-demographic, lifestyle and health-related factors associated with BSE practice among women in Ireland.

Methods

This study was conducted using Wave 4 data from The Irish Longitudinal Study on Ageing (TILDA), which collects health-related information from people aged 50 plus in biennial data collection waves. Those women aged 50-64 (eligible breast screening age in 2016) were selected. Following univariate analysis, logistic regression analysis was performed on selected variables to determine the factors independently associated with BSE practice.

Results

The prevalence of BSE was 70.7%. There was no significant association found between socio-demographic, lifestyle or health related factors and BSE. On logistic regression analysis, family history of cancer was not found to be associated with increased practice of BSE (Adjusted Odds Ratio (OR) 1.02, 95% Confidence Interval (CI) 0.79-1.31, p = 0.86). Having attended for mammogram showed a non-significant reduction in the likelihood of doing BSE (Adjusted OR 0.77, 95% CI 0.58-1.02, p = 0.07).

Conclusions

There are few studies on BSE from developed countries and this is the first from Ireland. BSE prevalence was 61%, 22.6% and 46.8% from Canada, United Kingdom and United States respectively, and was considerably lower from Asian and African countries. Women in this study were more educated than the general population counterparts, this might have overestimated BSE prevalence and obscured true associations. While we did not identify significant associations there is a suggestion that attending for mammography reduces women's interest in BSE.

Key messages

Being ‘Breast Aware’ and BSE are important alongside mammography for early detection of breast cancer. In countries where screening mammography is unavailable, BSE is an important detection tool.

Has the national fall in smoking rate in Ireland been replicated in cancer patients? a 5-year report

Background

Population smoking rates are falling in Ireland, however many cancer patients continue smoking post diagnosis, despite its association with poorer treatment and clinical outcomes. As part of a feasibility study of smoking cessation for cancer patients in Ireland, a review of smoking rates in cancer patients was undertaken.

Methods

The Hospital Inpatient Enquiry system (HIPE), a national database which collects administrative, demographic & clinical data on discharges from public hospitals in Ireland, provided data (2014-2018) on smoking status of adult discharges with a cancer diagnosis (overall, breast, lung, cervical and head & neck (H&N). Smoking trends were compared with Healthy Ireland data (2015-2018), from a national survey for adults on health & wellbeing.

Results

During 2014-18, current smoking rose for all cancers (10.5%-11.4%), cervical cancer (11%-19.8%) and initially (2014-2016) for H&N (3%-12.7%) and lung (24.7%-27.2%), which dropped to 7.6% and 24% respectively in 2018; breast was stable at 6 ± 0.6%. Rates are lower than the general population (23%-20%). During 2014-17, past smoking rates demonstrated an upward trend among all cancers and specific cancers, with the highest prevalence among lung (30.3-39%) and lowest among breast (7.3-11%); comparative general population data was 23-28%. Current smoking rates for all cancers were highest among 50-59-year-olds (14-16%), which contrasts with the general population (24-35 years at 32-28%). Current and past smoking rates for all cancers were consistently higher among males, similar to the general population.

Conclusions

HIPE data is limited by duplicate episodes of care, and it is recognised that smoking documentation may be an underestimate. However, it is useful to analyse trends, as these limitations should be stable over the 5-year study period. Rates remain high; our further research will document barriers and facilitators to smoking cessation among cancer patients.

Key messages

Smoking rates in cancer patients are high despite proven benefits of smoking cessation. Supportive smoking cessation services as part of routine cancer care are indicated.

Impact of COVID-19 on hospital care, employment and mental health of people with Cystic Fibrosis

Background

The COVID-19 pandemic has been challenging for many but especially for people with pre-existing co-morbidities such as people with cystic fibrosis (PWCF). The aim of this study was to examine the impact of COVID-19 pandemic on hospital services access to essential medication, employment, and mental health of PWCF.

Methods

A cross-sectional survey developed by University College Dublin and Cystic Fibrosis Ireland was uploaded on SmartSurvey UK and advertised by CF Ireland to CF community via CFI website and social media in October 2020. Logistic Regression was used for analysis.

Results

119 PWCF participated. 56 (47.5%) deferred hospital visits for CF care from 1-6 months: (57.4%) to 3 months; 42.6% 4 months-over 6 months), due to hospital closure (11.5%) & fear (69.8%). When adjusted for gender and location, PWCF aged <35 years were twice as likely to defer hospital visits as compared to those >35 years (P = 0.048). Online consultation and prescription via email was new for >50% of PWCF and >80% found it useful. Amongst those who worked (46.2%), 87.2% (n = 48) worked from home during COVID19. More PWCF <35 years (9.6%) worked onsite as compared to those >35 years (1.9%). 95% of employers were sympathetic for PWCF who cocooned while working from home (41.7%), however, overall, approximately 1/3rd of all employers were considered unsympathetic. 24.4% found access to CF medications challenging and 7 (5.9%) had to find alternative. After adjustment for gender and working, PWCF < 35 years were more likely to feel “nervous” (OR: 3.28; P = 0.017), “nothing could cheer them up” (OR: 3.24; P = 0.038) and “tired” (OR: 2.76; P = 0.016) compared to those >35 years.

Conclusions

Fear was a strong reason for essential hospital visit deferrals in COVID19, but hospital closures played an important part also. Prescription by email was novel and popular. There has been a serious impact on the mental health of this vulnerable group.

Key messages

COVID-19 impacted hospital visits due to fear and hospital closures; younger PWCF deferred more and for longer. The negative impact of COVID-19 on mental health was more pronounced in older PWCF.

Ductal Carcinoma in Situ in Ireland, 2008-2020: Screening Data related to Low-Risk Management Trials

Background

Four clinical trials are on-going to determine if active surveillance is a feasible management option for patients with low-risk ductal carcinoma in situ (DCIS), in response to concerns that breast cancer screening programmes have increased the incidence of DCIS, some of which may never progress to invasive cancer. This study aimed to describe the epidemiology of screen-detected DCIS in Ireland through the BreastCheck, the national breast screening programme in Ireland (commenced 2000 but fully national since 2008).

Methods

This was a cross-sectional analysis of anonymised BreastCheck data provided by the National Screening Service, including all cases of screen-detected DCIS between 2008 and 2020. Statistical tests included Mann-Whitney U, Chi square, and multivariable logistic regression.

Results

2,240 women were diagnosed with DCIS through BreastCheck between 2008 and 2020 (1353 (60.4%) high-grade and 876 (39.1%) low/intermediate grade). The overall rate of screen-detected DCIS incidence has remained relatively stable during this time. Women with high- grade DCIS were older than women with low/intermediate DCIS (57 (IQR 53-61) years v 56 (IQR 56-61) years; p < 0.001). They were also more likely to have been diagnosed at a subsequent screening episode than at an initial episode (71.0% v 57.5%; p < 0.001). After adjustment (deprivation score, screening unit and year) the odds ratio for high-grade was 1.62 (95% CI 1.30-2.03; p < 0.001) for subsequent compared with initial screening episode.

Conclusions

When trial results are available, these data will assist with service planning should active surveillance be approved as a management option. Based on trial inclusion criteria, up to 40% of women diagnosed with DCIS through BreastCheck may be eligible for consideration for active surveillance. These women are younger and often diagnosed on initial screening episode, so may require longer active follow-up.

Key messages

Majority of DCIS in national screening programme is high grade. Randomised controlled trial evidence will provide guidance on management of low-risk DCIS.

Good perception of own lifestyle associated with poor attendance at Diabetic RetinaScreen Programme

Background

Untreated diabetic retinopathy is the most common cause of sight loss in people of working age. The Diabetic RetinaScreen programme (DRS) is the national diabetic retinopathy screening programme in Ireland which commenced in 2013 with aim to prevent diabetic retinopathy and subsequent blindness, through free screening and ophthalmology services. High uptake is crucial for the effectiveness of the programme. This study aimed to determine the sociodemographic, lifestyle and healthcare factors associated with attendance at the DRS programme in Ireland, using data from a national cohort study, the Irish Longitudinal Study on Ageing (TILDA).

Methods

The TILDA wave-4 dataset (anonymised) was utilised for the current study. Questions on DRS invitation and attendance formed part of the wave 4 study questionnaire. Multivariate logistic regression was used to examine independent factors associated with attendance. SPSS was used for analysis.

Results

418 respondents (7.3%) were invited to DRS and 373 (89.2%) attended. Among all those who were invited to DRS, 244 (58.4%) were male and 174 (41.6%) were female. The mean age was 69.8 years (53-84 years). Following multivariate logistic regression, following a good diet/taking exercise (OR = 0.29, 95% CI 0.10-0.82) was negatively associated with attendance, after adjustment for age, male gender, higher education and medical card.

Conclusions

Recognising factors linked with uptake is important to develop goal directed strategies. Interestingly those who stated they followed a good diet & took exercise and were compliant with DM prevention were less likely to attend DRS. Previous research has also indicated that a higher physical activity level is associated with higher self-perceived health status

Key messages

Persons with DM with good compliance to diet and exercise were found to have poor attendance at the DRS programme. Targeted advertising is required to raise awareness of diabetic retinopathy.

Factors associated with PSA testing in men ≥ 50 years in Ireland

Background

Ireland has among the highest rates of prostate cancer in the EU, primarily due to widespread PSA screening. PSA screening is not recommended for asymptomatic men. Due to the potential for harm to the patient, and the economic and clinical repercussions for the healthcare system caused by inappropriate screening, this study aimed to investigate associations between PSA screening and sociodemographic, lifestyle, and health-related factors in men ≥50 years in Ireland.

Methods

A cross-sectional study was completed using data from Wave 4 of The Irish Longitudinal Study on Aging (TILDA), a nationally representative sample of community dwellers ≥ 50 years in Ireland. Participants self-reported having or not having a PSA test to screen for prostate cancer in the previous two years. Variables were entered into a multivariable logistic regression to estimate adjusted odds ratios (OR) for associations between PSA testing and the factors of interest.

Results

There were 2,426 male participants, with 68% reporting a PSA test in the previous two years. In adjusted analysis, older age (OR 1.78, 95%CI 1.32-2.31), third level education (OR 1.34, 95%CI 1.07-1.69) and a higher household net income (OR 2.14, 95% CI 1.52-3.02) increased the likelihood of PSA testing. Health-related factors positively associated with PSA testing screening were private health insurance (OR 1.89, 95%CI 1.52-2.35), blood pressure measurement in the previous year (OR 8.80, 95%CI 6.06-12.77) and a positive family history of cancer (OR 1.42, 95%CI 1.13-1.78).

Conclusions

High rates of prostate cancer screening are taking place in Ireland, despite the absence of a population-based screening programme. Men of older age, higher socioeconomic status and who demonstrate health-protective-behaviours have an increased risk of PSA screening. This subgroup of the population should be targeted to increase awareness of the potential benefits and harms of PSA testing.

Key messages

Rates of PSA screening remain high in Ireland, despite the absence of a population-based screening programme. Increased awareness of the potential harms and benefits of PSA screening is needed.

MO769COMPARISON OF HEMODIALYSIS CONNECTORS CAPS VS ANTIMICROIAL BARRIER CAPS IN CENTERAL LINE-ASSOICATED BLOOSTREAM INFECTION RATES FOR HEMODIALYSIS PATIENTS

Background and Aims

Central line-associated bloodstream infections (CLABSI) lead to increased morbidity and mortality in hemodialysis-dependent patients and are costly to treat. Devices such as hemodialysis connector caps (Tego) and antimicrobial barrier caps (ClearGuardHD) represent promising interventions to reduce CLABSIs. The aim of this study was to assess the efficacy of these devices in reducing CLABSIs in hemodialysis patients who use tunneled dialysis catheters at outpatient dialysis units in a healthcare system.

Method

In a retrospective review of a quality improvement project, we compared cumulative 6-month CLABSI infection rates before and after transition from Tego connectors to ClearGuardHD caps. CLABSI events, reported to National Healthcare Safety Network (NHSN), were expressed as CLABSI events per 100 patient-months. All adult patients (age >18 years) receiving hemodialysis via a tunneled central catheter were included in the study from February 2018-August 2020. The study cohort was comprised of 13 outpatient dialysis units in a healthcare system with locations throughout the Northern Midwest and Southeastern United States. The date of change from Tego to ClearGuardHD was phased throughout the different units over the study period with events recorded 6 months pre- and post-intervention. Patients receiving home dialysis therapies were excluded from the study.

Results

The cumulative 6-month CLABSI event rate decreased by 75.7%; Tego (0.465/100 patient-months) vs. ClearGuardHD caps (0.113/100 patient-months). A total of 17 CLABSI occurrences were reported within 3,654 patient-months with Tego use. However, only 4 CLABSI occurrences were reported within 3,527 patient-months during ClearGuardHD use.

Conclusion

ClearGuardHD caps reduced the rate of CLABSI among hemodialysis patients and are superior to Tego connectors. These findings support prior studies. Implementation of ClearGuardHD caps may help eliminate CLABSI-associated morbidity among individuals requiring maintenance hemodialysis therapy.

Introduction of the low risk ankle rule to a paediatric emergency department

INTRODUCTION

Ankle injuries are a common presentation to the paediatric emergency department (PED), accounting for approximately 2% of presentations.¹ X-rays are ordered for 85-95% of patients but only 12% of x-rays reveal a fracture. Clinical prediction rules, such as The Low Risk Ankle Rule (LRAR) exist to help clinicians safely reduce the frequency of radiography in these injuries. The LRAR has been shown to reduce imaging by up to 60% without missing any clinically significant fractures. We sought to introduce The LRAR into our department and study its outcomes on our practice.

AIMS

To introduce the LRAR into our department and study its effects on our radiography rate and length of stay (LOS).

METHODS

An audit of x-ray rates in ankle injuries in 2016 was performed to determine our department's baseline rate of radiography and LOS. We then conducted education sessions and created x-ray ordering prompts to encourage clinicians to use the LRAR. We introduced the LRAR, with a pilot period initially, and gathered data prospectively.

RESULTS

969 patients presented in with an ankle injury in 2016, 90.7% of these patients had an x-ray. The median LOS was 109 min. 92 patients presented during  the LRAR implementation period with an ankle injury. Nine patients had exclusion criteria from using the LRAR and the attending physician did not use the LRAR in four patients. Of the remaining 79 patients, 49 had a LRAR positive exam. Only one of these patients went on to have an x-ray, which was normal. The 30 patients with a LRAR negative exam all had an x-ray. Overall, our x-ray rate during the study period was 40/92 (43.4%), a reduction of 47.3%. The average LOS during the study was 101 min. No clinically significant fractures were missed.

CONCLUSION

The LRAR can safely and effectively reduce the rate of radiography in ankle injuries, without missing any clinically significant fractures.

Learning from calorie posting/traffic light systems introduction in a University hospital canteen

Key messages

Introduction of traffic light system and calorie posting needs evaluation. Females appear more likely to avail of traffic light systems and calorie posting in relation to food choices.

One year update following removal of high sugar sweetened beverages from a university campus

Key messages

Removal of high sugar sweetened drinks from a university campus is possible; advice must be provided to those who may feel negatively impacted by the change. Sales can grow despite health-related changes of the food environment.

Abstract P5-07-08: Withdrawn

This abstract was withdrawn by the authors.

Citation Format: Persson E, Gregersson P, Fitzpatrick P, Ståhlberg A, Landberg G. Withdrawn [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-07-08.

Abstract P2-06-11: Sortilin targeted therapy in breast cancer with elevated progranulin expression

Background: A major challenge concerning breast cancer therapy is the occasional lack of effects using drugs that target cancer cells unspecifically. One possible explanation for this treatment failure is the existence of the small subpopulation of breast cancer stem cells that are believed to be more resistant towards conventional therapy and possesses the ability to drive tumor formation and disease progression. Cytokines secreted by nearby cells and other factors in the surrounding tumor microenvironment further stimulate the cancer cells, contributing to a heterogeneous and potentially more treatment resistant tumor. Thus, a more specific treatment approach targeting the breast cancer stem cell niche is crucial in preventing disease recurrences. In a cytokine screen, we identified progranulin as one of the main compounds secreted from cells exposed to hypoxia, leading to cancer stem cell propagation. Progranulin is involved in biological processes such as wound healing, inflammation and cancer progression. Progranulin and its receptor sortilin are known to be highly expressed in subgroups of breast cancer and are further associated with a clinically aggressive phenotype.

Methods/Results: By carrying out a number of in vitro and in vivo like screening assays, we demonstrate that progranulin influences the stem cell population in breast cancer and is responsible for spreading a cancer stem cell promoting signal to normoxic tumor areas. In breast cancer, progranulin induces a dedifferentiation process in the receiving cancer cells and expression of cancer stem cell markers together with an EMT-associated gene expression profile, leading to cancer stem cell expansion. By using siRNA and pharmacological inhibition of sortilin, we show that sortilin is a functional receptor of progranulin and is responsible for driving progranulin induced breast cancer stem cell propagation. Supporting the role of progranulin in cancer progression, administration of progranulin in immunocompromised mice induce lung metastasis in our breast cancer xenograft models. The use of different approaches for blocking sortilin, such as sortilin inhibitors, down-modulators or sortilin-targeted antibodies can prevent this dedifferentiation process, both in vitro and in vivo, making the tumor cells less aggressive and metastatic.

Conclusion: Targeting progranulin through its associated receptors is a potential therapeutic strategy for the treatment of patients with breast tumors having elevated progranulin or sortilin expression. By inhibiting the secretion based breast cancer progression, we could possibly block the formation of metastasis and cancer cell infiltration.

Citation Format: Berger K, Rhost S, Hughes E, Harrison H, Rafnsdottir S, Jacobsson H, Gregersson P, Magnusson Y, Fitzpatrick P, Andersson D, Ståhlberg A, Landberg G. Sortilin targeted therapy in breast cancer with elevated progranulin expression [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P2-06-11.

Treatment of scabies using a tea tree oil-based gel formulation in Australian Aboriginal children: protocol for a randomised controlled trial

INTRODUCTION

In remote Aboriginal communities in Australia, scabies affects 7 out of 10 children before their first birthday. This is more than six times the rate seen in the rest of the developed world. Scabies infestation is frequently complicated by bacterial infection, leading to the development of skin sores and other more serious consequences, such as septicaemia and chronic heart and kidney diseases. Tea tree oil (TTO) has been used as an antimicrobial agent for several decades with proven clinical efficacy. Preclinical investigations have demonstrated superior scabicidal properties of TTO compared with widely used scabicidal agents, such as permethrin 5% cream and ivermectin. However, current data are insufficient to warrant a broad recommendation for its use for the management of scabies because previous studies were small or limited to in vitro observations.

METHODS AND ANALYSIS

A pragmatic first trial will examine the clinical efficacy of a simple and low-cost TTO treatment against paediatric scabies and the prevention of associated secondary bacterial infections, with 1:1 randomisation of 200 participants (Aboriginal children, aged 5-16 years and living in remote Australia) into active control (permethrin 5% cream) and treatment (5% TTO gel) groups. The primary outcome for the study is clinical cure (complete resolution). Secondary outcome measures will include relief of symptoms, recurrence rate, adverse effects, adherence to treatment regimen and patient acceptability.

ETHICS AND DISSEMINATION

The project has received approvals from the University of Canberra Human Research Ethics Committee (HREC 16-133), Wurli-Wurlinjang Health Service Indigenous subcommittee and the Aboriginal Medical Services Alliance Northern Territory reference group. The results of this study will be published in core scientific publications, with extensive knowledge exchange activities with non-academic audiences throughout the duration of the project.

TRIAL REGISTRATION

ACTRN12617000902392; Pre-results.

Transection versus infection: acute appendicitis in a peritoneal dialysis patient presenting as catheter dysfunction and discontinuity on X-ray

Acute appendicitis in peritoneal dialysis patients generally presents as abdominal pain and cloudy dialysate. We report a case of acute appendicitis in a peritoneal dialysis patient that presented as poor dialysate fluid drainage and an abnormal abdominal X-ray showing breakage in the continuity of the catheter. Catheter dysfunction in this case was caused by acute appendicitis leading to the formation of adhesions with peritoneal dialysis catheter trapped in it. This resulted in radiological appearance of catheter breakage, although catheter itself was intact. Clinicians should be aware of this rare presentation of acute appendicitis-poor drain alarm and radiological appearance of catheter discontinuity.

Protein and chemotherapy profiling of extracellular vesicles harvested from therapeutic induced senescent triple negative breast cancer cells

Triple negative breast cancer (TNBC) is an aggressive subtype with relatively poor clinical outcomes and limited treatment options. Chemotherapy, while killing cancer cells, can result in the generation of highly chemoresistant therapeutic induced senescent (TIS) cells that potentially form stem cell niches resulting in metastases. Intriguingly, senescent cells release significantly more extracellular vesicles (EVs) than non-senescent cells. Our aim was to profile EVs harvested from TIS TNBC cells compared with control cells to identify a potential mechanism by which TIS TNBC cells maintain survival in the face of chemotherapy. TIS was induced and confirmed in Cal51 TNBC cells using the chemotherapeutic paclitaxel (PTX) (Taxol). Mass spectrometry (MS) analysis of EVs harvested from TIS compared with control Cal51 cells was performed using Ingenuity Pathway Analysis and InnateDB programs. We demonstrate that TIS Cal51 cells treated with 75 nM PTX for 7 days became senescent (senescence-associated β-galactosidase (SA-β-Gal) positive, Ki67-negative, increased p21 and p16, G2/M cell cycle arrest) and released significantly more EVs (P=0.0002) and exosomes (P=0.0007) than non-senescent control cells. Moreover, TIS cells displayed an increased expression of the multidrug resistance protein 1/p-glycoprotein. MS analysis demonstrated that EVs derived from senescent Cal51 cells contained 142 proteins with a significant increased fold change compared with control EVs. Key proteins included ATPases, annexins, tubulins, integrins, Rabs and insoluble senescence-associated secretory phenotype (SASP) factors. A fluorescent analogue of PTX (Flutax-2) allowed appreciation of the removal of chemotherapy in EVs from senescent cells. Treatment of TIS cells with the exosome biogenesis inhibitor GW4869 resulted in reduced SA-β-Gal staining (P=0.04). In summary, this study demonstrates that TIS cells release significantly more EVs compared with control cells, containing chemotherapy and key proteins involved in cell proliferation, ATP depletion, apoptosis and the SASP. These findings may partially explain why cancer senescent cells remain viable despite chemotherapeutic challenge.

Effect of Intensive Blood-Pressure Treatment on Patient-Reported Outcomes

BACKGROUND

The previously published results of the Systolic Blood Pressure Intervention Trial showed that among participants with hypertension and an increased cardiovascular risk, but without diabetes, the rates of cardiovascular events were lower among those who were assigned to a target systolic blood pressure of less than 120 mm Hg (intensive treatment) than among those who were assigned to a target of less than 140 mm Hg (standard treatment). Whether such intensive treatment affected patient-reported outcomes was uncertain; those results from the trial are reported here.

METHODS

We randomly assigned 9361 participants with hypertension to a systolic blood-pressure target of less than 120 mm Hg or a target of less than 140 mm Hg. Patient-reported outcome measures included the scores on the Physical Component Summary (PCS) and Mental Component Summary (MCS) of the Veterans RAND 12-Item Health Survey, the Patient Health Questionnaire 9-item depression scale (PHQ-9), patient-reported satisfaction with their blood-pressure care and blood-pressure medications, and adherence to blood-pressure medications. We compared the scores in the intensive-treatment group with those in the standard-treatment group among all participants and among participants stratified according to physical and cognitive function.

RESULTS

Participants who received intensive treatment received an average of one additional antihypertensive medication, and the systolic blood pressure was 14.8 mm Hg (95% confidence interval, 14.3 to 15.4) lower in the group that received intensive treatment than in the group that received standard treatment. Mean PCS, MCS, and PHQ-9 scores were relatively stable over a median of 3 years of follow-up, with no significant differences between the two treatment groups. No significant differences between the treatment groups were noted when participants were stratified according to baseline measures of physical or cognitive function. Satisfaction with blood-pressure care was high in both treatment groups, and we found no significant difference in adherence to blood-pressure medications.

CONCLUSIONS

Patient-reported outcomes among participants who received intensive treatment, which targeted a systolic blood pressure of less than 120 mm Hg, were similar to those among participants who received standard treatment, including among participants with decreased physical or cognitive function. (Funded by the National Institutes of Health; SPRINT ClinicalTrials.gov number, NCT01206062 .).

Perceptions of Australian clients towards male radiographers working in breast imaging: Quantitative results from a pilot study

AIM

Breast cancer is the second most common cause of cancer-related death in Australian women, therefore early breast cancer detection is essential. Female radiographers currently conduct breast screening in Australia; however there is a projected shortage. With many women already feeling apprehensive about attending a breast examination, possible proposals to fill this shortage must be carefully considered. Training male radiographers is one proposal however, this raises some gender concerns. This study aimed to pilot an investigation into whether it would change women's willingness to attend breast screening if conducted by a male radiographer.

METHOD

A questionnaire completed by 146 women aged over 40 asked questions on attitude, initial reaction and how they would proceed if attended to by a male in three clinical situations (Mammography; Ultrasound and Breast Surgery).

RESULTS

The results revealed that women would have had their mammogram (90%), ultrasound (95%) and surgery (100%) conducted by a male, though some would have preferred a female for mammography (25%), ultrasound (24%) and surgery (12%). A total of 9% of women agreed to the statement 'If there were male radiographers I would not return for another screening appointment' and 9% agreed to the statement 'if I heard there could be male radiographers it would change my opinion of Breast Screening for the worse'.

CONCLUSIONS

This first Australian study investigating the perceptions of women to male radiographers in the breast screening arena suggest that a mix of male and female radiographers could be accommodated and indicates the need for a larger national survey.

Quick-Wee: A Novel Non-Invasive Urine Collection Method for Infants in the Emergency Department

BACKGROUND: Urinary tract infection is one of the commonest paedi-atric infections, and important to diagnose or exclude in young children with fever. Limitations exist with all current urine collection methods, guidelines vary, and clinicians have different preferences. Clean catch urine (CCU) is a preferred non-invasive collection method and is convenient and painless compared to suprapubic aspirate and catheterisation. However, it can be unreliable and time-consuming, with high rates of sample contamination and collection failure. Only 12% void within 5 minutes based on recent data. An ideal method of urine collection would be fast, reliable and simple. Suprapubic stimulation may trigger involuntary parasympathetic detrusor contraction, inducing voiding via early childhood exteroceptive somato-bladder reflexes.

OBJECTIVES: We conducted a pilot study using a novel method (termed ‘Quick-Wee’) of gentle cutaneous suprapubic stimulation with saline-soaked gauze, to hasten voiding for non-invasive urine collection.

DESIGN/METHODS: Prospective pilot study of 40 pre-continent children age 1-24 months requiring CCU in a paediatric emergency department in Australia. Standard CCU was augmented by 5 minutes of suprapubic cutaneous stimulation (Quick-Wee method), with either cold (3 degrees Celsius) or room-temperature saline-soaked gauze. PRIMARY OUTCOME: Void <5 minutes. SECONDARY OUTCOMES: Successful catch of sample (if voids), contamination rate, parental/clinician satisfaction with technique.

RESULTS:

Urine Clean Catch Collection in the Paediatric Emergency Department: Success, Time to Void and Contamination Rates

BACKGROUND: Young children frequently require investigation for urinary tract infection (UTI). Clean catch urine (CCU) is a common urine collection method in pre-continent children but can be time consuming or unsuccessful, and contaminated cultures may lead to an inability to diagnose or exclude UTI. There are few data available examining the success and time required for CCU and factors influencing contamination. We hypothesise that time taken to obtain CCU influences contamination, due to accidental contamination during collection.

OBJECTIVES: To determine the time taken to obtain CCU in pre-conti-nent children, and if time to collection is related to the contamination rate.

DESIGN/METHODS: Prospective observational study of CCU collection in pre-continent children aged 2-48 months at a paediatric emergency department in Australia. A standardised CCU collection protocol was used. Primary outcome was time to first void; secondary outcomes were success of obtaining (catching) CCU and contamination of urine cultures obtained. Contamination was defined as per hospital microbiology standards. Descriptive analysis of time to void included median and interquartile range (IQR). We performed a regression analysis of key factors possibly related to contamination, including age, sex and time to collection.

RESULTS: Of the 218 recruited patients, 61% were male, mean age 11.4 months (SD 8.5). The main indication for CCU was: 128 fever of unknown origin (59%), 31 vomiting (14%), 27 specifically suspected UTI (12%), 32 other reason (15%). From first CCU attempt, 174 voided (80%) of which 139 were successful catches (64%) and 34 were missed on voiding (16%). 44 first CCU attempts were stopped before voiding (20%), 26 patients had 2 attempts (12%), and 2 patients had 3 CCU attempts (1%). Median time to first void was 25 minutes (IQR 8 – 49). 27 children (12%) voided <5 minutes, 33 (19%) voided >1hr. Of the 130 patients who had urine culture results available, 50 were contaminated (38%). There was no significant difference in contamination rate by age, sex or time to sample collection. Of 218 patients where ED clinicians set out to collect CCU in the emergency department, only 80 (37%) resulted in a successful CCU attempt with an uncontaminated culture.

CONCLUSION: Contamination rates are high in clean catch urine, but not related to the time taken for sample collection. CCU attempts are often unsuccessful, and have a low diagnostic yield for investigation of UTI in young children in clinical practice.

Newborn bloodspot screening for cystic fibrosis: What do antenatal and postnatal women know about cystic fibrosis?

BACKGROUND

The Republic of Ireland has one of the highest reported incidences of cystic fibrosis (CF) in the world (1/1353) with an estimated carrier rate of 1/20. No cure exists, however there have been significant advances in available treatments. Newborn bloodspot screening (NBS) for CF was added to the NBS programme in Ireland in July 2011. Little is known about antenatal or postnatal women's knowledge about CF.

METHODS

This was a cross-sectional study of 662 antenatal (≥36weeks gestation) and 480 postnatal women (post NBS). Women were asked to self-complete a questionnaire including 14 CF knowledge questions.

RESULTS

Among the respondents significantly more postnatal than antenatal women were aware that CF is included on the NBS (81.8% vs 63.5%; p<0.001). 92.7% believe that there are health consequences to being a carrier and 33.6% believe there is a cure for CF. In the multivariate analysis, lower educational status (OR 2.13; 95% CI 1.31, 3.46) being an antenatal mother (OR 1.51; 95% CI 1.04, 2.18), having no family history of CF (OR 5.82; 95% CI 1.62, 20.90) were associated with poor CF knowledge, while increasing age was found to be protective against poor CF knowledge (OR 0.96; 95% CI 0.92, 0.99).

CONCLUSIONS

Results from this study provide a useful insight into women's preexisting knowledge about CF, which could be used to inform initial discussions with parents about their child's diagnosis.

Age related influence on screening coverage and satisfaction. with CervicalCheck

The aim of this study was to evaluate levels of satisfaction of women attending the CervicalCheck programme and reasons for the age differential in screening uptake. A questionnaire was sent to 5,000 randomly selected attenders with a normal smear test (3,500 aged 25-44, 1,500 aged 45-60). Almost all in both age groups said they would return to CervicalCheck if invited (98.5%; 98.5%) and recommend the service to family/friend (99.6%; 99.5%). The single independent predictor of 'would recommend to family/friend' was willingness to return to CervicalCheck (OR = 31 (5.2-183.7)). Predictors of 'would return if invited' were knowledge of when due to return (OR = 2.5 (1.3-5.0)) and having contacted or having received a letter of invitation from CervicalCheck (OR = 3.1 (1.6-6.1)). Independent predictors of 'knowledge of when due to return' were older age group (OR = 0.5 (0.4-0.7)) and willingness to return to CervicalCheck (OR = 3.2 (1.2-6.3)). The GP is particularly important in informing older women and encouraging attendance.