Hot avulsion versus argon plasma coagulation for the management of the non-ensnarable polyp: A multicenter, randomized controlled trial

Background and Aim

Snare resection of nonlifting colonic lesions often requires supplemental techniques. We compared the success rates of neoplasia eradication using hot avulsion and argon plasma coagulation in colonic polyps when complete snare polypectomy had failed.

Methods

Polyps that were not completely resectable by snare polypectomy were randomized to argon plasma coagulation or hot avulsion for completion of resection. Argon plasma coagulation was delivered using a forward shooting catheter, using a nontouch technique (flow 1.2 L, 35 watts). Hot avulsion was performed by grasping the neoplastic tissue with hot biopsy forceps and applying traction away from the bowel wall while using EndoCut I or soft coagulation for avulsion. Surveillance colonoscopies were performed at 6, 12, and 18 months.

Results

From November 2013 to July 2017, 59 patients were randomized to argon plasma coagulation (28) or hot avulsion (31). The median age was 69 (60-75), with 46% being female. The median residual tissue size was 10 mm (6-12). The residual adenoma rate at 6 months (hot avulsion 6% vs argon plasma coagulation 21% P = 0.09) and 18 months was not different between the groups (6.6% vs 3.6% P = 0.25). One patient in the argon plasma coagulation arm was diagnosed with metastatic cancer of likely colorectal origin despite benign histology in the original polypectomy specimen, supporting the importance of tissue acquisition.

Conclusion

Both hot avulsion and argon plasma coagulation are effective and safe modalities to complete resection of non-ensnarable colonic polyps.

Improving mental health following multiple disasters in Australia: a randomized controlled trial of the Skills for Life Adjustment and Resilience (SOLAR) programme

Background: The mental health impacts of climate change-related disasters are significant. However, access to mental health services is often limited by the availability of trained clinicians. Although building local community capability for the mental health response is often prioritised in policy settings, the lack of evidence-based programs is problematic. The aim of this study was to test the efficacy of the Skills for Life Adjustment and Resilience programme (SOLAR) delivered by trained local community members following compound disasters (drought, wildfires, pandemic-related lockdowns) in Australia.Method: Thirty-six community members were trained to deliver the SOLAR programme, a skills-based, trauma informed, psychosocial programme. Sixty-six people with anxiety, depression and/or posttraumatic stress symptoms, and impairment were randomised into the SOLAR programme or a Self-Help condition. They were assessed pre, post and two months following the interventions. The SOLAR programme was delivered across five 1-hourly sessions (either face to face or virtually). Those in the Self-Help condition received weekly emails with self-help information including links to online educational videos.Results: Multigroup analyses indicated that participants in the SOLAR condition experienced significantly lower levels of anxiety and depression, and PTSD symptom severity between pre - and post-intervention (T1 to T2), relative to the Self-Help condition, while controlling for scores at intake. These differences were not statistically different at follow-up. The SOLAR programme was associated with large effect size improvements in posttraumatic stress symptoms over time.Conclusion: The SOLAR programme was effective in improving anxiety, depression and posttraumatic stress symptoms over time. However, by follow-up the size of the effect was similar to an active self-help condition. Given the ongoing stressors in the community associated with compounding disasters it may be that booster sessions would have been useful to sustain programme impact.Trial registration: Australian New Zealand Clinical Trials Registry identifier: ACTRN12621000283875..

"It just made me feel better": qualitative examination of the implementation of a novel virtual psychosocial support program for adolescents with cancer

PURPOSE

Adolescents with cancer routinely report feelings of isolation and exclusion, including from medical decision-making. To address this problem and support adolescents, we designed and implemented the novel, virtual, weekly Teens4Teens peer support group and patient education program. We examined the views of participating adolescents, program guest speakers, and program moderators as they pertained to the need for the program, its feasibility, acceptability, and perceived impact.

METHODS

We recruited all available adolescents, moderators, and guest speakers who participated in Teens4Teens to take part in audio-recorded, semi-structured interviews. Interviews were transcribed, coded, and analyzed using thematic analysis.

RESULTS

We conducted 21 interviews across participant groups. We identified four broad themes: pathways into the Teen4Teens program, Teens4Teens implementation capacity, perspectives of the positive impact of Teens4Teens, and suggestions to improve Teens4Teens. These themes described a perceived need for adolescent-centered psychosocial programming in pediatric cancer care, provided lessons on how best to build and apply such a program, and highlighted the value of the program for both adolescents' and clinicians' acceptability, feasibility, and perceived utility.

CONCLUSION

Adolescents, guest speakers, and moderators valued Teens4Teens and made suggestions to improve capacity to routinely implement the program. Adolescent-tailored psychosocial programming, such as Teens4Teens, is positioned to be integrated into clinical care with relative ease and may serve to improve the cancer care experience of adolescents and their families. This study has potential to provide researchers and clinicians with valuable information about the content, design, and delivery of virtual peer support programming for adolescents with cancer.

Is the Motion Causing a Commotion? Two-Fraction Prostate SBRT on the MR-Linac

PURPOSE/OBJECTIVE(S)

In HERMES (NCT04595019) men with localized prostate cancer are treated on the Unity MR-Linac platform (MRL, Elekta AB, Stockholm) and randomized between stereotactic body radiotherapy (SBRT) with 36.25 Gy in 5 fractions and 24 Gy in 2 fractions. Patients randomized to two fractions receive 24 Gy to the high risk PTV, 20 Gy to the low risk PTV and a boost of 27 Gy to the dominant intraprostatic lesion. This study explores dose received by the target and organs at risk (OARs) when considering intrafraction motion in two fraction SBRT.

MATERIALS/METHODS

Targets and OARs were delineated and a reference plan generated on Monaco v5.40.01 (Elekta). An Adapt-to-Shape (ATS) workflow was used. Contours were propagated to the session MRI (MRIsession) and edited accordingly. Prior to delivery, a verification MRI (MRIverif) was acquired with baseline shifts corrected for using the Adapt-to-Position (ATP-of-ATS) workflow. A post treatment MRI (MRIpost) was acquired after delivery. Men in the 2-fraction arm received each fraction in 2 sub-fractions sequentially on the same day, to mitigate intrafraction motion. The plans of 5 men receiving 2 fraction SBRT were analyzed. The targets, urethra, bladder and rectum were recontoured on the MRIverif and MRIpost. Delivered plans were recalculated on the corresponding MRIverif and MRIpost. The percentage of optimal and mandatory target dose constraints met were calculated. Accumulated OAR doses were calculated by averaging their respective dose statistics across all sub-fractions, conservatively assuming that the same area of the OAR receives the maximum dose each fraction. Analysis was carried out separately for MRIverif and MRIpost as the true 'delivered dose' most likely lies between these two estimates.

RESULTS

There was good coverage across all fractions. The mandatory constraints of CTVpsv V24.0 Gy > 95% and CTVsv V20.0 Gy > 95% were met in 100% of fractions and V2700cGy > 95% in 90% on the MRIpost. Table 3 shows OAR dose.

CONCLUSION

This work demonstrates that target coverage is good, even for the GTV where no margin is applied. With our conservative dose calculation approach, we found dose constraints are exceeded for some patients. However, treatment has been well tolerated, suggesting that that our current dose constraints may be cautious. Once Elekta's True Tracking and automated gating software is implemented at our center we will be able to further improve OAR clinical goal compliance.

Comparing the unified protocol for transdiagnostic treatment of emotional disorders to prolonged exposure for the treatment of PTSD: Design of a non-inferiority randomized controlled trial

Background

Prolonged Exposure (PE), a trauma-focused therapy, is one of the most efficacious treatments available for PTSD. However, many people with PTSD do not lose their diagnosis following delivery of PE. The Unified Protocol (UP) for Transdiagnostic Treatment of Emotional Disorders is a non-trauma focused treatment that may offer an alternative treatment for PTSD.

Methods

This paper describes the study protocol for IMPACT, an assessor-blinded randomized controlled trial that examines the non-inferiority of UP relative to PE for participants who meet DSM-5 criteria for current PTSD. One hundred and twenty adult participants with PTSD will be randomized to receive either 10 × 90-min sessions of UP or PE with a trained provider. The primary outcome is severity of PTSD symptoms assessed by the Clinician Administered PTSD Scale for DSM-5 (CAPS-5) at post-treatment.

Discussion

While evidence-based treatments are available for PTSD, high levels of treatment dropout and non-response require new approaches to be tested. The UP is based on emotion regulation theory and is effective in treating anxiety and depressive disorders, however, there has been limited application to PTSD. This is the first rigorous study comparing UP to PE in a non-inferiority randomized controlled trial and may help improve clinical outcomes for those with PTSD.

Trial registration

This trial was prospectively registered with the Australian New Zealand Clinical Trials Registry, Trial ID (ACTRN12619000543189).

AB1507 ATTRIBUTES INFLUENCING THE SELECTION OF FELLOWSHIP PROGRAMS BY RHEUMATOLOGY APPLICANTS: A PILOT WEB-BASED SURVEY

Background

Recruitment of candidates is a cost- and effort-intensive aspect of rheumatology fellowship programs. For program leaders to efficiently use the available resources and improve recruitment outcomes, it is imperative to understand the attributes that influence the candidates’ choice of a program. Previous studies have examined the type and relative importance of the factors that candidates use in selecting other fellowship programs (1, 2). However, no such studies have been conducted in the field of rheumatology.

Objectives

To examine the factors that influence the selection of fellowship programs by rheumatology applicants.

Methods

An anonymous, web-based survey comprised of 13 questions was shared with rheumatology fellowship applicants on messaging applications and online forums. The survey was open from 10/29/2021-11/06/2021. Participation was voluntary and informed consent was implied through the participants’ response. Three reminders to complete the survey were sent. Four domains of the applicant’s perception in relation to their preference of ranking rheumatology programs were assessed: (1) program prestige, (2) program structure, (3) interview day experience, and (4) career path of the alumni. The survey questions were devised in one of the following formats: (1) 5-point Likert scale, (2) rank order questions, (3) yes/no questions, (4) multiple choice questions, and (5) open-ended questions.

Results

Thirty-two rheumatology applicants responded to the survey. The prestige of the program was reported to be extremely important by 16%, very important by 19%, somewhat important by 44%, and little or not important by 21% responders. The opportunity to see a diverse patient population was reported to be important by 97% respondents. The call schedule and higher number of fellows were considered important by 88% of the respondents. 66% preferred programs with higher number of faculty members. 69% favored programs with an ultrasound curriculum. The availability of clinician-educator track (18%), MCR/MPH (14%), and T32 grand (4%) were considered less important. 69% reported that the opportunity to train at a Veterans Administration hospital did not influence their choice. Regarding interview day experience, interaction with the faculty (63%) and the fellows (17%) were considered important factors influencing program ranking. Respondents preferred programs with alumni in academic clinician track (45%) and private practice (43%) compared to programs with alumni in academic research (13%) or industry pathway (4%). The geographical location of the program including the cost of living and location of significant others also influenced the applicants’ choice.

Conclusion

To the best of our knowledge, this is the first survey to assess the attributes that influence a candidate’s choice of a rheumatology fellowship program. Our survey demonstrated that a positive interview day experience and program attributes including the opportunity to interact with a diverse patient population, relaxed call schedule, higher number of fellows and faculty, the presence of an ultrasound curriculum, and the location were the dominant factors influencing applicants’ choice of a program. The main limitation of our study is the lack of generalizability due to selection bias. Understanding the factors involved in decision making of the rheumatology fellowship applicants can provide valuable information for both the applicants and the programs and therefore lead to a better match.

References

[1]Kelm DJ, Skalski JH, Nelson DR, Kashani KB, Lee AS, Wesselius LJ, et al. Attributes Influencing the Selection of Fellowship Programs by Pulmonary and Critical Care Applicants: A Pilot Study. Ann Am Thorac Soc. 2016;13(4):572-4.

[2]Caiola E, Litaker D. Factors influencing the selection of general internal medicine fellowship programs: a national survey. J Gen Intern Med. 2000;15(9):656-8.

Disclosure of Interests

None declared

A neuroendocrine cause for refractory symptoms in coeliac disease

Neuroendocrine tumours while rare, need to be considered in patients with chronic diarrhoea. Reported herein is a case of vasoactive intestinal peptideoma in a patient with refractory diarrhoea following a diagnosis of coeliac disease.

1312 Characteristics of Those Who Present with Self-Inflicted Burns: A Burns Unit Service Evaluation Which Challenges Stereotypes

Introduction

Self-harm rates in the UK are increasing. Healthcare professionals’ beliefs regarding repeat attendance; attention-seeking; and poor treatment compliance may contribute to patients’ stigma. Self-inflicted burns (SIB) constitute a minority of burns cases, but require disproportionate healthcare input, yet little is known about these patients. Our aim was to evaluate presentations, compliance and outcomes in this patient group.

Method

A retrospective audit of outpatients with SIBs attending a UK Burns Unit over four years (Jan 2016-Dec 2019).

Results

Over the study period, 58 patients presented with 94 burn wounds. Incidence doubled over one year (2018-2019). Most patients were female (85%) with a median age of 29 years (range 19-62). The most commonly associated psychiatric diagnosis was personality disorder. On presentation 22% (n = 21) were admitted under the Mental Health Act. For 83% (n = 48) it was their first presentation with a SIB, although 74% had previously presented with non-burn self-harm. Median burn size was 0.5% TBSA, the most common mechanism was contact (48%) and 77% were deep (n = 77). 92% were compliant with treatment and did not tamper with their wounds or dressings.

Conclusions

The majority, 70% (n = 41), of patients only presented once to the Burns Department during the study period. This challenges the commonly held stereotype that those who self-harm will also seek attention through repeat presentation. Ongoing education among health professionals may dispel some myths regarding these individuals. Further, larger investigations, may permit rigorous comparison of treatment outcomes with non-SIB patients.

Differences in obstetrical care and outcomes associated with the proportion of the obstetrician's shift completed

BACKGROUND

Understanding and improving obstetrical quality and safety is an important goal of professional societies, and many interventions such as checklists, safety bundles, educational interventions, or other culture changes have been implemented to improve the quality of care provided to obstetrical patients. Although many factors contribute to delivery decisions, a reduced workload has addressed how provider issues such as fatigue or behaviors surrounding impending shift changes may influence the delivery mode and outcomes.

OBJECTIVE

The objective was to assess whether intrapartum obstetrical interventions and adverse outcomes differ based on the temporal proximity of the delivery to the attending's shift change.

STUDY DESIGN

This was a secondary analysis from a multicenter obstetrical cohort in which all patients with cephalic, singleton gestations who attempted vaginal birth were eligible for inclusion. The primary exposure used to quantify the relationship between the proximity of the provider to their shift change and a delivery intervention was the ratio of time from the most recent attending shift change to vaginal delivery or decision for cesarean delivery to the total length of the shift. Ratios were used to represent the proportion of time completed in the shift by normalizing for varying shift lengths. A sensitivity analysis restricted to patients who were delivered by physicians working 12-hour shifts was performed. Outcomes chosen included cesarean delivery, episiotomy, third- or fourth-degree perineal laceration, 5-minute Apgar score of <4, and neonatal intensive care unit admission. Chi-squared tests were used to evaluate outcomes based on the proportion of the attending's shift completed. Adjusted and unadjusted logistic models fitting a cubic spline (when indicated) were used to determine whether the frequency of outcomes throughout the shift occurred in a statistically significant, nonlinear pattern RESULTS: Of the 82,851 patients eligible for inclusion, 47,262 (57%) had ratio data available and constituted the analyzable sample. Deliveries were evenly distributed throughout shifts, with 50.6% taking place in the first half of shifts. There were no statistically significant differences in the frequency of cesarean delivery, episiotomy, third- or fourth-degree perineal lacerations, or 5-minute Apgar scores of <4 based on the proportion of the shift completed. The findings were unchanged when evaluated with a cubic spline in unadjusted and adjusted logistic models. Sensitivity analyses performed on the 22.2% of patients who were delivered by a physician completing a 12-hour shift showed similar findings. There was a small increase in the frequency of neonatal intensive care unit admissions with a greater proportion of the shift completed (adjusted P=.009), but the findings did not persist in the sensitivity analysis.

CONCLUSION

Clinically significant differences in obstetrical interventions and outcomes do not seem to exist based on the temporal proximity to the attending physician's shift change. Future work should attempt to directly study unit culture and provider fatigue to further investigate opportunities to improve obstetrical quality of care, and additional studies are needed to corroborate these findings in community settings.

POS0537 TRENDS AND PREDICTORS OF INPATIENT MORTALITY IN PATIENTS WITH CLOSTRIDIODES DIFFICILE INFECTION AMONG THOSE WITH AND WITHOUT RHEUMATOID ARTHRITIS: A NATIONWIDE ANALYSIS

Background:

People with rheumatoid arthritis (RA) have a higher risk of serious infections. The most common nosocomial infection in the United States (US) is Clostridioides difficile infection (CDI) and yet, little is known regarding the impact of comorbid RA on outcomes in persons hospitalized with CDI.

Objectives:

To evaluate the trends over time and predictors of inpatient mortality in hospitalized patients with CDI comparing those with and without RA.

Methods:

We used the National Inpatient Sample (NIS) database, the largest available all-payer database of inpatient hospitalizations in the US. Patients aged ≥18 years admitted with CDI from 2006-2018 were included. Patients with RA were identified using the International Classification of Diseases (ICD) 9 and 10 codes. Categorical variables between CDI patients with and without RA were compared using Chi-squared test. Temporal trends of hospitalization charges, length of stay (LOS) and inpatient mortality were assessed using the Cochrane Armitage test. Predictors of inpatient mortality were assessed using multivariable logistic regression adjusting for: age ≥65, sex, race, presence of RA, and Elixhauser comorbidity index.

Results:

There were 4,396,945 hospitalizations with a discharge diagnosis of CDI in the study period, of which 111,336 (2.5%) had a coexisting diagnosis of RA. Over the study period, the proportion of CDI patients with a diagnosis of RA increased from 1.7% in 2006 to 3.3% in 2018 with a statistically significant trend of rise (p trend<0.001). There were significantly more females in the RA group (78.2%) than without RA (57.5%), p <0.001. RA group was significantly younger (68.0 vs 70.7, P<0.001). Races were similar between the groups.

The inflation-adjusted average charge for hospitalization for CDI without RA was significantly higher than for CDI with RA ($95,863 vs $73,025, p<0.001). There was an increasing trend in inflation-adjusted average charge for hospitalization for both CDI without RA ($76,966 in 2006 to $104,552 in 2018, p<0.001) and CDI with RA ($55,689 in 2006 to $77,295 in 2018, p<0.001). Patients with or without RA had the same median length of stay (LOS) of 7 days. But when trended over time, for patients without RA, the median LOS decreased from 8 days in 2006-08 to 6 days in 2016-18 whereas for patients with RA, the median LOS fluctuated between 6 and 7 days over the course of study period.

CDI patients without RA had a significantly higher mortality over the study period than those with RA (7.8% vs 6.1%, p<0.001). Among non-RA CDI patients, mortality decreased from 9.3% in 2006 to 6.3% in 2018 (p trend <0.001). Hospitalizations of people with CDI and comorbid RA showed an overall decreasing trend (p trend <0.001).

The multivariable analyses found age≥65 was associated with increased inpatient mortality (adjusted odds ratio [aOR], 1.77, 95% confidence interval [CI], 1.73-1.80), whereas a diagnosis of RA was associated with a decreased mortality (aOR 0.86, 95% CI, 0.81-0.91) (Table 1).

Table 1.

Predictors of inpatient mortality

aOR95% C.I. for aORP-valueLowerUpperAge ≥ 651.7651.7301.801<0.001Hospitalization years -Years 2006-2011Ref -Years 2011-20140.7070.6930.721<0.001 -Years 2015-20180.5820.5690.594<0.001Elixhauser Comorbidity Index1.0561.0551.056<0.001Rheumatoid Arthritis0.8590.8100.911<0.001Female0.8700.8550.885<0.001Race -WhiteRef -African American1.0711.0441.099<0.001 -Hispanic1.1441.1081.180<0.001 -Asian/Pacific Islander1.2671.2001.337<0.001 -Native American1.0220.9101.1470.716 -Other races1.2631.2011.329<0.001

aOR = Adjusted Odds Ratio; C.I.= confidence interval

Conclusion:

In this nationwide study, among hospitalized patients with CDI, those with comorbid RA had significantly decreased odds of inpatient mortality than those without RA. Further studies are needed to understand this association.

Figure 1.

Disclosure of Interests:

None declared

Using Robson's Ten-Group Classification System for comparing caesarean section rates in Europe: an analysis of routine data from the Euro-Peristat study

Objective

Robson's Ten Group Classification System (TGCS) creates clinically relevant sub‐groups for monitoring caesarean birth rates. This study assesses whether this classification can be derived from routine data in Europe and uses it to analyse national caesarean rates.

Design

Observational study using routine data.

Setting

Twenty‐seven EU member states plus Iceland, Norway, Switzerland and the UK.

Population

All births at ≥22 weeks of gestational age in 2015.

Methods

National statistical offices and medical birth registers derived numbers of caesarean births in TGCS groups.

Main outcome measures

Overall caesarean rate, prevalence and caesarean rates in each of the TGCS groups.

Results

Of 31 countries, 18 were able to provide data on the TGCS groups, with UK data available only from Northern Ireland. Caesarean birth rates ranged from 16.1 to 56.9%. Countries providing TGCS data had lower caesarean rates than countries without data (25.8% versus 32.9%, P = 0.04). Countries with higher caesarean rates tended to have higher rates in all TGCS groups. Substantial heterogeneity was observed, however, especially for groups 5 (previous caesarean section), 6, 7 (nulliparous/multiparous breech) and 10 (singleton cephalic preterm). The differences in percentages of abnormal lies, group 9, illustrate potential misclassification arising from unstandardised definitions.

Conclusions

Although further validation of data quality is needed, using TGCS in Europe provides valuable comparator and baseline data for benchmarking and surveillance. Higher caesarean rates in countries unable to construct the TGCS suggest that effective routine information systems may be an indicator of a country's investment in implementing evidence‐based caesarean policies.

Tweetable abstract

Many European countries can provide Robson's Ten‐Group Classification to improve caesarean rate comparisons.

Many European countries can provide Robson's Ten‐Group Classification to improve caesarean rate comparisons.

Loss of the laminin subunit alpha-3 induces cell invasion and macrophage infiltration in cutaneous squamous cell carcinoma

BACKGROUND

Cutaneous squamous cell carcinoma (cSCC) is a common cancer that invades the dermis through the basement membrane. The role of the basement membrane in poorly differentiated cSCC is not well understood.

OBJECTIVES

To study the effect that loss of the laminin subunit alpha-3 (α3) chain from the tumour microenvironment has on tumour invasion and inflammatory cell recruitment.

METHODS

We examined the role of the basement membrane proteins laminin subunits α3, β3 and γ2 in SCC invasion and inflammatory cell recruitment using immunohistochemistry, short hairpin RNA knockdown, RNA-Seq, mouse xenograft models and patient tumour samples.

RESULTS

Analysis of SCC tumours and cell lines using antibodies specific to laminin chains α3, β3 and γ2 identified a link between poorly differentiated SCC and reduced expression of laminin α3 but not the other laminin subunits investigated. Knockdown of laminin α3 increased tumour invasion both in vitro and in vivo. Western blot and immunohistochemical staining identified increased phosphorylated myosin light chain with loss of laminin α3. Inhibition of ROCK (rho-associated protein kinase) but not Rac1 significantly reduced the invasive potential of laminin α3 knockdown cells. Knockdown of laminin subunits α3 and γ2 increased monocyte recruitment to the tumour microenvironment. However, only the loss of laminin α3 correlated with increased tumour-associated macrophages both in xenografted tumours and in patient tumour samples.

CONCLUSIONS

These data provide evidence that loss of the laminin α3 chain in cSCC has an effect on both the epithelial and immune components of cSCC, resulting in an aggressive tumour microenvironment.

Impact of implementation of a breech clinic in a tertiary hospital

BACKGROUND

The incidence of breech presentation in single pregnancies at term is between three to 5 %. In order to support eligible women in their choice of mode of delivery, a dedicated breech clinic with a care pathway was developed in December 2015 in a tertiary referral centre in Brussels. The primary objective of this study was to evaluate the vaginal birth rate before and after the introduction of a dedicated breech clinic. The secondary objective was to compare the early neonatal outcomes before and after the breech clinic was introduced.

METHODS

This was a single centre retrospective and prospective study. The inclusion criteria were term (from 37 weeks), singleton fetus and breech presentation at delivery. The exclusion criteria were suspected intrauterine growth restriction, severe fetal malformations and intrauterine fetal demise. We used a composite outcome as an indicator of neonatal morbidity and mortality.

RESULTS

After the introduction of the breech clinic, we observed a significant increase in planned vaginal delivery from 7.4% (12/162) to 53.0% (61/115) (OR: 13.5; 95% CI: 6.7-27.0). The effective vaginal breech delivery rate (planned and unexpected) significantly increased from 4.3% (7/162) pre-implementation of breech clinic to 43.5% (50/115) post-implementation (OR: 17.0; 95% CI: 7.3-39.6). Neonatal outcomes were not statistically different between the before and after periods.

CONCLUSION

The introduction of a dedicated breech clinic has led to an increase in vaginal deliveries for breech babies without adversely affecting neonatal outcomes.

Clinical and financial impacts of introducing an endoscopic mucosal resection service for treatment of patients with large colonic polyps into a regional tertiary hospital

Background and study aims  Endoscopic mucosal resection (EMR) of large sessile or laterally spreading colonic lesions is a safe alternative to surgery. We assessed reductions in Surgical Resection (SR) rates and associated clinical and financial benefits following the introduction of an EMR service to a large regional center. Patients and methods  Ongoing prospective intention-to-treat analysis of EMR was undertaken from time of service inception in 2009 to 2017. Retrospective data for SR of large sessile/laterally spreading colonic lesions were collected for the period 4 years before commencement of the EMR service (2005 - 2008) and 9 years after its introduction (2009 - 2017). Results  From 2005 to 2008, 32 surgical procedures were performed for non-malignant colonic neoplasia (50 % male, median age 68 years, median Length of Stay (LoS) 10 days). Following the introduction of the EMR service, there was a 56 % reduction in the number of patients referred for surgery (32 surgical procedures, 47 % male, median age 70 years, median LoS 8.5 days). During this period, EMR was successfully performed in 183 patients with 216 lesions resected (60 % male, median age 68 years, median LoS 1 day). Compared to the SR group, the EMR cohort had a lower peri-procedural complication rate (7.7 % vs 54.7 %, P  < 0.0001), and shorter average LoS (1 vs 9 days, P  < 0.0001). A cost saving of AUD $ 19 543.5 was seen per lesion removed with EMR compared to SR. Conclusions  The introduction of a dedicated EMR service into a large regional center as an alternative to SR can lead to a substantial decrease in unnecessary surgery with subsequent clinical and financial benefits.

Levelling the Playing Fields: A Pilot Intervention

Key messages

Access to urban outdoor play is critical for children’s well-being. Road closures can increase urban outdoor play, thereby contributing to physical and mental health and promoting social interaction. Child and youth participation in the planning and development of urban play spaces can increase their relevance and broaden their social, environmental, health and policy impacts.

Outcome of Surgical Inspection of the Gallbladder in Relation to Final Pathology

INTRODUCTION

Routine histopathologic gallbladder examination after cholecystectomy has been a point of discussion. The aim of this study was to evaluate the macroscopic examination by the surgeon in relation to the final histology.

METHODS

A prospective study was conducted to investigate the practice of macroscopic gallbladder examination by a surgeon compared to routine histopathology by a pathologist. All consecutive cholecystectomies were included between November 2009 and February 2011.

RESULTS

A total of 319 consecutive cholecystectomies were performed. Of all macroscopic examinations, the surgeon identified 62 gallbladders with macroscopic abnormalities, ranging from polyps to wall thickening or ulcers. In 55 (17.2%) cases, the surgeon judged that further examination of the specimen by the pathologist could possibly lead to additional and relevant findings. There was a strong agreement between the surgeon and the pathologist concerning the macroscopic examination (κappa = 0.822). The surgeon and the pathologist had disagreement on the macroscopic examination of 18 gallbladders, without clinical consequences for the patient.

DISCUSSION

The present prospective study shows that the surgeon should be able to select those gallbladders needing a microscopic gallbladder examination. Potentially, about 80% of this kind of routine histology can be reduced.

Relationship of Creatinine and Cystatin C-based Estimated Glomerular Filtration rates with Measured Glomerular Filtration Rate in Healthy Kidney Donors from South Asia

Chronic Kidney Disease-Epidemiology Collaboration (CKD-EPI) equation is currently recommended for the estimation of glomerular filtration rate (GFR). This retrospective study aimed to evaluate the correlation between creatinine and cysC-based estimated GFRs and measured GFR in healthy adults. Consecutive healthy adults who were accepted as voluntary kidney donors at our center between January 2008 and December 2012 were included in the study. The 336 individuals who comprised the study population had a mean age of 41.6 ± 11.8 years, male:female ratio 1:1.7, mean creatinine 0.9 ± 0.1 mg/dl, and mean cysC 0.8 ± 0.1 mg/dl. Mean measured GFR by Tc-99m diethylenetriaminepentaacetic acid using Gates method was 98.4 ± 21.2 ml/min/1.73 m². The mean ± standard deviation of eGFRs by various formulae were as follows: Cockcroft–Gault (CG) = 88.1 ± 15.9 ml/min/1.73 m², Modification of Diet in Renal Disease (MDRD) = 78 ± 14.7 ml/min/1.73 m², CKD-EPI creatinine = 88.1 ± 15.5 ml/min/1.73 m², CKD-EPI cysC = 97 ± 19.9 ml/min/1.73 m², CKD-EPI creatinine-cysC (CKD-EPI cr-cysC) = 92.5 ± 14.1 ml/min/1.73 m². The CKD-EPI cr-cysC equation had the highest accuracy, with 43% and 72% of values lying within ±10% and ±20% of the measured GFR, respectively. Bland–Altman analyses for levels of agreement showed least bias with CKD-EPI cysC overall and among females, while among males, CKD-EPI creatinine equation had the least bias. The CKD-EPI equation showed a higher performance than the MDRD and CG equation in GFR estimation of a healthy population. Among CKD-EPI equations, CKD-EPI cr-cysC had the highest accuracy and CKD-EPI cysC the least bias.

Neonatal outcomes of elective early-term births after demonstrated fetal lung maturity

BACKGROUND

Studies of early-term birth after demonstrated fetal lung maturity show that respiratory and other outcomes are worse with early-term birth (37⁰-38⁶ weeks) even after demonstrated fetal lung maturity when compared with full-term birth (39⁰-40⁶ weeks). However, these studies included medically indicated births and are therefore potentially limited by confounding by the indication for delivery. Thus, the increase in adverse outcomes might be due to the indication for early-term birth rather than the early-term birth itself.

OBJECTIVE

We examined the prevalence and risks of adverse neonatal outcomes associated with early-term birth after confirmed fetal lung maturity as compared with full-term birth in the absence of indications for early delivery.

STUDY DESIGN

This is a secondary analysis of an observational study of births to 115,502 women in 25 hospitals in the United States from 2008 through 2011. Singleton nonanomalous births at 37-40 weeks with no identifiable indication for delivery were included; early-term births after positive fetal lung maturity testing were compared with full-term births. The primary outcome was a composite of death, ventilator for ≥2 days, continuous positive airway pressure, proven sepsis, pneumonia or meningitis, treated hypoglycemia, hyperbilirubinemia (phototherapy), and 5-minute Apgar <7. Logistic regression and propensity score matching (both 1:1 and 1:2) were used.

RESULTS

In all, 48,137 births met inclusion criteria; the prevalence of fetal lung maturity testing in the absence of medical or obstetric indications for early delivery was 0.52% (n = 249). There were 180 (0.37%) early-term births after confirmed pulmonary maturity and 47,957 full-term births. Women in the former group were more likely to be non-Hispanic white, smoke, have received antenatal steroids, have induction, and have a cesarean. Risks of the composite (16.1% vs 5.4%; adjusted odds ratio, 3.2; 95% confidence interval, 2.1-4.8 from logistic regression) were more frequent with elective early-term birth. Propensity scores matching confirmed the increased primary composite in elective early-term births: adjusted odds ratios, 4.3 (95% confidence interval, 1.8-10.5) for 1:1 and 3.5 (95% confidence interval, 1.8-6.5) for 1:2 matching. Among components of the primary outcome, CPAP use and hyperbilirubinemia requiring phototherapy were significantly increased. Transient tachypnea of the newborn, neonatal intensive care unit admission, and prolonged neonatal intensive care unit stay (>2 days) were also increased with early-term birth.

CONCLUSION

Even with confirmed pulmonary maturity, early-term birth in the absence of medical or obstetric indications is associated with worse neonatal respiratory and hepatic outcomes compared with full-term birth, suggesting relative immaturity of these organ systems in early-term births.

The independent patient factors that affect length of stay following hip fractures

Introduction Management of hip fractures has evolved over recent years to drive better outcomes including length of hospital stay. We aimed to identify and quantify the effect that patient factors influence acute hospital and total health service length of stay. Methods A retrospective observational study based on National Hip Fracture Database data was conducted from 1 January 2014 to 31 December 2015. A multiple regression analysis of 330 patients was carried out to determine independent factors that affect acute hospital and total hospital length of stay. Results American Society of Anesthesiologists (ASA) grade 3 or above, Abbreviated Mental Test Score (AMTS) less than 8 and poor mobility status were independent factors, significantly increasing length of hospital stay in our population. Acute hospital length of stay can be predicted as 8.9 days longer when AMTS less than 8, 4.2 days longer when ASA grade was 3 or above and 20.4 days longer when unable to mobilise unaided (compared with independently mobile individuals). Other factors including total hip replacement compared with hemiarthroplasty did not independently affect length of stay. Conclusions Our analysis in a representative and generalisable population illustrates the importance of identifying these three patient characteristics in hip fracture patients. When recognised and targeted with orthogeriatric support, the length of hospital stay for these patients can be reduced and overall hip fracture care improved. Screening on admission for ASA grade, AMTS and mobility status allows prediction of length of stay and tailoring of care to match needs.

No effect of prenatal vitamin D deficiency on autism-relevant behaviours in multiple inbred strains of mice

Autism Spectrum Disorders (ASD) is a group of neurodevelopmental disorders commonly characterised by verbal and non-verbal communication deficits, impaired social interaction and repetitive, stereotypic behaviours. The aetiology of ASD is most likely a combination of genetic and environmental factors. Epidemiological evidence suggests that prenatal vitamin D deficiency is associated with an increased incidence of ASD. The overall aim of this study was to investigate prenatal vitamin D deficiency on ASD-related behavioural phenotypes in multiple inbred strains of mice. We included two commonly used inbred mouse strains (C57BL/6J and BALB/c) as well as inbred BTBR mice, which show ASD-related behaviours, such as excessive self-grooming, hyperlocomotion, social interaction deficits and altered communication. We also studied the effect of prenatal vitamin D deficiency in a fourth strain; an F1 cross of C57BL/6J x BTBR mice, which have a partial BTBR phenotype. To implement prenatal vitamin D deficiency, female mice were placed on vitamin D deplete diets for ten weeks, including mating and gestation, until littering, when all dams were switched to the control diet. Behavioural symptoms related to ASD were measured, including isolation-induced ultrasonic vocalisations to measure communication, the three-chambered social interaction task to observe social interaction, the open field test to examine hyperlocomotion, assessment of grooming and rearing behaviour and finally the active place avoidance task to observe spatial learning and memory in response to a mild foot shock. Prenatal vitamin D deficiency had a negative impact on preference for social novelty in C57BL/6J mice, despite similar vocalisation phenotypes, and prenatal vitamin D-deficient F1 mice were found to be hypolocomotive in the open field test yet performed better on the active place avoidance task. Despite clear differences between strains, there were no other consistent significant main effects of maternal diet on the behaviour of the offspring. Vitamin D deficiency has been implicated as a risk factor for ASD and these data show that there is greater variation between different inbred strains in ASD-related behaviour, suggesting that prenatal vitamin D deficiency is not sufficient to recapitulate an ASD phenotype in multiple inbred strains of mice.

Influence of food and lifestyle on the risk of developing inflammatory bowel disease

BACKGROUND

The Barwon area in Australia has one of the highest incidence rates of inflammatory bowel disease (IBD) and therefore is an ideal location to study the impact of environmental exposures on the disease's development.

AIM

To study these exposures prior to the development of IBD in a population-based cohort.

METHOD

One hundred and thirty-two incident cases (81 Crohn disease (CD) and 51 ulcerative colitis (UC)) from an IBD registry and 104 controls replied to the International Organization of Inflammatory Bowel Diseases environmental questionnaire. This included 87 questions about pre-illness exposures that included childhood illnesses, vaccinations, breastfeeding, house amenities, pets and swimming, diet and smoking.

RESULTS

The factors associated with CD included smoking (odds ratio (OR): 1.42, confidence interval (CI): 1-2.02, P = 0.029); childhood events, including tonsillectomy (OR: 1.74, CI: 1.15-2.6, P = 0.003) and chicken pox infection (OR: 3.89, CI: 1.61-9.4, P = 0.005) and pre-diagnosis intake of frequent fast food (OR: 2.26, CI: 1.76-4.33, P = 0.003). In UC, the risk factors included smoking (OR: 1.39, CI: 1.1-1.92, P = 0.026) and pre-diagnosis intake of frequent fast food (OR: 2.91, CI: 1.54-5.58, P < 0.001), and high caffeine intake was protective (OR: 0.51, 95% CI: 0.3-0.87, P = 0.002). Other protective exposures for UC included high fruit intake (OR: 0.59, CI: 0.4-0.88, P = 0.003) and having pets as a child (OR: 0.36, CI: 0.2-0.79, P = 0.001).

CONCLUSION

This first Australian population-based study of environmental risk factors confirms that smoking, childhood immunological events and dietary factors play a role in IBD development; while high caffeine intake and pet ownership offer a protective effect.

Concentrations of calcium and 25-hydroxycholecalciferol (vitamin D3) in plasma of wild kākāpō (Strigops habroptilus) living on two islands in New Zealand

AIMS This preliminary study had the objectives of describing the concentrations of ionised calcium and 25-hydroxycholecalciferol (25(OH)D₃) in the blood of wild kākāpō (Strigops habroptilus) living on two islands in New Zealand, and to determine the effects of supplementary feeding on these blood parameters. METHODS Blood samples were obtained from 33 kākāpō living on two offshore islands during routine health checks in 2015. Birds on Hauturu were sampled in May (n=5) and birds on Whenua Hou were sampled in July (n=15) and November (n=26). Of the birds sampled on Whenua Hou in November, 15 received supplementary food prior to sampling. Samples were analysed for pH, and concentrations of ionised calcium, total calcium, phosphorous, total protein, albumin, globulin, uric acid and 25(OH)D₃. RESULTS Concentrations of ionised calcium did not differ between unsupplemented birds on the two islands, nor between supplemented (median 1.17 (95% CI=1.12-1.20) mmol/L) and unsupplemented (median 1.09 (95% CI=1.08-1.14) mmol/L) birds sampled in November on Whenua Hou (p>0.05), and were comparable with published normal ranges for other psittacines. Concentrations of 25(OH)D₃ did not differ between unsupplemented birds on the two islands (p>0.05), but were higher in supplemented (median 8.00 (95% CI=4.76-8.45) nmol/L) than unsupplemented (median 0.00 (95% CI=-0.16-0.48) nmol/L) birds on Whenua Hou (p<0.001). All values were much lower than published ranges for healthy psittacines. There was no difference between male and female birds on Whenua Hou for any parameter measured (p>0.05). CONCLUSIONS AND CLINICAL RELEVANCE The calcium status of the kākāpō in this study was comparable to other wild psittacines, however concentrations of 25(OH)D₃ were much lower. The concentrations of 25(OH)D₃ may be within the normal range for the species, however further data are required to confirm this. The significant increase in concentrations of 25(OH)D₃ in supplementary fed birds suggests that this food was providing more of the nutrient than the wild diet at that time of year, although the effects of this are unknown. Further investigation is required into the calcium and vitamin D₃ status of kākāpō, across a wider range of locations, seasons and ages. This would help define normal ranges for these parameters, allow interpretation in clinically abnormal individuals, and guide the refinement of supplementary foods. This information would, therefore, assist the future conservation management of this critically endangered species.