Cattle, carcass, economic, and estimated emission impacts of feeding finishing steers lubabegron or ractopamine hydrochloride

Lubabegron (Experior; Elanco, Greenfield, IN, USA) is the first U.S. Food and Drug Administration approved feed additive for reducing gas emissions from feedlot animals or their waste; it does not have live or carcass performance claims. Our primary objective was to determine the effect of lubabegron on feedlot performance and carcass traits in finishing beef steers compared to ractopamine hydrochloride (Optaflexx; Elanco, Greenfield, IN, USA). A commercial feedlot trial using cross-bred beef steers (n = 2,117; 373 ± 15 kg initial body weight [BW]) was completed with a randomized complete block design. Treatments consisted of two feed additives: (1) OPT targeted to deliver 300 mg/animal/d of ractopamine hydrochloride for 28 ± 7 d out from harvest and (2) EXP targeted to deliver 36 mg/animal/d of lubabegron 56 ± 7 d out from harvest and a 4-d preslaughter withdrawal period. Twenty 70 to 142 hd pens with 10 pens per treatment were used. Cattle were weighed at arrival processing and at harvest and fed for an average of 167 d. Data were used to calculate production metrics, partial budgets, and estimated greenhouse gas emissions using published methods, and were analyzed using linear mixed models with pen as the experimental unit and block as a random intercept. A statistical significance threshold of α = 0.05 was determined a priori. There was no evidence for statistically significant differences between treatments for initial BW (P = 0.70), health-related outcomes (P values ≥ 0.43), or mobility scores (P = 0.09). Cattle-fed EXP had increased final BW, ADG, G:F, and decreased dry matter intake (P values ≤ 0.01) compared to OPT. Carcasses were 11 ± 1.76 kg (hot carcass weight) heavier in EXP group (P < 0.01), and differed between treatments for both yield grades (YG) and quality grades distributions (P values ≤ 0.01). Cattle-fed EXP had a shift toward more YG 1 and 2, select and sub-select carcasses compared to OPT, which had as shift toward more YG 3, 4, 5, prime and choice carcasses. With increased beef production and efficiency compared to OPT, the estimated CO2 equivalent emissions from production were reduced by 6.2% per unit of carcass weight for EXP (P ≤ 0.01). Estimated net returns/animal shipped were $56.61 ± 9.37 more for EXP than OPT (P ≤ 0.01). In conclusion, when cattle were fed for the same total number of days, feeding EXP compared to OPT increased net returns, feedlot performance, and efficiency, but resulted in carcass yield and quality characteristics that may impact marketing programs.

Development of a radiographic technique for porcine head ballistic research

INTRODUCTION

The porcine model shows structural features comparable to that of humans and are routinely used within research, due to the ethical, legal, and practical use of post-mortem human samples. Methods for obtaining high quality and comparable reference data using standardised acquisition protocols are essential.

METHODS

The decapitated heads of three adult white sows were subjected to radiographic imaging before and after cranial trauma (9 mm, Heckler and Koch MP5). Digital radiographs were generated using a Siemens MULTIX TOP system with an Agfa digital detector, with foam blocks and sandbags as ancillary equipment. An iterative approach was adopted by the authors to generate reproducible radiographic views from two perpendicular angles. Specimens were kept at 5 °C and wrapped in polythene bags to reduce the impact of putrefaction.

RESULTS

Standardised head radiography technique was developed for superior-inferior and lateral views demonstrating porcine anatomy. Key parameters included: automatic exposure control for tube current (∼4 mAs), tube voltage of 73 kVp, 100 cm source to image receptor distance, and an anti-scatter grid. Slight variances in specimen morphology, developmental status, and soft tissue changes did not affect imaging outcomes.

CONCLUSION

The technique and positioning proposed in this study allows for the acquisition of high quality and reproducible radiographic images for comparable ballistic research datasets. Specimen positioning and centring of the primary beam may be applied across porcine breeds, although individual radiographic parameters may differ according to equipment specifications and specimen size.

IMPLICATIONS FOR PRACTICE

Development of a reproducible radiographic technique of porcine heads in forensic and veterinary research.

Evaluation of C4 Gene Copy Number in Pediatric Acute Neuropsychiatric Syndrome

Pediatric acute-onset neuropsychiatric syndrome (PANS) is an abrupt-onset neuropsychiatric disorder. PANS patients have an increased prevalence of comorbid autoimmune illness, most commonly arthritis. In addition, an estimated one-third of PANS patients present with low serum C4 protein, suggesting decreased production or increased consumption of C4 protein. To test the possibility that copy number (CN) variation contributes to risk of PANS illness, we compared mean total C4A and total C4B CN in ethnically matched subjects from PANS DNA samples and controls (192 cases and 182 controls). Longitudinal data from the Stanford PANS cohort (n = 121) were used to assess whether the time to juvenile idiopathic arthritis (JIA) or autoimmune disease (AI) onset was a function of total C4A or C4B CN. Lastly, we performed several hypothesis-generating analyses to explore the correlation between individual C4 gene variants, sex, specific genotypes, and age of PANS onset. Although the mean total C4A or C4B CN did not differ in PANS compared to controls, PANS patients with low C4B CN were at increased risk for subsequent JIA diagnosis (hazard ratio = 2.7, p value = 0.004). We also observed a possible increase in risk for AI in PANS patients and a possible correlation between lower C4B and PANS age of onset. An association between rheumatoid arthritis and low C4B CN has been reported previously. However, patients with PANS develop different types of JIA: enthesitis-related arthritis, spondyloarthritis, and psoriatic arthritis. This suggests that C4B plays a role that spans these arthritis types.

The Patient's perspective: A review of the results from a radiotherapy patient experience survey in the North-West of England

INTRODUCTION

A patient experience survey was undertaken for patients completing radiotherapy at the three Northwest of England Radiotherapy Providers.

METHODS

A previously reported National Radiotherapy Patient Experience Survey was adapted and undertaken in the Northwest of England. Quantitative data was analysed to establish trends. Frequency distribution was applied to appraise the number of participants selecting each of the pre-determined responses. Thematic analysis of free text responses was conducted.

RESULTS

The questionnaire received 653 responses from the 3 providers across seven departments. Thematic analysis revealed 3 themes; logistics, information and operational.

CONCLUSION

The results indicate that the majority of patients are satisfied with their treatment and care. Patients' responses indicate areas for improvements. Expectancy theory states that an individual's satisfaction is related to the difference between expected service and the service received. Consequently, when reviewing services and developing improvement it is important to understand patients' expectations^. This regional survey starts to capture what people receiving radiotherapy expect from the service and the professionals delivering their treatment.

IMPLICATIONS FOR PRACTICE

This survey responses make a case for reviewing the information provision pre and post radiotherapy. This includes clarifying the understanding of consent for treatment including the intended benefits and potential late effects. There is an argument to offer information sessions prior to radiotherapy to achieve more relaxed and informed patients. A recommendation from this work is for the radiotherapy community undertake a national radiotherapy patient experience survey, facilitated via the 11 Radiotherapy ODNs. A national radiotherapy survey has multiple benefits to inform improvements in practice. This includes benchmarking services against national averages. This approach is aligned with the principles of the service specification in terms of reducing variation and increasing quality.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Textbook outcome following oesophagectomy for cancer: international cohort study

Background

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

Methods

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

Results

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

Conclusion

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

Textbook outcome following oesophagectomy for cancer: international cohort study

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

79 SIMULATION-BASED MEDICAL EDUCATION: A ‘HIP’ WAY TO LEARN ABOUT ORTHO-GERIATRICS!

Background

Simulation-based medical education (SBME) is emerging as a key method of medical education, particularly in the setting of the COVID-19 pandemic. As part of a simulation development competition (SimStars) run by the National Doctors Training and Planning Unit and the South–South West Hospital Group, we brought together an inter-disciplinary team to develop a simulation scenario on hip fracture.

Methods

Our development team consisted of members of the Geriatric Medicine and Orthopaedic Departments. We developed a scenario that can be adapted to suit the needs of learners in orthopaedics, medicine, or nursing. We ran the simulation on a medical ward with one candidate and four facilitators from the Geriatric Medicine Department. The candidate (medical SHO) was presented with a patient (facilitator one), who had sustained a hip fracture following a fall. The candidate was directed to elicit a falls and bone health history, screen for delirium, and suggest further investigations and management. Subsequently, feedback was sought from all participants.

Results

The simulation took twenty minutes, debriefing took fifteen minutes. All considered, the simulation an enjoyable and feasible method for teaching and learning, and a novel way to promote team-building. The candidate felt competent in some areas, reporting that the scenario provided positive reinforcement. She reported feeling supported in identifying areas for further learning. The facilitators also considered this method a useful way to highlight a candidate’s learning needs and direct further teaching. The candidate requested further SBME-based sessions.

Conclusion

This SBME session in Ortho-Geriatrics was well-received by the candidate and facilitators. All participants enjoyed teaching and learning through this medium. Areas of high competency were reinforced and areas for future learning were identified. Further SBME was requested across more topics and for simulation training to be brought in as part of formal training.

Postoperative outcomes in oesophagectomy with trainee involvement

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Multi-modality imaging in hypertrophic cardiomyopathy: intermodal discrepancies in key prognostic parameters

Background/Introduction

Multi-modality imaging is crucial for confirming diagnosis and assessing prognosis in patients with hypertrophic cardiomyopathy (HCM). However, inter-modality discrepancies in key parameters are commonly reported.

Purpose

To assess real-world inter-modal reporting discrepancies between transthoracic echocardiography (TTE) and cardiac magnetic resonance (CMR) imaging in the measurement of four key parameters in HCM patients.

Methods

Consecutive HCM patients with TTE and CMR performed within 6 months of each other at a tertiary centre were retrospectively assessed for reported maximum wall thickness (MWT), left atrial diameter (LAd), left ventricular ejection fraction (LVEF) and presence of left ventricular apical aneurysm (LVAA). The CMR report was considered gold standard. Data are reported as mean ± standard deviation (SD) or median and interquartile range (IQR) as appropriate.

Results

353 consecutive HCM patients (72% male, median age 60.9 years, IQR 49.8–71.6 years) with TTE and CMR within 6 months (median difference 1.7 months, IQR 1.1–3.4 months) were assessed between 4th January 2018 and 9th April 2019. Of 284 patients with paired MWT data, median difference was 0.0 mm (IQR −1.0 to 3.0 mm, p=0.02), likely representing a difference in distributions of MWT. TTE both over and underestimated MWT (in 36% and 46% cases respectively).

Of the 94 patients with paired LAd data, mean difference was 0.4±5.7 mm (95% CI −0.8010 to 1.546, p=0.5).

N=320 patients with paired LVEF data (after excluding patients with atrial fibrillation (n=20)). Median difference in LVEF was 12% (IQR 5–19% p&lt;0.0001). TTE underestimated LVEF in 88% of cases. CMR and TTE both identified 14 (5%) patients as having LVEF &lt;50%. There were however 8 cases of disagreement in classification of LVEF &lt;50%, due to over (n=4) or underestimation (n=4) by TTE.

LVAA was accurately identified by TTE in only 9/30 (30%) of those patients with demonstrable LVAA by CMR (p=0.0008). TTE evidence of a discreet apical chamber (paradoxical jet on spectral or colour Doppler) was present in 16/21 (76%) cases where TTE failed to overtly identify LVAA. However, apical or mid-cavity obliteration was reported in 15/21 (71%) cases where TTE failed to identify LVAA.

Conclusion(s)

Echocardiography and CMR measurements are often used interchangeably in clinical practice but inter-modality discrepancies can affect diagnosis and sudden cardiac death (SCD) risk assessment. This is particularly important for binary risk factors such as LVEF&lt;50% or LVAA which are considered major SCD risk factors in the latest American Heart Association guidelines. 25 (7%) patients in our cohort had major risk factors identified by CMR that were not identified on TTE. CMR is an important, recommended tool where TTE imaging is suboptimal, but attention to more subtle elements of abnormal intracavity blood flow may be able to increase LVAA detection during TTE.

Funding Acknowledgement

Type of funding sources: None.

A cost analysis of cardiac magnetic resonance imaging in the diagnostic pathway of a population with unexplained acute myocardial injury and normal coronary angiography

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): National Institute for Health Research (NIHR) Biomedical Research Centre at St Bartholomew"s Hospital London. Irish Cardiac Society

OnBehalf

European Association of Cardiovascular Imaging (EACVI) -Task Force for Cost Effectiveness.

Background

Acute presentations with myocardial injury that occur despite culprit-free coronary angiography were first reported over 70 years ago, with a prevalence between 5-9%.  1-3 There is increasing evidence that a more accurate diagnosis is available and that CMR is a key tool to determine the underlying pathology. This is reflected with the most recent international guidelines advocating for the use of CMR in the diagnostic pathways of this heterogeneous population.  However, to date there is no formal assessment of the financial implications of adopting these new guidelines.

Purpose

To determine the financial impact of implementing cardiac magnetic resonance imaging in the diagnostic pathway of a population with unexplained acute myocardial injury and normal coronary angiography in comparison to existing clinical practice.

Methods

We performed a focused cost-benefit analysis using a hypothetical population of 2,000 patients with unexplained acute myocardial injury and normal coronary angiography.  The population was split evenly into two groups of either standard, or CMR guided management, and extrapolated over a ten-year period. Standard management was defined as 66% of the population receiving dual antiplatelet therapy (ticagrelor and aspirin) for one year followed by aspirin for life, and the remaining 34% of the population receiving aspirin for life. CMR guided management determined antiplatelet therapy according to the imaging findings. This analysis focused on CMR’s ability to accurately identify those patients who may have had an MI and facilitate tailored treatment with evidence based dual antiplatelet therapy. Costs and rates were defined in Table 1. A one-way sensitivity analysis was also performed to determine the variables with largest impact on the costs. Each variable was varied by +/- 20% and the change in cost determined at year 10.

Results

Using CMR in the diagnostic pathway resulted in an increased cost of £72,656 in the first year. After year 7, CMR guided practice becomes cost neutral, resulting in cost saving of £24,054 over a ten-year period in a population of 1000 patients. Figure 1. Utilizing CMR in this population also resulted in 7 fewer myocardial infarctions and 14 fewer major bleeding events over a ten-year time horizon.

The three most sensitive variables were, in decreasing order, the cost of CMR, the cost of ticagrelor and the percentage of the population with MI requiring DAPT. A 20% change from baseline resulted in a 320%, 247% and 162% change in costs at 10 years, respectively.

Conclusion

Utilizing CMR in this population may be associated with reduced costs in the medium to long term. The initial increased cost of CMR is offset over time, by delivering a more personalised, higher quality level of care to patients.

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSION

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

Investigating duration and intensity of Covid-19 social-distancing strategies

The exponential character of the recent Covid-19 outbreak requires a change in strategy from containment to mitigation. Meanwhile, most countries apply social distancing with the objective to keep the number of critical cases below the capabilities of the health care system. Due to the novelty and rapid spread of the virus, an a priori assessment of this strategy was not possible. In this study, we present a model-based systems analysis to assess the effectiveness of social distancing measures in terms of intensity and duration of application. Results show a super-linear scaling between intensity (percent contact reduction) and required duration of application to have an added value (a lower number of fatalities). This holds true for an effective reproduction of [Formula: see text] and is reverted for [Formula: see text]. If R is not reduced below 1, secondary effects of required long-term isolation are likely to unravel the added value of disease mitigation. If an extinction is not feasible, we recommend moderate social-distancing that is well balanced against capability limits of national health-care systems.

Impact of the 2020 COVID-19 pandemic on the workload of the orthopaedic service in a busy UK district general hospital

INTRODUCTION

The COVID -19 outbreak has had a profound effect on the management of healthcare service provision in the UK. Orthopaedic departments have been no exception to this and have needed to adapt to the changing circumstances by releasing resources and focusing on 'essential' activity. The aim of this study is to quantify the reduction in trauma and, in addition, describe any changes in the type of referrals to the trust which may have been affected by the pandemic itself and the social distancing measures employed by the UK government.

METHODS

The study was performed in a UK District Hospital which is also a Trauma Unit providing trauma and orthopaedic care to a population of 625,000 people. The trust based electronic database of trauma referrals was used to compare the numbers of, and types of referral to our trauma service during the COVID-19 pandemic and the corresponding time periods in the previous 3 years.

RESULTS

The mean number of referrals per week to the service reduced by 33% in the time period following the confirmation of the outbreak as a pandemic (p<0.0001). Number of operations performed per week reduced by 26% (p = 0.001). There was no change in the number of referrals relating to domestic abuse or non-accidental injury. In addition, numbers of hip fractures, periprosthetic fractures and prosthetic joint dislocations were unchanged. There was a significant reduction in the number of referrals for simple fractures, native joint dislocations, wounds and soft tissue injuries. Within the paediatric population, similarly, a reduction in simple fracture referrals was demonstrated.

DISCUSSION

An association between the outbreak of the pandemic and a reduction in referral numbers to our department has been demonstrated. The direct cause of this may be multifactorial but proposing that it is, in part, due to the social distancing measures introduced by the government is certainly conceivable. The patterns of injury would reflect this also with low energy and fragility trauma persisting whilst injuries associated with younger people have reduced. We would suggest that information such as this could be useful in healthcare planning and resource allocation in future pandemic situations.

The Relationship Between Streptococcal Antibodies and the Course of OCD and Tics in a Pediatric Population

The clinical phenotype of pediatric OCD and tic disorders in relation to streptococcal antibody patterns will be discussed. Also, cellular and other immune findings will be presented on a group of children with OCD and tic disorders taking into account clinical phenotype data.

Protocol for the Process Evaluation of the Online Remote Behavioural Intervention for Tics (ORBIT) randomized controlled trial for children and young people

BACKGROUND

Process evaluations are an important component in the interpretation and understanding of outcomes in trials. The Online Remote Behavioural Intervention for Tics (ORBIT) study is a randomized controlled trial evaluating the effectiveness of an Internet-delivered behavioural intervention (called BIP TIC) compared to an Internet-delivered education programme aimed at children and young people with tics. A process evaluation will be undertaken alongside the main trial to determine precisely how the behavioural intervention works and ascertain whether, and if so, how, the intervention could be successfully implemented in standard clinical practice. This protocol paper describes the rationale, aims, and methodology of the ORBIT trial process evaluation.

METHODS

The process evaluation will have a mixed-methods design following the UK Medical Research Council 2015 guidelines, comprising both quantitative and qualitative data collection. This will include analysing data usage of participants in the intervention arm; purposively sampled, semi-structured interviews of parents and children, therapists and supervisors, and referring clinicians of the ORBIT trial, as well as analysis of qualitative comments put into the online therapy platform by participants at the end of treatment. Qualitative data will be analysed thematically. Quantitative and qualitative data will be integrated in a triangulation approach, to provide an understanding of how the intervention works, and what resources are needed for effective implementation, uptake and use in routine clinical care.

DISCUSSION

This process evaluation will explore the experiences of participants, therapists and supervisors and referring clinicians of a complex online intervention. By contextualising trial efficacy results, this will help understand how and if the intervention worked and what may be required to sustain the implementation of the treatment long term. The findings will also aid in our understanding of factors that can affect the success of complex interventions. This will enable future researchers developing online behavioural interventions for children and young people with mental health and neurological disorders to gain invaluable information from this process evaluation.

TRIAL REGISTRATION

International Standard Randomised Controlled Trials Number, ISRCTN70758207. Registered on 20 March 2018. ClinicalTrials.gov, NCT03483493. Registered on 30 March 2018.

A radio counterpart to a neutron star merger

Gravitational waves have been detected from a binary neutron star merger event, GW170817. The detection of electromagnetic radiation from the same source has shown that the merger occurred in the outskirts of the galaxy NGC 4993, at a distance of 40 megaparsecs from Earth. We report the detection of a counterpart radio source that appears 16 days after the event, allowing us to diagnose the energetics and environment of the merger. The observed radio emission can be explained by either a collimated ultrarelativistic jet, viewed off-axis, or a cocoon of mildly relativistic ejecta. Within 100 days of the merger, the radio light curves will enable observers to distinguish between these models, and the angular velocity and geometry of the debris will be directly measurable by very long baseline interferometry.

Illuminating gravitational waves: A concordant picture of photons from a neutron star merger

Merging neutron stars offer an excellent laboratory for simultaneously studying strong-field gravity and matter in extreme environments. We establish the physical association of an electromagnetic counterpart (EM170817) with gravitational waves (GW170817) detected from merging neutron stars. By synthesizing a panchromatic data set, we demonstrate that merging neutron stars are a long-sought production site forging heavy elements by r-process nucleosynthesis. The weak gamma rays seen in EM170817 are dissimilar to classical short gamma-ray bursts with ultrarelativistic jets. Instead, we suggest that breakout of a wide-angle, mildly relativistic cocoon engulfing the jet explains the low-luminosity gamma rays, the high-luminosity ultraviolet-optical-infrared, and the delayed radio and x-ray emission. We posit that all neutron star mergers may lead to a wide-angle cocoon breakout, sometimes accompanied by a successful jet and sometimes by a choked jet.

Clinical Management of Pediatric Acute-Onset Neuropsychiatric Syndrome: Part II-Use of Immunomodulatory Therapies

Introduction: Pediatric Acute-onset Neuropsychiatric Syndrome (PANS) is a clinically heterogeneous disorder with a number of different etiologies and disease mechanisms. Inflammatory and postinfectious autoimmune presentations of PANS occur frequently, with some clinical series documenting immune abnormalities in 75%-80% of patients. Thus, comprehensive treatment protocols must include immunological interventions, but their use should be reserved only for PANS cases in which the symptoms represent underlying neuroinflammation or postinfectious autoimmunity, as seen in the PANDAS subgroup (Pediatric Autoimmune Neuropsychiatric Disorders associated with Streptococcal infections). Methods: The PANS Research Consortium (PRC) immunomodulatory task force is comprised of immunologists, rheumatologists, neurologists, infectious disease experts, general pediatricians, psychiatrists, nurse practitioners, and basic scientists with expertise in neuroimmunology and PANS-related animal models. Preliminary treatment guidelines were created in the Spring of 2014 at the National Institute of Health and refined over the ensuing 2 years over conference calls and a shared web-based document. Seven pediatric mental health practitioners, with expertise in diagnosing and monitoring patients with PANS, were consulted to create categories in disease severity and critically review final recommendations. All authors played a role in creating these guidelines. The views of all authors were incorporated and all authors gave final approval of these guidelines. Results: Separate guidelines were created for the use of immunomodulatory therapies in PANS patients with (1) mild, (2) moderate-to-severe, and (3) extreme/life-threatening severity. For mildly impairing PANS, the most appropriate therapy may be "tincture of time" combined with cognitive behavioral therapy and other supportive therapies. If symptoms persist, nonsteroidal anti-inflammatory drugs and/or short oral corticosteroid bursts are recommended. For moderate-to-severe PANS, oral or intravenous corticosteroids may be sufficient. However, intravenous immunoglobulin (IVIG) is often the preferred treatment for these patients by most PRC members. For more severe or chronic presentations, prolonged corticosteroid courses (with taper) or repeated high-dose corticosteroids may be indicated. For PANS with extreme and life-threatening impairment, therapeutic plasma exchange is the first-line therapy given either alone or in combination with IVIG, high-dose intravenous corticosteroids, and/or rituximab. Conclusions: These recommendations will help guide the use of anti-inflammatory and immunomodulatory therapy in the treatment of PANS.

Clinical Management of Pediatric Acute-Onset Neuropsychiatric Syndrome: Part I-Psychiatric and Behavioral Interventions

OBJECTIVE

This article outlines the consensus guidelines for symptomatic treatment for children with Pediatric Acute-Onset Neuropsychiatric Syndrome (PANS) and Pediatric Autoimmune Neuropsychiatric Syndrome Associated with Streptococcal Infection (PANDAS).

METHODS

Extant literature on behavioral, psychotherapeutic, and psychopharmacologic treatments for PANS and PANDAS was reviewed. Members of the PANS Research Consortium pooled their clinical experiences to find agreement on treatment of PANS and PANDAS symptoms.

RESULTS

Current guidelines result from consensus among the Consortium members.

CONCLUSION

While underlying infectious and inflammatory processes in PANS and PANDAS patients are treated, psychiatric and behavioral symptoms need simultaneous treatment to decrease suffering and improve adherence to therapeutic intervention. Psychological, behavioral, and psychopharmacologic interventions tailored to each child's presentation can provide symptom improvement and improve functioning during both the acute and chronic stages of illness. In general, typical evidence-based interventions are appropriate for the varied symptoms of PANS and PANDAS. Individual differences in expected response to psychotropic medication may require marked reduction of initial treatment dose. Antimicrobials and immunomodulatory therapies may be indicated, as discussed in Parts 2 and 3 of this guideline series.

Biological and clinical consequences of NPM1 mutations in AML

Acute myeloid leukemia (AML) is characterized by accumulation of myeloid cells in the bone marrow because of impaired differentiation and proliferation, resulting in hematopoietic insufficiency. NPM1 is one of the most commonly mutated genes in AML, present in 20-30% of cases. Mutations in NPM1 represent a distinct entity in the World Health Organization (WHO) classification and commonly indicate a better risk prognosis. In this review, we discuss the many functions of NPM1, the consequence of mutations in NPM1 and possible mechanisms through which mutations lead to leukemogenesis. We also discuss clinical consequences of mutations, associated gene expression patterns and the role of NPM1 mutations in informing prognosis and therapeutic decisions and predicting relapse in AML.

Deutetrabenazine in Tics Associated with Tourette Syndrome

Background

Deutetrabenazine, an inhibitor of vesicular monoamine transporter type 2 (VMAT2) depletes presynaptic dopamine and is useful in the treatment of hyperkinetic movement disorders. This study explored the safety, tolerability, and preliminary efficacy of deutetrabenazine in adolescents with moderate-to-severe tics associated with Tourette syndrome (TS).

Methods

In this open-label study of 12–18-year-old patients with TS-related tics, deutetrabenazine was titrated up to 36 mg/day over 6 weeks to adequately suppress tics without bothersome adverse effects (AEs), followed by maintenance at optimal dose for 2 weeks. An independent blinded rater assessed tic severity using the Yale Global Tic Severity Scale (YGTSS), which was the primary outcome measure. Secondary outcome measures included the TS Clinical Global Impression (TS-CGI) and TS Patient Global Impression of Change (TS-PGIC).

Results

Twenty-three enrolled patients received deutetrabenazine and had at least 1 post-baseline YGTSS assessment. The mean (SD [standard deviation]) baseline YGTSS Total Tic Severity Score (TTS) was 31.6 (7.9) and had decreased by 11.6 (8.2) points at week 8, a 37.6% reduction in tic severity (p<0.0001). The TS-CGI score improved by 1.2 (0.81) points (p<0.0001) and the TS-PGIC results at week 8 indicated that 76% of patients were much improved or very much improved compared with baseline. The mean (SD) daily deutetrabenazine dose at week 8 was 32.1 (6.6) mg (range 18–36 mg). One week after withdrawal of deutetrabenazine, the TTS scores increased by 5.6 (8.4) points, providing confirmation of the drug effect. No serious or severe adverse events were reported.

Discussion

The results of this open-label 8-week study suggest that deutetrabenazine is safe and associated with improvement in tic severity in adolescents with TS and troublesome tics.