Standards for clinical trials for treating TB

BACKGROUND: The value, speed of completion and robustness of the evidence generated by TB treatment trials could be improved by implementing standards for best practice.METHODS: A global panel of experts participated in a Delphi process, using a 7-point Likert scale to score and revise draft standards until consensus was reached.RESULTS: Eleven standards were defined: Standard 1, high quality data on TB regimens are essential to inform clinical and programmatic management; Standard 2, the research questions addressed by TB trials should be relevant to affected communities, who should be included in all trial stages; Standard 3, trials should make every effort to be as inclusive as possible; Standard 4, the most efficient trial designs should be considered to improve the evidence base as quickly and cost effectively as possible, without compromising quality; Standard 5, trial governance should be in line with accepted good clinical practice; Standard 6, trials should investigate and report strategies that promote optimal engagement in care; Standard 7, where possible, TB trials should include pharmacokinetic and pharmacodynamic components; Standard 8, outcomes should include frequency of disease recurrence and post-treatment sequelae; Standard 9, TB trials should aim to harmonise key outcomes and data structures across studies; Standard 10, TB trials should include biobanking; Standard 11, treatment trials should invest in capacity strengthening of local trial and TB programme staff.CONCLUSION: These standards should improve the efficiency and effectiveness of evidence generation, as well as the translation of research into policy and practice.

Evaluating newly approved drugs in combination regimens for multidrug-resistant tuberculosis with fluoroquinolone resistance (endTB-Q): study protocol for a multi-country randomized controlled trial

BACKGROUND

Treatment for fluoroquinolone-resistant multidrug-resistant/rifampicin-resistant tuberculosis (pre-XDR TB) often lasts longer than treatment for less resistant strains, yields worse efficacy results, and causes substantial toxicity. The newer anti-tuberculosis drugs, bedaquiline and delamanid, and repurposed drugs clofazimine and linezolid, show great promise for combination in shorter, less-toxic, and effective regimens. To date, there has been no randomized, internally and concurrently controlled trial of a shorter, all-oral regimen comprising these newer and repurposed drugs sufficiently powered to produce results for pre-XDR TB patients.

METHODS

endTB-Q is a phase III, multi-country, randomized, controlled, parallel, open-label clinical trial evaluating the efficacy and safety of a treatment strategy for patients with pre-XDR TB. Study participants are randomized 2:1 to experimental or control arms, respectively. The experimental arm contains bedaquiline, linezolid, clofazimine, and delamanid. The control comprises the contemporaneous WHO standard of care for pre-XDR TB. Experimental arm duration is determined by a composite of smear microscopy and chest radiographic imaging at baseline and re-evaluated at 6 months using sputum culture results: participants with less extensive disease receive 6 months and participants with more extensive disease receive 9 months of treatment. Randomization is stratified by country and by participant extent-of-TB-disease phenotype defined according to screening/baseline characteristics. Study participation lasts up to 104 weeks post randomization. The primary objective is to assess whether the efficacy of experimental regimens at 73 weeks is non-inferior to that of the control. A sample size of 324 participants across 2 arms affords at least 80% power to show the non-inferiority, with a one-sided alpha of 0.025 and a non-inferiority margin of 12%, against the control in both modified intention-to-treat and per-protocol populations.

DISCUSSION

This internally controlled study of shortened treatment for pre-XDR TB will provide urgently needed data and evidence for clinical and policy decision-making around the treatment of pre-XDR TB with a four-drug, all-oral, shortened regimen.

TRIAL REGISTRATION

ClinicalTrials.Gov NCT03896685. Registered on 1 April 2018; the record was last updated for study protocol version 4.3 on 17 March 2023.

Outcomes of WHO-conforming, longer, all-oral multidrug-resistant TB regimens and analysis implications

BACKGROUND: Evidence of the effectiveness of the WHO-recommended design of longer individualized regimens for multidrug- or rifampicin-resistant TB (MDR/RR-TB) is limited.OBJECTIVES: To report end-of-treatment outcomes for MDR/RR-TB patients from a 2015-2018 multi-country cohort that received a regimen consistent with current 2022 WHO updated recommendations and describe the complexities of comparing regimens.METHODS: We analyzed a subset of participants from the endTB Observational Study who initiated a longer MDR/RR-TB regimen that was consistent with subsequent 2022 WHO guidance on regimen design for longer treatments. We excluded individuals who received an injectable agent or who received fewer than four likely effective drugs.RESULTS: Of the 759 participants analyzed, 607 (80.0%, 95% CI 77.0-82.7) experienced successful end-of-treatment outcomes. The frequency of success was high across groups, whether stratified on number of Group A drugs or fluoroquinolone resistance, and ranged from 72.1% to 90.0%. Regimens were highly variable regarding composition and the duration of individual drugs.CONCLUSIONS: Longer, all-oral, individualized regimens that were consistent with 2022 WHO guidance on regimen design had high frequencies of treatment success. Heterogeneous regimen compositions and drug durations precluded meaningful comparisons. Future research should examine which combinations of drugs maximize safety/tolerability and effectiveness.

Concordance of three approaches for operationalizing outcome definitions for multidrug-resistant TB

BACKGROUND: The WHO provides standardized outcome definitions for rifampicin-resistant (RR) and multidrug-resistant (MDR) TB. However, operationalizing these definitions can be challenging in some clinical settings, and incorrect classification may generate bias in reporting and research. Outcomes calculated by algorithms can increase standardization and be adapted to suit the research question. We evaluated concordance between clinician-assigned treatment outcomes and outcomes calculated based on one of two standardized algorithms, one which identified failure at its earliest possible recurrence (i.e., failure-dominant algorithm), and one which calculated the outcome based on culture results at the end of treatment, regardless of early occurrence of failure (i.e., success-dominant algorithm).METHODS: Among 2,525 patients enrolled in the multi-country endTB observational study, we calculated the frequencies of concordance using cross-tabulations of clinician-assigned and algorithm-assigned outcomes. We summarized the common discrepancies.RESULTS: Treatment success calculated by algorithms had high concordance with treatment success assigned by clinicians (95.8 and 97.7% for failure-dominant and success-dominant algorithms, respectively). The frequency and pattern of the most common discrepancies varied by country.CONCLUSION: High concordance was found between clinician-assigned and algorithm-assigned outcomes. Heterogeneity in discrepancies across settings suggests that using algorithms to calculate outcomes may minimize bias.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

REGISTRATION NUMBER

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

Comparison of two fascial defect closure methods for laparoscopic incisional hernia repair

PURPOSE

Currently there is no consensus regarding the optimal surgical approach to an incisional hernia measuring less than 10 cm. Certain hernia features including defect size, intra-abdominal adhesions, and overlying scar/skin properties contribute to choosing an open versus a laparoscopic approach. This retrospective cohort study was designed to compare incisional hernia defects repaired with laparoscopic suture closure to a hybrid approach with open defect closure, both with laparoscopic intraperitoneal onlay mesh (IPOM) reinforcement.

METHODS

We identified 164 consecutive patients who underwent incisional hernia repair from two centers, North York General Hospital (NYGH) and Humber River Hospital (HRH) between 2015 and 2020. Patients were grouped by totally laparoscopic or hybrid fascial closure. Both techniques included laparoscopically placed intra-peritoneal mesh with 5 cm of overlap in all directions. Patients were analyzed by age, sex, body mass index (BMI), ASA class and hernia size. Primary outcomes included surgical site infection (SSI), other wound complications including seroma/hematoma, length of hospital stay, pain reported at follow-up appointment, and hernia recurrence.

RESULTS

Post-operative pain, surgical site infections and seromas did not differ between the totally laparoscopic and hybrid approach. The recurrence rates were 5.8% and 6.8% for the laparoscopic and hybrid group, respectively, which were not significantly different. The time to recurrence was 15 months (range 8-12) in the laparoscopic group and 7 months (range 6-36) in the hybrid group, also not significantly different. The hernia defect size and BMI were significantly higher in the hybrid group, without increased wound complications.

CONCLUSION

These results suggest that a hybrid approach to incisional ventral hernia repair with open defect closure is comparable to a totally laparoscopic closure. The hybrid technique can help facilitate fascial closure and resection of the hernia sac in patients with higher BMI and hernia defects up to 6 cm.

The impact of COVID-19 pandemic on type A aortic dissection care

Funding Acknowledgements

Type of funding sources: None.

Introduction

COVID-19 created a challenging situation for cardiac surgery and associated acute care programs around the world. While non-urgent cases might be postponed, operating on life-threatening conditions, including type A aortic dissection (TAAD), must be sustained despite the ongoing pandemic. Therefore, we investigated the impact of the COVID-19 pandemic on our urgent aortic program.

Methods

36 individuals presenting with TAAD in a single centre were analysed from the pre-pandemic period (2019, n=16) and the pandemic era (2020, n=20). Retrospective data review was conducted on patient characteristics, TAAD presenting symptoms, operative techniques, postoperative outcomes and length of stay. A comparison was made between both eras applying appropriate testing methods, and a p-value <0.05 was considered statistically significant.

Results

A 25% increase in TAAD referrals occurred during the pandemic era. Patients were featured by younger age of presentation in contrast to Western data (pre-pandemic group: 47.6 ± 18.7, and the pandemic group: 50.6 ± 16.2 years, p=0.6) but showed similar male predominance (4:1) in both groups. There was no statistical difference in baseline comorbidities between the groups. Length of hospital and intensive care unit stays were comparable between both groups. Low rates of postoperative complications were registered in both groups with no significant between-group difference.

Conclusion

Emergent surgical management remains essential in patients with TAAD regardless of the pandemic. Furthermore, temporary structural departmental re-configuration and optimal personal protective equipment utilisation warrant maintained satisfactory outcomes in such critical healthcare scenarios.

A205 IS REPEAT ERCP REQUIRED AFTER INITIAL ENDOSCOPIC MANAGEMENT OF POST-SURGICAL BILE LEAKS? MULTI-CENTER VALIDATION OF THE CALGARY BILE LEAK RULE

Background

The Calgary Bile Leak Rule was developed to identify patients in whom biliary stent removal via gastroscopy could be safely performed in lieu of ERCP for post-surgical bile leaks.

Aims

This study aimed to evaluate a Modified Calgary Bile Leak Rule (MCBLR) for a cohort of patients who underwent laparoscopic cholecystectomy complicated by bile leak.

Methods

This retrospective cohort study included patients who underwent ERCP for management of laparoscopic cholecystectomy-induced bile leaks between 2005 and 2017. The primary outcome was defined as the absence of persisting bile leak or other pathology on follow-up ERCP. The MCBLR includes a) normal post-surgical serum alkaline phosphatase, b) small or absent leak with no other biliary pathology on initial ERCP, and c) time between initial and follow-up ERCP was 4–8 weeks. Test performance of the prediction rule was analyzed by calculating sensitivity, specificity, positive predictive value and negative predictive value.

Results

124 cases met inclusion criteria, of which 116 (94%) of bile leak cases had no leak identified during the follow-up ERCP. 8 (6.4%) had a persisting bile leak on follow-up ERCP. Bivariate analysis found no factors significantly associated with the primary outcome. The MCBLR demonstrated a sensitivity of 100% (95% CI 63% - 100%), a specificity of 35% (95% CI 26% - 44%), a positive predictive value of 10% (95% CI 4% - 18%), and a negative predictive value of 100.0% (91% to 100%).

Conclusions

The MCBLR demonstrated high sensitivity and negative predictive value for determining the need for repeat ERCP following endoscopic management of laparoscopic cholecystectomy-induced bile leaks.

Funding Agencies

None

170 Social and Environmental Benefits of Virtual Fracture Clinics in Trauma and Orthopaedic Surgery: Reduced Patient Travel Time, Patient Cost and Air Pollutant Emissions

Aim

Several papers have analysed the clinical benefits and safety of Virtual Fracture Clinics (VFCs). A significant increase in the use of Trauma and Orthopaedic (T&O) VFCs was seen during the COVID-19 pandemic. This study aims to investigate the social impact of VFCs on the travel burden and travel costs of T&O patients, as well as the potential environmental benefits in relation to fuel consumption and travel-related pollutant emissions.

Method

All patients referred for T&O VFC review from March 2020 to June 2020 were retrospectively analysed. The travel burden and environmental impacts of hypothetical face-to-face consultations were compared with these VFC reviews. The primary outcomes measured were patient travel time saved, patient travel distance saved, patient cost savings and reduction in air-pollutant emissions.

Results

Over a four-month period, 1359 VFC consultations were conducted. The average travel distance saved by VFC review was 88.6 kilometres (range 3.3-615), with an average of 73 minutes (range 9-390) of travel-time saved. Patients consumed, on average, 8.2 litres (range 0.3-57.8) less fuel and saved an average of €11.02 (range 0.41-76.59). The average reduction in air-pollutant vehicle emissions, including carbon dioxide, carbon monoxide, nitric oxides and volatile organic compounds was 20.3 kilograms (range 0.8-140.8), 517.3 grams (g) (range 19.3-3592.3), 38.1g (range 1.4-264.8) and 56.9g (range 2.1-395.2), respectively.

Conclusions

VFCs reduce patient travel distance, travel time and travel costs. In addition, VFCs confer significant environmental benefits through reduced fuel consumption and reduction of harmful environmental emissions.

The effect of lockdown during SARS-CoV-2 pandemic on maxillofacial injuries in a level I trauma centre: a comparative study

INTRODUCTION

The SARS-CoV-2 pandemic forced many governments to impose nation-wide lockdowns. Government legislation forced limited travel on the population with restrictions on the normal way of life to limit spread of the SARS-CoV-2 virus. The aim of this study is to explore the effects of lockdown on the presentation of maxillofacial trauma in a level I trauma centre.

METHODS

Comparative analysis was carried out using prospective and retrospective review of all consecutive patients admitted with any maxillofacial fracture in the lockdown period between 15th March and 15th June 2020 with the same period in 2019 to a Regional Trauma Maxillofacial Surgery Unit. Data included basic demographics and mechanism of injury including alcohol/drug influence, polytrauma, site of injury and treatment modality including escalation of care.

RESULTS

Across both periods, there were a total of one hundred and five (n = 105) recorded episodes of traumatic fractures with fifty-three (n = 53) in the pre-lockdown cohort and fifty-two (n = 52) in the lockdown. Included patients were significantly (p = 0.024) older during lockdown (mean age 41.44 years SD 20.70, range 5-96) with no differences in gender distribution between cohorts (p = 0.270). Patients in lockdown were more likely to be involved in polytrauma (p < 0.05) and have sustained their injury by cycling/running or any outdoor related activity (p = 0.013). Lockdown saw a significant reduction in alcohol and drug related violence (p < 0.05). Significantly more patients required operative management (p = 0.038).

CONCLUSION

Local lockdowns form part of the governments public health strategy for managing future outbreaks of SARS-CoV-2. Our study showed no significant reduction in volume of trauma during lockdown. It is vital that hospitals maintain trauma capacity to ensure that patients are treated in a timely manner.

Evaluating newly approved drugs for multidrug-resistant tuberculosis (endTB): study protocol for an adaptive, multi-country randomized controlled trial

BACKGROUND

Treatment of multidrug- and rifampin-resistant tuberculosis (MDR/RR-TB) is expensive, labour-intensive, and associated with substantial adverse events and poor outcomes. While most MDR/RR-TB patients do not receive treatment, many who do are treated for 18 months or more. A shorter all-oral regimen is currently recommended for only a sub-set of MDR/RR-TB. Its use is only conditionally recommended because of very low-quality evidence underpinning the recommendation. Novel combinations of newer and repurposed drugs bring hope in the fight against MDR/RR-TB, but their use has not been optimized in all-oral, shorter regimens. This has greatly limited their impact on the burden of disease. There is, therefore, dire need for high-quality evidence on the performance of new, shortened, injectable-sparing regimens for MDR-TB which can be adapted to individual patients and different settings.

METHODS

endTB is a phase III, pragmatic, multi-country, adaptive, randomized, controlled, parallel, open-label clinical trial evaluating the efficacy and safety of shorter treatment regimens containing new drugs for patients with fluoroquinolone-susceptible, rifampin-resistant tuberculosis. Study participants are randomized to either the control arm, based on the current standard of care for MDR/RR-TB, or to one of five 39-week multi-drug regimens containing newly approved and repurposed drugs. Study participation in all arms lasts at least 73 and up to 104 weeks post-randomization. Randomization is response-adapted using interim Bayesian analysis of efficacy endpoints. The primary objective is to assess whether the efficacy of experimental regimens at 73 weeks is non-inferior to that of the control. A sample size of 750 patients across 6 arms affords at least 80% power to detect the non-inferiority of at least 1 (and up to 3) experimental regimens, with a one-sided alpha of 0.025 and a non-inferiority margin of 12%, against the control in both modified intention-to-treat and per protocol populations.

DISCUSSION

The lack of a safe and effective regimen that can be used in all patients is a major obstacle to delivering appropriate treatment to all patients with active MDR/RR-TB. Identifying multiple shorter, safe, and effective regimens has the potential to greatly reduce the burden of this deadly disease worldwide.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT02754765. Registered on 28 April 2016; the record was last updated for study protocol version 3.3, on 27 August 2019.

500 Tetraminos Flap

30 year old male, who had been hit at 90mph whilst on a motorbike sustaining femoral, tibial and right foot open fractures. He underwent an open reduction and internal fixation (ORIF) of his right lateral femoral condyle, a right retrograde femoral nail, and ORIF of the tibia. He had 2 separate free flaps (a chimera scapular/parascapular and antero-lateral thigh-ALT) to his right lower leg, and split skin grafting to the remainder of the right lower limb. Upon regular post-operative review it was found that whilst healed the limb was showing a poor return of function and a major contributor was the lack of motion of the right knee joint. Patient had an excision of the split skin graft, with a quadriceps plasty, where the myofascial planes were released, and the contractures incised, with a chimeric scapular and parascapular free flap onto the defect. This resulted in coverage of large soft tissue defect with no need to skin graft donor sites and no functional implication of muscle harvest. Tetraminos in appearance, like the popular computer game, which has never before been described, compared with normal coverage, which would be latissimus dorsi free flap and graft.

Clinical perspectives on treatment of rifampicin-resistant/multidrug-resistant TB

Rapid diagnostics, newer drugs, repurposed medications, and shorter regimens have radically altered the landscape for treating rifampicin-resistant TB (RR-TB) and multidrug-resistant TB (MDR-TB). There are multiple ongoing clinical trials aiming to build a robust evidence base to guide RR/MDR-TB treatment, and both observational studies and programmatic data have contributed to advancing the treatment field. In December 2019, the WHO issued their second 'Rapid Communication´ related to RR-TB management. This reiterated their prior recommendation that a majority of people with RR/MDR-TB receive all-oral treatment regimens, and now allow for specific shorter duration regimens to be used programmatically as well. Many TB programs need clinical advice as they seek to roll out such regimens in their specific setting. In this Perspective, we highlight our early experiences and lessons learned from working with National TB Programs, adult and pediatric clinicians and civil society, in optimizing treatment of RR/MDR-TB, using shorter, highly-effective, oral regimens for the majority of people with RR/MDR-TB.

Setting up pharmacovigilance based on available endTB Project data for bedaquiline

SETTING: Active pharmacovigilance (PV) is recommended for TB programmes, notably for multidrug-resistant TB (MDR-TB) patients treated with new drugs. Launched with the support of UNITAID in April 2015, endTB (Expand New Drug markets for TB) facilitated treatment with bedaquiline (BDQ) and/or delamanid of >2600 patients in 17 countries, and contributed to the creation of a central PV unit (PVU).OBJECTIVE: To explain the endTB PVU process by describing the serious adverse events (SAEs) experienced by patients who received BDQ-containing regimens.DESIGN: The overall PV strategy was in line with the ‘advanced´ WHO active TB drug safety monitoring and management (aDSM) system. All adverse events (AEs) of clinical significance were followed up; the PVU focused on signal detection from SAEs.RESULTS and CONCLUSION: Between 1 April 2015 and 31 March 2019, the PVU received and assessed 626 SAEs experienced by 417 BDQ patients. A board of MDR-TB/PV experts reviewed unexpected and possibly drug-related SAEs to detect safety signals. The experts communicated on clusters of risks factors, notably polypharmacy and off-label drug use, encouraging a patient-centred approach of care. Organising advanced PV in routine care is possible but demanding. It is reasonable to expect local/national programmes to focus on clinical management, and to limit reporting to aDSM systems to key data, such as the SAEs.

Introducing new and repurposed TB drugs: the endTB experience

In 2015, the initiative Expand New Drug Markets for TB (endTB) began, with the objective of reducing barriers to access to the new and repurposed TB drugs. Here we describe the major implementation challenges encountered in 17 endTB countries. We provide insights on how national TB programmes and other stakeholders can scale-up the programmatic use of new and repurposed TB drugs, while building scientific evidence about their safety and efficacy. For any new drug or diagnostic, multiple market barriers can slow the pace of scale-up. During 2015-2019, endTB was successful in increasing the number of patients receiving new and repurposed TB drugs in 17 countries. The endTB experience has many lessons, which are relevant to country level introduction of new TB drugs, as well as non-TB drugs and diagnostics. For example: the importation of TB drugs is possible even in the absence of registration; emphasis on good clinical monitoring is more important than pharmacovigilance reporting; national guidelines and expert committees can both facilitate and hinder innovative practice; clinicians use new and repurposed TB drugs when they are available; data collection to generate scientific evidence requires financial and human resources; pilot projects can drive national scale-up.

Use of Enzymes in Dairy Industry: A Review of Current Progress

This review paper aimed to provides precious information about the function and use of different enzymes in dairy food applications. An enzyme is called a protein and catalyzes a specific reaction. Every enzyme is intended to initiate a particular reaction with a specific outcome. Moreover, numerous enzymes are present in the human body. Dairy food applications include the use of different enzymes, such as protease, to lessen the allergic properties of bovine milk products and lipase to improve the flavor of the cheese. Caseins, which are acid-soluble, are free from a flavor and can be suitable for addition to beverages and acidy foods by the limitation of proteolysis. The hydrolysates of casein are better to use in foods based on milk proteins for newborn children with allergy to bovine milk. Lipolysis makes a significant role in the flavor of Swiss cheese. The peppery flavor of Blue cheese is produced by short-chain unsaturated fats and methyl ketones. Many minor enzymes with limited application in dairy processes are sulphydryl oxidase, lactoperoxidase, glucose oxidase, catalase, lysozyme, and superoxide dismutase. Both catalase and glucose oxidase are utilized in food preservation processes. The scope minor enzymes in milk products needed for better production of dairy products and for the future of dairy technology. The worldwide market for the production of microbial enzymes used in dairy products processing is impressively increasing; however, there are a limited number of enzyme-producing industries in the market. The production of proteinase, lactase, lipase, and microbial rennet is increasing in the laboratory and small scales. In near future, the need for these enzymes will be undoubtedly significantly increasing essentially due to the requirement of significant nutritional valuable dairy products in the country to overcome malnutrition and obesity and shift toward low-fat and healthy foods.

A272 THE CANADIAN DIRECT OBSERVATION OF PROCEDURAL SKILLS (CANDOPS) TOOL FOR ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY: A MULTI-CENTRE PROSPECTIVE STUDY

Background

Previous studies have demonstrated that many graduating trainees may not have all of the skills needed to independently practice endoscopic retrograde cholangiopancreatography (ERCP) safely and effectively. As a part of competency-based learning curriculum development, it is essential to provide formative feedback to trainees and ensure they acquire the knowledge and skills for independent practice.

Aims

To assess the performance of advanced endoscopy trainees across Canada using the Canadian Direct Observation of Procedural Skills (CanDOPS) ERCP assessment tool. Procedural items evaluated include both technical (cannulation, sphincterotomy, stone extraction, tissue sampling, and stent placement) and non-technical (leadership, communication and teamwork, judgment and decision making) skills.

Methods

We conducted a prospective national multi-centre prospective study. Advanced endoscopy trainees with at least two years of gastroenterology training or five years of general surgery in North America and minimal experience performing ERCPs (less than 100 ERCP procedures) were invited to participate. The CanDOPS tool was used to measure every fifth ERCP performed by trainees over a 12-month fellowship training period. ERCPs were evaluated by experienced staff endoscopists at each study site under standard clinical protocol. Cumulative sum (CUSUM) analyses were used to generate learning curves.

Results

The data from five Canadian sites and 11 trainees participated in the study. A total of 261ERCP evaluations were completed. Median number of evaluations by site and trainee was 49 (IQR 31–76) and 15 (IQR 11–45). Median number of cases trainees performed prior to their ERCP training was 50 (IQR 25–400). There was a significant improvement in almost all scores over time, including selective cannulation, sphincterotomy, biliary stenting and all non-technical skills (P&lt;0.01). CUSUM analyses using acceptable and unacceptable failure rates of 20% and 50% demonstrated trainees achieved competency for most measures in their final month of their training. Competency in tissue sampling was not achieved within a one-year training period.

Conclusions

This is the first ERCP performance evaluation tool that examines multiple technical and non-technical aspects of the procedure. Although trainee ERCP skills do improve during their training period, there exists a notable variability in time to competency for the different skills measured using the CanDOPS tool. Large prospective research is required to determine if competency is achieved using more stringent definitions of ERCP competency and to determine factors associated with reaching competency.

Funding Agencies

None

79Experience from heart or heart/lung transplantation from a single centre for adult congenital heart disease: too little, too late?

Introduction

Heart failure is the leading cause of death in adults with congenital heart disease (ACHD). Heart or heart and lung transplantation (H/HLTx) can be effective therapy for these patients, but unfavourable anatomy, end-organ damage, pulmonary vascular disease, HLA sensitization and lack of robust selection criteria currently limit its application.

Methods

Consecutive ACHD patients >16 years of age who were considered for H/HLTx at our tertiary centre between 2006 and 2018 constitute our study population. Baseline characteristics and outcome, including H/HLTx and death were obtained for all from designated databases, medical records and the UK Office for National Statistics.

Results

Of a total of more than 9,000 active ACHD patients, 130 (53.1% male, mean age 42.2, IQR 32.6–50.2 years) fulfilled inclusion criteria with a broad spectrum of underlying ACHD and considerable mortality across all anatomic subgroups [Table 1].

82% of patients had previous cardiac surgery (55.5% with ≥2 sternotomies or thoracotomies). Cardinal presenting features were poor functional capacity, low cardiac output, cyanosis and/or end-organ disease; “only” 47% had moderate or severe dysfunction of the systemic and 37% of the subpulmonary ventricle. Frequent comorbidities were atrial arrhythmia 68.7%, PH 30.4%, CKD 23.5%, liver dysfunction or cirrhosis 11.3%; 36.8% of patients had an ICD and 16.5% a CRT, whereas 79.8% were on diuretics, 70.5% MRA, 51.6% beta blockers, 32.6% ACEI, 18.9% ARB, 10.5% Digoxin and 29.5% on pulmonary vasodilators. HLA antibodies were positive in 47.3% (high sensitization >90% in 13.2%).

There was high overall mortality with 35.4% of patients dying over a median of 2.7 years (IQR 1.1–4.9). Only 13.6% from our cohort were transplanted, with a survival of 76.5% at a mean of 5.9 years from H/HLTx.

ACHD subgroup % of total % transplanted Mortality (%) Median follow-up (years) Univentricular heart 25.4 6.1 30.3 2.5 Systemic RV 21.5 7.4 35.7 2.6 Shunts with PAH / Eissenmenger 13.9 5.9 27.8 3 Tetralogy of Fallot with Pulmonary atresia 12.3 14.3 50 3.5 Left sided valvar disease, CoA, Marfan 10.8 14.3 50 0.6 CHD associated with cardiomyopathy 9.2 50 33.3 5.3 Other 6.9 22.2 22.2 2.2 RV: right ventricle; PAH: Pulmonary arterial hypertension; CoA: aortic coarctation.

Survival in end-stage heart failure

Conclusion

Of the small number of patients with heterogenous ACHD considered for H/HLTx in our contemporary practice, there was high overall mortality, whereas only a fraction of patients was actually transplanted. Better patient selection and timing are clearly warranted so that more ACHD patients benefit from this effective therapy.

Acknowledgement/Funding

None

Orthoplastic reconstruction of type IIIB open tibial fractures retaining debrided devitalized cortical segments: the Bristol experience 2014 to 2018

AIMS

Type IIIB open tibial fractures are devastating high-energy injuries. At initial debridement, the surgeon will often be faced with large bone fragments with tenuous, if any, soft-tissue attachments. Conventionally these are discarded to avoid infection. We aimed to determine if orthoplastic reconstruction using mechanically relevant devitalized bone (ORDB) was associated with an increased infection rate in type IIIB open tibial shaft fractures.

PATIENT AND METHODS

This was a consecutive cohort study of 113 patients, who had sustained type IIIB fractures of the tibia following blunt trauma, over a four-year period in a level 1 trauma centre. The median age was 44.3 years (interquartile range (IQR) 28.1 to 65.9) with a median follow-up of 1.7 years (IQR 1.2 to 2.1). There were 73 male patients and 40 female patients. The primary outcome measures were deep infection rate and number of operations. The secondary outcomes were nonunion and flap failure.

RESULTS

In all, 44 patients had ORDB as part of their reconstruction, with the remaining 69 not requiring it. Eight out of 113 patients (7.1%) developed a deep infection (ORDB 1/44, non-ORDB 7/69). The median number of operations was two. A total of 16/242 complication-related reoperations were undertaken (6.6%), with 2/16 (12.5%) occurring in the ORDB group.

CONCLUSION

In the setting of an effective orthoplastic approach to type IIIB open diaphyseal tibial fractures, using mechanically relevant debrided devitalized bone fragments in the definitive reconstruction appears to be safe. Cite this article: Bone Joint J 2019;101-B:1002-1008.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

Onychomycosis due to Achaetomium strumarium

Onychomycosis is the most common infection of the toe-nails or finger-nails and it may be caused by a large variety of fungal species. Achaetomium species which belong to the phylum Ascomycota (Family Chaetomiaceae), are usually soil saprophytes or endophytic fungi which have been rarely reported as human or animal pathogens. Here, we report a case of onychomycosis caused by Achaetomium strumarium in a healthy person who showed involvement of all fingers of both hands with yellowish brown discoloration. The causative agent isolated was identified as Achaetomium species by morphology, colony morphometry and growth at high temperature and as A. strumarium from DNA sequence of ITS region. Onychomycosis from this case responded satisfactorily with per os (P. O.; oral) and topical application of Terbinafine.

Experimental investigation and micromagnetic simulations of hybrid CoCr2O4/Ni coaxial nanostructures

Multiphase CoCr₂O₄/Ni core-shell nanowires (NWs) have been synthesized within anodic aluminum oxide membranes by the combination of the sol-gel method with electrodeposition techniques. X-ray diffraction and x-ray photoemission spectroscopy results confirmed the formation of a cubic spinel structure of CoCr₂O₄ shell with space group Fd-3m (227). The morphology and composition of the as-grown NWs were studied by field emission scanning electron microscopy, as well as transmission electron microscopy. The magnetic properties of the CoCr₂O₄ NT shell and hybrid CoCr₂O₄/Ni NWs were measured at low temperature using a physical property measurement system. The temperature dependence of the magnetization curves showed that CoCr₂O₄ NTs undergo a transition from a paramagnetic state to a ferrimagnetic state at about 90 K and a spiral ordering transition temperature near 22 K. An enhanced coercivity and saturation field were observed for the CoCr₂O₄/Ni core-shell NWs compared to the single-phase Ni NWs. Micromagnetic simulation results indicated that there is a strong coupling between the shell and core layers during the magnetization reversal process. The combination of hard CoCr₂O₄ and soft Ni in a single NW structure may have potential applications in future multifunctional devices.

Longitudinal development of initial, chronic and mucoid Pseudomonas aeruginosa infection in young children with cystic fibrosis

BACKGROUND

While the emergence of chronic and mucoid Pseudomonas aeruginosa (Pa) infection are both associated with poorer outcomes among CF patients, their relationship is poorly understood. We examined the longitudinal relationship of incident, chronic and mucoid Pa in a contemporary, young CF cohort in the current era of Pa eradication therapy.

METHODS

This retrospective cohort was comprised of patients in the U.S. CF Foundation Patient Registry born 2006-2015, diagnosed before age 2, and with at least 3 respiratory cultures annually. Incidence and age-specific prevalence of Pa infection stages (initial and chronic [≥ 3Pa+cultures in prior year]) and of mucoid Pa were summarized. Transition times and the interaction between Pa stage and acquisition of mucoid Pa were examined via Cox models.

RESULTS

Among the 5592 CF patients in the cohort followed to a mean age of 5.5years, 64% (n=3580) acquired Pa. Of those, 13% (n=455) developed chronic Pa and 17% (n=594) cultured mucoid Pa. Among those with mucoid Pa, 36% (211/594) had it on their first recorded Pa+culture, while mucoid Pa emerged at or after entering the chronic stage in 12% (73/594). Mucoidy was associated with significantly increased risk of transition to chronic Pa infection (HR=2.59, 95% CI 2.11, 3.19).

CONCLUSIONS

Two-thirds of early-diagnosed young children with CF acquired Pa during a median 5.6years of follow up, among whom 13% developed chronic Pa and 17% acquired mucoid Pa. Contrary to our hypothesis, 87% of young children who developed mucoid Pa did so before becoming chronically infected.