How is bioelectrical impedance used in neonatal intensive care? A scoping review

Poor growth and nutrition management in the neonatal period can have a negative impact upon both the short- and long-term outcomes for the infant. Improvements in bioelectrical impedance technology and accompanying licencing agreements now make this enhanced device available for use in infants as small as 23 weeks gestational age. An exploration of this technology and its use is now timely. The aim of the scoping review was to answer the following question: in preterm and sick term infants in the neonatal intensive care unit, how is bioelectrical impedance being utilized, in what situations, and when? The scoping review was conducted using Arksey and O'Malley's (Int J Soc Res Methodol 8(1):19-32, 2005) framework. Forty-nine papers were initially identified and 16 were included in the scoping review. Three studies were experimental designs, and 13 were observational studies. The review found that BIA was used in neonatal intensive care in three main ways, for, (1) fluid status evaluation, (2) as a measure of adequate nutrition and growth, (3) to validate the technology as an outcome measure in neonates.

CONCLUSION

There is a paucity of recent robust research papers which investigate the use of bioelectrical impedance in preterm neonates. Available evidence spans a range of 30 years, with technological advancement reducing the application of older studies to the modern neonatal setting. Although this technology may be helpful for decision-making around fluid management and nutrition, in preterm infants, robust evidence is needed to demonstrate the clinical benefit of bioelectrical impedance beyond that of usual care.

WHAT IS KNOWN

• Clinical decisions regarding neonatal nutrition and fluid management are currently based upon the interpretation of vital signs, fluid balance, weight trend, biochemical markers, and physical examination. • Bioelectrical Impedance Analysis (BIA) is a non-invasive method of assessing body composition which is now available to be used in infants as small as 23 weeks gestation.

WHAT IS NEW

• Bioelectrical Impedance has been used in three main ways in the NICU, for fluid status evaluation, for measuring nutrition and growth and to validate BIA as an outcome. • There is a lack of recent robust research data to support the use of the device within clinical decision making in neonatal intensive care.

Enhanced bacterial cancer therapy delivering therapeutic RNA interference of c-Myc

BACKGROUND

Bacterial cancer therapy was first trialled in patients at the end of the nineteenth century. More recently, tumour-targeting bacteria have been harnessed to deliver plasmid-expressed therapeutic interfering RNA to a range of solid tumours. A major limitation to clinical translation of this is the short-term nature of RNA interference in vivo due to plasmid instability. To overcome this, we sought to develop tumour-targeting attenuated bacteria that stably express shRNA by virtue of integration of an expression cassette within the bacterial chromosome and demonstrate therapeutic efficacy in vitro and in vivo.

RESULTS

The attenuated tumour targeting Salmonella typhimurium SL7207 strain was modified to carry chromosomally integrated shRNA expression cassettes at the xylA locus. The colorectal cancer cell lines SW480, HCT116 and breast cancer cell line MCF7 were used to demonstrate the ability of these modified strains to perform intracellular infection and deliver effective RNA and protein knockdown of the target gene c-Myc. In vivo therapeutic efficacy was demonstrated using the Lgr5creERT2Apcflx/flx and BlgCreBrca2flx/flp53flx/flx orthotopic immunocompetent mouse models of colorectal and breast cancer, respectively. In vitro co-cultures of breast and colorectal cancer cell lines with modified SL7207 demonstrated a significant 50-95% (P < 0.01) reduction in RNA and protein expression with SL7207/c-Myc targeted strains. In vivo, following establishment of tumour tissue, a single intra-peritoneal administration of 1 × 106 CFU of SL7207/c-Myc was sufficient to permit tumour colonisation and significantly extend survival with no overt toxicity in control animals.

CONCLUSIONS

In summary we have demonstrated that tumour tropic bacteria can be modified to safely deliver therapeutic levels of gene knockdown. This technology has the potential to specifically target primary and secondary solid tumours with personalised therapeutic payloads, providing new multi-cancer detection and treatment options with minimal off-target effects. Further understanding of the tropism mechanisms and impact on host immunity and microbiome is required to progress to clinical translation.

The association between area-level factors and mortality in severe mental illnesses: A systematic review

BACKGROUND

Premature mortality is a well-documented adverse outcome for people living with severe mental illnesses (SMI). Emerging evidence suggests that area-level factors play a role that are experienced disproportionately by this population. This review assesses the potential association between area-level factors and mortality in people with SMI.

METHOD

We searched Medline, EMBASE, PsychINFO, Social Policy and Practice, Web of Science and OpenGrey databases. Literature searches were conducted in May 2020 and updated in June 2023. Reference lists were hand-searched and authors of included studies contacted to identify additional studies and minimise publication biases. Narrative synthesis was used to appraise the included studies. The review protocol was registered on PROSPERO (CRD42019155447).

RESULTS

Our searches identified 7 studies (8 papers), which were included in the review, and indicated evidence of an association between deprivation and mortality. One study suggested an association between mortality in SMI and urbanicity in low to middle income settings which was not observed in studies from high income settings. One study suggested a protective association of area-level ethnic density with mortality within urbanised settings.

CONCLUSION

Consistent associations were reported between residence in areas of higher deprivation and increased risk of mortality in SMI. Two studies suggested an association between area-level ethnic density and urbanicity and mortality in SMI. Most studies were conducted across high income countries and therefore future research could benefit from similar investigations being conducted in low- and middle-income countries. These methods would inform health and social policies, including interventions to reduce premature mortality in SMI.

Tobacco use in first-episode psychosis, a multinational EU-GEI study

BACKGROUND

Tobacco is a highly prevalent substance of abuse in patients with psychosis. Previous studies have reported an association between tobacco use and schizophrenia. The aim of this study was to analyze the relationship between tobacco use and first-episode psychosis (FEP), age at onset of psychosis, and specific diagnosis of psychosis.

METHODS

The sample consisted of 1105 FEP patients and 1355 controls from the European Network of National Schizophrenia Networks Studying Gene-Environment Interactions (EU-GEI) study. We assessed substance use with the Tobacco and Alcohol Questionnaire and performed a series of regression analyses using case-control status, age of onset of psychosis, and diagnosis as outcomes and tobacco use and frequency of tobacco use as predictors. Analyses were adjusted for sociodemographic characteristics, alcohol, and cannabis use.

RESULTS

After controlling for cannabis use, FEP patients were 2.6 times more likely to use tobacco [p ⩽ 0.001; adjusted odds ratio (AOR) 2.6; 95% confidence interval (CI) [2.1-3.2]] and 1.7 times more likely to smoke 20 or more cigarettes a day (p = 0.003; AOR 1.7; 95% CI [1.2-2.4]) than controls. Tobacco use was associated with an earlier age at psychosis onset (β = -2.3; p ⩽ 0.001; 95% CI [-3.7 to -0.9]) and was 1.3 times more frequent in FEP patients with a diagnosis of schizophrenia than in other diagnoses of psychosis (AOR 1.3; 95% CI [1.0-1.8]); however, these results were no longer significant after controlling for cannabis use.

CONCLUSIONS

Tobacco and heavy-tobacco use are associated with increased odds of FEP. These findings further support the relevance of tobacco prevention in young populations.

Gastric Radiotherapy in the UK - Current Practice and Opinion on Future Directions

PURPOSE/OBJECTIVE(S)

Gastric radiotherapy (RT) is more commonly practiced in the US compared to the UK, where postoperative chemoradiotherapy (CRT) is reserved for selected high-risk patients, and preoperative CRT is not standard of care pending the results of phase 3 trials, TOPGEAR and CRITICSII. CRT for inoperable, non-metastatic gastric cancer is also not recommended in the UK, despite being listed in NCCN guidelines. Recent systematic review of definitive gastric CRT (dCRT) conducted by the authors found median overall survival of 11-26.4 months, clinical complete response rates of 8-45% and acceptable rates of ≥G3 toxicity, supporting further research. Given these promising findings and perceived low uptake of gastric RT in the UK, we set out to establish current UK practice, opinion and RT technique to inform the development of a UK gastric RT protocol and future clinical trials.

MATERIALS/METHODS

A 19 question survey was developed. Following local ethical approval and pilot by 4 clinical oncologists, the final survey was distributed electronically on 13/12/22 to UK Consultant Clinical Oncologists specializing in esophago-gastric (OG) cancer. Responses were anonymous. Survey was closed 6/2/23 and data analyzed using JISC/spreadsheet software.

RESULTS

A total of 43 clinicians completed the survey. For gastric cancer, 28.6%, 7.1% and 9.5% would agree/strongly agree with use of postoperative (postopRT), preoperative (preopRT) or definitive RT (dRT) respectively, compared to 26.2%, 45.2% and 46.6% for type III gastro-esophageal junction tumors. 93% had prescribed palliative gastric RT in the last 3 years compared to 40.5% postopRT, 16.7% dRT and 9.5% preopRT. Main reasons for infrequent use were; rarely indicated within standard UK practice 88.4%, lack of UK gastric RT protocol 53.5%, toxicity concerns 44.2%. 45Gy/25# was most commonly used for preopRT (66%) and postopRT (86%), and 50Gy/25# for dRT (58%). 96% use IMRT/VMAT, 85% CT simulation with IV/oral contrast, 69% gastric filling protocol and 54% 4DCT. When ranked out of 10 (1 = low 10 = high), clinician confidence in accurately delineating gastric volumes mean rank was 4.33 for postopRT, with 9% rating ≥8/10, and 4.52 for dCRT/preopRT with 17% rating ≥8/10. However, 48.8% were experienced in outlining upper abdominal nodes and 62.8% duodenum. 93% would find a detailed outlining protocol useful, 81.4% wanted some form of peer review, 76.7% a nodal atlas, and 74.4% a workshop with an expert. 77.6% would be supportive of a future clinical trial of dCRT, with 23.4% needing more supporting evidence. No-one would not support a future trial in this setting.

CONCLUSION

Gastric RT is not often practiced in the UK, due to lacking evidence and toxicity concerns. Given the growing evidence and supportive OG community, it is time to consider a trial of dCRT in the UK, which must include detailed RT protocols, atlases and educational materials to improve clinician confidence and ensure good RT quality assurance.

Patient Satisfaction and Sensory Attributes of Nasal Spray Treatments of Olopatadine Hydrochloride/Mometasone Furoate Monohydrate and Azelastine Hydrochloride/Fluticasone Propionate for Allergic Rhinitis in Australia - An Observational Real-World Clinical Study

PURPOSE

Combination intranasal corticosteroid and antihistamine sprays are a first-line treatment option for allergic rhinitis (AR), of which Azelastine Hydrochloride and Fluticasone Propionate nasal spray (AZE/FLU; Dymista^®), and Olopatadine Hydrochloride and Mometasone Furoate Monohydrate nasal spray (OLO/MOM; Ryaltris^®) are currently registered in Australia. As it is not known how patients value treatment attributes of current combination nasal sprays, this observational, real-world clinical study aimed to understand patients' satisfaction with, and importance of, treatment attributes of OLO/MOM and AZE/FLU using an Anchored Best-Worst Scaling (ABWS) exercise.

PARTICIPANTS AND METHODS

Four hundred and twenty-six adults in Australia with moderate to severe AR using either OLO/MOM or AZE/FLU completed an online survey incorporating an ABWS with 11 domains: 7 sensory (immediate taste of medication, aftertaste of medication, smell of medication, irritation to your nose, urge to sneeze, dripping out your nose/down your throat, dryness of your nose/throat) and 4 treatment-related (convenience, fast acting, duration of effect, and AR symptom control). The ABWS involved rescaling individual BWS scores using anchored ratings (0-10) for most and least satisfied/important domains to create a total satisfaction index (TSI) (0-100) to be compared across groups. Statistical comparisons were completed using ANOVA (TSI) and MANOVA (individual domains).

RESULTS

Participants using OLO/MOM (M = 68.26, SE = 1.39) had significantly higher TSI than participants using AZE/FLU (M=62.78, SE = 0.70) (p < 0.001), significantly higher satisfaction on 7 of 11 domains and regarded 8 of 11 domains as significantly more important compared to participants using AZE/FLU (all p < 0.05). Preferred domains were predominantly sensory attributes.

CONCLUSION

Current findings showed that participants using OLO/MOM were more satisfied with their overall treatment compared to participants using AZE/FLU, particularly with sensory attributes, thus highlighting the suitability of OLO/MOM for people with AR who value sensory attributes. Prescribers of AR treatments are encouraged to discuss treatment attributes with patients to facilitate shared decision-making.

Leaving no one behind: Defining and implementing an integrated life course approach to vaccination across the next decade as part of the immunization Agenda 2030

Strategic Priority 4 (SP4) of the Immunization Agenda 2030 aims to ensure that all people benefit from recommended immunizations throughout the life-course, integrated with essential health services. Therefore, it is necessary for immunization programs to have coordination and collaboration across all health programs. Although there has been progress, immunization platforms in the second year of life and beyond need continued strengthening, including booster doses and catch-up vaccination, for all ages, and recommended vaccines for older age groups. We note gaps in current vaccination programs policies and achieved coverage, in the second year of life and beyond. In 2021, the second dose of measles-containing vaccine (MCV2), given in the second year of life, achieved 71% global coverage vs 81% for MCV1. For adolescents, 60% of all countries have adopted human papillomavirus vaccines in their vaccination schedule with a global coverage rate of only 12 percent in 2021. Approximately 65% of the countries recommend influenza vaccines for older adults, high-risk adults and pregnant women, and only 25% recommended pneumococcal vaccines for older adults. To achieve an integrated life course approach to vaccination, we reviewed the evidence, gaps, and strategies in four focus areas: generating evidence for disease burden and potential vaccine impact in older age groups; building awareness and shifting policy beyond early childhood; building integrated delivery approaches throughout the life course; and identifying missed opportunities for vaccination, implementing catch-up strategies, and monitoring vaccination throughout the life course. We identified needs, such as tailoring strategies to the local context, conducting research and advocacy to mobilize resources and build political will. Mustering sufficient financial support and demand for an integrated life course approach to vaccination, particularly in times of COVID-19, is both a challenge and an opportunity.

Association between immune-mediated adverse events and efficacy in metastatic non-small-cell lung cancer patients treated with durvalumab and tremelimumab

Purpose

Immune-mediated adverse events (imAEs) may be associated with response to immune checkpoint inhibitors. We assessed the relationship between imAE development and efficacy in metastatic non-small-cell lung cancer patients treated with durvalumab (anti-programmed cell death ligand-1 [PD-L1]) alone or in combination with tremelimumab (anti-cytotoxic T-lymphocyte-associated protein 4).

Methods

The analysis used individual patient-level data from 307 and 310 patients in the monotherapy and combination arms of MYSTIC, respectively. We evaluated the association between treatment efficacy and development of imAEs using univariate and multivariate survival analyses. Using machine learning, we built a predictive model utilizing baseline clinical and laboratory features to identify patients at risk of developing imAEs and further evaluated patient survival based on a threshold index extracted from the model.

Results

Patients who developed any grade of imAE had improved overall survival versus patients without (hazard ratio [HR] 0.51; 95% confidence interval [CI]: 0.41–0.62). imAE development was associated with improved overall survival (HR 0.54; 95% CI 0.44–0.66) in a multivariate Cox proportional hazard model considering patient demographic features and baseline characteristics. Higher odds of imAE development were observed (odds ratio 3.023; 95% CI: 1.56–5.83) in responders versus non-responders in patients treated with immunotherapy. Based on baseline characteristics, the random forest classification algorithm was used to formulate a predictive model to identify patients at increased risk of developing imAEs during treatment.

Conclusion

Post-hoc exploratory analysis found that the efficacy of immunotherapy was improved in patients who developed on-treatment imAEs. This was independent of severity of imAEs or the need for steroid treatment, which is important in allowing patients to remain on treatment and derive optimal clinical benefit. Further research is warranted to establish the correlation between incidence of imAEs and efficacy in this patient population.

1029 EVEN LIMITED GERIATRICIAN INVOLVEMENT REDUCES LENGTH OF STAY FOR ALL-AGE ACUTE GENERAL SURGERY PATIENTS

Background

More than half of patients undergoing emergency general surgery are older than 651. The Emergency Laparotomy and Frailty (ELF) study identified that frail patients (CFS ≥5) were vulnerable to adverse outcomes and longer hospital stays and should be reviewed by a geriatrician2. The 2021 National Emergency Laparotomy Audit (NELA) found that only 27% were reviewed by a geriatrician1. Local problem A local hospital had no routine geriatrician input to perioperative care of older people admitted under the care of general surgeons.

Method/Intervention

In one month prior to intervention, we noted CFS recorded once and a geriatrician involved in only 3 patients over the age of 65 (n = 35). We introduced a service comprising twice-weekly geriatrician-led multi-disciplinary team (MDT) meetings of all-age patients followed by selected patient ward rounds. This equated to 2.5 Programmed Activity’s (PA) per week. After another month we measured the number of patients having CFS recorded, those who had geriatrician involvement and length of stay. We also surveyed members of the MDT.

Results

All 31 patients aged over 65 received geriatrician input with 93.5% having a CFS recorded. Length of stay of all-age patients (n = 75) was reduced from 12.8 to 8.8 days, with the most significant reduction of 6.5 days in over 65’s (16.7 to 10.2); &gt;200 bed days saved for older people. The MDT comments included: ‘improved MDT communication’, ‘early identification of discharge barriers’ and ‘pro-active approach’.

Conclusion

NELA highlights that consistent geriatrician input remains generally poor. Even a limited geriatrician-led service can be highly effective at guaranteeing review of appropriate patients in line with recommendations from NELA. Alongside targeted patient review geriatricians can support and lead decision making of all-age patients. This cost-effective strategy can reduce length of stay for young and old alike and gained excellent feedback from the MDT.

Parental education and youth suicidal behaviours: a systematic review and meta-analysis

AIMS

Lower parental education has been linked to adverse youth mental health outcomes. However, the relationship between parental education and youth suicidal behaviours remains unclear. We explored the association between parental education and youth suicidal ideation and attempts, and examined whether sociocultural contexts moderate such associations.

METHODS

We conducted a systematic review and meta-analysis with a systematic literature search in PubMed, PsycINFO, Medline and Embase from 1900 to December 2020 for studies with participants aged 0-18, and provided quantitative data on the association between parental education and youth suicidal ideation and attempts (death included). Only articles published in English in peer-reviewed journals were considered. Two authors independently assessed eligibility of the articles. One author extracted data [e.g. number of cases and non-cases in each parental education level, effect sizes in forms of odds ratios (ORs) or beta coefficients]. We then calculated pooled ORs using a random-effects model and used moderator analysis to investigate heterogeneity.

RESULTS

We included a total of 59 articles (63 study samples, totalling 2 738 374 subjects) in the meta-analysis. Lower parental education was associated with youth suicidal attempts [OR = 1.12, 95% Confidence Interval (CI) = 1.04-1.21] but not with suicidal ideation (OR = 1.05, 95% CI = 0.98-1.12). Geographical region and country income level moderated the associations. Lower parental education was associated with an increased risk of youth suicidal attempts in Northern America (OR = 1.26, 95% CI = 1.10-1.45), but with a decreased risk in Eastern and South-Eastern Asia (OR = 0.72, 95% CI = 0.54-0.96). An association of lower parental education and increased risk of youth suicidal ideation was present in high- income countries (HICs) (OR = 1.14, 95% CI = 1.05-1.25), and absent in low- and middle-income countries (LMICs) (OR = 0.91, 95% CI = 0.77-1.08).

CONCLUSIONS

The association between youth suicidal behaviours and parental education seems to differ across geographical and economical contexts, suggesting that cultural, psychosocial or biological factors may play a role in explaining this association. Although there was high heterogeneity in the studies reviewed, this evidence suggests that the role of familial sociodemographic characteristics in youth suicidality may not be universal. This highlights the need to consider cultural, as well as familial factors in the clinical assessment and management of youth's suicidal behaviours in our increasingly multicultural societies, as well as in developing prevention and intervention strategies for youth suicide.

737 STOOLS FOR STOOLS - COMBINING MEDICAL AND CONSERVATIVE TREATMENTS TO REDUCE CONSTIPATION IN THE ELDERLY INPATIENT POPULATION

Introduction

Constipation is a common cause of morbidity in the elderly. Its management is particularly challenging in the inpatient population, where many factors exacerbate constipation. We describe a Quality Improvement Project to reduce the rates of constipation on a female Medicine for the Elderly ward.

Aims

Our aim was to increase bowel chart documentation (nursing and doctor entries) and increase patient frequency of bowel motions to at least once every two days. In particular we focused on conservative measures such as the use of footstools to optimise posture when using commodes and toilets [R Hari Krishnan, Proc Inst Mech Eng H, 2019, 233(4):464–475].

Method

• Weekly monitoring of ward inpatients. • Measurements taken were: days since last bowel motion, laxatives prescribed, bowel chart and ward round documentation, and episodes of diarrhoea over the past week. • One episode of diarrhoea was defined as 3 motions of type 6 or type 7 stool in 24 hours. • A new intervention was introduced every two weeks, over a total of 2 months. Interventions: 1. Recording bowel motions at the daily ‘Board Round’ Multi-Disciplinary Meeting. 2. Ward staff education sessions. 3. Footstools for use with commodes and toilets. 4. High-fibre foods to patients with constipation.

Results

Level of constipation was successfully reduced, with 100% patients moving bowels every 2 days from a baseline of 68%. Ward round and bowel chart documentation improved to 100% and 93.3% respectively (from 41.3% and 33.3%). However, incidence of diarrhoea increased from 0 episodes/week to 8 episodes/week, with laxative prescriptions similarly increased from 50% to 86%.

Conclusion

Constipation improved with our interventions, but at the unintended cost of laxative-associated diarrhoea. Our next steps will be to reduce laxative prescriptions in favour of conservative measures, in order to reduce episodes of loose stool while maintaining our improved constipation rates.

780 IMPROVING NUTRITIONAL SUPPORT FOR POST-SURGICAL FEMUR FRACTURE PATIENTS AT ST MARY’S HOSPITAL, LONDON

Introduction

Malnutrition represents a common complication in femur fracture patients and is primarily caused by poor dietary intake. Malnutrition is associated with poor clinical outcomes, and is the strongest independent risk factor for recurrent femur fracture. High protein oral nutrition supplements (ONS) have been associated with improved clinical outcomes after femur fracture, including reduced complications, length of hospital stay, mortality and bone mineral density loss, and increases in functional status and quality of life (Volkert, Beck, Cederholm et al., Clinical Nutrition, 38, 10–47)). Accordingly, the European Society for Clinical Nutrition and Metabolism (ESPEN) advocates the use of ONS with all femur fracture patients in hospital.

Aim To improve nutritional support for post-surgical femur fracture patients at St Mary’s Hospital, London.

Methods

We plan to carry out three PDSA cycles to evaluate whether two separate interventions are effective in increasing the prescription rate of ONS in post-surgical femur patients. Each PDSA cycle included all patients who underwent surgical treatment for femur fracture during a one month period.

Results

‘Cycle 1’ included 18 patients (mean age: 84.6 years; range: 68–98 years) treated in March 2021. ONS were prescribed in 11% (2/18) post-surgical femur fracture patients. ‘Intervention 1’ comprised a dietician-led presentation during the Geriatric department weekly teaching session on 17/05/21. ‘Cycle 2’ data will be collected one month after ‘Intervention 1’.

Conclusion

‘Cycle 1’ results revealed low rates of ONS prescriptions for post-surgical femur patients. We anticipate higher ONS prescription rates following ‘Intervention 1’. We believe that doctors’ and dieticians’ awareness of the importance of nutritional support for post-surgical femur fracture patients is key to the success of this quality improvement project.

787 THE PRUNE PROJECT: USING PRUNES AS A CONSTIPATION AID IN OLDER SURGICAL INPATIENTS

Introduction

Constipation is a common and difficult issue in elderly surgical patients, often contributing to prolonged stay on inpatient wards (Sethi et al, Am J Gastroenterol. 2014;109:250–256). Increasing dietary fibre is a commonsense tactic to mitigate against constipation. However it is rarely formally employed on NHS wards. Prunes are beneficial in increasing fibre intake and are a natural source of sorbitol, which acts as an osmotic laxative (Stacewicz-Sapuntzakis et al, Crit Rev Food Sci Nutr. 2001;41:251–86.)

Method

We performed a closed-loop audit on the use of prunes in reducing constipation. We collected data from surgical inpatients over 60 years, including the number of days since bowels were last opened, and the number of laxatives that each patient was taking. Patients were then given a prune product (either 3 dried prunes, 125 mL prune juice or 70 g prune puree) three times a week. Following the intervention, the data was recollected to complete the audit cycle.

Results

In our cohort of 36 patients, the mean time since bowels were last opened reduced from 1.49 to 1.17 days (p = 0.1624) after introducing prunes three times a week, and the mean number of laxatives reduced from 1.81 to 1.50 (p = 0.1671).

Conclusion

Surgical patients are at increased risk of constipation (Davies et al, J Clin Pharm Ther. 2008; 31:561–566) due to multiple factors including immobility, poor oral intake and opiate use. Constipation is more common in the elderly (Talley et al, Am J Gastroenterol. 1996;91:19–25), who are also at increased risk of polypharmacy (Morin et al, Clin Epidemiol. 2018;10:289–298). These results show that using prunes to aid regular bowel motion can have a positive impact on reducing pharmacy and increasing frequency of bowels opening. We hope that, by introducing tactics to promote regular bowel motions in hospital, we can reduce polypharmacy and instill good health habits post-discharge.

694 IMPROVING OPIATE PRESCRIBING IN OLDER ADULTS WITH HIP FRACTURES TO COMBAT THE IATROGENIC FALLOUT

Background

The number of opioid prescriptions in older patients has increased dramatically and it is recognised that opioids are the fourth most likely drug to cause preventable hospital admissions. The adverse effects of opioids occur more frequently in the geriatric population. Little is known about the impact of postoperative pain in older adults. NICE recommends paracetamol with additional opioids if there is insufficient postoperative pain relief. Multidisciplinary management with early and then daily physiotherapy is critical. We have assessed pre-morbid, immediate and prolonged use of opioids in patients following hip fracture. Local problem Pre-intervention analysis identified 79% (57/72) of all patients being discharged on opiates. At 4-months, 37% (17/46) of those were still using them. This represents 28% (17/61) of all patients.

Methods

Analysis of all patients (excluding poly-trauma) with hip fractures over the age of 60 years admitted to St Mary’s Hospital. Interventions Development of local guideline on analgesia prescribing; particularly focusing senior geriatrician led decision making. Prescribing oxycodone for first 72-hours and initially using nerve block. Avoidance of transdermal preparations and withdrawing stronger opioids prior to discharge. Clear instructions for GP’s on a stop date and need for community review. Patient information leaflet dispensed with all discharge opioid prescriptions.

Results

Post-intervention cycle; 17% (11/63) of patients were taking prescribed opioids prior to admission (similar to the pre-cohort). 52% (33/63) were discharged on opiates, down from 79%. At 4-months, of those discharged on opioids, 30% (9/30) were still using them; lower than in the first cycle (37%). Overall reduction from 28% to 16% of patients on opioids at 4-months.

Conclusion

The use of specific hip fracture analgesia guideline, senior geriatrician decision-making and support to community colleagues can reduce in-patient and community opiate prescribing, and stem the growing problem of opioid addiction, misuse and iatrogenic re-admission.

Injury patterns of e-scooter-related orthopaedic trauma in central London: a multicentre study

PURPOSE

Electric scooters (E-Scooters) are being increasingly used in urban areas as a new means of transport. E-scooter sharing schemes have recently been piloted in the United Kingdom; however, there are no published data on orthopaedic injuries and user behaviour patterns in the UK. We aim to identify the patterns and severity of orthopaedic injuries related to e-scooter use.

METHODS

We performed a retrospective review of all orthopaedic referrals relating to e-scooter use from 1 March to 30 November 2020 at three hospitals, including one major trauma centre in central London. Data including patient demographics, mechanism of injury, diagnosis and treatment were collected.

RESULTS

One hundred and five orthopaedic injuries were identified in 83 patients. The median age was 32 years and 83% were male. Seventy-nine (95.2%) patients were riders, four were pedestrians. All e-scooters were privately owned. There were 93 fractures (88.6% of total injuries noted) including 12 (12.9%) open. Fifty-two (56.0%) were upper limb fractures, 39 (41.9%) lower limb and 2 (2.1%) spinal and rib fractures. Twenty-five patients (30.1%) required an operation and 29 (34.9%) required hospital admission. Helmet use was present in 34.1%. The most common place of injury was the road (65.1%) followed by pavement (32.9%).

CONCLUSION

E-scooters can cause serious injury, most commonly in males. There was an equal distribution of upper and lower limb injuries, with many associated with high-energy trauma requiring operative intervention. Helmet use was seen in one third of riders. As e-scooter use continues to increase across the UK, additional steps should be taken to ensure the safety of the riders and public.

Treatment patterns in patients with Familial hypercholesterolemia: evidence from real-world studies in Germany and the UK

Background

Familial hypercholesterolemia (FH) includes a spectrum of disease as per the number and effect of mutations in specific proteins involved in low-density lipoprotein cholesterol (LDL-C) metabolism, together with other genetic factors. Elevated LDL-C levels have been strongly associated with risk of cardiovascular and coronary heart disease, with up to 10-fold risk in patients (pts) with FH than without FH. The aim of lipid-lowering treatments (LLTs) is to reduce the LDL-C levels, although there is limited research describing treatment patterns and LDL-C outcomes in FH pts in routine care.

Purpose

To characterize the treatment patterns and LDL-C outcomes of FH pts in the real-world setting in Germany (GER) and the UK.

Methods

We conducted two descriptive, non-interventional and retrospective cohort studies. Pts in GER were identified from General Physician (GP) and Cardiology practices available in electronic medical records database Disease Analyzer (January 1992-June 2020). Pts in the UK were identified from the Clinical Practice Research Datalink linked to the Hospital Episode Statistics admitted pts care and Office of National Statistics datasets. Pts were included if they had diagnosis of FH (index date [ID]) and data available within 6-month before and 3-month after the ID. The first diagnosis of FH in the identification period (GER, 1/07/2015–30/06/2019; UK, 01/01/2010–31/05/2018) was considered the ID. Persistence and adherence to the recorded LLT at ID was analyzed for pts with at least 12 months and 24 months of follow-up. Persistence was measured as the duration (in days) with allowed gap of 60 days and adherence as proportion of days covered (PDC).

Results

Analysis included 2,105 FH pts from GER and 9,846 from the UK. Data are presented as GER/UK. The mean (SD) age of pts was 60 (15)/52 (14) years, and 60%/61% were females. Hypertension (53%/27%) and depression (31%/38%) were the common comorbidities. At ID, statin monotherapy (29%/68%) was the most commonly prescribed LLT. The use of ezetimibe, fibrates and PCSK9 inhibitors was very low in both countries (Table 1). Of note, LDL-C measurements at ID (−6m/+3m) were available for 31%/73% of pts. In pts with uncontrolled LDL-C (≥55 mg/dL), 34%/64% were receiving statin monotherapy, whereas there was no use of LLT in 62%/29% of pts. During the 24 months follow-up, the mean (SD) persistence and PDC to statins monotherapy was 471 (264)/489 (289) days and 0.65 (0.36)/0.69 (0.46), respectively, with 50%/70% of pts being adherent (PDC ≥0.80).

Conclusions

In our study, in GER, the rate of LDL-C measurements was low. In both GER and UK, almost all measured patients had LDL-C ≥55mg/dL at ID. Findings indicate low prescriptions of LLTs in GP setting, particularly non-statin LLTs in both countries. The mean adherence (PDC) in GER and the UK was 65% and 69%, respectively within 24 months after ID. Improved LDL-C monitoring and new therapies with potential to lower LDL-C are warranted.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Novartis Pharma AG, Basel, Switzerland

Innovation in the time of SARS-CoV-2: A collaborative journey between NHS clinicians, engineers, academics and industry

During the pandemic healthcare faced great pressure on the availability of protective equipment. This paper describes the entire novel innovative process of design optimisation, production and deployment of face-visors to NHS frontline workers during SARS-CoV-2 pandemic. The described innovative journey spans collaboration between clinicians and academic colleagues for design to the implementation with industry partners of a face-visor for use in a healthcare setting. It identifies the enablers and barriers to development along with the strategies employed to produce a certified reusable, adjustable, high volume and locally produced face-visor. The article also explores aspects of value, scalability, spread and sustainability all of which are essential features of innovation.

Fallow time determination in dentistry using aerosol measurement in mechanically and non-mechanically ventilated environments

Aim To calculate fallow time (FT) required following dental aerosol generating procedures (AGPs) in both a dental hospital (mechanically ventilated) and primary care (non-mechanically ventilated). Secondary outcomes were to identify spread and persistence of aerosol in open clinics compared to closed surgeries (mechanically ventilated environment), and identify if extraoral scavenging (EOS) reduces FT and production of aerosol.Methods In vitro simulation of fast handpiece cavity preparations using a manikin was conducted in a mechanically and non-mechanically ventilated environment using Optical Particle Sizer and NanoScan at baseline, during the procedure and fallow period.Results AGPs carried out in the non-mechanically, non-ventilated environment failed to achieve baseline particle levels after one hour. In contrast, when windows were opened after AGPs, there was an immediate reduction in all particle sizes. In mechanically ventilated environments, the baseline levels of particles were very low and particle count returned to baseline within ten minutes following the AGP. There was no detectable difference between particles in mechanically ventilated open bays and closed surgeries. The effect of the EOS on reducing the particle count was greater in the non-mechanically ventilated environment; additionally, it also reduced the spikes in particle counts in mechanically ventilated environments.Conclusion High-efficiency particulate, air-filtered mechanical ventilation, along with mitigation (high-volume suction), resulted in reduction of fallow time (ten minutes). Non-ventilated rooms failed to reach baseline level even after one hour of fallow time. There was no difference in particle counts in open bays or closed surgeries in mechanically ventilated settings with an extraoral suction device reducing particulate spikes. This study confirms that AGPs are not recommended in dental surgeries where no ventilation is possible.

Epidemiology and pathogenesis of stroke in preterm infants: A systematic review

BACKGROUND:

Perinatal stroke is one of the principal causes of cerebral palsy (CP) in preterm infants. Stroke in preterm infants is different from stroke in term infants, given the differences in brain maturation and the mechanisms of injury exclusive to the immature brain. We conducted a systematic review to explore the epidemiology and pathogenesis of periventricular hemorrhagic infarction (PVHI), perinatal arterial ischemic stroke (PAIS) and cerebral sinovenous thrombosis (CSVT) in preterm infants.

METHODS:

Studies were identified based on predefined study criteria from MEDLINE, EMBASE, SCOPUS and WEB OF SCIENCE electronic databases from 2000 –2019. Results were combined using descriptive statistics.

RESULTS:

Fourteen studies encompassed 546 stroke cases in preterm infants between 23 –36 weeks gestational ages and birth weights between 450 –3500 grams. Eighty percent (436/546) of the stroke cases were PVHI, 17%(93/546) were PAIS and 3%(17/546) were CSVT. Parietal PVHI was more common than temporal and frontal lobe PVHI. For PAIS, left middle cerebral artery (MCA) was more common than right MCA or cerebellar stroke. For CSVT partial or complete thrombosis in the transverse sinus was universal. All cases included multiple possible risk factors, but the data were discordant precluding aggregation within a meta-analysis.

CONCLUSION:

This systematic review confirms paucity of data regarding the etiology and the precise causal pathway of stroke in preterm infants. Moreover, the preterm infants unlike the term infants do not typically present with seizures. Hence high index of clinical suspicion and routine cUS will assist in the timely diagnosis and understanding of stroke in this population.

Perceptions of anonymised data use and awareness of the NHS data opt-out amongst patients, carers and healthcare staff

BACKGROUND

England operates a National Data Opt-Out (NDOO) for the secondary use of confidential health data for research and planning. We hypothesised that public awareness and support for the secondary use of health data and the NDOO would vary by participant demography and healthcare experience. We explored patient/public awareness and perceptions of secondary data use, grouping potential researchers into National Health Service (NHS), academia or commercial. We assessed awareness of the NDOO system amongst patients, carers, healthcare staff and the public. We co-developed recommendations to consider when sharing unconsented health data for research.

METHODS

A patient and public engagement program, co-created and including patient and public workshops, questionnaires and discussion groups regarding anonymised health data use.

RESULTS

There were 350 participants in total. Central concerns for health data use included unauthorised data re-use, the potential for discrimination and data sharing without patient benefit. 94% of respondents were happy for their data to be used for NHS research, 85% for academic research and 68% by health companies, but less than 50% for non-healthcare companies and opinions varied with demography and participant group. Questionnaires showed that knowledge of the NDOO was low, with 32% of all respondents, 53% of all NHS staff and 29% of all patients aware of the NDOO. Recommendations to guide unconsented secondary health data use included that health data use should benefit patients; data sharing decisions should involve patients/public. That data should remain in close proximity to health services with the principles of data minimisation applied. Further, that there should be transparency in secondary health data use, including publicly available lists of projects, summaries and benefits. Finally, organisations involved in data access decisions should participate in programmes to increase knowledge of the NDOO, to ensure public members were making informed choices about their own data.

CONCLUSION

The majority of participants in this study reported that the use of healthcare data for secondary purposes was acceptable when accessed by NHS. Academic and health-focused companies. However, awareness was limited, including of the NDOO. Further development of publicly-agreed recommendations for secondary health data use may improve both awareness and confidence in secondary health data use.

Traumatic events and psychotic experiences: a nationally representative study in Thailand

AIMS

Most research exploring the link between traumatic events and psychotic experiences has focused on either Australia, Europe or North America. In this study, we expand the existing knowledge to Thailand and investigate the impact of the type and the number of traumatic events on psychotic experiences in Thailand.

METHODS

We used data from the nationally representative 2013 Thai National Mental Health Survey (TNMHS), including questions on traumatic events and psychotic experiences. We regressed the lifetime experience of hallucinations or delusions against the following independent variables: the experience of any traumatic event during lifetime (dichotomous; hypothesis 1); the experience of either no traumatic event, one interpersonal, one unintentional or both interpersonal and unintentional traumatic events (categorical; hypothesis 2) and the number of traumatic events experienced during lifetime (categorical; hypothesis 3). We adjusted the regression models for sociodemographic indicators and psychiatric disorders, and considered survey weights.

RESULTS

About 6% (95% confidence interval: 4.9-7.0) of the respondents stated that they had either hallucinatory or delusional experiences during their lifetime. The risk of reporting such experiences was more than doubled as high among respondents who had experienced at least one traumatic event during their lifetime than among those who had not yet experienced one, with higher risks for interpersonal or multiple traumatic events. Our results further indicated an increase in the risk of psychotic experiences as the number of traumatic events increased, with up to an eight-fold higher risk for people exposed to five or more traumatic events in their lifetime, compared to those with no traumatic events.

CONCLUSIONS

Individuals reporting interpersonal or multiple traumatic events face much higher risk of psychotic experiences. Effective and widely accessible secondary prevention programmes for people having experienced interpersonal or multiple traumatic events constitute a key intervention option.

Multicentre Investigation of Prognostic Factors Incorporating p16 and Tumour Infiltrating Lymphocytes for Anal Cancer After Chemoradiotherapy

AIMS

Anal squamous cell carcinomas (ASCC) are strongly associated with human papillomaviruses. Standard of care is chemoradiotherapy at uniform doses with no treatment stratification. Immunohistochemical staining for p16INK4A (p16), a surrogate for human papillomaviruses, is prognostic for outcomes. We investigated this alongside clinical-pathological factors, including tumour infiltrating lymphocyte (TIL) scores.

MATERIALS AND METHODS

Using an independent, multicentre cohort of 257 ASCC treated with chemoradiotherapy, pretreatment biopsies were stained and scored for p16 and TIL. Kaplan-Meier curves were derived for outcomes (disease-free survival [DFS], overall survival and cancer-specific survival), by stage, p16 and TIL scores and Log-rank tests were carried out to investigate prognostic effect. A multivariate analysis was carried out using Cox regression.

RESULTS

Stage, sex, p16 and TILs were independently prognostic. Hazard ratios for death (overall survival) were 2.51 (95% confidence interval 1.36-4.63) for p16 negative versus p16 positive, 2.17 (1.34-3.5) for T3/4 versus T1/2, 2.42 (1.52-3.8) for males versus females and 3.30 (1.52-7.14) for TIL1 versus TIL3 (all P < 0.05).

CONCLUSIONS

We have refined prognostic factors in ASCC. p16 adds to stratification by stage with respect to DFS in early disease and overall survival/DFS in locally advanced cancers. Our data support the role of the host immune response in mediating outcomes. These factors will be prospectively evaluated in PLATO (ISRCTN88455282).

Migration history, first episode psychosis and child abuse: Results from the EU-GEI study

Introduction

Child abuse is associated with a wide range of mental disease including psychotic disorders. Few studies have investigated the role of child abuse in contributing to increase the risk of psychosis in migrant population.

Objectives

To explore the risk of first episode psychosis (FEP) in migrants and natives for each type of trauma i.e. physical abuse (P.A.), sexual abuse (S.A.), emotional abuse (E.A.), physical neglect (P.N.) and emotional neglect (E.N.).

Methods

Within a large case- control incidence sample of FEP from the EU-GEI study (The EUropean Network of National Schizophrenia Networks Studying Gene–Environment Interactions) we evalued the assocition of childhood trauma with FEP in migrants and natives. Associations were adjusted for age, gender, social status, level of education, family history of psychosis and cannabis use. Trauma was assessed through Childhood Trauma Questionnaire (CTQ).

Results

CTQ mean score was higher in FEP migrants (45.4, sd 15.6) than in FEP natives (41.7, sd 13.9) (p = 0.002). In natives every type of child abuse was associated with FEP. In migrants P.A., S.A., P.N. were associated with FEP. We found a dose – dependent relationship between trauma and FEP.

Conclusions

Child abuse is common in individuals with psychosis. FEP migrants are more exposed to childhood trauma. Clinicians should routinely assess patients for childhood trauma. When treating a FEP migrant patient, clinicians must be aware of an underlying traumatic childhood adversity more than of a traumatic migration history.

Thirty-day mortality following surgical management of hip fractures during the COVID-19 pandemic: findings from a prospective multi-centre UK study

PURPOSE

Thirty-day mortality of patients with hip fracture is well researched and predictive; validated scoring tools have been developed (Nottingham Hip Fracture Score, NHFS). COVID-19 has significantly greater mortality in the elderly and comorbid patients which includes hip fracture patients. Non-operative treatment is not appropriate due to significantly higher mortality, and therefore, these patients are often exposed to COVID-19 in the peri-operative period. What is unclear is the effect of concomitant COVID-19 infection in these patients.

METHODS

A multicentre prospective study across ten sites in the United Kingdom (responsible for 7% of hip fracture patients per annum in the UK). Demographic and background information were collected by independent chart review. Data on surgical factors included American Society of Anesthesiologists (ASA) score, time to theatre, Nottingham Hip fracture score (NHFS) and classification of fracture were also collected between 1st March 2020 and 30th April 2020 with a matched cohort from the same period in 2019.

RESULTS

Actual and expected 30-day mortality was found to be significantly higher than expected for 2020 COVID-19 positive patients (RR 3.00 95% CI 1.57-5.75, p < 0.001), with 30 observed deaths compared against the 10 expected from NHFS risk stratification.

CONCLUSION

COVID-19 infection appears to be an independent risk factor for increased mortality in hip fracture patients. Whilst non-operative management of these fractures is not suggested due to the documented increased risks and mortality, this study provides evidence to the emerging literature of the severity of COVID-19 infection in surgical patients and the potential impact of COVID-19 on elective surgical patients in the peri-operative period.

Quantitative analysis of particulate matter release during orthodontic procedures: a pilot study

Introduction Transmission of SARS-CoV-2 through aerosol has been suggested, particularly in the presence of highly concentrated aerosols in enclosed environments. It is accepted that aerosols are produced during a range of dental procedures, posing potential risks to both dental practitioners and patients. There has been little agreement concerning aerosol transmission associated with orthodontics and associated mitigation.Methods Orthodontic procedures were simulated in a closed side-surgery using a dental manikin on an acrylic model using composite-based adhesive. Adhesive removal representing debonding was undertaken using a 1:1 contra-angle handpiece (W&H Synea Vision WK-56 LT, Bürmoos, Austria) and fast handpiece with variation in air and water flow. The removal of acid etch was also simulated with the use of combined 3-in-1 air-water syringe. An optical particle sizer (OPS 3330, TSI Inc., Minnesota, USA) and a portable scanning mobility particle sizer (NanoScan SMPS Nanoparticle Sizer 3910, TSI Inc., Minnesota, USA) were both used to assess particulate matter ranging in dimension from 0.08 to 10 μm.Results Standard debonding procedure (involving air but no water) was associated with clear increase in the 'very small' and 'small' (0.26-0.9 μm) particles but only for a short period. Debonding procedures without supplementary air coolant appeared to produce similar levels of aerosol to standard debonding. Debonding in association with water tended to produce large increases in aerosol levels, producing particles of all sizes throughout the experiment. The use of water and a fast handpiece led to the most significant increase in particles. Combined use of the 3-in-1 air-water syringe did not result in any detectable increase in the aerosol levels.Conclusions Particulate matter was released during orthodontic debonding, although the concentration and volume was markedly less than that associated with the use of a fast handpiece. No increase in particulates was associated with prolonged use of a 3-in-1 air-water syringe. Particulate levels reduced to baseline levels over a short period (approximately five minutes). Further research within alternative, open environments and without air exchange systems is required.

miR-150-PTPMT1-cardiolipin signaling in pulmonary arterial hypertension

Circulating levels of endothelial miR-150 are reduced in pulmonary arterial hypertension (PAH) and act as an independent predictor of patient survival, but links between endothelial miR-150 and vascular dysfunction are not well understood. We studied the effects of endothelial miR-150 supplementation and inhibition in PAH mice and cells from patients with idiopathic PAH. The role of selected mediators of miR-150 identified by RNA sequencing was evaluated in vitro and in vivo. Endothelium-targeted miR-150 delivery prevented the disease in Sugen/hypoxia mice, while endothelial knockdown of miR-150 had adverse effects. miR-150 target genes revealed significant associations with PAH pathways, including proliferation, inflammation, and phospholipid signaling, with PTEN-like mitochondrial phosphatase (PTPMT1) most markedly altered. PTPMT1 reduced inflammation and apoptosis and improved mitochondrial function in human pulmonary endothelial cells and blood-derived endothelial colony-forming cells from idiopathic PAH. Beneficial effects of miR-150 in vitro and in vivo were linked with PTPMT1-dependent biosynthesis of mitochondrial phospholipid cardiolipin and reduced expression of pro-apoptotic, pro-inflammatory, and pro-fibrotic genes, including c-MYB, NOTCH3, transforming growth factor β (TGF-β), and Col1a1. In conclusion, we are the first to show that miR-150 supplementation attenuates pulmonary endothelial damage induced by vascular stresses and may be considered as a potential therapeutic strategy in PAH.

The influence of risk factors on the onset and outcome of psychosis: What we learned from the GAP study

The GAP multidisciplinary study carried out in South London, recruited 410 first episode of psychosis patients and 370 controls; the aim was to elucidate the multiple genetic and environmental factors influencing the onset and outcome of psychosis. The study demonstrated the risk increasing effect of adversity in childhood (especially parental loss, abuse, and bullying) on onset of psychosis especially positive symptoms. Adverse life events more proximal to onset, being from an ethnic minority, and cannabis use also played important roles; indeed, one quarter of new cases of psychosis could be attributed to use of high potency cannabis. The "jumping to conclusions" bias appeared to mediate the effect of lower IQ on vulnerability to psychosis. We confirmed that environmental factors operate on the background of polygenic risk, and that genetic and environment act together to push individuals over the threshold for manifesting the clinical disorder. The study demonstrated how biological pathways involved in the stress response (HPA axis and immune system) provide important mechanisms linking social risk factors to the development of psychotic symptoms. Further evidence implicating an immune/inflammatory component to psychosis came from our finding of complement dysregulation in FEP. Patients also showed an upregulation of the antimicrobial alpha-defensins, as well as differences in expression patterns of genes involved in NF-κB signaling and Cytokine Production. Being of African origin not only increased risk of onset but also of a more difficult course of illness. The malign effect of childhood adversity predicted a poorer outcome as did continued use of high potency cannabis.

Improving the quality of maternal and newborn care in the Pacific region: A scoping review

Background

Quality care is essential for improving maternal and newborn health. Low- and middle-income Pacific Island nations face challenges in delivering quality maternal and newborn care. The aim of this review was to identify all published studies of interventions which sought to improve the quality of maternal and newborn care in Pacific low-and middle-income countries.

Methods

A scoping review framework was used. Databases and grey literature were searched for studies published between January 2000 and July 2019 which described actions to improve the quality of maternal and newborn care in Pacific low- and middle-income countries. Interventions were categorised using a four-level health system framework and the WHO quality of maternal and newborn care standards. An expert advisory group of Pacific Islander clinicians and researchers provided guidance throughout the review process.

Results

2010 citations were identified and 32 studies included. Most interventions focused on the clinical service or organisational level, such as healthcare worker training, audit processes and improvements to infrastructure. Few addressed patient experiences or system-wide improvements. Enablers to improving quality care included community engagement, collaborative partnerships, adequate staff education and training and alignment with local priorities.

Conclusions

There are several quality improvement initiatives in low- and middle-income Pacific Island nations, most at the point of health service delivery. To effectively strengthen quality maternal and newborn care in this region, efforts must broaden to improve health system leadership, deliver sustaining education programs and encompass learnings from women and their communities.

The efficacy of an extraoral scavenging device on reduction of splatter contamination during dental aerosol generating procedures: an exploratory study

Introduction This study was conducted in light of the SARS-CoV-2 pandemic, which brought UK dentistry to a standstill. The market has seen a recent influx of unproven extraoral scavengers (EOSs), which claim to reduce the risk of particulate spread.Aims To investigate the efficacy of a commercially available EOS device on contamination reduction during dental aerosol generating procedures (AGPs). The secondary aim was to investigate differences between open and closed dental operatories.Method Dental procedures were simulated on a dental manikin using citric acid (10%) added to the water lines with universal indicating paper (UIP) placed in strategic locations in the operatory, on the clinician and assistant. Chromatic change related to settling of splatter containing citric acid on the UIP was analysed to calculate percentage intensity of splatter contamination.Results EOSs resulted in 20% reduction in frequency and 75% reduction in mean intensity of contamination of operatory sites. There was a 33% and 76% reduction in mean intensity contamination for clinician and assistant, respectively. Use of rubber dam and four-handed dentistry resulted in further reduction.Discussion This exploratory study demonstrates contamination by splatter in a simulated dental setting. The concern in dentistry regarding aerosol requires further quantitative investigation of smaller particles.Conclusions The routine use of four-handed dentistry and rubber dam should continue where possible to maximise risk mitigation during AGPs. However, on the basis of our findings, the use of an EOS device can further mitigate the magnitude and concentration of splatter.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Temporin A and Bombinin H2 Antimicrobial Peptides Exhibit Selective Cytotoxicity to Lung Cancer Cells

BACKGROUND

Recently, antimicrobial peptides (AMPs) have been investigated for their use in cancer therapy. They have been reported to selectively target and kill cancer cells whilst leaving normal healthy cells unaffected. Certain Anura AMPs have expressed selective cytotoxicity against tumour cells.

AIM

To test the potential of Anura AMPs bombinin H2, bombinin H4, temporin A, and temporin L for use as therapeutic agents for non-small cell lung carcinoma (NSCLC).

METHODS

Cytotoxic effects on NSCLC cell lines A549 and Calu-3 and normal epithelial cell line Beas-2B were tested using the CellTox Green Cytotoxicity Assay. Their haemolytic effects on human erythrocytes were also tested for their clinical relevance. Cell membrane profiling, using MALDI-TOF, was performed to ascertain if membrane characteristics of the NSCLC and Beas-2B cell lines may contribute to the AMPs mode of action.

RESULTS

Bombinin H4 (100-1.5 μM, p < 0.05) and temporin A (100-50 μM, p < 0.05) showed selective cytotoxicity towards the NSCLC cell lines. Furthermore, they exhibited low levels of haemolytic activity (bombinin H4, 0.061%; temporin A, 0.874%) comparable to untreated cells. Cell membrane profiling showed the phospholipid composition of normal epithelial cell line Beas-2B to be divergent from the cancerous cell lines. However, there was an overlap in the phospholipid profiles of the NSCLC cell lines supporting the hypothesis that the AMPs may have a selective affinity via the membrane composition of cancerous cell lines.

CONCLUSION

These results suggest that bombinin H4 and temporin A show potential for application in lung cancer therapies. Further in vitro and in vivo studies are required to develop a greater understanding of their use as anticancer agents.

Differential Effects of THC and CBD in Cannabis Smokers

Cannabis contains a myriad of different chemicals, more than 60 of which are unique to the plant and called cannabinoids. The main psychoactive ingredient is delta9-tetrahydrocannabinol (THC) and this produces the effects that users seek (Curran et al., 2002 Psychopharmacology 164: 61-70). When given intravenously to healthy humans, THC produces psychotic-like and anxiogenic effects (D’Souza et al., 2004 Neuropsychopharmacology 29: 1558-1572). In contrast, cannabidiol (CBD), another major constituent of most strains of cannabis, appears to have anti-psychotic properties, is anxiolytic (Guimares et al., 1990 Psychopharmacology 100: 558-559)and may be neuroprotective in humans (Hermann et al., 2007 Biol. Psychiatry 61: 1281-1289). The relative THC/CBD ratio of cannabis varies greatly. Although high THC cannabis has become increasingly available over recent years, little is known on changes in levels of other cannabinoids as these are seldom measured. One study in the U.S. however found that the THC content of cannabis trebled in resin and doubled in leaf, whilst the average level of other cannabinoids, including CBD, remained unchanged. We recently found that users with high levels of THC in hair and little CBD demonstrated greater levels of schizophrenia like symptoms than users with higher levels of CBD (Morgan & Curran, 2008, Br J. Psychiatry, 192: 306-307). We are currently exploring the relationship between cannabinoids in naturalistically smoked cannabis and the acute and chronic effects of the drug. This presentation will focus on the implications of the increased ratio of THC/CBD and the different effects of CBD and THC in cannabis smokers.

Best practice guidelines for communicating to parents the diagnosis of disability

Conveying a diagnosis of a disability to the parents of young children is difficult both for the parent and the clinician, however there is an ethical and medical imperative to do so. However, the process and manner of disclosure needs to be done well. When communication between parent and clinicians fails, parental mental health can be adversely affected. This paper adapts and explains how to use the SPIKES protocol to deliver "bad news" about a developmental disability diagnosis with families of infants <12-months old, using cerebral palsy as an example. Next, the range of responses parents experience to the delivery of bad news from "watchful waiting" to "acceptance" are outlined and explained. The knowledge needs of parents range from causes and prognosis to treatments and outcomes. Using clinical scenarios of recently diagnosed infants, commonly asked questions and suggested answers are tabled.

Neoadjuvant chemotherapy in patients with breast cancer: Does response in the breast predict axillary node response?

INTRODUCTION

Determining the extent of residual disease in the breast and axilla following neoadjuvant chemotherapy (NACT) is vital for surgical planning. Traditionally patients with incomplete radiological response in the breast after NACT undergo axillary node clearance, regardless of axillary clinical and radiological response. The aim of this study was to determine whether radiological and/or pathological response in the breast to NACT were predictive of axillary response.

MATERIALS AND METHODS

A retrospective cohort study of patients with operable breast cancer with histologically proven axillary lymph node involvement who received NACT and underwent definitive surgical treatment between 1/1/2016 and 31/12/2018 were included. All had MRI and/or US of the breast and axilla before, mid-treatment and at the end of NACT.

RESULTS

The 83 patients had a median age of 50 years (range 25-77). MRI had a positive predictive value (PPV) of 52.6% and negative predictive value (NPV) of 81.8% for breast pathological complete response (pCR). For axillary pCR, US had a PPV of 60.0% and NPV of 89.6%. Only 71% of patients had radiological concordance; 15.9% had radiological complete response (rCR) in breast and axilla whilst 55.1% had neither breast nor axillary rCR. 85.6% of patients had pathological concordance (20.5% with breast and axillary pCR: 65.1% with residual disease in both).

CONCLUSION

Radiological and pathological response in the breast to NACT does not accurately predict axillary response. The axilla and the breast should be viewed and assessed as two separate entities for treatment plans.

Patients’ Knowledge of the Qualifications and Roles of Anaesthetists

Patients’ knowledge of anaesthetists’ qualifications and roles remains inaccurate despite the efforts of professional bodies worldwide. However, patients have not been surveyed on this subject in Australia for more than 20 years. We therefore surveyed 200 patients attending the pre-admission clinic prior to elective non-cardiothoracic surgery in an Australian teaching hospital to determine current knowledge. Most (90.5%) patients stated that anaesthetists are medically qualified and 83.5% stated that they are medical specialists. Younger age, an English-speaking background and previous experience with surgery predicted knowledge of anaesthetists’ qualifications. Most patients believed that anaesthetists work in the operating theatre and are continually present during surgery, but few recognised their leading role in the care of patients during surgery or their other roles outside the operating theatre. Increased efforts are required to inform patients about the roles of anaesthetists in their care.

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.