Evolution of extracorporeal membrane oxygenation trigger criteria in COVID-19 acute respiratory distress syndrome

OBJECTIVE

To understand the implications of a tiered extracorporeal membrane oxygenation (ECMO) criteria framework and the outcomes of patients with COVID-19 acute respiratory distress syndrome who we were consulted on for ECMO but ultimately declined.

METHODS

All patients declined for ECMO support by a large regional health care system between March 2020 and July 2021 were included. Restrictive selection criteria were enacted midway through the study stratifying the cohort into 2 groups. Primary outcomes included 30-day mortality. Secondary outcomes included reasons for declining ECMO and survival stratified by phase.

RESULTS

One hundred ninety-three patients with COVID-19 acute respiratory distress syndrome were declined for ECMO within the study period out of 260 ECMO consults. At the time of consult, 71.0% (n = 137) were mechanically ventilated and 38% (n = 74) were proned and chemically paralyzed. Thirty-day mortality was 66% (n = 117), which increased from 53% to 73% (P = .010) when restrictive criteria were enacted. Patients with multisystem organ failure, prolonged ventilator time, and advanced age had respectively an 11-fold (odds ratio, 10.6; 95% CI, 1.7-65.2), 4-fold (odds ratio, 3.5; 95% CI, 1.1-12.0), and 4-fold (odds ratio, 4.4; 95% CI, 1.9-10.2) increase in the odds of mortality.

CONCLUSIONS

Patients with COVID-19 acute respiratory distress syndrome declined for ECMO represent a critically ill cohort. We observed an increase in the severity of disease and 30-day mortality in consults in the latter phase of our study period. These findings may reflect our use of tiered selection criteria coupled with ongoing education and communication with referring centers, sparing both patients likely to respond to medical therapy and those who were unsalvageable by ECMO.

Trajectories of Host-Response Subphenotypes in Patients With COVID-19 Across the Spectrum of Respiratory Support

BACKGROUND

Hospitalized patients with severe COVID-19 follow heterogeneous clinical trajectories, requiring different levels of respiratory support and experiencing diverse clinical outcomes. Differences in host immune responses to SARS-CoV-2 infection may account for the heterogeneous clinical course, but we have limited data on the dynamic evolution of systemic biomarkers and related subphenotypes. Improved understanding of the dynamic transitions of host subphenotypes in COVID-19 may allow for improved patient selection for targeted therapies.

RESEARCH QUESTION

We examined the trajectories of host-response profiles in severe COVID-19 and evaluated their prognostic impact on clinical outcomes.

STUDY DESIGN AND METHODS

In this prospective observational study, we enrolled 323 inpatients with COVID-19 receiving different levels of baseline respiratory support: (1) low-flow oxygen (37%), (2) noninvasive ventilation (NIV) or high-flow oxygen (HFO; 29%), (3) invasive mechanical ventilation (27%), and (4) extracorporeal membrane oxygenation (7%). We collected plasma samples on enrollment and at days 5 and 10 to measure host-response biomarkers. We classified patients by inflammatory subphenotypes using two validated predictive models. We examined clinical, biomarker, and subphenotype trajectories and outcomes during hospitalization.

RESULTS

IL-6, procalcitonin, and angiopoietin 2 persistently were elevated in patients receiving higher levels of respiratory support, whereas soluble receptor of advanced glycation end products (sRAGE) levels displayed the inverse pattern. Patients receiving NIV or HFO at baseline showed the most dynamic clinical trajectory, with 24% eventually requiring intubation and exhibiting worse 60-day mortality than patients receiving invasive mechanical ventilation at baseline (67% vs 35%; P < .0001). sRAGE levels predicted NIV failure and worse 60-day mortality for patients receiving NIV or HFO, whereas IL-6 levels were predictive in all patients regardless of level of support (P < .01). Patients classified to a hyperinflammatory subphenotype at baseline (< 10%) showed worse 60-day survival (P < .0001) and 50% of them remained classified as hyperinflammatory at 5 days after enrollment.

INTERPRETATION

Longitudinal study of the systemic host response in COVID-19 revealed substantial and predictive interindividual variability influenced by baseline levels of respiratory support.

Evaluation of Newly Integrated Bivalirudin Titration Protocol in Patients With Mechanical Circulatory Support

BACKGROUND

Patients with cardiogenic shock or end-stage heart failure can be maintained on mechanical circulatory support (MCS) devices. Once a patient undergoes placement of a device, obtaining and maintaining therapeutic anticoagulation is vital. Guidelines recommend the use of institutional protocols to assist in dosing and titration of anticoagulants.

OBJECTIVE

The purpose of this study was to characterize the use of bivalirudin before and after the implementation of a standardized titration protocol in patients with MCS.

METHODS

A retrospective review of patients who received bivalirudin for MCS (VA ECMO [veno-arterial extracorporeal membrane oxygenation], Impella, or LVAD [left ventricular assist device]) before and after the implementation of the titration protocol into the electronic health record (EHR) was conducted. The primary outcome was to compare the proportion of therapeutic activated partial thromboplastin time (aPTT). Secondary outcomes included number of subtherapeutic and supratherapeutic aPTTs, incidence of bleeding and clotting events, bivalirudin titrations per day, and percentage of patients with therapeutic aPTT level.

RESULTS

A total of 100 patients were included (precohort = 67; postcohort = 33). The proportion of therapeutic aPTTs was significantly higher in the postcohort than that in the precohort (62% vs 48%; P < 0.001). The postcohort had 0% of patients failing to achieve therapeutic aPTT levels. The number of titrations per day was significantly lower in the postcohort, with 1.20 titrations per day versus 1.93 in the precohort (P < 0.001).

CONCLUSIONS

Implementation of the bivalirudin titration nomograms within the EHR significantly increased the number of therapeutic aPTTs, reduced the number of patients who never achieved a therapeutic aPTT, and reduced the required number of titrations per day.

Trajectories of host-response biomarkers and inflammatory subphenotypes in COVID-19 patients across the spectrum of respiratory support

Purpose

Enhanced understanding of the dynamic changes in the dysregulated inflammatory response in COVID-19 may help improve patient selection and timing for immunomodulatory therapies.

Methods

We enrolled 323 COVID-19 inpatients on different levels of baseline respiratory support: i) Low Flow Oxygen (37%), ii) Non-Invasive Ventilation or High Flow Oxygen (NIV_HFO, 29%), iii) Invasive Mechanical Ventilation (IMV, 27%), and iv) Extracorporeal Membrane Oxygenation (ECMO, 7%). We collected plasma samples upon enrollment and days 5 and 10 to measure host-response biomarkers. We classified subjects into inflammatory subphenotypes using two validated predictive models. We examined clinical, biomarker and subphenotype trajectories and outcomes during hospitalization.

Results

IL-6, procalcitonin, and Angiopoietin-2 were persistently elevated in patients at higher levels of respiratory support, whereas sRAGE displayed the inverse pattern. Patients on NIV_HFO at baseline had the most dynamic clinical trajectory, with 26% eventually requiring intubation and exhibiting worse 60-day mortality than IMV patients at baseline (67% vs. 35%, p<0.0001). sRAGE levels predicted NIV failure and worse 60-day mortality for NIV_HFO patients, whereas IL-6 levels were predictive in IMV or ECMO patients. Hyper-inflammatory subjects at baseline (<10% by both models) had worse 60-day survival (p<0.0001) and 50% of them remained classified as hyper-inflammatory on follow-up sampling at 5 days post-enrollment. Receipt of combined immunomodulatory therapies (steroids and anti-IL6 agents) was associated with markedly increased IL-6 and lower Angiopoietin-2 levels (p<0.05).

Conclusions

Longitudinal study of systemic host responses in COVID-19 revealed substantial and predictive inter-individual variability, influenced by baseline levels of respiratory support and concurrent immunomodulatory therapies.

ECMO and Impella Support Strategies as a Bridge to Surgical Repair of Post-Infarction Ventricular Septal Rupture

Background and Objectives: Post-infarct ventricular septal rupture (PIVSR) continues to have significant morbidity and mortality, despite decreased prevalence. Impella and venoarterial extracorporeal membranous oxygenation (VA-ECMO) have been proposed as strategies to correct hemodynamic derangements and bridge patients to delayed operative repair when success rates are higher. This review places VA-ECMO and Impella support strategies in the context of bridging patients to successful PIVSR repair, with an additional case report of successful bridging with the Impella device. Materials and Methods: We report a case of PIVSR repair utilizing 14 days of Impella support. We additionally conducted a systematic review of contemporary literature to describe the application of VA-ECMO and Impella devices in the pre-operative period prior to surgical PIVSR correction. Expert commentary on the advantages and disadvantages of each of these techniques is provided. Results: We identified 19 studies with 72 patients undergoing VA-ECMO as a bridge to PIVSR repair and 6 studies with 11 patients utilizing an Impella device as a bridge to PIVSR repair. Overall, outcomes in both groups were better than expected from patients who were historically managed with medicine and balloon pump therapy, however there was a significant heterogeneity between studies. Impella provided for excellent left ventricular unloading, but did result in some concerns for reversal of shunting. VA-ECMO resulted in improved end-organ perfusion, but carried increased risks of device-related complications and requirement for additional ventricular unloading. Conclusions: Patients presenting with PIVSR in cardiogenic shock requiring a MCS bridge to definitive surgical repair continue to pose a challenge to the multidisciplinary cardiovascular team as the diverse presentation and management issues require individualized care plans. Both VA-ECMO and the Impella family of devices play a role in the contemporary management of PIVSR and offer distinct advantages and disadvantages depending on the clinical scenario. The limited case numbers reported demonstrate feasibility, safety, and recommendations for optimal management.

1100. A Prospective Evaluation of Neurotoxicity Among Patients Receiving Dose-Optimized Cefepime or Meropenem With Concomitant Therapeutic Drug Monitoring

Background

Cefepime (FEP) induced neurotoxicity (NT) may have serious implications for patients (pts). Retrospective studies have employed variable definitions of NT, finding renal impairment and FEP trough concentrations (Cmin) > 20 mg/L as risk factors. Prospective studies comparing antibiotics have not been performed.

Methods

We conducted a prospective study of pts receiving FEP or meropenem (MEM) with neurologic evaluation and therapeutic drug monitoring (TDM). A NT advisory board (NTAB) was established to develop standardized definitions of possible, probable and definitive NT (Fig 1). Cases of potential NT were adjudicated by the NTAB who were blinded to study treatment. FEP and MEM midpoint and Cmin concentrations were measured at steady-state by validated methods.

Results

127 patients were included (70 FEP, 57 MEM). Demographics and treatment characteristics were similar between groups (Fig 2); 63% were in the ICU. FEP and MEM Cmin varied from 1.9 – 140.5 and 0.6 – 31.3 mg/L, respectively. Median FEP Cmin and total exposures (AUC) were 23.1 mg/L and 347.6 hr*mg/L, respectively. Corresponding MEM values were 5.9 mg/L and 124.8 hr*mg/L, respectively. Cmin values were inversely correlated with renal function for both FEP and MEM (P< 0.001). Rates of possible, probable, or definitive NT were 10% and 5% for FEP and MEM, respectively (P=0.51; Fig 3). 16% and 3% of pts with FEP Cmin > or < 20 mg/L had NT, respectively (P=0.11; Fig 4). Median MEM Cmin were 12.3 and 5.4 mg/L among pts with and without NT, respectively (P=0.09; Fig 4). Rates of NT did not vary by infusion length or dose. FEP and MEM exposures were similar between patients with (17%) or without (83%) microbiologic recurrence due to the same pathogen. FEP was discontinued in 4 pts due to NT; no pts stopped MEM due to NT.

Conclusion

Our study is the first to evaluate FEP NT prospectively and compare rates of NT to pts receiving MEM. We established criteria that were applied by a blinded NTAB. In doing so we found rates of NT to be lower than previously reported and not statistically different between FEP and MEM. Cmin values were highly variable and associated with numerically, but not statistically higher rates of NT for both agents. These findings serve as the basis for larger, multicenter studies and justify use of routine TDM to limit NT among high-risk pts.

Disclosures

Brandon Smith, MD, PharmD, Shionogi (Consultant, Advisor or Review Panel member) Alexandra Urban, MD, Neuropace (Consultant) Ryan K. Shields, PharmD, MS, Shionogi (Consultant, Research Grant or Support)

292. Antibiotic Use Is Increased in Patients with Acute Respiratory Distress Syndrome (ARDS) Requiring Extracorporeal Membrane Oxygenation (ECMO) due to COVID-19 Compared with Influenza

Background

During the COVID-19 pandemic, >50% of hospitalized patients (pts) received an antimicrobial. ECMO is increasingly used in COVID-19 pts with severe ARDS. ECMO has been used for ARDS due to influenza at our center in prior years. Pts on ECMO are at high risk for infections. We compared the rates of antibiotic (Ab) and antifungal (AF) use in pts on ECMO for COVID-19 vs influenza ARDS.

Methods

This was a retrospective review of pts on ECMO for COVID-19 (2020-2021) or influenza (2013-2019). Antimicrobials (Abs and AFs) were categorized as anti-MRSA, anti-pseudomonal β-lactams (AP-BL), carbapenems, and new broader spectrum β-lactams. We calculated total Ab and AF utilization, adjusted for ECMO duration.

Results

Seventy-one pts (36 COVID-19 and 35 influenza) were included. COVID-19 pts had longer ECMO duration (median: 25 vs 11 days, p=.03). 100% and 97% of pts with COVID-19 and influenza received ≥1 Ab, respectively, and 42% and 33% an AF, respectively. COVID-19 pts received longer duration of Abs (26 vs 10 days, p< 0.001) and but not AF. COVID-19 group (gp) were more likely to receive anti-MRSA Ab (69% vs 33%, p=.004); otherwise, there were no differences between gps in types of Abs used. When adjusted for ECMO days, COVID-19 gp received higher median number of Abs (1.23 vs 1, p=.06). Specifically, COVID-19 gp received higher median number of anti-MRSA Ab (0.2 vs 0, p=.007) and AP-BL (0.44 vs 0.28, p=.08). There was no difference in Ab-free days between gps, though the proportion of Ab-free days was lower (0.2 vs 0.36) in COVID-19 pts (p=.08). More COVID-19 pts had pathogens recovered from clinical cultures, especially S. aureus and Enterobacterales (Figure).

Pathogens recovered from clinical cultures

Patients recovered from clinical cultures of patients with COVID-19 and Influenza ARDS requiring ECMO

Conclusion

Among pts on ECMO, those with COVID-19 received significantly longer courses of Abs than those with influenza, even after adjusting for longer durations of ECMO. Differences were driven by receipt of anti-MRSA and AP-BLs. Recovery of pathogenic bacteria was greater in COVID-19 pts than influenza pts. Given difficulties in distinguishing pneumonia from airway colonization among ARDS pts on ECMO, development of diagnostic criteria for pt care, rational antimicrobial stewardship and further research are needed.

Disclosures

Cornelius J. Clancy, MD, Merck (Grant/Research Support)

Outcomes of systemic anticoagulation with bivalirudin for Impella 5.0

Temporary mechanical circulatory support (tMCS) devices are used for the management of cardiogenic shock. The Impella 5.0 (Abiomed; Danvers, MA) (IMP5) is a commonly used, surgically implanted, tMCS device that requires systemic anticoagulation and purge solution to avoid pump failure. To avoid heparin-induced thrombocytopenia (HIT) from unfractionated heparin (UFH) use, our program has explored the utility of bivalirudin (BIV) for systemic anticoagulation in IMP5. This single center, retrospective study included patients supported on IMP5 with BIV based AC. The efficacy and safety end points were recovery, bridge to left ventricular assist device (LVAD), cardiac transplant (HTX), or death as well as clinically significant bleeding, incidence of Tissue Plasminogen Activator (tPA) use for suspected pump thrombosis, stroke, and device failure. There were 31 patients included, and 26 (84%) received BIV purge solutions. The median duration of IMP5 was 6 (IQR 4-10) days. Most patients were bridged to LVAD (39%, 12); 16% (5) were bridged to HTX, 16% (5) recovered, and 29% (9) died. One patient (3%) suffered from ischemic stroke and 12% (4) patients developed clinically significant bleeding. tPA was administered to 8 (26%) patients. Logistic regression analysis demonstrated that duration of IMP5 was a significant predictor of tPA use (OR 1.28; 95% Confidence Interval 1.04-1.56). There were no cases of pump failure. Our experience highlights the feasibility of utilizing BIV for routine AC use in IMP5.

Platelet transfusion is associated with 90-day and 1-year mortality for adult patients requiring veno-arterial extracorporeal membrane oxygenation

BACKGROUND

Studies examining one-year mortality respecting component blood transfusion are sparse. We hypothesize that component blood product transfusions are negatively associated with 90-day and 1-year survival for all patients requiring veno-arterial (VA) or veno-venous (VV) ECMO.

STUDY DESIGN AND METHODS

This was an IRB-approved retrospective cohort analysis of 676 consecutive patients requiring ECMO at the University of Pittsburgh between 2005 and 2016. Patients were analysed both as an entire cohort and as two subsets with respect to ECMO modality (VA vs. VV). Additional data collected and analysed included patient characteristics, laboratory values and blood product transfusion.

RESULTS

Multivariable analysis revealed that platelet transfusion was associated with 90-day mortality (OR: 1·05, P = 0·037) and one-year mortality for the entire cohort (OR = 1·05, P = 0·046,). Platelet transfusion volume was also associated with mortality in the VA-ECMO subset of patients at both 90 days (OR = 1·08, P = 0·03) and one year (OR: 1·11, P = 0·014). Age, peak International Normalized Raton ECMO, nadir haemoglobin (on ECMO) and final haemoglobin (after ECMO) were significantly associated with mortality for patients requiring VA-ECMO. For VV-ECMO patients, age, INR and peak creatinine on ECMO were associated with mortality. No individual component blood product was associated with one-year mortality for patients requiring VV-ECMO.

CONCLUSION

Platelet transfusion was associated with increased 90-day and 1-year mortality for patients requiring VA-ECMO.

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.

Process evaluation of a cluster-randomised controlled trial of multi-component weight management programme in adults with intellectual disabilities and obesity

BACKGROUND

Providing effective weight management to adults with intellectual disabilities is necessary to challenge the high rates of obesity. The aim of this process evaluation was to explore the feasibility of conducting a full-scale clinical trial of the TAKE 5 multi-component weight management programme.

METHODS

The study was a 12-month pilot cluster-randomised controlled trial. Adults with intellectual disabilities and obesity were randomised to either TAKE 5, which included an energy deficit diet (EDD) or Waist Winners Too, based on health education principles. A mixed-methods process evaluation was conducted focussing on the reach, recruitment, fidelity, implementation, dose (delivered/received) and context.

RESULTS

The study successfully recruited adults with intellectual disabilities. Both weight management programmes were delivered with high fidelity and implemented as intended. Only one weight management programme, TAKE 5, demonstrated potential efficacy in reducing body weight and body composition. The effectiveness was largely attributed to the EDD and social support from carers.

CONCLUSIONS

The extensive process evaluation illustrated that a full-scale trial of a multi-component programme including an EDD is feasible and an acceptable approach to weight management for adults with intellectual disabilities and obesity.

Abstract P6-08-17: Pregnancy associated breast cancer: Evaluating maternal outcomes. A multicentre study

Background

Pregnancy associated breast cancer (PABC) is defined as breast cancer (BC) diagnosed during the gestational period (GP) or in the first year postpartum (PP). Despite its infrequent occurrence, the incidence of PABC appears to be rising due to the increasing propensity for women to delay childbirth. We have established the first combined prospective and retrospective registry study of PABC in Ireland to examine specific clinicopathological characteristics, treatments and maternal outcomes. We present the retrospective findings to date.

Methods

We performed a retrospective multicentre observational study of patients (pts) with PABC treated in the eight Irish cancer centres from August 2001 to March 2017. Data extracted included information on pt demographics, tumour biology, staging, treatment administered and maternal outcomes. Standard biostatistical methods were used for analysis.

Results

111 PABC patients were identified. Sixty pts (54%) were diagnosed during the GP and 51 (46%) within 1 year PP. Median age at diagnosis was 36 years (yrs). Table 1 illustrates baseline characteristics. Two thirds of pts were node positive and a similar proportion had grade 3 pathology. Seventy pts (63%) were estrogen receptor (ER) positive, 36 (32%) HER2 positive, 25 (22%) triple negative. Twenty-two pts (20%) were metastatic at presentation. Seven pts (6%) had a known BRCA 1/2 mutation. The median OS (overall survival) and DFS (disease free survival) for the entire cohort was 107.4 and 94.2 months respectively (resp). There was no survival difference between those diagnosed during the GP versus PP. 5 yr DFS and OS was 68.6% and 69.2% resp. This compares unfavourably to results reported by the National Cancer Registry of Ireland in a similar age-matched BC population between 2000-2012 where the 5 yr OS was 86.5%. Variables in our study associated with poorer outcomes included younger age, tumour size, node positivity and lack of estrogen expression.

Baseline characteristics PABC patients (n=11) %(n)Diagnosed in GP (n=60) %(n)Diagnosed 1yr PP (n=51) %(n)p valueDemographic    Age at diagnosis3636(25-49)36(21-44)0.31Stage    I-II54(60)55(33)53(27)0.85III23(26)23(14)23(12)1IV20(22)18(11)22(11)0.81Unknown3(3)3(2)2(1)1Pathology    Grade 366(74)70(42)63(32)0.43Node positive66(73)68(41)63(32)0.55ER+/HER2-41(45)38(23)43(22)0.69ER+/HER2+23(25)28(17)16(8)0.17ER-/HER2+14(16)17(10)12(6)0.59Triple negative22(25)17(10)29(15)0.11Surgery    Breast conservation23(26)25(15)21(11)0.82Mastectomy56(63)57(34)59(30)0.84Adjuavnt/Neoadjuvant treatment    Chemotherapy73(81)77(46)69(35)0.39Anthracycline68(55)78(36)54(19)0.03Taxane89(72)93(43)83(29)0.16Anti HER2 agent21(23)18(11)24(12)0.63Endocrine therapy64(52)63(29)66(23)0.84Radiotherapy79(64)74(34)86(30)0.85Relapse in Stage I-III    Local relapse15(13)12(6)18(7)0.55Distant relapse24(21)22(11)25(10)0.80

Conclusions

PABC patients may have a poorer outcome. Our study reported higher rates of triple negative and HER2 positive breast cancer which are associated with more aggressive biology. Prospective evaluation of clinicopathological features, pharmacokinetics of treatments selected and maternal and fetal outcomes is imperative in this distinct pt group.

Citation Format: Prior L, Teo M, Greally M, Ward C, O'Leary C, Aslam R, Darwish W, Ahmed N, Watson G, Kelly D, Kiely L, Hassan A, Gleeson J, Featherstone H, Lim M, Murray H, Gallagher D, Westrup J, Hennessy B, Leonard G, Grogan L, Breathnach O, Horgan A, Coate L, O'Mahony D, Coate L, O'Reilly S, Gupta R, Keane M, Duffy K, O'Connor M, Kennedy J, McCaffrey J, Higgins M, Kelly C, Carney D, Gullo G, Crown J, Walshe J. Pregnancy associated breast cancer: Evaluating maternal outcomes. A multicentre study [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P6-08-17.

The effects of physical activity interventions on preventing weight gain and the effects on body composition in young adults with intellectual disabilities: systematic review and meta-analysis of randomized controlled trials

The aim of this study was to examine the literature on randomized controlled trials examining the efficacy of physical activity interventions to prevent weight gain and the effects on body composition in young adults with intellectual disabilities.A systematic search of Medline, Emabse, CINHAL, PsychINFO, Cochrane library and ERIC was conducted from 1946 to September 2014. Eligibility criteria included; randomized controlled trials of a physical activity intervention: objective measure of body weight and body composition; young adults (age range 16-24 years) with intellectual disabilities. Six studies met the eligibility criteria. The interventions varied in their prescription of physical activity including aerobic and strength-based activities. The mean duration of the interventions was 15.3 (range 10-21 weeks). There was no significant effect of physical activity interventions on body weight (weighted mean difference: -0.17 kg, 95% confidence interval, -1.04 kg to 0.72 kg) and body composition outcomes. The meta-analysis showed that physical activity interventions did not prevent weight gain in young adults with intellectual disabilities. Published studies are inadequate to form firm conclusions. Future longer term studies of interventions specifically designed for this population group are required to elucidate the effects of physical activity interventions on body composition and the prevention of weight gain in young adults with intellectual disabilities.

A reflective study on abortions in theatre

This article discusses the concept of conscientious objection in relation to surgical terminations of pregnancy. It explores a scrub nurse's duty of care not only to the patient but to themselves. It highlights the importance of being self-aware of one's moral and emotional attitude towards abortions in theatre. Doing so enables the nurse/ODP to practice professionally and autonomously, and to deliver the highest level of perioperative care whilst respecting their personal rights.

Management of arterial lines and blood sampling in intensive care: a threat to patient safety

In 2008, the UK National Patient Safety Agency (NPSA) made recommendations for safe arterial line management. Following a patient safety incident in our intensive care unit (ICU), we surveyed current practice in arterial line management and determined whether these recommendations had been adopted. We contacted all 241 adult ICUs in the UK; 228 (94.6%) completed the survey. Some NPSA recommendations have been widely implemented - use of sodium chloride 0.9% as flush fluid, two-person checking of fluids before use - and their practice was consistent. Others have been incompletely implemented and many areas of practice (prescription of fluids, two-person checking at shift changes, use of opaque pressure bags, arterial sampling technique) were highly variable. More importantly, the use of the wrong fluid as an arterial flush was reported by 30% of respondents for ICU practice, and a further 30% for practice elsewhere in the hospital. Our survey provides evidence of continuing risk to patients.

Interrater variation in scoring radiological discrepancies

OBJECTIVE

Discrepancy meetings are an important aspect of clinical governance. The Royal College of Radiologists has published advice on how to conduct meetings, suggesting that discrepancies are scored using the scale: 0=no error, 1=minor error, 2=moderate error and 3=major error. We have noticed variation in scores attributed to individual cases by radiologists and have sought to quantify the variation in scoring at our meetings.

METHODS

The scores from six discrepancy meetings totalling 161 scored events were collected. The reliability of scoring was measured using Fleiss' kappa, which calculates the degree of agreement in classification.

RESULTS

The number of cases rated at the six meetings ranged from 18 to 31 (mean 27). The number of raters ranged from 11 to 16 (mean 14). Only cases where all the raters scored were included in the analysis. The Fleiss' kappa statistic ranged from 0.12 to 0.20, and mean kappa was 0.17 for the six meetings.

CONCLUSION

A kappa of 1.0 indicates perfect agreement above chance and 0.0 indicates agreement equal to chance. A rule of thumb is that a kappa ≥0.70 indicates adequate interrater agreement. Our mean result of 0.172 shows poor agreement between scorers. This could indicate a problem with the scoring system or may indicate a need for more formal training and agreement in how scores are applied.

ADVANCES IN KNOWLEDGE

Scoring of radiology discrepancies is highly subjective and shows poor interrater agreement.

Postterm pregnancy

Postterm pregnancy is a pregnancy that extends to 42 weeks of gestation or beyond. Fetal, neonatal and maternal complications associated with this condition have always been underestimated. It is not well understood why some women become postterm although in obesity, hormonal and genetic factors have been implicated. The management of postterm pregnancy constitutes a challenge to clinicians; knowing who to induce, who will respond to induction and who will require a caesarean section (CS). The current definition and management of postterm pregnancy have been challenged in several studies as the emerging evidence demonstrates that the incidence of complications associated with postterm pregnancy also increase prior to 42 weeks of gestation. For example the incidence of stillbirth increases from 39 weeks onwards with a sharp rise after 40 weeks of gestation. Induction of labour before 42 weeks of gestation has the potential to prevent these complications; however, both patients and clinicians alike are concerned about risks associated with induction of labour such as failure of induction and increases in CS rates. There is a strong body of evidence however that demonstrates that induction of labour at term and prior to 42 weeks of gestation (particularly between 40 & 42 weeks) is associated with a reduction in perinatal complications without an associated increase in CS rates. It seems therefore that a policy of induction of labour at 41 weeks in postterm women could be beneficial with potential improvement in perinatal outcome and a reduction in maternal complications.

A randomised study of peri-prosthetic bone density after cemented versus trabecular fixation of a polyethylene acetabular component

The ideal acetabular component is characterised by reliable, long-term fixation with physiological loading of bone and a low rate of wear. Trabecular metal is a porous construct of tantalum which promotes bony ingrowth, has a modulus of elasticity similar to that of cancellous bone, and should be an excellent material for fixation. Between 2004 and 2006, 55 patients were randomised to receive either a cemented polyethylene or a monobloc trabecular metal acetabular component with a polyethylene articular surface. We measured the peri-prosthetic bone density around the acetabular components for up to two years using dual-energy x-ray absorptiometry. We found evidence that the cemented acetabular component loaded the acetabular bone centromedially whereas the trabecular metal monobloc loaded the lateral rim and behaved like a hemispherical rigid metal component with regard to loading of the acetabular bone. We suspect that this was due to the peripheral titanium rim used for the mechanism of insertion.

Environment. Sustainable development of the agricultural bio-economy

A U.S. farm policy shift to joint production of commodities and ecological services will advance sustainable agriculture.

Ethics roundtable debate: patients and surrogates want 'everything done'--what does 'everything' mean?

Highly complex and specialized care plans sometimes overwhelm the comprehension of patients and families. Many optimistic surrogates of critically ill patients err on the side of desiring that everything be done but with a nebulous idea of what 'everything' entails. Physicians must work closely to educate surrogates as to the benefits versus the risks of treatment. Our roundtable experts ponder the question of whether providers possess the authority to interpret unilaterally the nature of requests for everything.

Foetal intrauterine growth restrictions with Helicobacter pylori infection

BACKGROUND

Helicobacter pylori infection has been associated with growth restriction in young children.

AIM

To determine whether there is an association between H. pylori infection and intrauterine growth restriction.

METHODS

Four hundred and forty-eight consecutive pregnant women (aged 15-44 years), attending for routine examinations in the third trimester, were enrolled. Clinical, demographic and previous obstetric data, as well as smoking history, were collected. At delivery, the weight, height, gender and status of the neonate were recorded; intrauterine growth restriction was defined if the birth weight was below the 10th percentile according to the gestational age for infants born in Australia.

RESULTS

Eighty-nine (20%) women were seropositive for H. pylori. The prevalence of H. pylori was significantly lower in Caucasians (17%) vs. non-Caucasians (42%, P < 0.0001). There were 34 (7.5%) cases of intrauterine growth restriction (7% Caucasians, 16% Asians, 12% Aborigines and 0% Pacific Islanders). Intrauterine growth restriction was more common in H. pylori-seropositive women than in H. pylori-seronegative women [13.5% vs. 6%; odds ratio (OR) = 2.41; 95% confidence interval (CI), 1.14-5.08; P = 0.018]. A multiple logistic regression model revealed that smoking (OR = 3.55; 95% CI, 1.62-7.79; P = 0.002), maternal height (OR = 0.48; 95% CI, 0.28-0.80; P = 0.005) and H. pylori seropositivity (OR = 2.59; 95% CI, 1.12-5.95; P = 0.025) were all independent risk factors for intrauterine growth restriction.

CONCLUSIONS

H. pylori infection in pregnant women may affect foetal intrauterine growth.

Evaluation of HIV-1 immunogen, an immunologic modifier, administered to patients infected with HIV having 300 to 549 x 10(6)/L CD4 cell counts: A randomized controlled trial

CONTEXT

Despite enormous improvements achieved through the use of antiretroviral therapies (ARTs), the risk for eventual human immunodeficiency virus (HIV) disease progression remains high. Agents that enhance the immunologic mechanism for viral recognition might reduce disease progression.

OBJECTIVE

To determine whether the addition of HIV-1 Immunogen would confer added clinical efficacy to that achievable by ARTs.

DESIGN AND SETTING

Multicenter, double-blind, placebo-controlled, randomized trial beginning March 1996 and ending May 1999 conducted at 77 centers in the United States providing primary care or referral care for persons infected with HIV.

PATIENTS

Adults infected with HIV who have baseline CD4 cell counts between 300 x 10(6)/L and 549 x 10(6)/L without prior acquired immunodeficiency syndrome-defining conditions receiving stable ART (or no therapy) were screened and 2527 were randomized.

INTERVENTIONS

Ten units of HIV-1 Immunogen, derived from a Zairian HIV isolate, inactivated and formulated with incomplete Freund adjuvant, was administered intramuscularly every 12 weeks. The placebo was incomplete Freund adjuvant. Changes in ARTs were allowed.

MAIN OUTCOME MEASURES

HIV progression-free survival; secondary end points included overall survival, changes in HIV RNA, CD4 cell counts, CD4 percentage, body weight, and immunogenicity.

RESULTS

The overall event rate was 1.8 per 100 person-years of follow-up. Fifty-three subjects developed clinical progression in each treatment group (relative risk [RR], 0.97; 95% confidence interval [CI], 0.66-1.42; P =.89). There were 19 and 23 deaths in the placebo and HIV-1 Immunogen groups, respectively (RR, 0.81; 95% CI, 0.44-1. 48; P =.49). There were no statistically significant differences between the groups with respect to changes in HIV RNA (P =.59), CD4 percentage (P =.63), or body weight (P =.89). Subjects in the HIV-1 Immunogen group had an increase in average CD4 cell count of approximately 10 x 10(6)/L greater than the placebo group (P =.02).

CONCLUSION

HIV-1 Immunogen with unrestricted ART failed to demonstrate an increase in HIV progression-free survival. JAMA. 2000;284:2193-2202.

Sickle cell disease in pregnancy

Homozygous sickle cell anaemia (Hb S) is the most common major haemoglobinopathy in the United States, occurring in approximately 1 in 626 African Americans. While haemoglobinopathies involving Hb S occur commonly in blacks of African descent, they are also found in people of Middle Eastern, East Indian and Mediterranean origin. It is an uncommon disease, especially in homozygous form, in Australia. We present the case of a woman in her third pregnancy, originally from Ghana, with HB F, and discuss the current issues in the management of sickle cell disease in pregnancy.

A randomized clinical trial comparing oral misoprostol with synthetic oxytocin or syntometrine in the third stage of labour

This is a multicentre, blocked, randomized trial to compare the efficacy of oral misoprostol 400 microg with current injectable uterotonic agents (oxytocin/ Syntometrine) used prophylactically in the third stage of labour. Main outcome measures were blood loss, use of a second uterotonic agent and difference in haemoglobin level from antepartum to postpartum. Data analysis from 863 women showed a statistically significant increase in both the mean blood loss (p < 0.001) and the rate of postpartum haemorrhage > 500 mL, (RR 2.72: 95% C1 1.73-4.27) in the misoprostol group compared to the oxytocin/Syntometrine group. The use of a second uterotonic agent was higher in the misoprostol group (RR 2.89: 95% Cl 2.00-4.18) as well as a greater decrease in postpartum haemoglobin (p = 0.015). Oral misoprostol 400 microg is significantly less effective than the traditional intramuscular uterotonic agents currently used and therefore cannot be considered as a viable option to these agents in the management of the third stage of labour.

Community Learning: The Reach for Health Nursing Program-Middle School Collaboration

Nursing faculty and students have a vital role to play in promoting adolescent health at the community level. However, few nursing education programs have developed programs which provide nursing students with the skills and hands-on experiences they need to work with adolescents in community settings. A successful model for integrating community-based adolescent health promotion into nursing education is described in this article. Developed by nursing faculty from Medgar Evers College Department of Nursing, teachers and staff from a large middle school in Brooklyn, New York serving economically disadvantaged Black and Hispanic youth, and Education Development Center, Inc., the Reach for Health (RFH) Nursing Program-Middle School Collaboration has two mutually reinforcing components: (a) classroom-based health instruction taught by teachers with assistance from nursing students and faculty, and (b) community youth service in which middle school students spend approximately 3 hours per week providing assistance in health-related facilities under the guidance of nursing faculty and student nurse mentors. As part of an evaluation study, the authors conducted focus groups with nursing students involved in this program and administered an identical survey before and after intervention to assess potential benefits of participation. Compared to a control group of nursing students, those who participated in the RFH program reported increased skills and comfort working in school and community settings and with young adolescents, their teachers, and their parents. An example of other benefits was a greater understanding of the health and developmental needs of adolescents. At the same time they provided a service to the community, nursing students gained the skills and experience needed to be effective in community health promotion efforts.

The effectiveness of the Reach for Health Community Youth Service learning program in reducing early and unprotected sex among urban middle school students

OBJECTIVES

This study evaluated the effectiveness of a community youth service (CYS) program in reducing sexual risk behaviors among African American and Latino urban young adolescents.

METHODS

A total of 1061 students at 2 urban middle schools were surveyed at baseline and 6-month follow-up. Students at one school were randomly assigned by classroom to receive either the Reach for Health CYS program or the Reach for Health classroom curriculum only. Students at the other school served as controls.

RESULTS

At follow-up. CYS participants reported significantly less recent sexual activity (P < .05) and scored lower on a sexual activity index than those in the control condition (P < .03). The greatest effect was among eighth graders, who received the most intensive service program (P < .03). The benefit of the curriculum-only intervention appeared greatest among students in special education classes.

CONCLUSIONS

Well-organized CYS that couples community involvement with classroom health instruction can have a positive impact on the sexual behaviors of young adolescents at risk for HIV, sexually transmitted diseases, and unintended pregnancy. This study also suggests the importance of including students in special education classes in health education programs.

Violence prevention and young adolescents' participation in community youth service

PURPOSE

To examine whether participation in a school-sponsored community youth service program reduces self-reported violent behaviors among young urban adolescents.

METHODS

A total of 972 seventh- and eighth-grade students at two large, urban, public middle schools were surveyed at baseline and at 6-month follow-up. One school was assigned to interventions and the other served as a control. All students at the intervention school received the Reach for Health classroom curriculum that included a 10-lesson unit focusing on violence prevention. In addition, approximately half the students were randomly assigned by classroom to participate in the Reach for Health Community Youth Service program (CYS). Under the guidance of teachers and community nurses, these students spent several hours each week providing service in local health care agencies. Regression analyses were used to assess the influence of treatment condition on violent behavior outcomes.

RESULTS

Comparing students in the curriculum-only and curriculum-plus-CYS interventions to the control group, there is a statistically significant interaction (p < .03) among grade, CYS participation, and violence at follow-up. Eighth-grade CYS students reported significantly less violence at follow-up than students in the control school, taking into account baseline level of risk behavior, gender, ethnicity, and social desirability (p < .04). There was no significant difference between controls and students in the curriculum-only condition. Comparing students in the CYS intervention to the curriculum-only condition within the intervention school, the grade by intervention interaction again is significant (p < .05). Eighth-grade CYS students-who received the broadest CYS experience-reported less violence at follow-up than their curriculum-only counterparts.

CONCLUSION

When delivered with sufficient intensity, school programs which couple community service with classroom health instruction can have a measurable impact on violent behaviors of a population of young adolescents at high risk for being both the perpetrators and victims of peer violence. Community service programs may be an effective supplement to curricular interventions and a valuable part of multicomponent violence prevention programs.

Oral health status of Canadian-born and immigrant adolescents in North York, Ontario

Studies from a number of countries, including Canada, have demonstrated that the oral health status of immigrants is worse than that of their native-born counterparts and that they make less use of dental services. To date, however, little information is available which documents changes in immigrant oral health following immigration. This paper reports the results of a study conducted in the City of North York, Ontario, that examined the oral health status of Canadian-born and immigrant adolescents aged 13 and 14 years. The former had better oral health than the latter on all parameters assessed and made more use of dental services. Within the immigrant population, there was a significant association between oral health and time since immigration. Those who had been in Canada 6 or more years were significantly healthier than those who had arrived within the preceding 2 years. While changing patterns of immigration may account for part of these differences, the data suggest that access to dental public health programs, delivered to students between the ages of 4 and 14 years, have been effective in improving the oral health of those born outside Canada. Since these programs cease at age 13 or 14 years, barriers to accessing the private dental care sector may mean that the residual inequities and inequalities evident in the data widen as these individuals age.

Ectopic pregnancy in lower segment uterine scar

A case of ectopic pregnancy in a lower uterine segment scar following previous Caesarean section is reported. A significant scar defect may result in deep implantation within the myometrium with the risk of persistent pain and bleeding followed inevitably by uterine rupture. In this report we discuss a number of management options. Except in the special situation of superficial implantation in a shallow scar defect where there is ultrasound evidence of continuity of the gestational sac with the uterine cavity we would strongly advise termination of the pregnancy.

Epidemiology of periodontal disease among older adults: a review

Although many epidemiological studies have been conducted concerning periodontal disease, the majority were not included in this review because of deficiencies in the measures used. Although it is increasingly common for studies in this field to measure periodontal disease using clinical attachment level, attachment loss or bone loss, the evidence pertaining to prevalence, incidence and risk in older adult populations is limited. Although it is the best indicator to date, characterizing periodontal disease by means of attachment loss has some limitations. Prevalence and incidence rates may vary according to the number of teeth and sites probed and bias and case misclassification may occur because of the healthy survivor effect. Moreover, prevalence data that document lifetime disease experience are of little use in planning for periodontal treatment needs. Problems with sampling or subject selection and idiosyncratic ways of reporting data also limit the quality of the evidence currently available. In order to standardize the collection of data on loss of attachment and to measure it as accurately as possible, Papapanou (63) recommends that studies use full-mouth periodontal examinations and the assessment of clinical attachment level at four sites on each remaining tooth. Given the inconsistencies in and problems with the methods used in the studies reviewed above, only broad conclusions can be drawn concerning periodontal disease in older adults. These confirm the conclusions reached in other reviews of the literature. While moderate levels of attachment loss are to be found in a high percentage of middle-aged and elderly subjects, severe loss is confined to a minority, albeit a substantial one. Severe loss is evident in only a few sites and, in general, affects only a small proportion of sites examined. Nevertheless, approximately one-fifth of older individuals have experienced more generalized severe loss; the rate is much higher in the oldest subjects and subjects from minority groups. Although not universal, severe disease is common in some older populations and some population subgroups. Studies using common approaches are needed to fully elucidate the extent to which disease experience varies across different populations. Similar conclusions can be drawn from prevalence studies measuring bone loss. These show that a minority of subjects accounted for most sites with advanced loss. Studies of incidence suggest that 50-75% of older adults experience additional loss of attachment of 2 or 3 mm or more at a minimum of one site over relatively short periods of time. Rates fall dramatically when more stringent case definitions are used. Moreover, relatively few sites examined show evidence of additional loss so that, although rates are high, extent and severity are low. More detailed analyses of incidence data, although few, indicate that new lesions are more common than progressing lesions, and the pattern of loss tends to support an episodic model of periodontal disease progression.

Prenatal ultrasound findings in a fetus diagnosed with Gaucher's disease (type 2) at birth

A 26-year-old woman with no significant history was found to have a fetus with hepatosplenomegaly and neurological abnormalities in utero on ultrasound. The baby was found to have a severe clinical manifestation of type 2 Gaucher's disease.