How do Australian osteopaths manage migraines? Outcomes from a national practice-based research network

BACKGROUND

Individuals who experience migraines often seek out a variety of treatment options including manual or physical therapy. Evidence suggests that manual therapy, including osteopathy, can play a role in the management of migraines. Whilst there is some literature on the role osteopathy therapy plays in migraine management, none describes the treatment approaches used by practitioners.

OBJECTIVES

To explore the demographic, practice and clinical management characteristics of Australian osteopaths who report treating migraine 'often' in clinical practice.

METHODS

Secondary analysis of a cross-sectional survey of 988 osteopaths from the Osteopathy Research and Innovation Network (ORION), an Australian practice-based research network. Regression analysis was used to identify demographic, practice and clinical management characteristics of Australian osteopaths who reported 'often' treating migraine patients.

RESULTS

Over 40% of respondents (n = 400) indicated treating patients with migraines 'often'. These osteopaths were less likely to be involved in research and be co-located with a dietician compared to osteopaths who do 'not often' treat migraine. Osteopaths who reported 'often' treating migraine were: five times as likely to treat non-English speaking ethnic groups; 2.5 times as likely to treat chronic pain, temporomandibular joint disorders and hand musculoskeletal complaints; compared to those that do not treat migraines 'often'.

CONCLUSION

Australian osteopaths who treat migraine are five times more likely to treat non-English speaking ethnic groups; twice as likely to treat chronic pain; temporomandibular joint disorders, and hand musculoskeletal complaints. More research is needed to identify the practices and patient outcomes associated with osteopathy care for those experiencing migraines.

Ammonia gas treatment in low cost biological reactor

Ammonia gas contributes to a number of environmental and human health concerns. The use of chalk, a cheap alkalinity source may reduce costs for biological systems. This research studies a closed liquid flow reactor to treat ammonia gas using chalk as biomass media and alkalinity source with high value calcium nitrate fertilizer production. The proposed reactor showed complete ammonia gas removal at high rate (500 mg N/L/day) and with low cost; where chalk dissolution and ammonia gas absorption contributed to alkalinity in the water for nitrification. High calcium ion concentration (up to 10,000 mg Ca2+ as CaCO3/L) showed only minor effects on ammonia absorption and nitrification rate.

Dataset on risk factors for seroconversion against Mycobacterium avium subspecies paratuberculosis in dairy cows

Johne's disease (JD) is a chronic wasting disease caused by Mycobacterium avium subspecies paratuberculosis (MAP). MAP is responsible for large economic losses for the dairy sector and has been linked to human disease. Susceptibly to MAP is mainly limited to young animals and diagnostic tests are poor at detecting MAP in early stages of infection. Therefore, ascertaining the contribution of the dam to the risk of calf infection and the relative role of the different infection routes is important to inform disease control measures. This data article presents MAP exposures at time of calving on a cohort of 439 calves born between 2012 and 2013 from 6 UK dairy herds. Each calf participated in routine quarterly MAP milk ELISA testing using the IDEXX Porquire ELISA. Each animal was followed until testing MAP positive, being culled or end of follow up (January 2023). The dataset includes risk factors associated with transmission via colostrum route (MAP status of cow giving colostrum); transmission via the dam (MAP status of the dam) and transmission via fecal oral route (whether at birth the calf spent a long time in a dirty yard). Ascertainment of exposure to risk factors involved video recording and self-capture data forms from time of calving in the maternity area of the farms until calf left the area. The dataset provides a unique opportunity to examine MAP infection and its relationship with different exposures at time of birth, where cows were followed up during their entire lives.

Increasing Use of Conservative Management of Low-Risk Prostate Cancer in the Veterans Affairs System from 2012 to 2021

PURPOSE/OBJECTIVE(S)

Conservative management (CM), including either active surveillance or watchful waiting, is the preferred management strategy for men with low-risk prostate cancer. We sought to describe contemporary trends in CM among men with localized prostate cancer across the equal-access Veterans Affairs (VA) system.

MATERIALS/METHODS

Using VA tumor registry data, we identified all men with a new diagnosis of biopsy-proven, clinically node-negative, non-metastatic prostatic adenocarcinoma from 2012 to 2021, excluding men with missing National Comprehensive Cancer Network risk group. We quantified the yearly proportion of patients with low and favorable intermediate-risk (FIR) prostate cancer undergoing conservative management and examined age-specific rates. Multivariable logistic regression was used to identify independent clinical predictors of CM among men with low-risk and FIR disease.

RESULTS

The cohort included 86,415 patients with localized prostate cancer, of whom 20,290 (23.5%) had low risk and 25,447 (29.5%) had FIR disease. The proportion of men diagnosed with low-risk disease decreased from 27.7% in 2012 to 20.1% in 2021. The proportion of men with localized prostate cancer who were 70 years or older at diagnosis increased from 19.5% in 2012 to 46.4% in 2021, with similar increases seen across risk groups. The proportion of men with low-risk disease undergoing CM increased from 63.1% in 2012 to 86.6% in 2021. CM rates in 2021 among low-risk patients were largely consistent across age groups (50-59: 85.1%; 60-69: 87.4%; 70+: 86.3%). For FIR patients, CM rates increased among the subset with Gleason 6 disease (49.5% in 2012 to 80.7% in 2021). In multivariable models, independent predictors of CM in low-risk patients included older age, more recent year, lower PSA at diagnosis, North Atlantic or Pacific region, and presence of another cancer at diagnosis; similar predictors were found in FIR patients. Self-reported race (Black, White, or Other) was not associated with CM. While there was wide geographic variation in CM rates among low-risk patients early in the study period (2012-2014: 56.1% in Southeast region vs 74.1% in Pacific), these disparities resolved in recent years (2019-2021: 83.2% in Southeast vs 83.8% in Pacific).

CONCLUSION

Rates of conservative management for localized prostate cancer increased dramatically over time in the VA, with over 85% of low-risk patients managed conservatively in 2021. Recent years showed no differences in CM rates by self-reported race, geographic region, or age group. Despite this progress, we observed a concomitant increase in the proportion of men 70 years or older diagnosed with localized prostate cancer, including low risk disease. This raises a need to consider strategies to reduce the diagnosis of low-risk disease in elderly Veterans.

Association of dynamic contrast-enhanced MRI and 18F-Fluorodeoxyglucose PET/CT parameters with neoadjuvant therapy response and survival in esophagogastric cancer

INTRODUCTION

Better predictive markers are needed to deliver individualized care for patients with primary esophagogastric cancer. This exploratory study aimed to assess whether pre-treatment imaging parameters from dynamic contrast-enhanced MRI and 18F-fluorodeoxyglucose (18F-FDG) PET/CT are associated with response to neoadjuvant therapy or outcome.

MATERIALS AND METHODS

Following ethical approval and informed consent, prospective participants underwent dynamic contrast-enhanced MRI and 18F-FDG PET/CT prior to neoadjuvant chemotherapy/chemoradiotherapy ± surgery. Vascular dynamic contrast-enhanced MRI and metabolic 18F-FDG PET parameters were compared by tumor characteristics using Mann Whitney U test and with pathological response (Mandard tumor regression grade), recurrence-free and overall survival using logistic regression modelling, adjusting for predefined clinical variables.

RESULTS

39 of 47 recruited participants (30 males; median age 65 years, IQR: 54, 72 years) were included in the final analysis. The tumor vascular-metabolic ratio was higher in patients remaining node positive following neoadjuvant therapy (median tumor peak enhancement/SUVmax ratio: 0.052 vs. 0.023, p = 0.02). In multivariable analysis adjusted for age, gender, pre-treatment tumor and nodal stage, peak enhancement (highest gadolinium concentration value prior to contrast washout) was associated with pathological tumor regression grade. The odds of response decreased by 5% for each 0.01 unit increase (OR 0.95; 95% CI: 0.90, 1.00, p = 0.04). No 18F-FDG PET/CT parameters were predictive of pathological tumor response. No relationships between pre-treatment imaging and survival were identified.

CONCLUSION

Pre-treatment esophagogastric tumor vascular and metabolic parameters may provide additional information in assessing response to neoadjuvant therapy.

Association of Proton Pump Inhibitor Use and Severe Pneumonitis in Stage III Non-Small-Cell Lung Cancer Treated with Primary Chemoradiation and Adjuvant Durvalumab

PURPOSE/OBJECTIVE(S)

Prior studies have suggested gut microbiome changes induced by long-term acid-reducing medication use could modulate immunotherapy efficacy and toxicity. We assessed the relationship between baseline acid-reducing medication use (proton pump inhibitors [PPI] or H2 antagonists [H2A]) on treatment-related toxicity and efficacy in a large cohort of stage III non-small-cell lung cancer (NSCLC) patients treated with or without immunotherapy.

MATERIALS/METHODS

Patients with unresectable stage III NSCLC treated with primary concurrent chemoradiation with or without adjuvant durvalumab from 2015 to 2021 were identified in the Veterans Affairs (VA) system. We defined baseline acid-reducing medication use with VA and non-VA pharmacy records in the year prior to radiation start; the number of prescriptions and the cumulative duration of therapy were quantified. Using multivariable Cox models adjusting for potential baseline confounders and stratified by adjuvant durvalumab use, we estimated the association between PPI or H2A use and subsequent severe pneumonitis, progression-free survival, and overall survival. Pneumonitis was determined and graded by manual chart review.

RESULTS

We included 1994 patients with stage III NSCLC treated with primary chemoradiation, of whom 1005 (50%) received adjuvant durvalumab, 1064 (53%) received any PPI and 1030 (52%) received any H2A. In the overall sample, baseline use of any PPI was associated with increased risk of grade 3-5 pneumonitis (adjusted hazard ratio [aHR] 1.53, 95% CI 1.12-2.10, p = 0.008) and was found to be significant only in durvalumab-treated patients (aHR 1.67, 95% CI 1.10-2.54, p = 0.016), but not for patients treated without durvalumab (aHR 1.34, 95% CI 0.82-2.20, p = 0.2). Higher number of PPI prescriptions were associated with increased risk of severe pneumonitis (aHR 1.38 per 5 prescriptions, 95% CI 1.03-1.85, p = 0.03) and longer duration of PPIs trended toward significance (aHR 1.04 per 90 days, 95% CI 1.00-1.09, p = 0.066). Any PPI use was associated with worse OS in durvalumab-treated patients (aHR 1.30, 95% CI 1.05-1.61, p = 0.016) but not for patients without durvalumab use (aHR 0.99, 95% CI 0.86-1.14, p = 0.9). PPI use had no association with progression-free survival in either cohort. No significant associations between baseline H2A use and pneumonitis, PFS, or OS in either cohort were seen.

CONCLUSION

PPIs, but not H2As, are associated with increased risk of treatment-related pneumonitis and inferior OS in stage III NSCLC patients treated with chemoradiation and immunotherapy. This association was not observed among patients treated with chemoradiation alone. No association was found between PPI use and cancer progression. Further work is warranted to confirm these findings in other immunotherapy-treated cohorts.

Symptomatic Pneumonitis Rates Among Patients with Stage III Non-Small Cell Lung Cancer Receiving Adjuvant Durvalumab

PURPOSE/OBJECTIVE(S)

Adjuvant durvalumab after definitive chemoradiation for stage III non-small cell lung cancer (NSCLC) has improved overall survival with low reported pneumonitis rates in clinical trials. However, real-world rates of treatment-associated pneumonitis remain poorly defined. We sought to describe pneumonitis rates among a largest-to-date real-world cohort of stage III NSCLC patients receiving adjuvant durvalumab.

MATERIALS/METHODS

We performed a retrospective cohort study of patients with stage III NSCLC in the national Veterans Health Administration who received concurrent chemoradiation alone from 2015-2016 or concurrent chemoradiation followed by at least one dose of adjuvant durvalumab from 2017-2021. Incident pneumonitis was defined as new or worsening symptoms, radiographic changes on CT chest, at least one steroid prescription, and a likely diagnosis of pneumonitis by the treating physician within 2 years of the final radiation treatment; severity was graded by CTCAE v4.03 criteria. Pneumonitis events were ascertained by manual chart review assisted by keyword searches and steroid prescription data. Cox regression was used to identify baseline clinical factors associated with Grade 2+ pneumonitis.

RESULTS

Our cohort included 1,994 patients with stage IIII NSCLC, 989 of whom received concurrent chemoradiation alone and 1005 of whom received adjuvant durvalumab. The overall incidence of symptomatic pneumonitis among patients receiving concurrent chemoradiation alone vs those receiving adjuvant immunotherapy was 6.8% vs 11% (Grade 2, p = 0.0005), 6% vs 8.4% (Grade 3, p = 0.007) and 1.1% vs 1.6% (Grade 5, p = 0.292), respectively. The cumulative incidence of Grade 2-5 pneumonitis at 2 years was 13.8% among patients treated with chemoradiation alone versus 22.1% for patients treated with chemoradiation followed by durvalumab (p ≤0.0001). Of those with Grade 2 pneumonitis, pneumonitis occurred in 85% of patients within one year of receiving radiation, and 84% of those with Grade 3-5 pneumonitis developed pneumonitis within one year. Patients prescribed outpatient steroids for pneumonitis had active prescriptions lasting a mean of 153 days, and among those hospitalized for pneumonitis, ¾ needed supplemental oxygen support. On multivariate analysis, the use of durvalumab is associated with higher risk of Grade 2-5 pneumonitis (HR 1.4, p = 0.004). Current smokers have a 50% risk reduction for Grade 2+ pneumonitis relative to never smokers (p≤0.001).

CONCLUSION

In this largest-to-date cohort, we found that adjuvant immunotherapy is associated with higher risk of Grade 2+ pneumonitis. The increase in symptomatic pneumonitis associated with durvalumab should spur future work to refine patient selection, balance the risk/benefit of adjuvant immunotherapy, and potentially modify radiation dosimetric constraints to decrease pneumonitis rates.

Historical use of silver nitrate for the management of epistaxis - evidence-based practice?

OBJECTIVE

Epistaxis is one of the most common emergencies presenting to the ENT service, and silver nitrate cautery is the mainstay of epistaxis treatment in most centres worldwide. This review aimed to ascertain the historical evidence behind current common practice.

METHOD

A review was conducted of historical published literature pertaining to epistaxis management.

RESULTS

Silver in medicine dates back to 4000 BC, with silver nitrate first being used in 69 BC. Modern medical use for epistaxis is documented in case reports over the last 200 years.

CONCLUSION

The precise origin and evidence-based practice of using silver nitrate for epistaxis is not well-established or understood. The mechanism of action is questionable; novel research of silver nitrate for this common ENT emergency presentation may be required.

Robotic colorectal resection in combination with a multimodal enhanced recovery program - results of the first 100 cases

PURPOSE

In Germany, colorectal robot-assisted surgery (RAS) has found its way and is currently used as primary technique in colorectal resections at our clinic. We investigated whether RAS can be extensively combined with enhanced recovery after surgery (ERAS®) in a large prospective patient group.

METHODS

Using the DaVinci Xi surgical robot, all colorectal RAS from 09/2020 to 01/2022 were incorporated into our ERAS® program. Perioperative data were prospectively recorded using a data documentation system. The extent of resection, duration of the operation, intraoperative blood loss, conversion rate, and postoperative short-term results were analyzed. We documented the postoperative duration of Intermediate Care Unit (IMC) stay and major and minor complications according to the Clavien-Dindo classification, anastomotic leak rate, reoperation rate, hospital-stay length, and ERAS® guideline adherence.

RESULTS

One hundred patients (65 colon and 35 rectal resections) were included (median age: 69 years). The median durations of surgery were 167 min (colon resection) and 246 min (rectal resection). Postoperatively, four patients were IMC-treated (median stay: 1 day). In 92.5% of the colon and 88.6% of the rectum resections, no or minor complications occurred postoperatively. The anastomotic leak rate was 3.1% in colon and 5.7% in rectal resection. The reoperation rate was 7.7% (colon resection) and 11.4% (rectal resection). The hospital stay length was 5 days (colon resection) and 6.5 days (rectal resection). The ERAS® guideline adherence rate was 88% (colon resection) and 82.6% (rectal resection).

CONCLUSION

Patient perioperative therapy per the multimodal ERAS® concept is possible without any problems in colorectal RAS, leading to low morbidity and short hospital stays.

Enhancing diabetes care for the most vulnerable in the 21st century: Interim findings of the National Advisory Panel on Care Home Diabetes (NAPCHD)

Older adults with diabetes may carry a substantial health burden in Western ageing societies, occupy more than one in four beds in care homes, and are a highly vulnerable group who often require complex nursing and medical care. The global pandemic (COVID-19) had its epicentre in care homes and revealed many shortfalls in diabetes care resulting in hospital admissions and considerable mortality and comorbid illness. The purpose of this work was to develop a national Strategic Document of Diabetes Care for Care Homes which would bring about worthwhile, sustainable and effective quality diabetes care improvements, and address the shortfalls in care provided. A large diverse and multidisciplinary group of stakeholders (NAPCHD) defined 11 areas of interest where recommendations were needed and using a subgroup allocation approach were set tasks to produce a set of primary recommendations. Each subgroup was given 5 starter questions to begin their work and a format to provide responses. During the initial phase, 16 key findings were identified. Overall, after a period of 18 months, 49 primary recommendations were made, and 7 major conclusions were drawn from these. A model of community and integrated diabetes care for care home residents with diabetes was proposed, and a series of 5 'quick-wins' were created to begin implementation of some of the recommendations that would not require significant funding. The work of the NAPCHD is ongoing but we hope that this current resource will help leaders to make these required changes happen.

Determining the influence of the primary and specialist network of care on patient and system outcomes among patients with a new diagnosis of chronic obstructive pulmonary disease (COPD)

Introduction

Care for patients with chronic obstructive pulmonary disease (COPD) is provided by both family physicians (FP) and specialists. Ideally, patients receive comprehensive and coordinated care from this provider team. The objectives for this study were: 1) to describe the family and specialist physician network of care for Ontario patients newly diagnosed with COPD and 2) to determine the associations between selected characteristics of the physician network and unplanned healthcare utilization.

Methods

We conducted a retrospective cohort study using Ontario health administrative data housed at ICES (formerly the Institute for Clinical Evaluative Sciences). Ontario patients, ≥ 35 years, newly diagnosed with COPD were identified between 2005 and 2013. The FP and specialist network of care characteristics were described, and the relationship between selected characteristics (i.e., continuity of care) with unplanned healthcare utilization during the first 5 years after COPD diagnosis were determined in multivariate models.

Results

Our cohort consisted of 450,837 patients, mean age 61.5 (SD 14.6) years. The FP was the predominant provider of care for 86.4% of the patients. Using the Bice-Boxerman’s Continuity of Care Index (COCI), a measure reflecting care across different providers, 227,082 (50.4%) were categorized in a low COCI group based on a median cut-off. In adjusted analyses, patients in the low COCI group were more likely to have a hospital admission (OR = 2.27, 95% CI 2.20,2.22), 30-day readmission (OR = 2.44, 95% CI 2.39, 2.49) and ER visit (OR = 2.27, 95% CI 2.25, 2.29).

Conclusion

Higher indices of continuity of care are associated with reduced unplanned hospital use for patients with COPD. Primary care-based practice models to enhance continuity through coordination and integration of both primary and specialist care have the potential to enhance the health experience for patients with COPD and should be a health service planning priority.

Approach to initial management of canine generalised epileptic seizures in primary-care veterinary practices in the United Kingdom

OBJECTIVES

To investigate how primary care clinicians in the UK approach initial management of canine generalised epileptic seizures, including factors potentially associated with prescription and choice of anti-seizure drugs (ASDs).

MATERIALS AND METHODS

Electronic health records concerning 3,150,713 consultations (917,373 dogs) were collected from 224 veterinary practices by the Small Animal Veterinary Surveillance Network. Free-text clinical narratives were reviewed to identify those consistent with generalised epileptic seizure activity, including only those recording the first presentation for seizures. Dogs older than 6 years were excluded.

RESULTS

Five hundred and seventeen cases were included. Sixty-seven dogs (13.0%) received anti-seizure drugs at first presentation; this was significantly more likely in dogs presented with cluster seizures (CS) (odds ratio 13.8, 95% confidence interval 7.3 to 26.1). Phenobarbital (n=36) and imepitoin (n=29) were the most frequently chosen anti-seizure drugs. Presentation for a single epileptic seizure occurred in 321 dogs; seven were prescribed anti-seizure drugs. Eighty-six dogs were presented with cluster seizures; 38 were prescribed anti-seizure drugs, most frequently imepitoin (n= 19) and phenobarbital (n=17). Of the dogs presenting with a single seizure and at least 6-month follow-up (n=165), 33 (20%) did not have subsequent seizures recorded.

CLINICAL SIGNIFICANCE

Primary care clinicians rarely prescribed anti-seizure drugs following a single epileptic seizure in accordance with International Veterinary Epilepsy Task Force recommendations. Less than half of dogs initially presenting with cluster seizures were prescribed anti-seizure drugs. Imepitoin was frequently selected in the treatment of cluster seizures despite no authorisation for this purpose. These findings may ultimately contribute to improved cohesion in the management of canine epileptic seizures between primary care and referral institutions.

A Large Cluster of New Onset Autoimmune Myositis in the Yorkshire Region Following SARS-CoV-2 Vaccination

Background: The novel SARS-CoV-2 vaccines partially exploit intrinsic DNA or RNA adjuvanticity, with dysregulation in the metabolism of both these nucleic acids independently linked to triggering experimental autoimmune diseases, including lupus and myositis. Methods: Herein, we present 15 new onset autoimmune myositis temporally associated with SARS-CoV-2 RNA or DNA-based vaccines that occurred between February 2021 and April 2022. Musculoskeletal, pulmonary, cutaneous and cardiac manifestations, laboratory and imaging data were collected. Results: In total, 15 cases of new onset myositis (11 polymyositis/necrotizing/overlap myositis; 4 dermatomyositis) were identified in the Yorkshire region of approximately 5.6 million people, between February 2021 and April 2022 (10 females/5 men; mean age was 66.1 years; range 37–83). New onset disease occurred after first vaccination (5 cases), second vaccination (7 cases) or after the third dose (3 cases), which was often a different vaccine. Of the cases, 6 had systemic complications including skin (3 cases), lung (3 cases), heart (2 cases) and 10/15 had myositis associated autoantibodies. All but 1 case had good therapy responses. Adverse event following immunization (AEFI) could not be explained based on the underlying disease/co-morbidities. Conclusion: Compared with our usual regional Rheumatology clinical experience, a surprisingly large number of new onset myositis cases presented during the period of observation. Given that antigen release inevitably follows muscle injury and given the role of nucleic acid adjuvanticity in autoimmunity and muscle disease, further longitudinal studies are required to explore potential links between novel coronavirus vaccines and myositis in comparison with more traditional vaccine methods.

Development of a one-step RT-qPCR assay for the detection of Grapevine leafroll-associated virus 7

Grapevine leafroll disease (GLD) is one of the most economically important viral diseases of grapevines. GLD is caused by a complex of several ssRNA (+) viruses referred to as Grapevine leafroll-associated viruses (GLRaVs). To date, five different GLRaV species have been identified. One of those species, GLRaV-7, was first reported from a symptomless white-fruited wine grape cultivar from Albania. Since its discovery, GLRaV-7 has been reported from 14 countries. Although serological assays have been developed to detect GLRaV-7, commercially available antibodies produce high background signals making them unsuitable for regulatory testing. Furthermore, while molecular detection assays have been shown to be more sensitive when compared to the serological assays, published molecular assays, except the one Reverse Transcription-quantitaive Polymerase Chain Reaction (RT-qPCR) assay based on heat shock protein 70 homologue (HSP70h) gene, have been reported to be inadequate in detecting all reported isolates of GLRaV-7. Availability of multiple assays provides flexibility to diagnostic laboratories in cases where the chosen assay fails to detect a strain or an isolate of a pathogen due to variation in its targeted region or where additional confirmation of the results is required. In this study, we developed a sensitive and specific RT-qPCR assay, based on a region of p61 gene of GLRaV-7, which detected all available isolates.

[First 18 months as certified ERAS® center for colorectal cancer : Lessons learned and results of the first 261 patients]

BACKGROUND

Enhanced recovery after surgery (ERAS®) describes a multimodal, interdisciplinary and interprofessional treatment concept that optimizes the postoperative convalescence of the patient through the use of evidence-based measures.

GOAL OF THE WORK

The aim of this article is to present the experiences of our center certified by the ERAS® Society for colorectal resections 18 months after successful implementation.

MATERIAL AND METHODS

Since the beginning of the certification 261 patients have been treated in our clinic according to the specifications of the ERAS® concept. As a comparison group the last 50 patients prior to implementation were evaluated in terms of compliance with ERAS® requirements, length of hospital stay and readmission rate, the need for care in an intensive or intermediate care ward, the number of necessary reoperations and the complication rate.

RESULTS

Compliance increased from 39.3% preERAS® to 81.1% after ERAS® implementation (p < 0.001). At the same time the length of stay of ERAS® patients was reduced from 7 days to 5 days (p = 0.001). While the rate of surgical complications was the same between the two groups (p = 0.236), nonsurgical complications occurred significantly less frequently in the ERAS® cohort (p = 0.018).

DISCUSSION

There are well-known stumbling blocks in implementing and maintaining an ERAS® concept; however, it is worthwhile for the patient to circumnavigate this and establish ERAS® as the standard treatment path.

Substance use behaviours and the UK furlough scheme: evidence from eight longitudinal population surveys

Disruptions to economic activity such as job loss can impact substance use behaviours. During the COVID-19 pandemic many countries implemented a furlough scheme to prevent job loss. We examine how furlough was associated with respondents' substance use behaviours in the initial stages of the pandemic in the UK. Data were from over 27,000 participants in eight adult longitudinal surveys. Participants self-reported economic activity (furlough or job loss vs stable employment) and smoking (any current), vaping (any current) and drinking alcohol (>4 days/week or 5+ drinks per typical occasion) both before and during the initial stages of the pandemic. Changes in frequency/quantity of substance use were also examined. Risk ratios were estimated within each study using modified Poisson regression, adjusting for a range of potential confounders, including pre-pandemic behaviour (though this was excluded in analyses of behaviour change). Findings were synthesised using a random effects meta-analysis. Compared to stable employment, participation in the furlough scheme was associated with smoking (risk ratio: 1.24 [95% CI: 1.08-1.42]; I2=0%) while job loss was associated with vaping (1.72 [1.10-2.71]; I2=25%) and heavier drinking (1.21 [1.02-1.43]; I2=2%), but these associations were largely accounted for by confounders (adjusted risk ratios: smoking: 1.06 [0.96-1.16]; I2=8%; vaping: 1.55 [0.93-2.56]; I2=42%; and drinking: 1.03 [0.89-1.20]; I2=35%). Furlough was associated with drinking more than before the pandemic (adjusted risk ratio: 1.15 [1.00-1.33]; I2=70%), and with increases in vaping behaviour (1.54 [1.14-2.07]; I2=0%). Increased drinking associated with furlough is concerning, while increased vaping likely represents moves to reduce smoking and may be positive.

1627 We Are Donors: Redeveloping Educational Material for Schools in Response To COVID-19

Aim

We Are Donors is a UK registered charity aiming to increase the number of organ and blood donors across the UK through student led education at schools and universities. Over the last two years we have spoken to over 4000 students and have shown that the program improves awareness of organ donation, facilitates discussion within families and increases the number of planned organ donor registry sign ups. In response to COVID-19 our educational sessions moved online, and we studied what impact this had on engagement with the students and how our material could be redeveloped to improve outcomes.

Method

We compared the feedback from 1514 children aged 11-18 years who received face to face presentations in August 2018 - May 2019 with that from a group of 141 children aged 14 -18 years from 5 schools who received live online sessions using the same powerpoint presentation between March 2020 - June 2020.

Results

The change to online delivery reduced recommendation of the talk to a friend from 88% to 69%. Moving to online sessions also resulted in reduced post session feedback. To tackle these issues, we re-developed our presentation in collaboration with Slido to feature interactive elements, a quiz (including a leaderboard) and a real-time question and answer session. We also incorporated an immediate feedback survey.

Conclusions

Our study highlights new challenges that educators are facing when moving to online platforms. While moving online allows more students to be reached, maintaining high levels of student engagement is challenging.

Risk of infertility in female adolescents and young adults with cancer: a population-based cohort study

STUDY QUESTION

Do female adolescents and young adults (AYAs) with cancer have a higher risk of subsequent infertility diagnosis than AYAs without cancer?

SUMMARY ANSWER

Female AYAs with breast, hematological, thyroid and melanoma cancer have a higher risk of subsequent infertility diagnosis.

WHAT IS KNOWN ALREADY

Cancer therapies have improved substantially, leading to dramatic increases in survival. As survival improves, there is an increasing emphasis on optimizing the quality of life among cancer survivors. Many cancer therapies increase the risk of infertility, but we lack population-based studies that quantify the risk of subsequent infertility diagnosis in female AYAs with non-gynecological cancers. The literature is limited to population-based studies comparing pregnancy or birth rates after cancer against unexposed women, or smaller studies using markers of the ovarian reserve as a proxy of infertility among female survivors of cancer.

STUDY DESIGN, SIZE, DURATION

We conducted a population-based cohort study using universal health care databases in the province of Ontario, Canada. Using data from the Ontario Cancer Registry, we identified all women 15-39 years of age diagnosed with the most common cancers in AYAs (brain, breast, colorectal, leukemia, Hodgkin lymphoma, non-Hodgkin lymphoma, thyroid and melanoma) from 1992 to 2011 who lived at least 5 years recurrence-free (Exposed, n = 14,316). Women with a tubal ligation, bilateral oophorectomy or hysterectomy previous to their cancer diagnosis were excluded. We matched each exposed woman by age, census subdivision, and parity to five randomly selected unexposed women (n = 60,975) and followed subjects until 31 December 2016.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Infertility diagnosis after 1 year of cancer was identified using information on physician billing codes through the Ontario Health Insurance Plan database (ICD-9 628). Modified Poisson regression models were used to assess the risk of infertility diagnosis (relative risk, RR) adjusted for income quintile and further stratified by parity at the time of cancer diagnosis (nulliparous and parous).

MAIN RESULTS AND THE ROLE OF CHANCE

Mean age at cancer diagnosis was 31.4 years. Overall, the proportion of infertility diagnosis was higher in cancer survivors compared to unexposed women. Mean age of infertility diagnosis was similar among cancer survivors and unexposed women (34.8 years and 34.9 years, respectively). The overall risk of infertility diagnosis was higher in cancer survivors (RR 1.30; 95% CI 1.23-1.37). Differences in infertility risk varied by type of cancer. Survivors of breast cancer (RR 1.46; 95% CI 1.30-1.65), leukemia (RR 1.56; 95% CI 1.09-2.22), Hodgkin lymphoma (RR 1.49; 95% CI 1.28-1.74), non-Hodgkin lymphoma (RR 1.42; 95% CI 1.14, 1.76), thyroid cancer (RR 1.20; 95% CI 1.10-1.30) and melanoma (RR 1.17; 95% CI 1.01, 1.35) had a higher risk of infertility diagnosis compared to women without cancer. After stratification by parity, the association remained in nulliparous women survivors of breast cancer, leukemia, lymphoma and melanoma, whereas it was attenuated in parous women. In survivors of thyroid cancer, the association remained statistically significant in both nulliparous and parous women. In survivors of brain or colorectal cancer, the association was not significant, overall or after stratification by parity.

LIMITATIONS, REASONS FOR CAUTION

Non-biological factors that may influence the likelihood of seeking a fertility assessment may not be captured in administrative databases. The effects of additional risk factors, including cancer treatment, which may modify the associations, need to be assessed in future studies.

WIDER IMPLICATIONS OF THE FINDINGS

Reproductive health surveillance in female AYAs with cancer is a priority, especially those with breast cancer, leukemia and lymphoma. Our finding of a potential effects of thyroid cancer (subject to over-diagnosis) and, to a lesser extent, melanoma need to be further studied, and, if an effect is confirmed, possible mechanisms need to be elucidated.

STUDY FUNDING/COMPETING INTEREST(S)

Funding was provided by the Faculty of Health Sciences and Department of Obstetrics and Gynecology, Queen's University. There are no competing interests to declare.

TRIAL REGISTRATION NUMBER

N/A.

Innovations for the future of breast surgery

BACKGROUND

Future innovations in science and technology with an impact on multimodal breast cancer management from a surgical perspective are discussed in this narrative review. The work was undertaken in response to the Commission on the Future of Surgery project initiated by the Royal College of Surgeons of England.

METHODS

Expert opinion was sought around themes of surgical de-escalation, reduction in treatment morbidities, and improving the accuracy of breast-conserving surgery in terms of margin status. There was emphasis on how the primacy of surgical excision in an era of oncoplastic and reconstructive surgery is increasingly being challenged, with more effective systemic therapies that target residual disease burden, and permit response-adapted approaches to both breast and axillary surgery.

RESULTS

Technologies for intraoperative margin assessment can potentially half re-excision rates after breast-conserving surgery, and sentinel lymph node biopsy will become a therapeutic procedure for many patients with node-positive disease treated either with surgery or chemotherapy as the primary modality. Genomic profiling of tumours can aid in the selection of patients for neoadjuvant and adjuvant therapies as well as prevention strategies. Molecular subtypes are predictive of response to induction therapies and reductive approaches to surgery in the breast or axilla.

CONCLUSION

Treatments are increasingly being tailored and based on improved understanding of tumour biology and relevant biomarkers to determine absolute benefit and permit delivery of cost-effective healthcare. Patient involvement is crucial for breast cancer studies to ensure relevance and outcome measures that are objective, meaningful, and patient-centred.

41 Diagnosing Bone Metastases in Breast Cancer – CT Vs Nuclear Medicine Bone Scan

Introduction

Guidelines advise use of CT or MRI to detect bone metastasis in breast cancer. Bone-scintigraphy (BS) is not routinely indicated. However, our patients with new node positive breast cancer, or symptoms suggestive of bone metastases, undergo both CT and BS. We aimed to evaluate discrepancies between CT and BS results, and assess whether CT is more accurate in diagnosing bone metastases in breast cancer patients.

Method

Over a 2-year period, breast cancer patients who underwent CT and BS within 28 days of each other, were included. Scan reports were reviewed, and where unclear, MDT outcome was consulted.

Results

Of 149 patients, 15 (10.1%) had discordant scan results. Where CT was negative, and BS suspicious (n = 6) or positive (n = 3), patients were either found to have visceral metastases on CT, BS was found to be a false positive, or MDT concluded there were no bone metastases. Where CT was positive and BS negative (n = 4), MDT confirmed metastases.

Conclusions

CT is as good as BS in demonstrating bone metastases, and also detects visceral metastases. Using CT only would reduce radiation exposure, costs, and burden on service provision. We advise a change in local policy, with CT scan as the primary investigation for breast cancer staging.