Establishment and initial implementation of the Australasian Pelvic Floor Procedure Registry

INTRODUCTION AND HYPOTHESIS

Stress urinary incontinence (SUI) and pelvic organ prolapse (POP) are common pelvic floor disorders (PFDs). Owing to significant adverse events associated with mesh-related pelvic floor procedures (PFPs) in a proportion of the surgically treated population, and deficits in collection and reporting of these events, the Australian Government identified an urgent need for a tracking mechanism to improve safety and quality of care. The Australasian Pelvic Floor Procedure Registry (APFPR) was recently established following the 2018 Senate Committee Inquiry with the aim of tracking outcomes of PFP involving the use of devices and/or prostheses, with the objective of improving the health outcomes of women who undergo these procedures. This paper will describe the APFPR's aims, development, implementation and possible challenges on the way to its establishment.

METHODS

The APFPR has been developed and implemented in accordance with the national operating principles of clinical quality registries (CQRs). The minimum datasets (MDS) for the registry's database have been developed using a modified Delphi process, and data are primarily being collected from participating surgeons. Patient recruitment is based on an opt-out approach or a waiver of consent. Patient-reported outcome measures (PROMs) providing additional health and outcome information will be obtained from participating women to support safety monitoring of mesh-related adverse events.

RESULTS

Currently in the Australasian Pelvic Floor Procedure Registry (APFPR) there are 32 sites from various jurisdictions across Australia, that have obtained relevant ethics and governance approvals to start patient recruitment and data collection as of January 2023. Additionally, there are two sites that are awaiting governance review and five sites that are having documentation compiled for submission. Seventeen sites have commenced patient registration and have entered data into the database. Thus far, we have 308 patients registered in the APFPR database. The registry also published its first status report and a consumer-friendly public report in 2022.

CONCLUSIONS

The registry will act as a systematic tracking mechanism by collecting outcomes on PFP, especially those involving devices and/or prostheses to improve safety and quality of care.

Dietary fatty acids and endometrial cancer risk within the European Prospective Investigation into Cancer and Nutrition

BACKGROUND

Diet may impact important risk factors for endometrial cancer such as obesity and inflammation. However, evidence on the role of specific dietary factors is limited. We investigated associations between dietary fatty acids and endometrial cancer risk in the European Prospective Investigation into Cancer and Nutrition (EPIC).

METHODS

This analysis includes 1,886 incident endometrial cancer cases and 297,432 non-cases. All participants were followed up for a mean of 8.8 years. Multivariable Cox proportional hazard models were used to estimate hazard ratios (HR) and 95% confidence intervals (CI) of endometrial cancer across quintiles of individual fatty acids estimated from various food sources quantified through food frequency questionnaires in the entire EPIC cohort. The false discovery rate (q-values) was computed to control for multiple comparisons.

RESULTS

Consumption of n-6 γ-linolenic acid was inversely associated with endometrial cancer risk (HR comparing 5th with 1st quintileQ5-Q1=0.77, 95% CI = 0.64; 0.92, ptrend=0.01, q-value = 0.15). This association was mainly driven by γ-linolenic acid derived from plant sources (HRper unit increment=0.94, 95%CI= (0.90;0.98), p = 0.01) but not from animal sources (HRper unit increment= 1.00, 95%CI = (0.92; 1.07), p = 0.92). In addition, an inverse association was found between consumption of n-3 α-linolenic acid from vegetable sources and endometrial cancer risk (HRper unit increment= 0.93, 95%CI = (0.87; 0.99), p = 0.04). No significant association was found between any other fatty acids (individual or grouped) and endometrial cancer risk.

CONCLUSION

Our results suggest that higher consumption of γ-linolenic acid and α-linoleic acid from plant sources may be associated with lower risk of endometrial cancer.

P01.21.A Testing Semantic Verbal Fluency (SVFT) in patients with headache suspicious of cancer helps predict those with tumour on imaging

Background

Differentiating secondary headache from primary headache on history alone can sometimes be difficult. Headache “plus” other subtle cognitive features improves prediction. Patients and relatives may attribute subtle cognitive or behavioural changes to other causes (e.g. anxiety, low mood). Sematic verbal fluency - “how many animals can you think of in a minute” is commonly impaired on admission in patients with headache harbouring a tumour. We were interested whether SVFT at point of referral for scan would help predict a tumour and requested GPs report the SVFT on electronic referral for direct access scanning in cases with a history of headache suspicious of cancer. The aim of the pilot study was to establish if the SVFT was a “red flag” for secondary causes of headache. We report the results of a 20-month audit of cases.

Material and Methods

An electronic Protocol Based Referral (PBR) was developed for Headache Suspicious of Cancer to expedite scanning. The PBR sat alongside the routine e-DACI system that had been in use for some years. The GP was asked to complete the SVFT at the time of referral for scanning. Other data were gathered: PMH cancer; other symptoms/signs; co-morbid conditions and medications.

Results

GPs submitted requests for ePBR scanning in 669 cases over 20 months (62% females; Mean age 53: 60% <60 years). SVFT was completed on the request form in 381 (57%) cases. In these cases median SVFT was 17 animals. 11/381 cases were found to have cancer on scanning (2.9%): 10/188 cases with intracranial tumours had a SVFT <17 (5.32%) compared with one with a SVFT >=17. The median SVFT in cases with cancer was 10 animals. Other possible causes of SVFT <17 were - 53 psychiatric or chronic pain conditions on multiple drugs;12 were not native English speakers; 19 had co-existing dementia; 5 had small vessel disease; 4 cysts; 4 Giant Cell Arteritis ; 2 Chiari 1 malformation; PMH - encephalitis (1).

Conclusion

A SVFT result <17, at the point of referral for brain imaging, in patients with headache suspicious of cancer was associated with intracranial cancer in more than 1:20 cases, whereas a SVFT of >=17 was associated with cancer in 1:200 cases. SVFT may be an additional useful “red flag”. The most appropriate SVFT cut-off requires more research in a larger study. Low SVFT in headache patients may inform Cancer Referral Guidelines, improve the identification of secondary headache and help expedite cases.

The coronavirus disease 2019 pandemic among adult congenital heart disease patients: findings of a one-year multicentric, international study

Introduction

One year after the beginning of the Coronavirus Disease 2019 (COVID-19) pandemic, the evidence on outcomes among adults with congenital heart disease (ACHD) is still limited.

Purpose

We aimed to compare patient characteristics and outcomes between the first and the subsequent COVID-19 waves and to identify overall predictors for complicated disease course among ACHD patients.

Methods

We collected reported COVID-19 cases among ACHD patients followed at 26 tertiary care centers in 10 European countries between March 27, 2020 and March 25, 2021. Patient characteristics, heart defect complexity and residual problems, medical history, date of diagnosis and course and outcome of COVID-19 were recorded. Cases were stratified into first vs. subsequent COVID-19 waves (cut-off date July 15, 2020). A complicated disease course was defined as hospitalization for COVID-19 requiring ventilation and/or inotropic support, extracorporeal membrane oxygenation or death. Data were reported as median (interquartile range) and counts (percentage).

Results

Overall, 548 cases were included (first wave: n=161; subsequent waves: n=387). Median age 33 (26–44) years, 52% female. Thirty-three patients (6%) had a complicated disease course. Between waves (first vs. subsequent), there were no statistically significant differences related to gender (women 57% vs. 49%, p=0.09), body mass index (BMI) category (p=0.7), heart defect complexity (p=0.08) and residual heart defect-related problems (p=0.6). Patients in the first wave were older, had more often ≥2 comorbidities and a complicated disease course (37 vs 33 years, p=0,001; 17% vs. 7%, p=0.0003; and 9% vs. 5%, p=0.04, respectively). The proportion of deaths did not significantly differed between waves (4% vs 2%, p=0.2). A detailed comparison of the above-reported characteristics is depicted in table 1. From multivariable models, adjusted odds ratios (OR) (95% confidence interval) for the prediction of complicated COVID-19 course are depicted in table 2. Main independent predictors for a complicated disease course were: cyanotic heart disease, including unrepaired cyanotic defects or severe pulmonary hypertension with Eisenmenger syndrome (OR 8.49 [3.14–22.94], p<0.001), BMI >25 kg/m2 (OR 3.91 [1.62–9.43], p=0.002), having ≥2 comorbidities (OR 2.63 [1.05–6.62], p=0.04) and age per five years (OR 1.21 [1.05–1.42], p=0.01).

Conclusion

Complicated COVID-19 course among ACHD patients is rare. Outcomes in the first wave were worse when compared to subsequent waves, mainly because patients of the first wave were older and had more comorbidities. Age, cyanotic heart disease (including unrepaired cyanotic defects or severe pulmonary hypertension with Eisenmenger syndrome), having ≥2 comorbidities and a BMI >25 kg/m2 were the main predictors for a complicated disease course.

Funding Acknowledgement

Type of funding sources: None.

50 A Cross-Sectional Study Examining the Association Between MRCS Performance and Surgeons Receiving Fitness to Practice Sanctions

Aim

Fitness to practice (FtP) investigations by the General Medical Council (GMC) can be one of the most stressful experiences in a surgeon’s career. Demographic factors are known to alter the likelihood of GMC investigation. Despite this there are no studies assessing risk factors in surgeons for FtP sanctions. Thus, we used the newly created Intercollegiate Membership of Royal College of Surgeons (MRCS) examination database to identify risk factors for and the prevalence of GMC sanctions in early-career surgeons.

Method

FtP sanction data contained in the GMC list of registered medical practitioners (LRMP) database was linked at person-level to all UK graduates who had attempted MRCS Part A or Part B between September 2007 and January 2020. Data were anonymised by the Royal College of Surgeons of England prior to analysis.

Results

f 11,660 candidates who had attempted the MRCS within the study period only 31 (0.3%) candidates had GMC FtP sanctions within the last two years. Of these, 12 had active conditions on their registration, 7 had active undertakings and 14 had warnings. Candidate demographics were similar between cohorts and there were no significant differences between MRCS performance identified.

Conclusions

In this, the largest study of MRCS candidates to date, the prevalence of active FtP sanctions in early-career surgeons was 0.3%, significantly lower than the prevalence of sanctions across more experienced UK surgeons (0.9%). These data highlight early-career surgeons as a low-risk group for disciplinary action and should reassure patients and medical professionals of the rarity of FtP sanctions.

238 MRCS Performance Predicts Surgical Career Outcomes

Aim

Successful completion of the MRCS examination is mandatory for progression into higher surgical (registrar) training in the UK. National selection for training programmes is a highly competitive process. Despite this, the ranking of applicants does not currently include MRCS performance scores. This offers a unique opportunity to compare two independent assessments of surgical trainees to establish whether MRCS performance can predict future surgical career outcomes and competitiveness in training.

Method

All UK candidates who attempted MRCS between 2007-2020 were matched to career outcome data using the GMC list of registered medical practitioners and anonymised (n = 2910). Chi-squared tests determined associations with first attempt MRCS pass/fail outcomes. Multinomial regression models were developed to establish the predictive power of success at MRCS in determining surgical specialty and training deanery choices.

Results

There was statistically significant variability in MRCS Part A pass rates, ranging from 55.1%-76.7% between surgical specialties (P=0.001) but no significant variability in Part B pass rates (P=0.655). There was significant variability in Part A and Part B pass rates between training deaneries (P=0.010 and P=0.036 respectively). Pass rates ranged from 59.9%-77.7% for Part A and 70.1%-85.0% for Part B between training deaneries. Those in more competitive specialties and training deaneries performed better in MRCS in terms of first attempt pass rate, scores and number of attempts taken to pass.

Conclusions

MRCS performance is an early predictor of surgical career choice and competitiveness. Trainees who perform well at MRCS are more likely to enter competitive surgical specialties and training deaneries.

51 The Impact of Disability on Performance in the Intercollegiate Membership of the Royal College of Surgeons examination (MRCS)

Aim

The number of clinicians with disabilities is increasing, however there is no data on the performance of doctors with registered disabilities in the postgraduate environment. If we are to ensure diversity and equality within the workforce, we must first identify whether attainment differences exist in markers of performance. To address this, we assessed the impact of disabilities on performance in the MRCS.

Method

All UK medical graduates who had attempted MRCS Part A (n = 9,597) and Part B (n = 4,562) between 2007-2017 with linked disability data in the UK Medical Education Database (https://www.ukmed.ac.uk) were included. Univariate analysis identified associations with MRCS performance and logistic regression models identified independent predictors of success.

Results

Candidates with registered disabilities (n = 635) had lower MRCS Part A pass rates (46.3% vs 59.8% (p < 0.001)) but similar Part B pass rates (68.2% vs 70.9% (p = 0.339)). They were nearly twice as likely to fail Part A (odds ratio 0.55 [95% Confidence Interval 0.46-0.64]). When prior academic attainment (A-Levels and medical school performance) was accounted for, there was no statistically significant difference in the likelihood of MRCS success (p>0.05). Pass rates were similar for candidates with specific learning difficulties and those with other registered disabilities (p>0.05).

Conclusions

This is the first study to assess the impact of disability status and type on performance at a postgraduate medical examination. It appears that candidates with registered disabilities performed less well in formal, written examinations generally. Although our data indicate that current MRCS testing accommodations are fair, enabling performance unrestricted by disability.

Improving endovascular access to the target vessel for thrombus aspiration -Use of the wedge device to overcome anatomic hurdles

BACKGROUND AND PURPOSE

Aspiration is a successful technique used in thrombectomy for acute stroke. It is contingent upon the appropriate position of the aspiration catheter, so that it is in contact with the thrombus. However, navigating the craniocervical vasculature is challenging is some patients. The wedge microcatheter (MicroVention®) is designed to reduce the gap between the microcatheter and the SofiaPlus 6F catheter for ease of advancement. The purpose of this study is to describe our initial experience with the wedge microcatheter.

MATERIALS AND METHODS

A retrospective review of 38 consecutive patients in whom the wedge microcatheter was used during thrombectomy was performed to determine whether the wedge microcatheter was successful in delivering the Sofia catheter to the desired location.

RESULTS

We have found this device to be successful in delivering the aspiration catheter to the correct position in 97% (N = 37) of cases. It was used predominantly to pass the origin of branching vessels and also to navigate the tortuous cavernous and petrous segments of the ICA.

CONCLUSION

The wedge microcatheter is a successful tool in delivering the aspiration catheter to the desired vessel for revascularisation.

485 Optimisation of The Evening Surgical Handover Process in A Large Tertiary Surgical Department - A Quality Improvement Project

Introduction

The aim of the project was to improve the quality and effectiveness of the evening surgical handover in a large tertiary surgical department, incorporating up to 150 patients.

Method

Audit standards were derived from GMC and RCSEng guidelines. An initial audit of the evening handover was conducted over a period of two weeks. Following this, a standard operating protocol (SOP) was introduced, with re-audit 4-weeks following implementation.

Results

The initial audit identified an inconsistent format and significant variability. Few handovers commenced with all team members present (11%) and were uninterrupted (33%). A laminated handover SOP checklist was produced and a new proforma was introduced to document tasks or reviews required overnight. A mandatory evening surgical HDU round was invoked and a “watchers” system was introduced to identify patients at highest risk of deterioration.

Re-audit demonstrated significant improvements in all domains to > 85%. ICU referrals overnight decreased from 6% to 2%. Further improvements measures were implemented in the form of a dynamic virtual handover document.

Conclusions

A structured SOP improved the consistency of the handover process. A night review of all HDU patients reduced the rate of ICU referrals. Implementation of virtual handover processes may be required in the COVID-era.

221 UK Medical School Selection Criteria Predicts Success in Part A of The Intercollegiate Membership of The Royal College of Surgeons (MRCS) Examination

Background

Selection into UK medical school typically involves a combination of three measures: prior academic attainment, selection tests (e.g., the University Clinical Aptitude Test (UCAT), Biomedical Admissions Test (BMAT), Graduate Medical School Admissions Test (GAMSAT)), and an interview. We investigated whether prior attainment and selection test scores can predict MRCS success.

Method

We used the UKMED database to analyse selection data for all UK graduates who attempted MRCS Part A (n = 9729) and Part B (n = 4644) between 2007-2017. Univariate analysis and Pearson correlation coefficients were used to examine the relationship between selection scores and first attempt MRCS success.

Results

Successful MRCS Part A candidates had better A-Levels and higher scores in UCAT, BMAT and GAMSAT examinations (p < 0.001) than their unsuccessful peers. No statistically significant difference was observed for MRCS Part B. A moderate positive correlation was found between Part A, BMAT (r = 0.315, p < 0.001) and GAMSAT scores (r = 0.346, p < 0.001). A weak positive correlation was found between Part A, A-Level (r = 0.144, p < 0.001) and UCAT scores (r = 0.246, p < 0.001).

Conclusions

A-level results and medical school selection tests predict success in the knowledge-based (Part A) MRCS examination.

525 Automated Continuous Instrument Tracking in Laparoscopic Box Trainers Predicts Performance at Assessment: A Prospective Cohort Study in Core Surgical Trainees

Introduction

Box-trainers enable deliberate practice of laparoscopic skills and can be equipped with instrument tracking metrics to provide feedback. However, the relationship between metrics, assessment outcomes and practice are unclear.

Method

Core surgical trainees were provided take-home box trainers with SurgTrac™ instrument tracking metrics for practice (eoSurgical Ltd., Scotland, UK). Practice was incentivised by certification and video assessment of a basic task, peg capping. Assessment was by consultant general surgeons, using objective structured assessment of technical skills (OSATS). The following metrics were analysed: task duration, distance moved by instruments, average instrument speed, average instrument acceleration, left- or right-handedness and instrument smoothness. Metrics were correlated to OSATS scores using regression analysis. Threshold for significance was p = 0.05.

Results

During the study period, there were 1639 peg capping performances by 85 trainees; 103 video recordings were submitted for assessment. All metrics were significantly associated with OSATS score, except instrument acceleration. The multiple linear regression model was highly correlated with actual scores (Pearson correlation 0.658; p < 0.001). Practice was positively correlated with regression model predicted OSATS score (regression analysis; ANOVA p < 0.001).

Conclusions

Instrument tracking metrics reliably predict OSATS performance and practice improves predicted score. Trainees can use metrics in unsupervised practice and gauge whether they are improving as expected.

191 Performance at Medical School and Foundation Programme Selection Can Predict Success in The MRCS Examination

Background

Identifying factors that predict success in the Membership of the Royal College of Surgeons (MRCS) examination can aid trainees’ exam preparation and help deaneries identify candidates likely to require additional support. We assessed whether performance at Medical School and UK Foundation Programme selection (Educational Performance Measurement (EPM) and Situational Judgement Test (SJT)) predicted MRCS success.

Method

We analysed data from the UKMED Database for UK graduates who had attempted MRCS Part A (n = 1,975) and Part B (n = 630) between 2013-2017. Univariate analysis examined the relationship between performance and the likelihood of passing MRCS at first attempt. Logistic regression identified independent predictors of MRCS success.

Results

Each additional EPM decile increased the chances of passing MRCS by 52% for Part A (odds ratio 1.52 [95% confidence interval 1.46-1.60]) and 27% for Part B (1.27 [1.18-1.38]). Each EPM point awarded for degrees increased the likelihood of passing Part A by 29% (1.29 [1.12-1.48]). SJT score was not a statistically significant independent predictor of MRCS success (P>0.05).

Conclusions

This is the first study to investigate the relationship between UK medical school performance and postgraduate surgical exam success. Higher ranked students are more likely to succeed in the MRCS compared to their lower ranked peers.

220 Choice of UK Medical School Predicts Success in The Intercollegiate Membership of The Royal College of Surgeons (MRCS) Examination

Background

UK medical schools vary in terms of factors such as mission, specific curricula and pedagogy. As relatively little is understood about the impact of these differences at a post-graduate level, we examined the relationship between medical school and MRCS success.

Method

Using the UKMED database we analysed data on UK medical graduates who attempted MRCS Part A (n = 9729) and MRCS Part B (n = 4644) between 2007-2017. Univariate analysis characterised the relationship between medical school and first attempt MRCS success. Logistic regression modelling identified independent predictors of MRCS success.

Results

MRCS pass rates differed significantly between medical schools (P < 0.001). Trainees from standard-entry 5-year programmes were more likely to pass MRCS at first attempt compared to those from extended (Gateway) courses ((Part A (Odds Ratio (OR) 3.72 [95% Confidence Interval (CI) 2.69-5.15]); Part B (OR 1.67 [1.02-2.76])). Non-graduates were more likely to pass Part A (OR 1.40 [1.19-1.64]) and Part B (OR 1.66 [1.24-2.24]). Russell Group graduates were more likely to pass MRCS Part A (OR 1.79 [1.56-2.05]) and Part B (OR 1.24 [1.03-1.49])).

Conclusions

Medical programme and medical school are associated with MRCS success. Further research is needed to tease out the relationship between individual factors, medical school and MRCS performance.

A prospective study of tea drinking temperature and risk of esophageal squamous cell carcinoma

Previous studies have reported an association between hot tea drinking and risk of esophageal cancer, but no study has examined this association using prospectively and objectively measured tea drinking temperature. We examined the association of tea drinking temperature, measured both objectively and subjectively at study baseline, with future risk of esophageal squamous cell carcinoma (ESCC) in a prospective study. We measured tea drinking temperature using validated methods and collected data on several other tea drinking habits and potential confounders of interest at baseline in the Golestan Cohort Study, a population-based prospective study of 50,045 individuals aged 40-75 years, established in 2004-2008 in northeastern Iran. Study participants were followed-up for a median duration of 10.1 years (505,865 person-years). During 2004-2017, 317 new cases of ESCC were identified. The objectively measured tea temperature (HR 1.41, 95% CI 1.10-1.81; for ≥60°C vs. <60°C), reported preference for very hot tea drinking (HR 2.41, 95% CI 1.27-4.56; for "very hot" vs. "cold/lukewarm"), and reported shorter time from pouring tea to drinking (HR 1.51, 95% CI 1.01-2.26; for <2 vs. ≥6 min) were all associated with ESCC risk. In analysis of the combined effects of measured temperature and amount, compared to those who drank less than 700 ml of tea/day at <60°C, drinking 700 mL/day or more at a higher-temperature (≥60°C) was consistently associated with an about 90% increase in ESCC risk. Our results substantially strengthen the existing evidence supporting an association between hot beverage drinking and ESCC.

Review of external referrals to a regional stroke centre: it is not just about thrombectomy

AIMS

To determine the experience of a regional stroke referral centre of external referrals for endovascular thrombectomy (EVT) in patients with symptoms of acute ischaemic stroke (AIS) and large vessel occlusion (LVO).

MATERIALS AND METHODS

Data were collected prospectively over two 4-month periods (2017-2018) on consecutive external referrals for EVT. Baseline demographics, imaging findings, and key time parameters were recorded. Reasons for not transferring patients and for not performing EVT were recorded. Key time intervals were calculated and compared between the transferred and non-transferred group with and without intracranial occlusion and between the transferred patients who underwent thrombectomy and those who did not.

RESULTS

Two hundred and sixty-two patients were referred. Sixty-one percent (n=159) were accepted and transferred for treatment. Of those transferred, 86% (n=136) had EVT. Fourteen percent (n=23) were unsuitable for EVT on arrival due to no vessel occlusion (48% n=11), poor Alberta Stroke Program Early CT Score (ASPECTS)/established infarct (30%, n=7) haemorrhage (9%, n=2), and clinical recovery (13% n=3). One hundred and three patients (39%) were ineligible for EVT following phone discussion due to absence of intracranial occlusion (59%, n=61), low ASPECTS (22%, n=23), distal occlusion (4%, n=4), low/improving National Institutes of Health Stroke Scale (NIHSS; 10.7%, n=11), and poor modified Rankin Scale (mRS) at baseline (3%, n=3). Patients with LVO but not transferred had longer onset to hospital arrival time compared with those transferred 151.5 versus 91 minutes (p<0.005), with a trend also toward a longer door to CT/CTA 40 minutes versus 30 minutes (p=0.142).

CONCLUSION

These data provide valuable insights into the service provision of a comprehensive stroke network. The present rates of EVT and futile transfers are modest compared to published data. Access to neuroradiology and specialised stroke assessment is crucial to optimise time to treatment.

Timing of HPV16-E6 antibody seroconversion before OPSCC: findings from the HPVC3 consortium

BACKGROUND

Human papillomavirus type 16 (HPV16)-E6 antibodies are detectable in peripheral blood before diagnosis in the majority of HPV16-driven oropharyngeal squamous cell carcinoma (OPSCC), but the timing of seroconversion is unknown.

PATIENTS AND METHODS

We formed the HPV Cancer Cohort Consortium which comprises nine population cohorts from Europe, North America and Australia. In total, 743 incident OPSCC cases and 5814 controls provided at least one pre-diagnostic blood sample, including 111 cases with multiple samples. Median time between first blood collection and OPSCC diagnosis was 11.4 years (IQR = 6-11 years, range = 0-40 years). Antibodies against HPV16-E6 were measured by multiplex serology (GST fusion protein based Luminex assay).

RESULTS

HPV16-E6 seropositivity was present in 0.4% of controls (22/5814; 95% CI 0.2% to 0.6%) and 26.2% (195/743; 95% CI 23.1% to 29.6%) of OPSCC cases. HPV16-E6 seropositivity increased the odds of OPSCC 98.2-fold (95% CI 62.1-155.4) in whites and 17.2-fold (95% CI 1.7-170.5) in blacks. Seropositivity in cases was more frequent in recent calendar periods, ranging from 21.9% pre-1996 to 68.4% in 2005 onwards, in those with blood collection near diagnosis (lead time <5 years). HPV16-E6 seropositivity increased with lead time: 0.0%, 13.5%, 23.7%, and 38.9% with lead times of >30 years (N = 24), 20-30 years (N = 148), 10-20 years (N = 228), and <10 years (N = 301 cases) (p-trend < 0.001). Of the 47 HPV16-E6 seropositive cases with serially-collected blood samples, 17 cases seroconverted during follow-up, with timing ranging from 6 to 28 years before diagnosis. For the remaining 30 cases, robust seropositivity was observed up to 25 years before diagnosis.

CONCLUSIONS

The immune response to HPV16-driven tumorigenesis is most often detectable several decades before OPSCC diagnosis. HPV16-E6 seropositive individuals face increased risk of OPSCC over several decades.

A Standardized Aspiration-First Approach for Thrombectomy to Increase Speed and Improve Recanalization Rates

BACKGROUND AND PURPOSE

Direct aspiration is a recognized technique for revascularization in large-vessel ischemic strokes. There is ongoing debate regarding its efficacy compared with stent retrievers. Every delay in achieving revascularization and a decrease in reperfusion rates reduces the likelihood of patients achieving functional independence. We propose a standardized setup technique for aspiration-first for all anterior circulation thrombectomy procedures for increasing speed and recanalization rates.

MATERIALS AND METHODS

We analyzed 127 consecutive patients treated by a standardized approach to thrombectomy with an intention to perform aspiration-first compared with 127 consecutive patients treated with a stent retriever-first approach. Key time metrics evaluated included groin to first angiogram, first angiogram to reperfusion, groin to first reperfusion, and length of the procedure. The degree of successful recanalization (TICI 2b-3) and the number of passes were compared between the 2 groups.

RESULTS

In 127 patients who underwent the standardized technique, the median time from groin puncture to first reperfusion was 18 minutes compared with 26 minutes (P < .001). The duration of the procedure was shorter compared with the stent retriever group (26 minutes in the aspiration first group versus 47 minutes, P < .001) and required fewer passes (mean, 2.4 versus 3.1; P < .05). A higher proportion of patients had a TICI score of 2b-3 in the aspiration-first group compared with stent retriever group (96.1% versus 85.8%, P < .005).

CONCLUSIONS

Our study highlights the increasing speed and recanalization rates achieved with fewer passes in a standardized approach to thrombectomy with an intention to attempt aspiration-first. Any attempt to reduce revascularization time and increase successful recanalization should be used.

Optimal remediation design and simulation of groundwater flow coupled to contaminant transport using genetic algorithm and radial point collocation method (RPCM)

The simulation-optimisation models of groundwater and contaminant transport can be a powerful tool in the management of groundwater resources and remediation design. In this study, using Multiquadratic Radial Basis Function (MRBF) a coupled groundwater flow and reactive transport of contaminant and oxidant was developed in the framework of the Meshfree method. The parameter analysis has determined the optimum shape parameter (0.97), and the results of the model were compared with a physical sandbox model which were in good agreement. The genetic algorithm approach was used to find the optimum design of the remediation using permanganate as an oxidant. To find the optimum design we considered two objectives and two constraints. The results revealed that the breakthrough of contaminant to the downstream area of interest and the concentration of the contaminant in this area is reduced significantly with optimisation.

Meeting report from the joint IARC-NCI international cancer seminar series: a focus on colorectal cancer

Despite significant progress in our understanding of the etiology, biology and genetics of colorectal cancer, as well as important clinical advances, it remains the third most frequently diagnosed cancer worldwide and is the second leading cause of cancer death. Based on demographic projections, the global burden of colorectal cancer would be expected to rise by 72% from 1.8 million new cases in 2018 to over 3 million in 2040 with substantial increases anticipated in low- and middle-income countries. In this meeting report, we summarize the content of a joint workshop led by the National Cancer Institute and the International Agency for Research on Cancer, which was held to summarize the important achievements that have been made in our understanding of colorectal cancer etiology, genetics, early detection and treatment and to identify key research questions that remain to be addressed.

TM1-4 Verbal fluency test in patients with a newly diagnosed brain tumour

Objectives

Utility of a simple 1 min cognitive screening tool, verbal fluency test, as a potential risk assessment tool for GPs for a suspected brain tumour.

Design

Case-control study; patients with new diagnosis of brain tumour with a history of headache and patients referred for direct-access-CT for headache without a brain tumour.

Subjects

102 brain tumour patients: 34.3% HGG, meningioma 21.6%, cerebrals metastases 17.6%, LGG 11.8%, others (pituitary, schwannoma, haemangioblastoma) 11.8%, and CNS lymphoma 2.9%.

Methods

Group differences analysed with ANCOVA with age/gender as covariates.

Results

Mean age was similar across both groups. There were more females in the control group. Tumour patients obtained significantly lower scores on fluency test measures. The largest effect size difference was observed for semantic total and phonemic total scores (Cohen’s d=−0.97 and −0.47, respectively. Brain tumour patients named on average 4.9 animals less (95% CI −6.32,–3.42) (p<0.001) than controls. On letter P task, there was a 2.2 word-mean difference (95% CI −3.6,–0.86)(p=0.001). Forty-eight (47.1%) tumour patients and 22 (23.4%) controls had subjective memory disturbance. Tumour patients performed equally on both fluency tasks regardless of memory complaints (p>0.5).

Conclusions

Semantic test is more reliable to discriminate patients with a brain tumour. In contrasts to patients without a brain tumour, subjective memory impairment is not associated with a reduced performance on verbal fluency tasks.

WP1-16 Does time to diagnosis influence surgical decision making in primary malignant brain tumours?

Objectives

To assess whether time to diagnosis influenced surgical procedure and survival in primary malignant brain tumours

Design

Retrospective cohort study of adult patients newly diagnosed with a primary intra-cerebral tumour April 2010 – March 2015 referred to neuro-oncology centre in South-East Scotland

Subjects

400 patients with primary malignant intracerebral tumours

Methods

Univariate logistic regression analysis and multivariate Cox regression survival analysis were performed

Results

Our dataset included 229 Males (57.7%), mean age 62.05 (SD14.01). Time to diagnosis did affect choice of surgical procedure. Patients undergoing biopsy had significantly longer TtD than those undergoing resection (28 vs 21 days, MWU test, p=0.035). 233 (58.3%) patients were deceased at 12 months. Having a cognitive first symptom (e.g confusion/memory changes) predicted not getting any surgical procedure (OR 2.95 [95% CI 1.8–4.8]). Where surgery was performed, first cognitive symptom was not predictive of type of surgery (biopsy vs debulking/excision) (OR 1.5 [95% CI 0.8–2.9] norhaving tumour in the frontal lobe (OR 0.9 [95% CI 0.5–1.7]. In multivariate analysis, increased hazard ratio of death at 12 month was significantly associated with a cognitive first symptom (HR 1.4 [95% CI 1.0–1.9] and KPS <70 (HR 1.69 [95% CI 1.2–2.4]).

Conclusions

Earlier diagnosis is associated with getting debulking surgery rather than biopsy, and patient’s presenting symptoms influence surgical decision making and outcome.

Vitamin B6 catabolism and lung cancer risk: results from the Lung Cancer Cohort Consortium (LC3)

BACKGROUND

Increased vitamin B6 catabolism related to inflammation, as measured by the PAr index (the ratio of 4-pyridoxic acid over the sum of pyridoxal and pyridoxal-5'-phosphate), has been positively associated with lung cancer risk in two prospective European studies. However, the extent to which this association translates to more diverse populations is not known.

MATERIALS AND METHODS

For this study, we included 5323 incident lung cancer cases and 5323 controls individually matched by age, sex, and smoking status within each of 20 prospective cohorts from the Lung Cancer Cohort Consortium. Cohort-specific odds ratios (ORs) and 95% confidence intervals (CIs) for the association between PAr and lung cancer risk were calculated using conditional logistic regression and pooled using random-effects models.

RESULTS

PAr was positively associated with lung cancer risk in a dose-response fashion. Comparing the fourth versus first quartiles of PAr resulted in an OR of 1.38 (95% CI: 1.19-1.59) for overall lung cancer risk. The association between PAr and lung cancer risk was most prominent in former smokers (OR: 1.69, 95% CI: 1.36-2.10), men (OR: 1.60, 95% CI: 1.28-2.00), and for cancers diagnosed within 3 years of blood draw (OR: 1.73, 95% CI: 1.34-2.23).

CONCLUSION

Based on pre-diagnostic data from 20 cohorts across 4 continents, this study confirms that increased vitamin B6 catabolism related to inflammation and immune activation is associated with a higher risk of developing lung cancer. Moreover, PAr may be a pre-diagnostic marker of lung cancer rather than a causal factor.

Mental Health Consumers' Motives for Seeking Advocacy Support: A Qualitative Exploration

Advocacy plays a vital role in ensuring that mental health consumers' rights are maintained. However, the primary issues for which consumers seek advocacy support remain unknown. Understanding these issues provides a sound basis from which advocacy organisations may develop a clear service delivery focus. This study addresses the literature gap through presenting a qualitative analysis of 60 records from an advocacy service. Four major themes emerged, across which two key issues were dominant: the sense of fearfulness and disempowerment. These issues accentuate the importance of advocates in enhancing the agency of mental health consumers.

Predictors of oropharyngeal cancer survival in Europe

OBJECTIVES

HPV16-positive oropharyngeal cancer (OPC) patients experience better outcomes compared to HPV16-negative patients. Currently, strategies for treatment de-escalation are based on HPV status, smoking history and disease stage. However, the appropriate cut-point for smoking and the role of other non-clinical factors in OPC survival remains uncertain.

MATERIALS AND METHODS

We examined factors associated with OPC outcome in 321 patients recruited in a large European multi-center study. Seropositivity for HPV16 E6 was used as a marker of HPV16 positive cancer. Hazard ratios (HR) and confidence intervals (CI) were estimated using Cox proportional models adjusted for potential confounders.

RESULTS

Overall 5-year survival following OPC diagnosis was 50%. HPV16-positive OPC cases were at significantly lower risk of death (aHR = 0.51, 95% CI: 0.32-0.80). A significant effect on OPC survival was apparent for female sex (aHR 0.50: 95% CI: 0.29-0.85) and being underweight at diagnosis (aHR: 2.41, 95% CI: 1.38-4.21). A 10 pack year smoking history was not associated with overall survival. Higher stage at diagnosis appeared as the only factor significantly associated with OPC recurrence (aHR: 4.88, 95% CI: 2.12-11.21).

CONCLUSION

This study confirms that HPV16 status is an independent prognostic factor for OPC survival while female sex lowers risk of death and being underweight at diagnosis increases the risk of death. Smoking was not an independent predictor of OPC survival.

No association between circulating concentrations of vitamin D and risk of lung cancer: an analysis in 20 prospective studies in the Lung Cancer Cohort Consortium (LC3)

Background

There is observational evidence suggesting that high vitamin D concentrations may protect against lung cancer. To investigate this hypothesis in detail, we measured circulating vitamin D concentrations in prediagnostic blood from 20 cohorts participating in the Lung Cancer Cohort Consortium (LC3).

Patients and methods

The study included 5313 lung cancer cases and 5313 controls. Blood samples for the cases were collected, on average, 5 years before lung cancer diagnosis. Controls were individually matched to the cases by cohort, sex, age, race/ethnicity, date of blood collection, and smoking status in five categories. Liquid chromatography coupled with tandem mass spectrometry was used to separately analyze 25-hydroxyvitamin D2 [25(OH)D2] and 25-hydroxyvitamin D3 [25(OH)D3] and their concentrations were combined to give an overall measure of 25(OH)D. We used conditional logistic regression to calculate odds ratios (ORs) and 95% confidence intervals (CIs) for 25(OH)D as both continuous and categorical variables.

Results

Overall, no apparent association between 25(OH)D and risk of lung cancer was observed (multivariable adjusted OR for a doubling in concentration: 0.98, 95% CI: 0.91, 1.06). Similarly, we found no clear evidence of interaction by cohort, sex, age, smoking status, or histology.

Conclusion

This study did not support an association between vitamin D concentrations and lung cancer risk.

Kernicterus with abnormal high-signal changes bilaterally in the globus pallidus: A case report

Kernicterus is a relatively rare consequence of hyperbilirubinemia. There is an important role for MRI imaging for this entity in the appropriate clinical context as there are distinct signal changes in the globus pallidus. A case report and image findings are presented

Patient-centered Information Systems

Patient-centered information systems augment traditional approaches to health information management with specific functions designed to support patient participation in health care decision making and treatment activities. In addition to computer-based record systems and business management applications, patient-centered information systems must include functionality that support communication between clinician and patient, and that provide information and peer support in a timely fashion to the patient. Current progress in information systems demonstrates the existence and feasibility of consumer health informatics, patient access to computerized clinical records, and technical and organizational solutions to integrating computerized patient information systems. We are now proposing a model of patient -centered system that incorporates all those components, and provides a vision of the future.

Outcomes of endovascular treatment for acute large-vessel ischaemic stroke more than 6 h after symptom onset

BACKGROUND AND OBJECTIVES

Benefit from endovascular thrombectomy (EVT) for large-vessel occlusion (LVO) acute ischaemic stroke (AIS) is well demonstrated. Furthermore, emerging evidence supports efficacy in appropriately selected patients treated beyond current recommendations of 6 h. We evaluated clinical outcomes in patients undergoing late EVT at our institution.

METHODS

Retrospective review of prospectively collected clinical database on 355 patients who underwent EVT for LVO AIS. Data collected consisted of patient demographics, radiological findings and outcome details. Outcomes, including 90-day functional status, recanalization, symptomatic intracranial haemorrhage (sICH) and 90-day mortality, for patients undergoing EVT <6 h, >6 h, and >7.3 h, were compared.

RESULTS

A total of 355 patients underwent EVT for LVO AIS at our institution during the review period, with 74 (21%) patients treated ≥6 h from symptom onset. Successful recanalization was achieved in 285 (80%) patients, with 228 (81%) achieving a mTICI ≥2b in the <6 h group, and 57 (77%) in the >6 h group (P = 0.429). Ninety-day functional independence (mRS 0-2) was achieved in 162 (46%) patients, with 130 (46%) achieving a mRS of 0-2 in the <6 h group, and 32 (43%) in the >6 h group (P = 0.643). No significant differences were found in rates of sICH or 90-day mortality. No significant differences in functional independence, recanalization rates, sICH or mortality were identified in patients treated with EVT >7.3 h compared to <7.3 h.

CONCLUSIONS

In appropriately selected patients, EVT >6 h was associated with comparable outcomes to those treated <6 h. These data support a physiological approach to patient selection.

Time for a Time Window Extension: Insights from Late Presenters in the ESCAPE Trial

BACKGROUND AND PURPOSE

The safety and efficacy of endovascular therapy for large-artery stroke in the extended time window is not yet well-established. We performed a subgroup analysis on subjects enrolled within an extended time window in the Endovascular Treatment for Small Core and Proximal Occlusion Ischemic Stroke (ESCAPE) trial.

MATERIALS AND METHODS

Fifty-nine of 315 subjects (33 in the intervention group and 26 in the control group) were randomized in the ESCAPE trial between 5.5 and 12 hours after last seen healthy (likely to have groin puncture administered 6 hours after that). Treatment effect sizes for all relevant outcomes (90-day mRS shift, mRS 0-2, mRS 0-1, and 24-hour NIHSS scores and intracerebral hemorrhage) were reported using unadjusted and adjusted analyses.

RESULTS

There was no evidence of treatment heterogeneity between subjects in the early and late windows. Treatment effect favoring intervention was seen across all clinical outcomes in the extended time window (absolute risk difference of 19.3% for mRS 0-2 at 90 days). There were more asymptomatic intracerebral hemorrhage events within the intervention arm (48.5% versus 11.5%, P = .004) but no difference in symptomatic intracerebral hemorrhage.

CONCLUSIONS

Patients with an extended time window could potentially benefit from endovascular treatment. Ongoing randomized controlled trials using imaging to identify late presenters with favorable brain physiology will help cement the paradigm of using time windows to select the population for acute imaging and imaging to select individual patients for therapy.