Laparoscopic cholecystectomy performed by a surgical care practitioner: a review of outcomes

INTRODUCTION

Surgical care practitioners (SCPs) are non-medical workers involved in various aspects of the management of surgical patients. The role includes assisting and performing surgical procedures. More than 60,000 laparoscopic cholecystectomies (LC) are performed annually in the UK. With ever-increasing pressure on waiting lists, it is important to look at fully utilising the skills of our entire workforce. We report what we believe is the first published series of LC performed by an SCP.

METHODS

A retrospective review of a prospectively collected database was performed. The primary outcome was any complication requiring intervention. Secondary outcomes were minor complications, operative time, length of stay, conversion and readmission.

RESULTS

In total, 170 patients were operated on. Indications were biliary colic in 127 (74.7%), cholecystitis in 30 (17.6%) and pancreatitis in 13 (7.6%). Mean operating time was 65min (range 35-152min). Fifty-three operations were assisted by a consultant, 110 by a specialist or associate specialist grade (SAS) doctor and 7 by a core trainee (CT2). Some 139 (81.7%) patients were discharged on the day of surgery and 24 (14.1%) stayed one night in hospital. There were no major complications. Five patients required readmission, three with pain and two with port site infections. There were no conversions or transfusions required.

CONCLUSIONS

There is a paucity of published data on surgical outcomes of procedures performed by SCPs. With a structured, supervised approach, SCPs could be trained to take on more complex procedures and further strengthen the surgical workforce. This study demonstrates that elective LC can be safely performed by an appropriately trained and supervised SCP.

The association between iron deficiency and outcomes: a secondary analysis of the intravenous iron therapy to treat iron deficiency anaemia in patients undergoing major abdominal surgery (PREVENTT) trial

In the intravenous iron therapy to treat iron deficiency anaemia in patients undergoing major abdominal surgery (PREVENTT) trial, the use of intravenous iron did not reduce the need for blood transfusion or reduce patient complications or length of hospital stay. As part of the trial protocol, serum was collected at randomisation and on the day of surgery. These samples were analysed in a central laboratory for markers of iron deficiency. We performed a secondary analysis to explore the potential interactions between pre-operative markers of iron deficiency and intervention status on the trial outcome measures. Absolute iron deficiency was defined as ferritin <30 μg.l^-1 ; functional iron deficiency as ferritin 30-100 μg.l^-1 or transferrin saturation < 20%; and the remainder as non-iron deficient. Interactions were estimated using generalised linear models that included different subgroup indicators of baseline iron status. Co-primary endpoints were blood transfusion or death and number of blood transfusions, from randomisation to 30 days postoperatively. Secondary endpoints included peri-operative change in haemoglobin, postoperative complications and length of hospital stay. Most patients had iron deficiency (369/452 [82%]) at randomisation; one-third had absolute iron deficiency (144/452 [32%]) and half had functional iron deficiency (225/452 [50%]). The change in pre-operative haemoglobin with intravenous iron compared with placebo was greatest in patients with absolute iron deficiency, mean difference 8.9 g.l^-1 , 95%CI 5.3-12.5; moderate in functional iron deficiency, mean difference 2.8 g.l^-1 , 95%CI -0.1 to 5.7; and with little change seen in those patients who were non-iron deficient. Subgroup analyses did not suggest that intravenous iron compared with placebo reduced the likelihood of death or blood transfusion at 30 days differentially across subgroups according to baseline ferritin (p = 0.33 for interaction), transferrin saturation (p = 0.13) or in combination (p = 0.45), or for the number of blood transfusions (p = 0.06, 0.29, and 0.39, respectively). There was no beneficial effect of the use of intravenous iron compared with placebo, regardless of the metrics to diagnose iron deficiency, on postoperative complications or length of hospital stay.

The impact of having a carer on adult health and social care utilisation across five settings of care: A matched cohort study

INTRODUCTION

An estimated 6.8 million people are (informal) carers in the UK. The economic value of annual carer contributions is an estimated .·132bn. Reliance on carers appears to be increasing. There is mixed evidence on whether carers are substitutes for formal care. This study investigated the association between having a carer and service use patterns across five care settings when compared to a matched cohort without a carer.

MATERIALS AND METHODS

A matched case-control group analysis using person-level data in Barking and Dagenham (B&D), a London borough in the U.K., to assess the impact of having a carer in terms of the differences in cost-weighted utilisation relative to a matched control group.

RESULTS

In 2016/17, for adult residents of B&D, having a carer (n = 1,295) was associated with 27% increased cost-weighted utilisation (mean difference of £2,662, CI £1,595, £3,729, p<0.001) compared to a matched cohort without a carer. 39% of the cost difference was social care.

CONCLUSIONS

Findings suggest additional service use induced by carers may dominate any substitution effect. Having a carer may be a key element in enabling access to services. As such, there may be wider inequalities in service access for people without a carer. For an ageing society with projections suggesting there will be more people without carers in the future, these inequalities need to be addressed.

A Longitudinal Study of Journal Club to Enhance Physical Therapy Students' Research Appraisal Skill for Evidence-Based Practice: A Mixed-Methods Study

Evidence-based practice (EBP) requires that clinicians possess skills in appraisal of evidence. Journal club (JC) is demonstrated to increase EBP skills in medicine, nursing, and occupational therapy. Study in physical therapy remains elusive. The objective of this study was to examine the impact of JC on appraisal skills in student physical therapists (SPTs) and explore factors enhancing or hindering the utility of JC. One hundred fifteen SPTs from three cohorts participated in this mixed-methods study. In the first year, participants completed a survey assessing self-reported confidence level on EBP skills before and after attending multiple JCs. Cohorts I and II continued participation in the second year. Additionally, 36 participants attended focus-group interviews after completing 2 years of JC. All cohorts' confidence level increased. Wilcoxon signed-rank test revealed a significant increase (p < 0.001) for cohort III. Remaining cohorts' confidence continuously increased in the subsequent year. Thematic analysis revealed themes on benefits and barriers of JC, strategies for improvements, and connection of JC to clinical practice. The findings indicate that integration of JC promotes SPTs' confidence in EBP skills and connects with practice. Utilizing JC as a pedagogical strategy impacts curricular design and strengthens future health professionals' EBP skills pivotal for delivering quality healthcare.

Paediatric quality-of-life following adenotonsillectomy: an evaluation of T14 paediatric throat disorder quality-of-life outcomes according to operative indication

INTRODUCTION

Adenotonsillectomy is the most common surgical intervention for obstructive sleep apnoea (OSA) or recurrent tonsillitis. The Paediatric Throat Disorder Quality of Life Outcome (T14) questionnaire is a validated tool completed by parents to compare the outcome of surgery by measuring the pre- and postoperative scores. This study was undertaken to evaluate the quality-of-life outcome in children undergoing surgical intervention for recurrent tonsillitis and/or OSA.

METHODS

This was a prospective, uncontrolled study of 117 children who underwent adenotonsillectomy and tonsillectomy at a single tertiary ear, nose and throat department. An analysis of pre- and postoperative T14 paediatric throat disorder quality-of-life outcomes was undertaken at 12 months.

RESULTS

Of the 117 children, 105 were included in the study sample; 75 with recurrent tonsillitis, 8 with OSA and 22 with both tonsillitis and OSA. All children had an improved T14 score postoperatively. The greatest change in pre- and postoperative T14 score was observed in the tonsillitis and OSA combined group (mean change -29.36, p<0.001). However, an improvement in T14 score was also noted in the tonsilitis (-24.453, p<0.001) and OSA groups (-14.25, p<0.001).

CONCLUSIONS

This study found a statistically significant improvement in the T14 quality-of-life score at 12 months postoperatively in children undergoing adenotonsillectomy. This demonstrates improved parental perception of their child's symptoms for all operative indications of adenotonsillectomy.

The role of collisional ionization in heavy ion acceleration by high intensity laser pulses

We present here simulation results of the laser-driven acceleration of gold ions using the EPOCH code. Recently, an experiment reported the acceleration of gold ions up to 7 MeV/nucleon with a strong dependency of the charge-state distribution on target thickness and the detection of the highest charge states [Formula: see text]. Our simulations using a developmental branch of EPOCH (4.18-Ionization) show that collisional ionization is the most important cause of charge states beyond Z = 51 up to He-like Au.

A comparison of the kinematics and kinetics of barefoot and shod running in children with cerebral palsy

BACKGROUND

The biomechanics of barefoot and shod running are different for typically developing children but unknown for children with cerebral palsy (CP). Such differences may have implications for injury and performance.

AIMS

The primary aims of this study were to compare the lower limb biomechanics of barefoot and shod running in children with CP, and to determine whether any differences were the same in GMFCS levels I and II.

METHODS

This cross-sectional study examined 38 children with CP (n = 24 (GMFCS) level I; n = 14 GMFCS II), running overground at 3 speeds (jog, run, sprint) in barefoot and shod conditions. Marker trajectories and force plate data were recorded, and lower limb kinematics, kinetics and spatiotemporal variables were derived. Differences between barefoot and shod running were analysed using linear mixed models.

RESULTS

For both GMFCS levels, barefoot running resulted in higher loading rates, but smaller impact peaks at all speeds. Barefoot running was associated with greater hip and knee power; less ankle dorsiflexion and hip flexion at initial contact, and less ankle and knee range of motion during stance, compared to shod running, at all speeds. Barefoot stride length was shortened, and cadence increased compared to shod during jogging and running but not sprinting. For GMFCS level I only, barefoot running involved a higher incidence of forefoot strike, greater ankle power generation and less hip range of motion during stance.

SIGNIFICANCE

Running barefoot may facilitate running performance by increasing power generation at the ankle in children with CP, GMFCS level I. Higher barefoot loading rates may have implications for performance and injury.

Associations with sub-optimal clinic attendance and reasons for missed appointments among heterosexual women and men living with HIV in London

Poor engagement in HIV care is associated with poorer health outcomes and increased mortality. Our survey examined experiential and circumstantial factors associated with clinic attendance among women (n = 250) and men (n = 106) in London with heterosexually-acquired HIV. While no associations were found for women, among men, sub-optimal attendance was associated with insecure immigration status (25.6% vs. 1.8%), unstable housing (32.6% vs. 10.2%) and reported effect of HIV on daily activities (58.7% vs. 40.0%). Among women and men on ART, it was associated with missing doses of ART (OR = 2.96, 95% CI:1.74-5.02), less belief in the necessity of ART (OR = 0.56, 95% CI:0.35-0.90) and more concern about ART (OR = 3.63, 95% CI:1.45-9.09). Not wanting to think about being HIV positive was the top reason for ever missing clinic appointments. It is important to tackle stigma and the underlying social determinants of health to improve HIV prevention, and the health and well-being of people living with HIV.

Feasibility and acceptability of a whole-school social-marketing intervention to prevent unintended teenage pregnancies and promote sexual health: evidence for progression from a pilot to a phase III randomised trial in English secondary schools

Background

Reducing unintended teenage pregnancy and promoting adolescent sexual health remains a priority in England. Both whole-school and social-marketing interventions are promising approaches to addressing these aims. However, such interventions have not been rigorously trialled in the UK and it is unclear if they are appropriate for delivery in English secondary schools. We developed and pilot trialled Positive Choices, a new whole-school social marketing intervention to address unintended teenage pregnancy and promote sexual health. Our aim was to assess the feasibility and acceptability of the intervention and trial methods in English secondary schools against pre-defined progression criteria (relating to randomisation, survey follow-up, intervention fidelity and acceptability and linkage to birth/abortion records) prior to carrying out a phase III trial of effectiveness and cost-effectiveness.

Methods

Pilot RCT with integral process evaluation involving four intervention and two control schools in south-east England. The intervention comprised a student needs survey; a student/staff-led school health promotion council; a classroom curriculum for year-9 students (aged 13–14); whole-school student-led social-marketing activities; parent information; and a review of local and school-based sexual health services. Baseline surveys were conducted with year 8 (aged 12–13) in June 2018. Follow-up surveys were completed 12 months later. Process evaluation data included audio recording of staff training, surveys of trained staff, staff log books and researcher observations of intervention activities. Survey data from female students were linked to records of births and abortions to assess the feasibility of these constituting a phase III primary outcome.

Results

All six schools were successfully randomised and retained in the trial. Response rates to the survey were above 80% in both arms at both baseline and follow-up. With the exception of the parent materials, the fidelity target for implementation of essential elements in three out of four schools was achieved. Student surveys indicated 80% acceptability among those who reported awareness of the programme and interviews with staff suggested strong acceptability. Linkage to birth/abortion records was feasible although none occurred among participants.

Conclusions

The criteria for progression to a phase III trial were met. Our data suggest that a whole-school social-marketing approach may be appropriate for topics that are clearly prioritised by schools. A phase III trial of this intervention is now warranted to establish effectiveness and cost-effectiveness. Births and terminations are not an appropriate primary outcome measure for such a trial.

Trial registration

ISRCTN65324176.

Effectiveness of PD-(L)1 Inhibitors Alone or in Combination With Platinum-Doublet Chemotherapy in First-Line (1L) Non-Squamous Non-Small Cell Lung Cancer (nsq-NSCLC) With PD-L1-High Expression Using Real-World Data

BACKGROUND

Anti-PD-(L)1 therapy alone (cancer immunotherapy [CIT]-mono) or combined with platinum-based chemotherapy (CIT-chemo) is used as first-line treatment for patients with metastatic non-small cell lung cancer (NSCLC). Our study compared clinical outcomes with CIT-mono vs CIT-chemo in the specific clinical scenario of non-squamous (Nsq)-NSCLC with a high PD-L1 expression of ≥50% (tumor proportion score (TPS) or tumor cells (TC)).

METHODS

This was a retrospective cohort study using a real-world de-identified database. Patients with metastatic Nsq-NSCLC with high PD-L1 expression initiating first-line CIT-mono or CIT-chemo between 24 October 2016 and 28 February 2019 were followed up to 28 February 2020. We compared overall survival (OS) and real-world progression-free survival (rwPFS) using Kaplan-Meier methodology. Hazard ratios (HR) were adjusted (aHR) for differences in baseline key prognostic characteristics using inverse probability of treatment weighting methodology.

RESULTS

Patients with PD-L1-high Nsq-NSCLC treated with CIT-mono (n=351), were older and less often presented with de novo stage IV disease than patients treated with CIT-chemo (n=169). With a median follow-up of 19.9 months for CIT-chemo vs 23.5 months for CIT-mono, median OS and rwPFS did not differ between the two groups (median OS: CIT-chemo, 21.0 months vs CIT-mono, 22.1 months, aHR=1.03, 95% CI 0.77-1.39, P=0.83; median rwPFS: CIT-chemo, 10.8 months vs CIT-mono, 11.5 months, aHR=1.04, 95% CI 0.78-1.37, P=0.81). CIT-chemo showed significant and meaningful improvement in OS and rwPFS vs CIT-mono only in the never-smoker subgroup, albeit among a small sample of patients (n=50; OS HR=0.25, 95% CI 0.07-0.83, interaction P=0.02; rwPFS HR=0.40, 95% CI 0.17-0.95, interaction P=0.04).

CONCLUSION

Except in the subgroup of never-smoker patients, sparing the chemotherapy in first-line CIT treatment does not appear to impact survival outcomes in Nsq-NSCLC patients with high PD-L1 expression.

A highly virulent variant of HIV-1 circulating in the Netherlands

We discovered a highly virulent variant of subtype-B HIV-1 in the Netherlands. One hundred nine individuals with this variant had a 0.54 to 0.74 log₁₀ increase (i.e., a ~3.5-fold to 5.5-fold increase) in viral load compared with, and exhibited CD4 cell decline twice as fast as, 6604 individuals with other subtype-B strains. Without treatment, advanced HIV-CD4 cell counts below 350 cells per cubic millimeter, with long-term clinical consequences-is expected to be reached, on average, 9 months after diagnosis for individuals in their thirties with this variant. Age, sex, suspected mode of transmission, and place of birth for the aforementioned 109 individuals were typical for HIV-positive people in the Netherlands, which suggests that the increased virulence is attributable to the viral strain. Genetic sequence analysis suggests that this variant arose in the 1990s from de novo mutation, not recombination, with increased transmissibility and an unfamiliar molecular mechanism of virulence.

1456 Back-To-Back Surgeries: A Clinic Case Report Regarding Multiple Complex Spinal Surgeries for Treatment of Multiple Osteochondroma With Histological Conversion to Chondrosarcoma

Background

Multiple Hereditary Osteochondromas [MHO], previously known as multiple hereditary exostoses, is a rare disorder of bone growth, whereby osseous transformation of the cartilage caps within the diaphyses of long bones or flat bones within the skeleton occurs. A significant complication of MHO is the conversion of any present osteochondroma into a malignant chondrosarcoma. Chondrosarcomas are mesenchymal, non-meningothelial tumours and most commonly present with insidious pain, associated neurological deficit by means of impingement of underlying nerves.

Case presentation

We present a clinical case of a 29-year-old female medical student with a background history of multiple hereditary osteochondromas. A previously competitive cross-fitter, she developed the conversion of MHO into a malignant chondrosarcoma. Presenting to outpatient clinic in late 2017, this lady had a 2-year history of lower back pain and an associated palpable lump. An MRI of the thoracolumbar spine demonstrated a large mass arising from the posterior elements of T11 to L2. A biopsy at the time was found to be of benign pathology, most likely in keeping with this patient’s diagnosis of MHO. The patient returned for review in early 2018, where a repeat MRI showed extension of the previously described lesion into the spinal canal at the level of L1 vertebra. This was concerning that this previously identified osteochondroma lesion could be undergoing malignant transformation. The patient went on to have a series of complex spinal surgeries which we will discuss below.

The effect of a low-load plyometric running intervention on leg stiffness in youth with cerebral palsy: A randomised controlled trial

AIM

To determine whether a running intervention utilising plyometric activities improved leg stiffness in youth with cerebral palsy (CP), GMFCS levels I and II.

METHOD

This stratified randomised controlled trial examined the lower limb kinetics and kinematics of a sample of youths with CP during sub-maximal hopping and running, prior to and immediately following a 12-week running intervention that incorporated low load plyometric training. Included participants were 13 in the control group (mean age 13 years 2 months [SD 2 years 7 months]; six males; nine GMFCS level I; six unilateral) and 18 in the intervention group (mean age 12 years 9 months [SD 2 years 10 months]; 13 males; 11 GMFCS level I; nine unilateral). Derived variables included three-dimensional leg stiffness as well as resultant ground reaction force and change in leg length. Generalised linear mixed models were developed for statistical analysis.

RESULTS

At follow-up the intervention group had greater leg stiffness than the control group during submaximal hopping (Intervention median = 3278Nm^-1; Control median = 1556Nm^-1; p < 0.01). At follow-up, participants in the intervention group in GMFCS Level I had greater leg stiffness than the control group during jogging (Intervention mean=38.84 (SD=25.55); Control mean=29.38 (SD=11.11); t = 2.61 p = 0.01).

INTERPRETATION

A running training intervention which includes plyometric activities can improve leg stiffness in young people with CP, especially those in GMFCS level I.

The association between use of chemsex drugs and HIV clinic attendance among gay and bisexual men living with HIV in London

OBJECTIVES

To investigate the association between chemsex drug use and HIV clinic attendance among gay and bisexual men in London.

METHODS

A cross-sectional survey of adults (> 18 years) diagnosed with HIV for > 4 months, attending seven London HIV clinics (May 2014 to August 2015). Participants self-completed an anonymous questionnaire linked to clinical data. Sub-optimal clinic attenders had missed one or more HIV clinic appointments in the past year, or had a history of non-attendance for > 1 year.

RESULTS

Over half (56%) of the 570 men who identified as gay or bisexual reported taking recreational drugs in the past 5 years and 71.5% of these men had used chemsex drugs in the past year. Among men reporting chemsex drug use (past year), 32.1% had injected any drugs in the past year. Sub-optimal clinic attenders were more likely than regular attenders to report chemsex drug use (past year; 46.9% vs. 33.2%, P = 0.001), injecting any drugs (past year; 17.1% vs. 8.9%, P = 0.011) and recreational drug use (past 5 years; 65.5% vs. 48.8%, P < 0.001). One in five sub-optimal attenders had missed an HIV clinic appointment because of taking recreational drugs (17.4% vs. 1.8%, P < 0.001). In multivariable logistic regression, chemsex drug use was significantly associated with sub-optimal clinic attendance (adjusted odds ratio = 1.71, 95% confidence interval: 1.10-2.65, P = 0.02).

CONCLUSIONS

Our findings highlight the importance of systematic assessment of drug use and development of tools to aid routine assessment. We suggest that chemsex drug use should be addressed when developing interventions to improve engagement in HIV care among gay and bisexual men.

557 A Novel Peer-Led Anatomage-Based Teaching Programme for Medical Students

Introduction

Anatomical knowledge is an essential part of surgical practice. However, its delivery lacks a standardised approach across medical school curricula. A student-led anatomy programme was implemented at a single institution, using near-peer teaching and Anatomage virtual dissection. This study aims to describe the methodology of this programme and determine the benefit of a near-peer taught anatomy course.

Method

The programme was organised by senior medical students, utilising Anatomage virtual dissection and techniques in line with Bigg’s constructive alignment. Attendees were asked to complete questionnaires with Likert scales (0-10) and open answer text to determine learners’ benefit. Both quantitative and qualitative analyses are presented.

Results

73 students attended eight sessions from January to March 2020. Students reported a statistically significant (p &lt; 0.01) increase in confidence after the sessions of 3.74±1.83. The quality and relevance of the teaching also scored highly (9.32±0.89 and 9.47±0.86 respectively). Qualitatively, students praised the "informal learning environment”, the structure of the sessions, the handout provided, and the interactivity of anatomage technology.

Conclusions

This study demonstrates how virtual dissection technology and near-peer teaching can derive significant benefit to undergraduate students, in line with previously published data.

Fast Organic Vapor Phase Deposition of Thin Films in Light-Emitting Diodes

Fast deposition of thin films is essential for achieving low-cost, high-throughput phosphorescent organic light-emitting diode (PHOLED) production. In this work, we demonstrate rapid and uniform growth of semiconductor thin films by organic vapor phase deposition (OVPD). A green PHOLED comprising an emission layer (EML) grown at 50 Å/s with bis[2-(2-pyridinyl-N)phenyl-C](acetylacetonato)iridium(III) (Ir(ppy)₂(acac)) doped into 4,4'-bis(N-carbazolyl)-1,1'-biphenyl (CBP) exhibits a maximum external quantum efficiency of 20 ± 1%. The morphology, charge transport properties, and radiative efficiency under optical and electrical excitation of the PHOLED EML are investigated as functions of the deposition rate via both experimental and theoretical approaches. The EML shows no evidence for gas phase nucleation of the organic molecules at deposition rates as high as 50 Å/s. However, the roll-off in quantum efficiency at high current progressively increases with deposition rate due to enhanced triplet-polaron annihilation. The roll-off results from accumulation of stress within the PHOLED EML that generates a high density of defect states. The defects, in turn, act as recombination sites for triplets and hole polarons, leading to enhanced triplet-polaron annihilation at high current. We introduce a void nucleation model to describe the film morphology evolution that is observed using electron microscopy.

Auto-Decompression - Preserved Neurological Function in Bilateral Cervical Facet Dislocations

Introduction Bilateral cervical facet dislocation (BCFD) is an uncommon injury with a high incidence of severe neurological impairment. We describe 4 cases of BCFD with preserved neurological function. Cases Case 1: A 78-year-old female who suffered two ground level falls (GLFs). Pre-operative American Spinal Injury Association (ASIA) Score was C5D. Imaging revealed a BCFD at C6/C7 and a C6 laminar fracture. Case 2: A 63-year-old male suffered a fall down 14 steps. Pre-operative ASIA score was E. Imaging demonstrated a BCFD at C7/T1, and a C6 laminar fracture. Case 3: A 46-year-old male collided with a tree while descending a hill on a bicycle. Pre-operative ASIA score was C6D. Imaging revealed a BCFD at C7/T1 and a C7 laminar fracture. Case 4: A 67-year-old male suffered a GLF while exiting a stationary car. Pre-operative ASIA score on admission was E. Imaging revealed a BCFD at C6/C7 with bilateral laminar fractures at C5 and C6. Outcome All cases underwent 2-stage surgical fixation. All cases maintained or had an improved ASIA score post-operatively. Conclusion In all cases, the presence of concurrent laminar fractures resulted in an auto-decompression of the spinal canal, preserving neurological function.

The effect of a running training intervention on ankle power generation in children and adolescents with cerebral palsy: A randomized controlled trial

BACKGROUND

Children and adolescents with cerebral palsy who are classified as Gross Motor Function Classification Scale level I or II are usually able to run but lack ankle power generation for push-off. The aim of this study was to analyze the efficacy of a running training program in improving ankle power generation in children and adolescents with cerebral palsy.

METHODS

This randomized controlled trial compared kinematic and spatiotemporal data collected during running from 38 children and adolescents with unilateral or bilateral cerebral palsy before and after a 12-week running program. Normalized speed, stride length, cadence, foot strike pattern, peak ankle power generation, peak hip flexor power generation in swing and propulsion strategy were calculated. Linear mixed models were developed to analyze differences between groups.

FINDINGS

At follow-up the intervention group had increased normalized speed of running (t = -3.68 p < .01) while the control group got slower (t = 3.17 p < .01). In running, children in Gross Motor Function Classification Scale level II in the intervention group increased ankle power (t = 2.49 p = .01) while the control group did not change (t = 0.38 p = .71). In sprinting, children in Gross Motor Function Classification Scale levels I and II in the intervention group maintained ankle power (level I t = 0.32 p = .75; level II t = 1.56 p = .12) while those in the control group decreased ankle power (level I t = 4.69 p < .01; level II t = 2.52 p = .01). Most within-group differences did not result in significant between-group differences at follow-up.

INTERPRETATION

Power generation for running may be responsive to targeted intervention in children with cerebral palsy.

P1409Effectiveness of atrial fibrillation ablation using a contact force stability module with contact force or non-contact force catheter

Funding Acknowledgements

This study was funded by Biosense Webster, Inc.

Background

Catheter ablation is a mainstream treatment option for atrial fibrillation (AF). Recently, contact force (CF) enabled ablation catheters and a stability module were developed to allow for real-time CF sensing and improvement of catheter-tissue stability, which is important for achieving an optimal clinical outcome.  We assessed the relative effectiveness of these new technologies, as well as the optimal CF stability parameters, in a real-world setting.

Purpose

To compare the clinical effectiveness of AF ablations performed with a CF catheter using location stability settings of 2.5 mm maximum distance for 12 s minimum (2.5/12) vs. a non-CF catheter with settings of 3 mm for 7 s (3/7).

Methods

Within 1/14–4/18, 176 de novo AF ablations using either a CF catheter with stability settings of 2.5/12 (n = 92, 5/16–4/18) or a non-CF catheter with stability settings of 3/7 (n = 84, 1/14–3/14) were performed by a single operator at a Canadian medical center. Patients routinely wore 48 hour Holter monitors every three months through the first year. The primary measures of effectiveness were Kaplan-Meier (KM) survival estimates of freedom from AF/atrial tachycardia (AT)/atrial flutter (AFL) recurrence after a 3-month blanking period and reablation.

Results

The CF group was 62.9 ± 10.0 years old, 57.6% male, and 66.3% paroxysmal (PAF). The non-CF group was 61.6 ± 9.9 years old, 63.1% male, and 76.2% PAF. Procedural complications consisted of a single vascular access complication in the non-CF group. The 12-month estimate of freedom from AF/AT/AFL recurrence was 79.4% in the CF group vs. 64.8% in the non-CF group (p = 0.058 for difference in survival over time). 12-month freedom from reablation was 90.4% in the CF group vs. 70.5% in the non-CF group (p = 0.002).

Conclusion

CF ablation with more stringent stability settings of 2.5/12 was more effective than non-CF ablation with stability settings of 3/7, likely attributable to the CF catheter enabling visualization of catheter-tissue contact and the stability module facilitating maintenance of CF stability during ablation.

Abstract Figure.

0751 Epworth Sleepiness Scale Test-Retest Reliability Analysis In Solriamfetol Studies

Introduction

The Epworth Sleepiness Scale (ESS) measures excessive daytime sleepiness. This analysis examined test-retest reliability of ESS scores in participants with narcolepsy or obstructive sleep apnea (OSA) in solriamfetol studies.

Methods

Intraclass correlation coefficient (ICC) estimates and 95% confidence intervals (CIs) for ESS scores from two 12-week, placebo-controlled trials (1 narcolepsy; 1 OSA), and one long-term open-label extension (OLE) trial (narcolepsy or OSA) were calculated separately for each trial, based on assessments (at time-point pairs) when scores were expected to be stable (at weeks 4 and 8, 8 and 12, and 4 and 12 in the 12-week trials, and weeks 14 and 26/27, 26/27 and 39/40, and 14 and 39/40 in the OLE). ICCs were analyzed for the overall population in each trial and by treatment and adherence to primary OSA therapy. An ICC &gt;0.7 has been recommended as a quality criterion for acceptable test-retest reliability.

Results

In the 12-week narcolepsy trial, ICCs (95% CI) were 0.83 (0.79, 0.87) for weeks 4 and 8 (n=199), 0.87 (0.83, 0.90) for weeks 8 and 12 (n=196), and 0.81 (0.76, 0.85) for weeks 4 and 12 (n=196). In the 12-week OSA trial, ICCs (95% CI) were 0.74 (0.69, 0.78) for weeks 4 and 8 (n=416), 0.80 (0.76, 0.83) for weeks 8 and 12 (n=405), and 0.74 (0.69, 0.78) for weeks 4 and 12 (n=405). In the OLE trial, ICCs (95% CI) were 0.82 (0.79, 0.85) for weeks 14 and 27/26 (n=495), 0.85 (0.82, 0.87) for weeks 27/26 and 40/39 (n=463), and 0.78 (0.74, 0.81) for weeks 14 and 40/39 (n=463). Treatment (solriamfetol combined/placebo) or adherence to primary OSA therapy did not impact reliability.

Conclusion

In 3 large clinical trials of participants with narcolepsy or OSA, the ESS demonstrated an acceptable level of test-retest reliability.

Support

Jazz Pharmaceuticals

Patient deprivation and perceived scan burden negatively impact the quality of whole-body MRI

AIM

To evaluate the association between the image quality of cancer staging whole-body magnetic resonance imaging (WB-MRI) and patient demographics, distress, and perceived scan burden.

MATERIALS AND METHODS

A sample of patients recruited prospectively to multicentre trials comparing WB-MRI with standard scans for staging lung and colorectal cancer were invited to complete two questionnaires. The baseline questionnaire, administered at recruitment, collated data on demographics, distress and co-morbidity. The follow-up questionnaire, completed after staging investigations, measured perceived WB-MRI scan burden (scored 1 low to 7 high). WB-MRI anatomical coverage, and technical quality was graded by a radiographic technician and grading combined to categorise the scan as "optimal", "sub-optimal" or "degraded". A radiologist categorised 30 scans to test interobserver agreement. Data were analysed using the chi-square, Fisher's exact, t-tests, and multinomial regression.

RESULTS

One hundred and fourteen patients were included in the study (53 lung, 61 colorectal; average age 65.3 years, SD=11.8; 66 men [57.9%]). Overall, 45.6% (n=52), scans were classified as "optimal" quality, 39.5% (n=45) "sub-optimal", and 14.9% (n=17) as "degraded". In adjusted analyses, greater deprivation level and higher patient-reported scan burden were both associated with a higher likelihood of having a sub-optimal versus an optimal scan (odds ratio [OR]: 4.465, 95% confidence interval [CI]: 1.454 to 13.709, p=0.009; OR: 1.987, CI: 1.153 to 3.425, p=0.013, respectively). None of the variables predicted the likelihood of having a degraded scan.

CONCLUSIONS

Deprivation and patients' perceived experience of the WB-MRI are related to image quality. Tailored protocols and individualised patient management before and during WB-MRI may improve image quality.

Systematic review of thromboprophylaxis in patients having orthognathic surgery

Orthognathic surgery is an elective procedure that is done in healthy individuals so complications such as thromboembolic events are rare. Pharmacological thromboprophylaxis, which reduces the risk of these events, may also increase blood loss and potentially the risk of life-threatening haemorrhage, so a state of clinical equipoise exists about whether it should be given routinely. We systematically reviewed published papers to identify the incidence of venous thromboembolism and haemorrhage in patients treated by orthognathic surgery who were, and were not, given pharmacological thromboprophylaxis. The pooled incidence of thromboembolic events was 0% in those who were, and 0.19% in those who were not. Return to theatre to control bleeding was required in 2.72% of the patients treated at centres where it was given, and in 0.55% at those where it was not. Small sample sizes, the heterogeneity of treatment protocols, and incomplete reporting made further statistical analysis impossible. The incidence of venous thromboembolism in patients who have orthognathic surgery is low when compared with the rest of the hospital population. Although pharmacological thromboprophylaxis may further reduce this, it can also increase blood loss, and uncertainty therefore remains over the best protocol for its routine use. The risk stratification of individual patients, and large randomised controlled trials are now required to establish the best treatment.

Leading article: What can we do to improve individual and team situational awareness to benefit patient safety?

It is increasingly being recognised that human factors can contribute to error in complex safety systems. Healthcare, however, has a long way to go before the promotion of training in, and awareness of, human factors will catch up with other high-risk organisations. A critical component that is deemed essential both for improving clinical performance and reducing medical error is situational awareness (SA). This is dynamic and can reduce quickly or be lost entirely, particularly when the workload is heavy. Tunnel vision, in which healthcare professionals concentrate on a single aspect of a patient's care, is just one example of reduced awareness that can be detrimental to safety. As in aviation and other high-risk organisations, a reduction in SA, if not recognised by individuals or the wider team, can lead to serious or potentially fatal outcomes. We therefore give an overview of SA and show how it can easily be reduced. We also suggest some simple but effective ways to improve it and in turn improve patient safety. We emphasise the importance of clinical teams looking out for each other, particularly in the operating theatre.

Antibiotic usage in chronic rhinosinusitis: analysis of national primary care electronic health records

BACKGROUND

The aim of this study was to analyse rates of antibiotic usage in chronic rhinosinusitis (CRS) in primary care in England and Wales and to identify trends in the choice of antibiotics prescribed.

METHODS

We used linked data from primary care EHRs, with diagnoses coded using the Read terminology (Clinical Practice Research Datalink) from consenting general practices, with (2) hospital care administrative records (Hospital Episode Statistics, HES recorded using ICD-10).

RESULTS

From the total of 88,317 cases of CRS identified, 40,462 (46%) had an antibiotic prescription within 5 days of their first CRS diagnosis. Of patients receiving a first line antibiotic within 5 days of CRS diagnosis, over 80%, in each CRS group, received a subsequent prescription for an antibiotic. Within 5 years of diagnosis, 9% are estimated to have had 5 or more antibiotics within 5 days of a CRS-related consultation. With data spanning almost 20 years, it was possible to discern trends in antibiotics prescriptions, with a clear increasing trend towards macrolide and tetracycline prescribing evident.

CONCLUSIONS

While antibiotics may have been prescribed for acute exacerbations, we have found high rates of repeated antibiotic prescription in some patients with CRS in primary care. There is a need for stronger evidence on the role of antibiotics in CRS management.

Safety and patient-reported outcomes of atezolizumab, carboplatin, and etoposide in extensive-stage small-cell lung cancer (IMpower133): a randomized phase I/III trial

BACKGROUND

The addition of atezolizumab to carboplatin and etoposide (CP/ET) significantly improved progression-free and overall survival for patients with extensive-stage small-cell lung cancer (ES-SCLC) in the IMpower133 study (NCT02763579). We have evaluated adverse events (AEs) and patient-reported outcomes in IMpower133 to assess the benefit-risk profile of this regimen.

PATIENTS AND METHODS

Patients received four 21-day cycles of CP/ET plus intravenous atezolizumab 1200 mg or placebo (induction phase), followed by atezolizumab or placebo (maintenance phase) until progression or loss of benefit. AEs were assessed and patient-reported outcomes were evaluated every 3 weeks during treatment using the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire - Core 30 (QLQ-C30) and QLQ-LC13.

RESULTS

Overall, 394 patients were assessable for safety in the induction phase and 318 in the maintenance phase. The frequency of AEs, grade 3-4 AEs, and serious AEs was similar between arms in both phases. Immune-related AEs were more frequent in the atezolizumab arm during both induction (28% versus 17%; leading to atezolizumab/placebo interruption 9% versus 5%, leading to withdrawal 4% versus 0%) and maintenance (26% versus 15%; leading to atezolizumab/placebo interruption, 3% versus 2%, leading to withdrawal 1% versus 1%), most commonly rash (induction 11% versus 9%, maintenance 14% versus 4%), and hypothyroidism (induction 4.0% versus 0%, maintenance 10% versus 1%). Changes in patient-reported treatment-related symptoms commonly associated with quality of life impairment were generally similar during induction and most of the maintenance phase. Patient-reported function and health-related quality of life (HRQoL) improved in both arms after initiating treatment, with more pronounced and persistent HRQoL improvements in the atezolizumab arm.

CONCLUSIONS

In patients with ES-SCLC, atezolizumab plus CP/ET has a comparable safety profile to placebo plus CP/ET, and the addition of atezolizumab did not adversely impact patient-reported HRQoL. These data demonstrate the positive benefit-risk profile of first-line atezolizumab plus CP/ET in ES-SCLC and further support this regimen as a new standard of care in this setting.

CLINICAL TRIALS NUMBER

NCT02763579.

Determination of Campesterol, Stigmasterol, and Beta-Sitosterol in Saw Palmetto Raw Materials and Dietary Supplements by Gas Chromatography: Collaborative Study

An interlaboratory study was conducted to evaluate a method for the determination of campesterol, stigmasterol, and beta-sitosterol in saw palmetto raw materials and dietary supplements at levels &gt;1.00 mg/100 g based on a 23 g sample. Test samples were saponified at high temperature with ethanolic KOH solution. The unsaponifiable fraction containing phytosterols (campesterol, stigmasterol, and beta-sitosterol) was extracted with toluene. Phytosterols were derivatized to trimethylsilyl ethers and then quantified by gas chromatography with hydrogen flame ionization detection. Twelve blind duplicates, one of which was fortified, were successfully analyzed by 10 collaborators. Recoveries were obtained for the sample that was fortified. The results were 99.8, 111, and 111% for campesterol, stigmasterol, and beta-sitosterol, respectively. For repeatability, the relative standard deviation (RSDr) ranged from 3.93 to 17.3% for campesterol, 3.56 to 22.7% for stigmasterol, and 3.70 to 43.9% for beta-sitosterol. For reproducibility, the RSDR ranged from 7.97 to 22.6%, 0 to 26.7%, and 5.27 to 43.9% for campesterol, stigmasterol, and beta-sitosterol, respectively. Overall, the Study Director approved 5 materials with acceptable HorRat values for campesterol, stigmasterol, and beta-sitosterol ranging from 1.02 to 2.16.

Could increasing income in lone-parent households reduce inequality in child mental health problems?

Key messages

Inequalities in CMHP between lone- and two-parent families in the UK are large. Levelling up income for lone-parents households could reduce differences in child mental health problems related to family structure.

Successful embolisation of pelvic fistulating vessels to the prostate arising after TURP - a rare cause of postoperative bleeding

Transurethral resection of the prostate (TURP) is considered the gold-standard operation to treat lower urinary tract symptoms due to benign prostatic enlargement in men. Postoperative bleeding is a recognised complication and managing it is a core skill required by attending urologists. We report a rare case of postoperative bleeding caused by fistulating vessels to the prostate which developed after TURP. These fistulas arose from the right internal iliac vessels and communicated with pre-existing pelvic varices affecting the right paraprostaticand seminal vesicle tissues. The fistulating vessels were successfully embolised with liquid embolic agent. Surgeons should be aware that persisting haemorrhage can occur post-TURP from the rare presence of fistulating vessels communicating with pelvic varices. Early computed tomography angiographic assessment is warranted in cases where bleeding is prolonged and refractory to standard management in view of timely referral for percutaneous embolisation.

Risk of mortality and cardiovascular events following macrolide prescription in chronic rhinosinusitis patients: a cohort study using linked primary care electronic health records

BACKGROUND

Macrolide antibiotics have demonstrated important anti-inflammatory and immunomodulatory properties in chronic rhinosinusitis (CRS) patients. However, reports of increased risks of cardiovascular events have led to safety concerns. We investigated the risk of all-cause and cardiac death, and cardiovascular outcomes, associated with macrolide use.

METHODOLOGY

Observational cohort (1997-2016) using linked data from the Clinical Practice Research Datalink, Hospital Episodes Statistics, and the Office for National Statistics. Patients aged 16-80 years with CRS prescribed a macrolide antibiotic or penicillin were included, comparing prescriptions for macrolide antibiotics to penicillin. Outcomes were all-cause mortality, cardiac death, myocardial infarction, stroke, diagnosis of peripheral vascular disease, and cardiac arrhythmia.

RESULTS

Analysis included 320,798 prescriptions received by 66,331 patients. There were 3,251 deaths, 815 due to cardiovascular causes, 925 incident myocardial infarctions, 859 strokes, 637 diagnoses of peripheral vascular disease, and 1,436 cardiac arrhythmias. A non-statistically significant trend towards increased risk of myocardial infarction during the first 30 days following macrolide prescription was observed. No statistically significant short- or long-term risks were observed for macrolide prescription. No significant risks were identified for clarithromycin in particular.

CONCLUSIONS

Although not statistically significant, our best estimates suggest an increased short-term risk of myocardial infarction in patients with CRS following macrolide prescription, supporting previous observational evidence. However, confounding by indication remains a possible explanation for this apparent increased risk. We found no evidence of longer term increased risks.