Who is in Your Waiting Room? Social Determinants of Health and Adverse Childhood Experiences in Pediatric Surgery Clinics

BACKGROUND

Social determinants of health (SDoH) influence overall health, although little is known about the SDoH for pediatric patients requiring surgical services. This study aims to describe SDoH for pediatric surgical patients attending out-patient, community, and outreach clinics, as well as demonstrate the feasibility of identifying and addressing SDoH and Adverse Childhood Experiences (ACEs) when appropriate.

METHODS

A cross-sectional study using surveys evaluating SDoH that were distributed to families attending pediatric surgical clinics over a two-year period. The pilot survey used validated questions and was later refined to a shorter version with questions on: Barriers to care, Economic factors, Adversity, Resiliency and Social capital (BEARS). Data was analyzed with descriptive and inferential statistics.

RESULTS

851 families across 13 clinics participated. One third of families reported not having a primary health care provider or being unable to turn to them for additional support. One in four families were found to have a household income less than the Canadian after-tax low-income threshold (<$40,000 CAD). Two-thirds of families answered questions about ACEs, and those with more ACEs were more likely to report a low income. Forty percent of families rarely or only sometimes had adequate social support.

CONCLUSION

This survey tool enabled discussions between families and care providers, which allowed clinicians to appropriately follow-up with families and refer them to social work for further support when indicated. Addressing concerns around SDoH within a busy surgical clinical is feasible and may positively affect long-term health outcomes and equitable resource allocation.

LEVEL OF EVIDENCE

IV.

Rupture of the sinus of Valsalva with fistulous connection with the cardiac chambers: A report of 2 cases

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Measuring the visual angle of polarization-related entoptic phenomena using structured light

The ability to perceive polarization-related entoptic phenomena arises from the dichroism of macular pigments held in Henle's fiber layer of the retina and can be inhibited by retinal diseases, such as age-related macular degeneration, which alters the structure of the macula. Structured light tools enable the direct probing of macular pigment density and retinal structure through the perception of polarization-dependent entoptic patterns. Here, we directly measure the visual angle of an entoptic pattern created through the illumination of the retina with a structured state of light and a perception task that is insensitive to corneal birefringence. The central region of the structured light stimuli was obstructed, with the size of the obstruction varying according to a psychophysical staircase. Two stimuli, one producing 11 azimuthal fringes and the other three azimuthal fringes, were presented to 24 healthy participants. The pattern with 11 azimuthal fringes produced an average visual angle threshold of 10° ± 1° and a 95% confidence interval (C.I.) of [6°, 14°]. For the pattern with three azimuthal fringes, a threshold extent of 3.6° ± 0.3° C.I. = [1.3°, 5.8°] was measured, a value similar to the published extent of Haidinger's brush (4°). The increase in apparent size and clarity of entoptic phenomena produced by the presented structured light stimuli offers the potential to detect the early signs of macular disease over perception tasks using uniform polarization stimuli.

Early Bone Mineral Density Changes and Endocrinal Dysfunction in Childhood Brain Tumor Patients: A Prospective Study

PURPOSE/OBJECTIVE(S)

Reduced bone mineral density (BMD) and hormonal dysfunction are considered as a late effect of cranial radiation (RT). Only few studies have reported the occurrence of these problems soon after the diagnosis of brain tumor or RT initiation, emphasizing that these are not necessarily the late effects of RT. Thus, we conducted the study to analyze the incidence of low BMD and hormonal dysfunction prior to or within 6 months of RT (early change) in children with brain tumors.

MATERIALS/METHODS

The study was conducted as a part of intramural funding program at a tertiary care center in India. Childhood and adolescent brain tumor patients were advised for dual energy X-ray absorptiometry scan (DXA) and hormonal evaluation prior to RT. In some patients, first DXA was done within 6 months of RT due to logistics. To see the effect of radiation, we have planned to repeat hormonal evaluation after 6 and 12 months and DXA after 12 months of RT.

RESULTS

Twenty-five patients were analyzed. Median age at diagnosis was 11 years with a male to female ratio of 5.2:1. Medulloblastoma was the commonest diagnosis (n = 12), followed by glioma (n = 8), pineal tumors (n = 3) and ependymoma (n = 2). Nineteen and six patients underwent DXA before RT and within 6 months of RT respectively. For BMD assessment, Z score was calculated at hip and lumbar spine. BMD was defined as low (Z score = -1 to-1.99), very low (Z score = -2 to -2.5) and secondary osteoporosis (Z score ≤ -2.5). Median Z score at femur neck and spine was -2 and -1.9 respectively. Overall; 6, 3 and 9 patients had normal, low and very low BMD respectively. Seven patients had secondary osteoporosis (Table 1). Two patients with secondary osteoporosis had low vitamin D levels. None of the patient had compression fracture. On statistical analysis, no correlation was found between BMD changes and age, sex and site of the tumor. Pre RT endocrinal assessment (N = 25) was done by tanner staging and serum hormonal levels (GH, T3/T4/TSH, ACTH, cortisol and prolactin). Gonadal hormonal assessment was done in children with early or delayed puberty. Three patients were found to have endocrinal abnormality before RT (precautious puberty, central hypothyroidism and low sex hormones in 1 patient each). Follow up DXA and hormonal evaluation are awaited to see the effect of RT.

CONCLUSION

The index study is one of the very few studies evaluating the early changes in BMD and hormonal dysfunction soon after brain tumor diagnosis or within 6 months of RT. We observed that a significant proportion of children had reduced BMD and hormonal dysfunction before RT, highlighting the importance of early assessment and referral to the specialist for better quality of life. Table 1: BMD and endocrinal dysfunction before or within 6 months of RT.

Sexual Function and Dosimetric Relationships to Erectile Structures among Patients Treated Definitively with Pd-103 LDR Prostate Brachytherapy

PURPOSE/OBJECTIVE(S)

Sexual potency and erectile function are important quality of life metrics for many men and is a significant consideration when planning and treating prostate cancer. There are limited long-term data correlating post-implant dosimetry with patient-reported sexual toxicity outcomes following LDR prostate brachytherapy using Pd-103, specifically as it pertains to genital substructures. Our aim was to correlate dosimetric patterns with quality-of-life outcomes to determine if dose to the pudendal arteries and neurovascular bundles is a significant consideration when planning prostate LDR brachytherapy.

MATERIALS/METHODS

We analyzed a prospectively collected IRB-approved database of men receiving LDR prostate brachytherapy between 11/2014-04/2019 at our institution. Patients received either LDR brachytherapy only, or combined with intensity-modulated radiation therapy (IMRT) to the prostate with or without pelvic lymph node coverage. Patients were given quality of life questionnaires at consultation and at subsequent follow up visits. Outcomes data related to sexual toxicity were evaluated based on the Sexual Health Inventory (SHIM) Questionnaire. The right/left pudendal arteries, and right/left neurovascular bundles (NVB) were contoured retrospectively on CT-MRI fusion sequences. Dosimetric data for each of the erectile substructures was analyzed. Statistical analyses included generalized linear mixed effects models with random intercept for patient to explore the association between dose and SHIM confidence.

RESULTS

A total of 50 patients met criteria for inclusion in the analysis. 5 patients received combined IMRT to 45 Gy with Pd-103 (90-100 Gy) and 45 patients received Pd-103 monotherapy (125 Gy). Median follow-up was 18 months for 50 patients; 40 (80%) patients had follow-up greater than 2 years, and 15 (30%) greater than 5 years. There were 344 individual questionnaires completed. 28% of records reported low or very low confidence level (Question #1 of SHIM questionnaire). Likelihood of moderate-very high confidence increased up to 2 years after beginning of treatment (p = 0.052) and then subsequently decreased between 2- and 5 years post treatment (p = 0.042). NVB doses were not associated with SHIM confidence level. D100 greater than 150 cGy to either pudendal artery was associated with worse SHIM confidence score after treatment (p = 0.003).

CONCLUSION

Sexual function is variable in the post treatment setting following definitive prostate radiation with Pd-103 LDR-brachytherapy. Avoiding pudendal artery dose may improve sexual outcomes and should be considered when planning prostate brachytherapy. Further investigation with a larger prospective, cohort may be warranted.

Competency-based medical education and the McNamara fallacy: Assessing the important or making the assessed important?

The McNamara fallacy refers to the tendency to focus on numbers, metrics, and quantifiable data while disregarding the meaningful qualitative aspects. The existence of such a fallacy in medical education is reviewed in this paper. Competency-based medical education (CBME) has been introduced in India with the goal of having Indian Medical Graduates competent in five different roles - Clinician, Communicator, Leader and member of the health care team, Professional, and Lifelong learner. If we only focus on numbers and structure to assess the competencies pertaining to these roles, we would be falling prey to the McNamara fallacy. To assess these roles in the real sense, we need to embrace the qualitative assessment methods and appreciate their value in competency-based education. This can be done by using various workplace-based assessments, choosing tools based on educational impact rather than psychometric properties, using narratives and descriptive evaluation, giving grades instead of marks, and improving the quality of the questions asked in various exams. There are challenges in adopting qualitative assessment starting with being able to move past the objective-subjective debate, to developing expertise in conducting and documenting such assessment, and adding the rigor of qualitative research methods to enhance its credibility. The perspective on assessment thus needs a paradigm shift - we need to assess the important rather than just making the assessed important; and this would be crucial for the success of the CBME curriculum.

Unravelling a novel, promising and convenient tool for differential diagnosis of delayed puberty: GnRHa-stimulated inhibin B (GnRH-iB)

BACKGROUND

Etiological diagnosis of delayed puberty is difficult. Despite availability of various basal and stimulation tests differentiation between constitutional delay in puberty and hypogonadotropic hypogonadism is still challenging.

OBJECTIVE

To elucidate the role of GnRH agonist-stimulated inhibin B (GnRH-iB) for the differential diagnosis of delayed puberty.

STUDY DESIGN

Participants were recruited into "exploratory cohort" (n = 39) and "validation cohort" (n = 16). "Exploratory cohort" included children with spontaneous puberty and patients with hypogonadotropic hypogonadism. "Validation cohort" constituted children who presented with delayed puberty.

INTERVENTION AND OUTCOME

GnRHa (Triptorelin) stimulation test along with measurement of inhibin B level at 24 h after GnRHa injection was performed in all the study participants. Cut-offs for GnRH-iB were derived from the "exploratory cohort". These cut-offs were applied to the "validation cohort". Basal LH, basal inhibin B(INH-B), GnRHa-stimulated LH at 4 h (GnRH-LH) and GnRH-iB were evaluated for the prediction of onset of puberty on prospective follow-up.

RESULTS

GnRH-iB at a cut-off value of 113.5 pg/ml in boys and 72.6 pg/ml in girls had 100% sensitivity and specificity for the documentation of puberty. In the "validation cohort" basal LH, basal INH-B, GnRH-LH, and GnRH-iB had a diagnostic accuracy of 68.75%, 81.25%, 68.75% and 93.75% respectively, for the prediction of onset of puberty. Basal LH, basal INH-B and GnRH-LH used alone or in combination were inferior to GnRH-iB used alone.

CONCLUSION

GnRHa-stimulated inhibin B (GnRH-iB) is a convenient and easily employable test for the differentiation of constitutional delay in puberty from hypogonadotropic hypogonadism.

CTRI REGISTRATION NO

CTRI/2019/10/021570.

96 Impact and Feasibility of a Pediatric Social Determinants of Health Questionnaire: A Pilot Mixed-Methods Study

Background

Social determinants of health (SDoH)—which are factors such as socioeconomic status (SES), access to transportation, food and housing security, disability and social supports—have been shown to influence up to 50% of health in patients. The project team developed a SDoH Questionnaire which evolved into what is now referred to as BEARS (Barriers to Care, Economic Factors, Adversity, Resiliency, Social Capital). Part of the BEARS Questionnaire includes an optional section for inquiring about Adverse Childhood Experiences (ACEs).

Objectives

The primary purpose of this study was to evaluate the impact and feasibility of the BEARS Questionnaire. Additional objectives were to assess the utility and functionality of the BEARS Questionnaire as a social history-taking tool, including the cumulative ACEs questions, and obtain suggestions for improvement of the tool.

Design/Methods

This was a mixed methods pilot study that consisted of quantitative surveys and qualitative structured interviews with clinicians who had experience using the BEARS Questionnaire. Descriptive statistics were performed on all survey results. Thematic analysis was performed on clinician interviews with recurrent themes being identified through iterative analysis and tagged quotations.

Results

15 clinicians completed the quantitative survey and five took part in a qualitative interview. Study participants included surgeons, pediatricians, speech language pathologists, social workers and nurse clinicians. The BEARS Questionnaire changed clinician practice by increasing the frequency and breadth of social screening in their patients and optimizing care to fit their patients’ social context. Participants described the BEARS as an effective screening tool for SDoH and ACEs that was feasible to implement into their clinic workflow.

Three themes emerged from our interviews: (1) Thorough social history taking highlights family resiliency and improves clinician-patient rapport, (2) Screening for ACEs is acceptable and feasible in a safe clinical environment, and (3) Social screening is feasible in a busy clinical environment and there is room for improvement.

Conclusion

This study highlights the importance of social screening in pediatric patients and their families, and how using a social screening tool allows providers to tailor care for a patients’ social context. The BEARS Questionnaire is feasible to implement within the context of a busy clinic. Finally, despite being a sensitive topic, an ACEs questionnaire can be incorporated when done in a trauma-informed way, and in the context of a longitudinal therapeutic relationship.

Manganese enhanced magnetic resonance imaging in type 1 and type 2 diabetes mellitus

Background

The pathophysiology of diabetic cardiomyopathy has yet to be established although pre-clinical studies suggest a role for altered myocardial calcium handling. Manganese-enhanced magnetic resonance imaging (MEMRI) is a novel non-invasive method of assessing in vivo myocardial calcium handling.

Purpose

To investigate whether myocardial calcium handling is impaired in patients with either type 1 or type 2 diabetes mellitus in the absence of underlying heart disease.

Methods

In a prospective case-control study, patients with type 1 (n=19) or type 2 (n=10) diabetes mellitus and healthy volunteers (n=15) underwent MEMRI. Participants with prior coronary artery disease, cardiomyopathy or an abnormal electrocardiogram were excluded. Manganese dipyridoxyl diphosphate (0.1 mL/kg) was administered over 10 min and myocardial T1 mapping was performed prior to and every 2.5 min for 30 min after contrast infusion (Figure 1). Quantitative manganese uptake analysis was performed by measuring T1 relaxation times in a region of interest within the interventricular septum and compared to the left ventricular blood pool. The rate of myocardial manganese uptake was determined by Patlak modelling [1].

Results

Participants with type 1 and type 2 diabetes mellitus were older (50±13 and 55±15.3 years) than the healthy volunteers (32±10 years). All participants had preserved left ventricular ejection fraction (type 1 diabetes mellitus, 67.7±6.1%; type 2 diabetes mellitus, 66.8±3.2%; healthy volunteers, 65±3.5%). Mean myocardial manganese uptake was reduced in participants with both type 1 (6.4±0.6 mL/100 g of tissue/min) and type 2 (6.4±0.5 mL/100 g of tissue/min) diabetes mellitus compared with healthy volunteers (8.3±0.5 mL/100 g of tissue/min; p&lt;0.0001 for both, Figure 2). There were no differences in myocardial manganese uptake between those with type 1 or type 2 diabetes mellitus (p=0.22). There was no statistically significant correlation between myocardial manganese uptake and age in the study population (r=−0.28, p=0.07).

Conclusion

Using MEMRI, we have demonstrated that myocardial calcium handling is impaired in patients with either type 1 or type 2 diabetes mellitus even in the absence of left ventricular systolic dysfunction. This suggests altered myocardial calcium handling may underlie, or contribute to, diabetic cardiomyopathy which has implications developing novel therapeutic targets for the prevention and treatment of diabetic cardiomyopathy.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): British Heart Foundation - Clinical Research Training Fellowship (FS/CRTF/20/24087)AstraZeneca - Investigator initiated award (ESR-19-20118)

Manganese-enhanced magnetic resonance imaging in Takotsubo syndrome

Background

Takotsubo syndrome is an increasingly common acute cardiac emergency characterised by profound transient left ventricular systolic dysfunction following a stressful event. Its pathophysiology remains poorly understood and a third of patients will have a major adverse cardiac or cerebrovascular event by 5 years [1]. Defective myocardial calcium homeostasis is central to contractile dysfunction and may be implicated in its pathophysiology. Manganese-enhanced magnetic resonance imaging is a novel non-invasive imaging technique that assesses myocardial manganese uptake as a measure of myocardial calcium handling [2]. Our aim was to investigate myocardial calcium handling using manganese-enhanced magnetic resonance imaging during the acute and recovery phase of takotsubo syndrome.

Methods

This single centre case-controlled observational longitudinal cohort study was conducted in accordance with the Declaration of Helsinki and ethical committee approval with written informed consent. Twenty patients with takotsubo syndrome and 20 age, sex and cardiovascular risk factor matched volunteers were recruited between March 2020 and September 2021. Patients underwent gadolinium and manganese-enhanced magnetic resonance imaging during the index event with repeat manganese-enhanced magnetic resonance imaging after 3 months. Myocardial manganese uptake was characterised by Patlak modelling.

Results

During the acute presentation, most patients had an “apical” pattern of takotsubo syndrome with reduced left ventricular ejection fraction (51±11 versus 67±8%, P&lt;0.001, Figure 1), elevated left ventricular mass (89±11 versus 57±14 g/m2, P&lt;0.01) and native T1 (1358±49 versus 1211±28 ms, P&lt;0.001) and T2 (60±7 versus 38±3 ms, P&lt;0.001) values compared to matched volunteers. Patlak modelling demonstrated reduced myocardial manganese uptake (5.1±0.5 versus 8.0±1.0 mL/100g of tissue/min, P&lt;0.0001) consistent with a major abnormality of myocardial calcium handling. Reduced myocardial manganese uptake attributable to apical takotsubo syndrome could be seen in one patient, scanned 18 days after symptom onset despite apparent resolution of cardiac function. Beyond 3 months of convalescence, left ventricular mass, ejection fraction, native T1 and T2 values were comparable to matched volunteers. Despite this, myocardial calcium handling remained abnormal compared to matched volunteers (6.7±0.7 versus 8.0±1.0 mL/100 g of tissue/min, P&lt;0.001, Figure 2).

Conclusions

In patients with takotsubo syndrome, there is a profound perturbation of myocardial calcium handling which is most marked acutely but persists after apparent recovery of left ventricular ejection fraction and resolution of myocardial oedema. Abnormal myocardial calcium handling is implicated in the pathophysiology of takotsubo syndrome and manganese-enhanced magnetic resonance imaging could play a major role in the diagnosis and risk stratification of patients with takotsubo syndrome.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Medical Research CouncilBritish Heart Foundation

Impaired myocardial calcium handling in people with type 2 diabetes: an in vivo manganese-enhanced magnetic resonance imaging study

Background

There is a high prevalence of subclinical cardiac dysfunction in people with type 2 diabetes (T2D) which is associated with subsequent development of heart failure. Dysregulated myocardial calcium handling has been demonstrated in animal models of T2D and may be a key mechanism driving the development of heart failure. Manganese-enhanced cardiac magnetic resonance imaging (MEMRI) provides a unique method to assess in vivo myocardial calcium handling.

Purpose

To determine whether myocardial calcium handling is perturbed in people with T2D with no history of cardiovascular disease. We hypothesised that myocardial manganese uptake would be reduced in people with T2D compared with healthy volunteers.

Methods

Cross-sectional case-control study, adults with (n=20) and without (n=9) T2D underwent both gadolinium-enhanced MRI and MEMRI. Standard gadolinium-enhanced MRI was used to assess cardiac structure, function and tissue characteristics. MEMRI scans were performed within two weeks of the initial scan. Native T1 maps were obtained in the mid-short axis slice position using a Modified Look-Locker Inversion recovery sequence. An intravenous infusion of manganese dipyridoxyl diphosphate (5 μmol/kg (0.1 mL/kg) at 1 mL/min) was administered and T1 maps at the same location were repetitively acquired every 2.5 min for 30 min. Regions of interest were drawn in the inferoseptal segment and blood pool for all T1 maps from 0 to 30 min by a single observer. The primary outcome was the rate of manganese uptake which was assessed by Patlak modelling as a measure of myocardial calcium handling. Manganese uptake constants were compared using analysis of co-variance, with age, sex and body mass index as co-variates.

Results

Subjects with T2D were older (62±7 vs. 57±5 years, p=0.046) but body mass index (29.0±4.5 vs. 26.2±3.4 kg/m2, p=0.106), systolic (135±16 vs. 134±17 mmHg, p=0.809) and diastolic (81±10 vs. 83±9 mmHg, p=0.736) blood pressures were similar. Compared to control subjects, participants with T2D had normal systolic function but more concentric left ventricular remodelling (mass/volume ratio 0.90±0.14 vs. 0.71±0.06 g/mL, p&lt;0.001) and reduced peak early diastolic strain rate (0.64±0.17 vs. 0.91±0.26 s–1, p=0.002). Myocardial manganese uptake was substantially reduced in people with T2D compared with controls (6.51±1.46 vs. 8.45±2.52 ml/100 g of tissue/min, p=0.003) (Figure 1).

Conclusions

For the first time, we have demonstrated in vivo that despite no history of cardiovascular disease and normal systolic function, patients with T2D have marked impairment of myocardial calcium handling. This has potential major implications for the pathogenesis, diagnosis and treatment of diabetic cardiomyopathy.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): British Heart Foundation and National Institute for Health Research

38 Virtual Trauma Meeting-the Game Changer During COVID 19 Era. A Quantitative Comparative Analysis

Introduction

In an orthopaedic department, majority of plans and decision-making cases occur at the daily trauma meeting. With the advent of COVID-19 pandemic, it was challenging to deliver the standard care maintaining social distancing guidelines. Therefore, virtual trauma handover replaced the traditional face-to-face handover as a standalone solution. This study has tried to report on effectivity of the new virtual trauma handover process.

Method

This single centre observational study compared retrospectively collected data during pre-COVID-19 period (2019) and prospectively followed data from virtual trauma meetings during COVID 19 pandemic. The study analysed comparison of meeting start and finish time, attendance of key members, punctuality of attendees and interruptions during the handover process.

Results

Changing from face-to-face to virtual trauma meetings, average participation doubled from 9 to 18 with increased consultant attendance (Mean: 7.5 vs 2) -statistically significant (p &lt; 0.05). Enhanced senior clinician participation helped in multidisciplinary decision making promptly. Punctuality of attendance noted as declining late arrivals in 28/34 face-to-face to 4/34 virtual meetings. Although meetings start-time remained similar overall, there was less interruptions during virtual handover and mean meeting span reduced by 13 minutes.

Conclusions

As part of adaptive changes during COVID-19 pandemic, virtual trauma handover meetings have introduced changes in delivery of existing acute trauma services. Within very few limitations, it could be an aid to improve clinician participation, easiness of having multidisciplinary opinion and decision making. Moreover, it helped to practice social distancing guidelines. Educational activities are also effectively managed through virtual meetings.

Use of vegetables for enhancing oxidative stability of omega-3 oils in the powdered state

The preliminary study examined the effectiveness of various vegetables for the stabilisation of omega-3 oil powders against oxidative deterioration. Purees made from different vegetables (mushroom, brussels sprouts, broccoli, cauliflower, snow peas, tomato, and garlic) were employed for preparation of vegetable-tuna oil emulsions, which were subsequently freeze-dried into powders. Oxipres® data showed that vegetable-tuna oil powders had longer induction periods than neat tuna oil. During accelerated oxidation storage (40 °C/4weeks), eicosapentaenoic and docosahexaenoic acids in the vegetable-tuna oil powders were protected against oxidation, and there were lower levels of headspace secondary and tertiary oxidation products. Whole vegetable purees were suitable protective matrices for omega-3 oils. Of the various vegetable purees examined for protective effects against omega-3 oxidation, mushroom, brussels sprouts, broccoli, and cauliflower were superior to snow peas, garlic and tomato. The antioxidant properties of phytonutrients inherent in various vegetables are likely contributors to protection of omega-3 oil powders against oxidation.

Developing a competency-based undergraduate logbook for pediatrics: Process and lessons

With the first MBBS batch admitted under the new National Medical Commission (NMC) undergraduate curriculum entering pediatric clinical posting soon, creation of a Pediatric logbook in consonance with this competency-based curriculum was felt to be a need of the hour. No such document is yet available in the public domain. The logbook template, created after enormous brainstorming amongst authors, includes 176 Shows (S), Shows How (SH) and Perform (P) level competencies. These were further segregated into certifiable (23), affective domain (25) and clinic/field visits (9) leaving 51 as documentable competencies. The institutions may use this template to build their own institute-specific logbook based on the infrastructure, faculty strength, clinical patient load, student intake and preferred assessment method(s). It would also be worthwhile to integrate this with the internship logbook (and later the postgraduate one for students opting for post-graduation in pediatrics) to provide a longitudinal record of each student's trajectory of learning.

The RAIS Device for Global Surgery: Using a Participatory Design Approach to Navigate the Translational Pathway to Clinical Use

Background: Over 5 billion people worldwide have no access to surgery worldwide, typically in low-resource settings, despite it being a primary life-saving treatment. Gas Insufflation-Less Laparoscopic Surgery (GILLS) can address this inequity, by improving current GILLS instrumentation to modern surgical standards. Objective: to develop and translate a new Retractor for Abdominal Insufflation-less Surgery (RAIS) into clinical use and thus provide a context-appropriate system to advance GILLS surgery. Methods: A collaborative multidisciplinary team from the UK and India was formed, embedding local clinical stakeholders and an industry partner in defining user and contextual needs. System development was based on a phased roadmap for ‘surgical device design in low resource settings’ and embedded participatory and frugal design principles in an iterative process supported by traditional medical device design methodologies. Each phase of development was evaluated by the stakeholder team through interactive workshops using cadaveric surgical simulations. A Commercialisation phase undertook Design to Manufacture and regulatory approval activities. Clinical validation was then conducted with rural surgeons performing GILLS procedures using the RAIS system. Semi-structured questionnaires and interviews were used to evaluate device performance. Results: A set of user needs and contextual requirements were defined and formalised. System development occurred across five iterations. Stakeholder participation was instrumental in converging on a design which met user requirements. A commercial RAIS system was then produced by an industry partner under Indian regulatory approval. This was successfully used in clinical validation to conduct 12 surgical procedures at two locations in rural India. Surgical feedback showed that the RAIS system provided a valuable and usable surgical instrument which was appropriate for use in low-resource contexts. Conclusions: Using a context-specific development approach with close engagement of stakeholders was crucial to develop the RAIS system for low-resource regions. The outcome is translation from global health need into a fully realized commercial instrument which can be used by surgeons in low-resource regions across India.

A comparison of effective dose and risk for different collimation options used in AP shoulder radiography

INTRODUCTION

Radiography forms the cornerstone of the evaluation of shoulder disorders. While the benefits of radiography exceed the risks, there continues to be a compelling case for reduction of radiation exposure from diagnostic radiography. The aim of this project was to evaluate the radiation dose and risk for a variety of collimation settings used during anteroposterior (AP) shoulder radiography.

METHODS

This was a phantom based study where an ATOM adult dosimetry phantom was loaded with 272 thermoluminescent dosimeters (TLDs). Following loading, the phantom was setup for an AP shoulder X-ray projection with standard 25 × 30 cm rectangular collimation. The phantom was exposed three times and then the TLDs were removed and read. The experiment was repeated using a diamond shaped collimation and rectangular collimation with a minimum field of view to portray only relevant anatomy. Using the TLD dose measurements the effective doses and radiation risks were determined and compared.

RESULTS

As expected, organs neighbouring the shoulder experienced the highest absorbed doses (greater than 0.01 mGy); these organs included breast, lung and thyroid gland. The effective doses for standard rectangular, small rectangular and diamond collimation were 0.011, 0.008 and 0.016 mSv, respectively. When compared to standard collimation, a small field of view reduced effective dose by 27.3% and when moving to a diamond shape there was a 45.5% increase. The differences are likely driven by differences in the coverage of the radiosensitive lung and breast tissue.

CONCLUSION

By utilising a variety of different collimation settings, effective dose can be reduced. Reducing the radiation dose is both financially beneficial and results in a lower stochastic risk for patients. Image quality must also be considered when choosing different collimation settings. It stands to reason that by reducing the field size, dose will be reduced, and our study has served to quantify the effects in a practical situation.

IMPLICATIONS FOR PRACTICE

The utilisation of smaller/tight collimation is recommended as it offers the lowest dose when compared with other types of collimations. Although well-known this study serves to remind practitioners of the practical importance of collimation and is associated effect on effective dose and risk.

Mechanisms of myocardial injury and clinical outcomes in patients hospitalised with suspected COVID-19

Background

Myocardial injury is associated with adverse outcomes in patients with COVID-19. However, the prognostic role of myocardial injury in COVID-19 compared to other acute illnesses and the underlying mechanisms of injury are poorly understood.

Methods

In a prospective, multi-centre, cohort study conducted in secondary and tertiary care hospitals in Scotland, all consecutive patients with suspected COVID-19 underwent cardiac troponin (ARCHITECTSTAT high-sensitive troponin I (hs-cTnI) assay; Abbott Laboratories) testing in plasma that was surplus to clinical requirements. The results were not reported unless required by the attending clinician. We evaluated the prevalence of myocardial injury, mechanisms and outcomes in all patients. In those with any hs-cTnI concentration above the sex-specific 99th centile the diagnosis was adjudicated according to the 4th Universal Definition of Myocardial Infarction. The primary outcome of all-cause mortality was compared in those with and without myocardial injury and COVID-19 by cox regression adjusted for age, sex, renal function and co-morbidities.

Results

A total of 2,916 (median age 69 [interquartile range, IQR 54–79] years, 53% women) consecutive patients with suspected COVID-19 were followed up for 228 [IQR 203–249] days. Myocardial injury occurred in 26% (750/2,916) with a median troponin concentration of 66 [35–178] ng/L; the prevalence was 41% (46/112) and 25% (704/2,804) in those with and without COVID-19, respectively. The most common mechanism was acute non-ischaemic myocardial injury occurring in 80% (37/46) and 71% (502/704) of patients with and without COVID-19, respectively. Type 1 myocardial infarction (2% and 4%), type 2 myocardial infarction (7% and 14%) and chronic myocardial injury (11% and 11%) were less common and only one patient had confirmed myocarditis. In patients with myocardial injury mortality was increased compared to those without (P&lt;0.001 log rank), whether they had COVID-19 (54% [25/46] versus 26% [17/66]) or not (35% [248/704] versus 14% [294/2100]). Myocardial injury was an independent predictor of death in all patients (adjusted hazard ratio [aHR] 2.04, 95% confidence interval [CI] 1.71 to 2.43), but this excess risk was not higher in patients with COVID-19 (aHR 1.58, 95% CI 0.75 to 3.15) compared to those without the condition (aHR 2.01, 95% CI 1.81 to 2.49).

Conclusion

Myocardial injury is common in hospitalised patients with suspected COVID-19 whether or not COVID-19 was the cause of their presentation. The majority of patients had acute non-ischaemic myocardial injury rather than a defined cardiac condition. Despite this the presence of myocardial injury was an independent predictor of death in all hospitalised patients.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): British Heart Foundation Kaplan-Meier curve for all-cause death

Ultrasonographic assessment of change in omasal position during the last month of gestation and first month of lactation in buffaloes

INTRODUCTION

This study was aimed to determine the effect of advanced pregnancy on the topography and size of the omasum in 22 healthy Murrah buffaloes. The omasum was scanned 15-20 days before and after parturition, as per the standard procedure. The dorsal and ventral margins of the omasum were identified and marked at each intercostal space (ICS). The dorsal and ventral limits up to the dorsal midline were measured. The omasum was scanned in 6th to 11th ICS during advanced pregnancy and 7th to 11th ICS after the parturition. Irrespective of the pregnancy, the dorsal and ventral margins of the omasum were located farther dorsal and close to the spine in the 6th, 7th and 11th ICS. Except in one buffalo, the omasum was scanned in four consecutive ICS during the advanced pregnancy. After parturition the omasum was scanned in four and five consecutive ICS in 17 and five buffaloes, respectively. The mean dorsal and ventral limits of the omasum increased significantly (P .

173 Early Results of a Variable-Angle Volar Locking Plate for Distal Radius Fractures: A Bi-Centre Study

Introduction

This study examines the clinical, functional and radiological outcomes of distal radius fracture fixation with the Aptus® (Medartis, Pennsylvania) locking plate in order to determine its efficacy and to identify notable findings related to treatment variations.

Method

This is a retrospective bi-centre study collecting patient details from a District General Hospital and a Regional Hand Unit. We assessed 61 consecutive patients with distal radius fractures (AO grade A = 19, B = 9, C = 33) fixed using Aptus® plate with a minimum of six months follow-up. Outcome measures included the DASH score, wrist range of movement and grip strength, and complications. Radiographs were reviewed to assess restoration of anatomy and union.

Results

All but two fractures united within six weeks. Mean ranges of movement were only mildly restricted compared to the normal wrist (flexion/extension = 102°; radial/ulna deviation = 53°; pronation/supination = 169°). Mean postoperative grip strength was 23.8kg which was comparable to the contralateral side at 31.5kg. The mean DASH score was 18.2. Seven patients had screws misplaced outside the distal radius although three of these remained asymptomatic.

Conclusions

Variable-angle locking systems benefit from flexibility of implant positioning and may allow enhanced inter-fragmentary reduction for accurate fixation of intra-articular fractures.

Blended programmatic assessment for competency based curricula

The uncertainty in all spheres of higher education due to the COVID-19 pandemic has had an unprecedented impact on teaching-learning and assessments in medical colleges across the globe. The conventional ways of assessment are now neither possible nor practical for certifying medical graduates. This has necessitated thoughtful considerations in making adjustments to the assessment system, with most institutions transitioning to online assessments that so far have remained underutilized. Programmatic assessment encourages the deliberate and longitudinal use of diverse assessment methods to maximize learning and assessment and at present can be utilized optimally as it ensures the collection of multiple low-stake assessment data which can be aggregated for high-stake pass/fail decisions by making use of every opportunity for formative feedback to improve performance. Though efforts have been made to introduce programmatic assessment in the competency-based undergraduate curriculum, transitioning to online assessment can be a potential opportunity if the basic tenets of programmatic assessment, choice of online assessment tools, strategies, good practices of online assessments and challenges are understood and explored explicitly for designing and implementing online assessments. This paper explores the possibility of introducing online assessment with face-to-face assessment and structuring a blended programmatic assessment in competency-based medical education.

Manganese-enhanced magnetic resonance imaging in dilated cardiomyopathy and hypertrophic cardiomyopathy

AIMS

The aim of this study is to quantify altered myocardial calcium handling in non-ischaemic cardiomyopathy using magnetic resonance imaging.

METHODS AND RESULTS

Patients with dilated cardiomyopathy (n = 10) or hypertrophic cardiomyopathy (n = 17) underwent both gadolinium and manganese contrast-enhanced magnetic resonance imaging and were compared with healthy volunteers (n = 20). Differential manganese uptake (Ki) was assessed using a two-compartment Patlak model. Compared with healthy volunteers, reduction in T1 with manganese-enhanced magnetic resonance imaging was lower in patients with dilated cardiomyopathy [mean reduction 257 ± 45 (21%) vs. 288 ± 34 (26%) ms, P < 0.001], with higher T1 at 40 min (948 ± 57 vs. 834 ± 28 ms, P < 0.0001). In patients with hypertrophic cardiomyopathy, reductions in T1 were less than healthy volunteers [mean reduction 251 ± 86 (18%) and 277 ± 34 (23%) vs. 288 ± 34 (26%) ms, with and without fibrosis respectively, P < 0.001]. Myocardial manganese uptake was modelled, rate of uptake was reduced in both dilated and hypertrophic cardiomyopathy in comparison with healthy volunteers (mean Ki 19 ± 4, 19 ± 3, and 23 ± 4 mL/100 g/min, respectively; P = 0.0068). In patients with dilated cardiomyopathy, manganese uptake rate correlated with left ventricular ejection fraction (r2 = 0.61, P = 0.009). Rate of myocardial manganese uptake demonstrated stepwise reductions across healthy myocardium, hypertrophic cardiomyopathy without fibrosis and hypertrophic cardiomyopathy with fibrosis providing absolute discrimination between the healthy myocardium and fibrosed myocardium (mean Ki 23 ± 4, 19 ± 3, and 13 ± 4 mL/100 g/min, respectively; P < 0.0001).

CONCLUSION

The rate of manganese uptake in both dilated and hypertrophic cardiomyopathy provides a measure of altered myocardial calcium handling. This holds major promise for the detection and monitoring of dysfunctional myocardium, with the potential for early intervention and prognostication.

The power of subjectivity in competency-based assessment

With the introduction of competency-based undergraduate curriculum in India, a paradigm shift in the assessment methods and tools will be the need of the hour. Competencies are complex combinations of various attributes, many of which being not assessable by objective methods. Assessment of affective and communication domains has always been neglected for want of objective methods. Areas like professionalism, ethics, altruism, and communication—so vital for being an Indian Medical Graduate, can be assessed longitudinally applying subjective means only. Though subjectivity has often been questioned as being biased, it has been proven time and again that a subjective assessment in expert hands gives comparable results as that of any objective assessment. By insisting on objectivity, we may compromise the validity of the assessment and deprive the students of enriched subjective feedback and judgement also. This review highlights the importance of subjective assessment in competency-based assessment and ways and means of improving the rigor of subjective assessment, with particular emphasis on the development and use of rubrics.

Single-use lidocaine hydrochloride 5 per cent w/v and phenylephrine hydrochloride 0.5 per cent w/v topical spray; can it now be employed as a multi-use atomiser?

OBJECTIVE

This study investigated the risk of contamination of lidocaine hydrochloride 5 per cent w/v and phenylephrine hydrochloride 0.5 per cent w/v topical solution after modification of the application technique.

METHODS

This paper reports a prospective basic sciences study involving 22 study samples and 1 control sample of the lidocaine hydrochloride and phenylephrine hydrochloride topical anaesthetic spray. The samples were assessed for microbiological contamination after a single use on patients using a modified application technique. The modification involves keeping the nozzle (actuator) pressed down whilst withdrawing the spray to at least 30 cm (1 ft) from the patient, before releasing the nozzle (actuator) and subsequently reapplying the spray.

RESULTS

Three of the 23 samples confirmed bacterial growth in the bottle contents, but there was no growth in any of the samples from the pump. These bacteria are considered to be contaminants.

CONCLUSION

There is a potential to use the lidocaine hydrochloride 5 per cent w/v and phenylephrine hydrochloride 0.5 per cent w/v topical solution as a multi-use spray by changing the actuator between patients. This would have significant beneficial cost implications without the attendant infection control risk.