The implementation of a hepatitis C testing service in community pharmacies: I-COPTIC consensus statement

OBJECTIVES

This aimed to develop a blueprint for an effective community pharmacy Hepatitis C virus (HCV) testing service by producing a consensus statement.

STUDY DESIGN

This was a modified Delphi process.

METHODS

We recruited a heterogenous panel of experts (who had been involved in the setup or delivery of a community pharmacy HCV testing service) by purposive and chain referral methods. We had three rounds of a modified Delphi process. The first was a series of questions with free text responses and was analysed using thematic analysis, and the second and third were statements for the respondents to rate using a 7-point Likert scale. Consensus was predefined in a published protocol, and the results were reviewed by a public and patient involvement panel before the statement was finalised.

RESULTS

We had 24 participants, including community and hospital-based pharmacists, local pharmaceutical committee members, charity representatives (Hepatitis C Trust), local clinical service lead, nurse specialists and doctors. The response rate of the first, second and third rounds were 100%, 96% and 88%, respectively. After the third round, we had 60 statements that reached consensus. We discussed the accepted statements with a patient and public involvement group. We used these statements to produce the I-COPTIC statement and a graphical summary.

CONCLUSIONS

We developed a blueprint for the design of a gold standard community pharmacy HCV testing service. We believe this will support the successful implementation of community pharmacy testing for HCV. Community pharmacy testing is an important service to help achieve and maintain HCV elimination.

Molecular biology of cholangiocarcinoma and its implications for targeted therapy in patient management

Cholangiocarcinoma (CCA) remains a devastating malignancy and a significant challenge to treat. The majority of CCA patients are diagnosed at an advanced stage, making the disease incurable in most cases. The advent of high-throughput genetic sequencing has significantly improved our understanding of the molecular biology underpinning cancer. The identification of 'druggable' genetic aberrations and the development of novel targeted therapies against them is opening up new treatment strategies. Currently, 3 targeted therapies are approved for use in CCA; Ivosidenib in patients with IDH1 mutations and Infigratinib/Pemigatinib in those with FGFR2 fusions. As our understanding of the biology underpinning CCA continues to improve it is highly likely that additional targeted therapies will become available in the near future. This is important, as it is thought up to 40 % of CCA patients harbour a potentially actionable mutation. In this review we provide an overview of the molecular pathogenesis of CCA and highlight currently available and potential future targeted treatments.

5,7-Dimethoxycoumarin ameliorates vincristine induced neuropathic pain: potential role of 5HT3 receptors and monoamines

Vincristine is the drug of choice for Hodgkin's lymphoma, acute lymphoblastic leukemia, and non-Hodgkin lymphoma. Despite its significant anticancer effects, it causes dose-dependent neuropathy, leading to compulsive dose reduction. The available drugs used for vincristine-induced neuropathic pain (VINP) have a range of safety, efficacy, and tolerability issues prompting a search for new therapies. 5,7-Dimethoxycoumarin (5,7-DMC) also known as citropten, is a natural coumarin found in the essential oils of citrus plants such as lime, lemons, and bergamots, and it possesses both antidepressant and anti-inflammatory effects. This study was designed to investigate the possible analgesic and antiallodynic effects of 5,7-DMC in a murine model of VINP. Vincristine was administered to groups of BALB/c male mice (0.1 mg/kg intraperitoneally) once daily for 14 days to induce VINP. Thermal hyperalgesia and mechanical allodynia were quantified using the tail immersion test and von Frey filament application method. The levels of monoamine neurotransmitters and vitamin C in frontal cortical, striatal and hippocampal tissues, as well as the TNF-α level in plasma, were quantified using high performance liquid chromatography and ELISA respectively. On day 15 of the protocol, acute treatment with 5,7-DMC clearly reversed VINP thermal hyperalgesia, mechanical static allodynia, mechanical dynamic allodynia, and cold allodynia. The activity of 5,7-DMC against hyperalgesia and allodynia was inhibited by pretreatment with ondansetron but not naloxone, implicating a 5-HT3 receptor involvement. VINP vitamin C levels were restored by 5,7-DMC in the frontal cortex, and changes in serotonin, dopamine, adenosine, inosine and hypoxanthine levels caused by vincristine were reversed either fully or partially. Additionally, the vincristine-induced rise in hippocampal serotonin, dopamine, inosine and striatal serotonin was appreciably reversed by 5,7-DMC. 5,7-DMC also reversed the vincristine-induced increase in the plasma level of TNF-α. In negating the changes in the levels of some neurotransmitters in the brain caused by vincristine, 5,7-DMC showed stronger effects than gabapentin. It was concluded that, there is a potential role of 5-HT3 receptors and monoamines in the amelioration of VINP induced by 5,7-DMC, and the use of this compound warrants further investigation.

Diosgenin normalization of disrupted behavioral and central neurochemical activity after single prolonged stress

Introduction: Post-traumatic stress disorder (PTSD) is a chronic mental illness triggered by traumatic experiences such as wars, natural disasters, or catastrophes, and it is characterized by anxiety, depression and cognitive impairment. Diosgenin is a steroidal sapogenin with known neuroprotective and antioxidant properties. This study aimed to assess the pharmacological potential of diosgenin in a single prolonged stress (SPS) model of PTSD, plus other behavioral models along with any consequent alterations in brain neurochemistry in male mice. Methodology: SPS was induced by restraining animals for 2 h, followed by 20 min of forced swim, recuperation for 15 min, and finally, exposure to ether to induce anesthesia. The SPS-exposed animals were treated with diosgenin (20, 40, and 60 mg/kg) and compared with the positive controls, fluoxetine or donepezil, then they were observed for any changes in anxiety/depression-like behaviors, and cognitive impairment. After behavioral screening, postmortem serotonin, noradrenaline, dopamine, vitamin C, adenosine and its metabolites inosine and hypoxanthine were quantified in the frontal cortex, hippocampus, and striatum by high-performance liquid chromatography. Additionally, animal serum was screened for changes in corticosterone levels. Results: The results showed that diosgenin reversed anxiety- and depression-like behaviors, and ameliorated cognitive impairment in a dose-dependent manner. Additionally, diosgenin restored monoamine and vitamin C levels dose-dependently and modulated adenosine and its metabolites in the brain regions. Diosgenin also reinstated otherwise increased serum corticosterone levels in SPS mice. Conclusion: The findings suggest that diosgenin may be a potential candidate for improving symptoms of PTSD.

HPB P07 A propensity matched retrospective study of metal vs plastic stents in the preoperative biliary drainage of patients with resectable perihilar cholangiocarcinoma

Background

Preoperative biliary drainage is required in the majority of patients with resectable perihilar cholangiocarcinoma (pCCA). Most centres use plastic stents rather than uncovered self-expanding metal stents (uSEMS) because of the potential difficulties associated in removing uSEMS. In the palliative setting, however, uSEMS are associated with superior patency and even improved survival. The aim of this study is to compare the utility of uSEMS versus plastic stents in the pre-operative drainage of patients with resectable pCCA.

Methods

In this retrospective, multicentre, international cohort study, all consecutive patients with a high suspicion of resectable pCCA who underwent an initial endoscopic biliary drainage with uSEMS or plastic stent between 2010–2020 were included. Analyses were stratified by groups according to initial stent type. The primary outcome was stent failure, which was a composite endpoint of cholangitis and/or re-intervention due to biliary complications or inadequate biliary drainage. Propensity score matching (1:1) was performed to adjust for age, gender, primary sclerosing cholangitis, Bismuth classification, WHO performance status and ASA classification.

Results

A total of 474 patients with successful initial stent placement were included. Of these patients 61 received uSEMS and 413 plastic stents. Matching resulted in two groups of 59 patients. Stent failure occurred significantly less in the uncovered uSEMS group (31% vs 64%, P<0.001) and resulted in a significant reduction in the number of repeat ERCP procedures (14% vs 54%, P<0.001). Despite this the number of patients eventually required percutaneous transhepatic biliary drainage was similar (9% vs 7%, P=1). uSEMS placement was also associated with a reduction in episodes of cholangitis (15% vs 31%, P=0.012), although other ERCP and stent related complications did not differ. The number of patients ultimately undergoing surgical resection was not significantly different (81% vs 90%, P=0.19) between groups with uSEMS removal during surgery successful in all patients. The median overall survival after initial stent placement was 482 days [95% CI, 338–787] in the uSEMS group and 429 [95% CI, 263–881] in the plastic stent group (log-rank P=0.81). Survival after surgical resection was similar and post-operative outcomes also comparable: R1 resections (58% vs 59%, P=0.569), complications according to Clavien-Dindo (P=0.227), and hepatico-jejunostomy associated complications (leak: 4% vs 14%, P=0.393, stricture: 15% vs 21%, P=0.822).

Conclusions

Stent failure occurred significantly less often in uSEMS group resulting in fewer drainage procedures and reduced episodes of cholangitis. Removal of uSEMS during surgery was feasible and surgical outcomes were comparable. Although preoperative biliary drainage by uSEMS shows promising results further study is warranted and multicentre randomized controlled trials with a clear treatment strategy should be performed.

Heterogeneity of management practices surrounding operable gallbladder cancer - results of the OMEGA-S international HPB surgical survey

BACKGROUND

Gallbladder cancer (GBC) is an aggressive, uncommon malignancy, with variation in operative approaches adopted across centres and few large-scale studies to guide practice. We aimed to identify the extent of heterogeneity in GBC internationally to better inform the need for future multicentre studies.

METHODS

A 34-question online survey was disseminated to members of the European-African Hepatopancreatobiliary Association (EAHPBA), American Hepatopancreatobiliary Association (AHPBA) and Asia-Pacific Hepatopancreatobiliary Association (A-PHPBA) regarding practices around diagnostic workup, operative approach, utilization of neoadjuvant and adjuvant therapies and surveillance strategies.

RESULTS

Two hundred and three surgeons responded from 51 countries. High liver resection volume units (>50 resections/year) organised HPB multidisciplinary team discussion of GBCs more commonly than those with low volumes (p < 0.0001). Management practices exhibited areas of heterogeneity, particularly around operative extent. Contrary to consensus guidelines, anatomical liver resections were favoured over non-anatomical resections for T3 tumours and above, lymphadenectomy extent was lower than recommended, and a minority of respondents still routinely excised the common bile duct or port sites.

CONCLUSION

Our findings suggest some similarities in the management of GBC internationally, but also specific areas of practice which differed from published guidelines. Transcontinental collaborative studies on GBC are necessary to establish evidence-based practice to minimise variation and optimise outcomes.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Deterministic and probabilistic occupancy detection with a novel heuristic optimization and Back-Propagation (BP) based algorithm

In this paper, a novel hybrid approach for deterministic and probabilistic occupancy detection is proposed with a novel heuristic optimization and Back-Propagation (BP) based algorithms. Generally, PB based neural network (BPNN) suffers with the optimal value of weight, bias, trapping problem in local minima and sluggish convergence rate. In this paper, the GSA (Gravitational Search Algorithm) is implemented as a new training technique for BPNN is order to enhance the performance of the BPNN algorithm by decreasing the problem of trapping in local minima, enhance the convergence rate and optimize the weight and bias value to reduce the overall error. The experimental results of BPNN with and without GSA are demonstrated and presented for fair comparison and adoptability. The demonstrated results show that BPNNGSA has outperformance for training and testing phase in form of enhancement of processing speed, convergence rate and avoiding the trapping problem of standard BPNN. The whole study is analyzed and demonstrated by using R language open access platform. The proposed approach is validated with different hidden-layer neurons for both experimental studies based on BPNN and BPNNGSA.

Principal component analysis technique for early fault detection

Online condition monitoring and predictive maintenance are crucial for the safe operation of equipments. This paper highlights an unsupervised statistical algorithm based on principal component analysis (PCA) for the predictive maintenance of industrial induced draft (ID) fan. The high vibration issues in ID fans cause the failure of the impellers and, sometimes, the complete breakdown of the fan-motor system. The condition monitoring system of the equipment should be reliable and avoid such a sudden breakdown or faults in the equipment. The proposed technique predicts the fault of the ID fan-motor system, being applicable for other rotating industrial equipment, and also for which the failure data, or historical data, is not available. The major problem in the industry is the monitoring of each and every machinery individually. To avoid this problem, three identical ID fans are monitored together using the proposed technique. This helps in the prediction of the faulty part and also the time left for the complete breakdown of the fan-motor system. This helps in forecasting the maintenance schedule for the equipment before breakdown. From the results, it is observed that the PCA-based technique is a good fit for early fault detection and getting alarmed under fault condition as compared with the conventional methods, including signal trend and fast Fourier transform (FFT) analysis.

An approach to solve OPF problems using a novel hybrid whale and sine cosine optimization algorithm

Nowadays, improvement in power system performance is essential to obtaine economic and technical benifits. To achieve this, optimize the large number of parameters in the system based on optimal power flow(OPF). For solving OPF problem efficiently, it needs robust and fast optimization techniques. This paper proposes the application of a newly developed hybrid Whale and Sine Cosine optimization algorithm to solve the OPF. It has been implemented for optimization of the control variables. The reduction of true power generation cost, emission, true power losses, and voltage deviation are considered as different objectives. The hybrid Whale and Sine Cosine optimization is validated by solving OPF problem with various intentions using IEEE30 bus system. To varidate the proposed technique, the results obtained from this are compared with other methods in the literature. The robustness achieved with the proposed algorithm has been analyzed for the considered OPF problem using statistical analysis and whisker plots.

Analyzing impact of relationship benefit and commitment on developing loyalty using machine intelligence approach

The purpose of this study was to examine the relationship of relationship benefit and commitment in developing customer loyalty first and then to develop the intelligent model to predict the customer loyalty. Survey methodology was used to gather data from three different service sectors based on the classification by Bowen. A sample of 600 customers and responses were collected randomly from the front desk of services. Regression analysis by Using SPSS 20 was applied to analyze the data collected. The findings of the study revealed that relationship benefit and commitment had direct positive influence on customer loyalty. Furthermore the commitment of customer towards an organization is instrumental in developing loyalty. After performing the advance data analytics, ANN model was developed to predict the loyalty, which can be utilized to prepare the further directions and road map for service industry. Obtained results reveals that proposed machine intelligence approach is very useful for service industry for short-term as well long-term future planning.

262 Analysis of the Factors Contributing to Unplanned Admissions of Surgical Day Cases

Introduction

Day surgery has many benefits including a reduction in waiting lists, cancellations, hospital acquired infections and need for inpatient beds. It is also highly cost effective. The aim of this study is to identify which factors lead to the unanticipated admission of day cases, in order to adjust future patient selection, and retain efficiency

Method

A list of day cases that took place in 2017 was obtained from the HIPE department in St. Luke’s General Hospital. Day case patients who required admission were retrospectively analysed with the use of patient charts. Patient factors such as age, gender and co morbidities were recorded. The root cause of admission was identified, and the data collated.

Results

457-day cases took place during 2017. 35/457 patients were admitted postoperatively (admission rate of 7.8%). The majority of patients were admitted post cholecystectomy (22) and incisional hernia repair (8). Surgical factors were responsible for almost all admissions.

Conclusions

Surgical factors/complications are not always predictable, but a thorough review of a patient’s background history and imaging can lead to the identification of patients, who should be directed away from day surgery, minimising the need for unexpected admissions, and maximising the efficiency of the unit.

381 Is There A Role for Tranexamic Acid in Upper GI Bleeding? A Systematic Review and Meta-Analysis

Introduction

Upper Gastrointestinal bleeding is associated with increased morbidity and mortality. It has been suggested that tranexamic acid (TXA) may be useful in arresting bleeding.

Aim:

To synthesise available evidence of the effect of TXA on upper GI bleeding.

Method

A systematic review was conducted. PubMed, EMBASE and Cochrane central register of controlled trials were searched for relevant studies. A random effects meta-analysis was performed to determine the risk ratio of primary and secondary outcomes.

Results

8 studies were included in the review. Total number of patients included was 12994 including 4550 females (35%). The effect of TXA on mortality: risk ratio was 0.95 which favoured TXA however the 95% CI ranged from 0.80 to 1.13 and was not statistically significant. The re-bleeding rate risk ratio was 0.64, which favoured the TXA group and with a 95% CI ranging from 0.47 to 0.86 this was statistically significant. The risk of adverse thromboembolic events: risk ratio was 0.93 favoured the TXA group however the 95% CI extended from 0.62 to 1.39 and so was not statistically significant.

Conclusions

We cannot recommend the routine use of TXA in the setting of acute upper GI bleeding outside its use in randomised controlled clinical trials.

Impact of acute kidney injury on in-hospital outcomes among patients hospitalized with acute heart failure: a propensity score matched analysis

Background

Acute kidney injury (AKI) is frequently present in patients admitted for acute heart failure (AHF). Several studies have evaluated the mortality risk and have concluded poor prognosis in any patient with AKI admitted for AHF. For the most part, the additional morbidity and mortality burden in AHF patients with AKI has been attributed to the concomitant comorbidities, and/or interventions.

Purpose

We sought to determine the impact of acute kidney injury (AKI) on in-hospital outcomes in patients presenting with acute heart failure (AHF). We identified isolated AKI patients after excluding other concomitant diagnoses and procedures, which may contribute to an increased risk of mortality and morbidity.

Methods

Data from the National Inpatient Sample (2012- 14) were used to identify patients with the principal diagnosis of AHF and the concomitant secondary diagnosis of AKI. Propensity score matching was performed on 30 baseline variables to identify a matched cohort. The outcome of interest was in-hospital mortality. We further evaluated in-hospital procedures and complications.

Results

Of 1,470,450 patients admitted with AHF, 24.3% had AKI. After propensity matching a matched cohort of 356,940 patients was identified. In this matched group, the AKI group had significantly higher in-hospital mortality (3.8% vs 1.7%, p&lt;0.001). Complications such as sepsis and cardiac arrest were higher in the AKI group. Similarly, in-hospital procedures including CABG, mechanical ventilation and IABP were performed more in the AKI group. AHF patients with AKI had longer in-hospital stay of ∼1.7 days.

Conclusions

In a propensity score-matched cohort of AHF with and without AKI, the risk of in-hospital mortality was &gt;2-fold in the AKI group. Healthcare utilization and burden of complications were higher in the AKI group.

Funding Acknowledgement

Type of funding source: None

Synergistic potential of propolis and vitamin e against sub-acute toxicity of AlCl(3) in albino mice: in vivo study

Current study evaluated the synergistic potential of propolis and vitamin E against sub-acute toxicity of aluminum chloride on different biochemical parameters and liver histology. Swiss albino mice (n=42) were randomly divided into seven groups. Group I received 0.2 ml of 0.9 % saline solution, Group II received Propolis (50 mg/kg b.w.), Group III received vitamin E (150 mg/kg b.w.), Group IV received AlCl(3) 50 mg/kg b.w., Group V received AlCl(3) + Propolis, Group VI received AlCl(3) + vitamin E and Group VII received AlCl(3) + propolis + vitamin E. Blood and tissue samples were collected after 7 and 21 days. The body weight of the animals significantly increased in all groups except Group IV. The concentration of serum high density lipoprotein significantly decreased in Group IV and increased in Group V, VI and VII. The level of aspartate aminotransferase, alanine transferase, alkaline phosphatase, triglycerides, total cholesterol, and low density lipoprotein significantly increased in AlCl(3) treated group and increased in Group V, VI and VII. Tissue sections were processed and stained by hematoxylin and eosin. Group II showed cellular necrosis. Group V, VI showed decreased number of vacuolization, sinusoidal spacing and macrophage cell infiltration. Group VI showed less degenerative changes in the third week. Vitamin E and propolis in combination with Al provides more protection against AlCl(3) induced toxicity.