Respiratory health and the Syrian conflict: a scoping literature review

Conflict adversely affects respiratory health in both direct and indirect ways among populations whose health is already compromised through the compounding effects of conflict. Our aim is to review academic and grey literature relevant to respiratory health in the Syrian conflict (now more than a decade in duration) to explore its impacts on populations across Syria. We performed a scoping literature review of academic and grey literature on respiratory health in Syria between March 2011 (taken as the start of the conflict for practicality) and December 2023. Of 11,472 papers screened, 34 met the inclusion criteria, of which 29 were peer reviewed. Key themes identified included the impact of conflict on asthma diagnosis and management; the burden of respiratory tract infections (RTIs) and COVID-19; the impact of chemical weapon use and the impact of destruction and interruptions to the health system(s) across Syria on respiratory health. This review highlights the need for more in-depth exploration of the impact of conflict on respiratory health in Syria with focus on social determinants, for example, shelter, public health interventions, smoking cessation, and supporting early diagnosis and treatment of respiratory conditions to counter the effects that conflict has had on respiratory health.

A high-fidelity quantum matter-link between ion-trap microchip modules

System scalability is fundamental for large-scale quantum computers (QCs) and is being pursued over a variety of hardware platforms. For QCs based on trapped ions, architectures such as the quantum charge-coupled device (QCCD) are used to scale the number of qubits on a single device. However, the number of ions that can be hosted on a single quantum computing module is limited by the size of the chip being used. Therefore, a modular approach is of critical importance and requires quantum connections between individual modules. Here, we present the demonstration of a quantum matter-link in which ion qubits are transferred between adjacent QC modules. Ion transport between adjacent modules is realised at a rate of 2424 s^-1 and with an infidelity associated with ion loss during transport below 7 × 10^-8. Furthermore, we show that the link does not measurably impact the phase coherence of the qubit. The quantum matter-link constitutes a practical mechanism for the interconnection of QCCD devices. Our work will facilitate the implementation of modular QCs capable of fault-tolerant utility-scale quantum computation.

The management of severe aortic stenosis during the COVID-19 pandemic: an observational study comparing TAVI and SAVR

Introduction

Outcomes and characteristics of patients with severe aortic stenosis (AS) treated during the COVID-19 pandemic is unknown.

Methods

This was a single-centre observational study of patients undergoing AS treatment with transcatheter (TAVI) or surgical (SAVR) therapy during the first-wave of the UK COVID-19 pandemic compared to a control cohort undergoing treatment in 2019.

Demographics, baseline echocardiogram, CT, procedural characteristics and outcome data were collated. The primary outcome was 30-day all-cause mortality. The secondary endpoint was duration of post-procedural hospitalisation.

Results

319 patients were recruited - 122 underwent intervention during the pandemic [73 TAVI; 49 SAVR] and 197 in 2019 [127 TAVI; 70 SAVR].

In 2020, TAVI patients had a higher Euroscore II (p<0.001) but there were no differences in procedural complications or mortality [p=0.16] compared to TAVI 2019 cases. Duration from TAVI to discharge was shorter in 2020 (p<0.001).

SAVR 2020 patients had similar baseline profile [p=0.48], surgical characteristics, mortality (p=0.68) and duration from SAVR to discharge compared to those in 2019.

During the pandemic, TAVI patients were older (p<0.001) and had a higher Euroscore II (p<0.001) than SAVR counterparts. TAVI patients had reduced 30-day mortality [0 (0%) vs 3 (6%); p=0.06] and were discharged more rapidly post-intervention than SAVR patients [median 1 [1] vs 7 [4] days; p<0.001) translating into shorter hospitalization (p<0.001).

Conclusions

TAVI and SAVR can be safely delivered with predictable resource utilisation during a pandemic. Despite the TAVI cohort incorporating higher risk, older patients, outcomes were at least as good as SAVR with a shorter length of post-procedural hospitalisation.

Funding Acknowledgement

Type of funding sources: None. Procedural Complications TAVI/SAVRDuration to discharge post TAVI/SAVR

638 The Implication of Telephone Consultations During COVID-19 Pandemic on Informed Consent

Aim

Is to find whether telephone consultations have affected patient’s comprehension of the proposed surgical management and possible risks until the day of surgery and accordingly ability for informed consent.

Method

This study included a sample of patients admitted to QEQM hospital for elective day case surgery during November 2020 and had only telephone consultation when referred for surgery. A feedback survey assessing quality of information given to patients before and on day of surgery was filled by the patients after the procedure.

Results

The sample included 40 patients undergoing different procedures [cholecystectomy (25), inguinal hernia repair (25), rectal examination under anaesthesia (5), ventral hernia repair (2), incisional hernia (2), inguinal lymph node biopsy (1)]. It was found that 27.5% of patients didn’t have thorough explanation of possible risks and no explanation about postoperative care in 35%.20% were not provided a leaflet about procedure, 57.5% had concerns before surgery and 75% of patients wished for a leaflet with illustrative diagrams, explanation of risks with their management to be able to take the right decision and majority of these patients were from cholecystectomy subgroup.

Conclusions

The lack of face-face appointment affected greatly the informed consent process resulting in patient dissatisfaction which raised the need for new leaflets containing diagrammatic explanation of procedures and possible risks with their management to ensure fulfilment of autonomy principle.

P–362 The effect of nolasiban on uterine contractility at the time of embryo transfer in in vitro fertilisation patients

Study question

What is the effect of nolasiban on the uterine contractility of in-vitro fertilisation (IVF) patients prior to embryo transfer (ET) ?

Summary answer

A single oral dose of nolasiban 900 mg administered 4 h before ET significantly decreased contraction frequency and increased coordination compared to placebo.

What is known already

Nolasiban is an investigational oral oxytocin receptor antagonist (OTRa) being developed to improve the chance of pregnancy following ET. Increased uterine contraction frequency can influence embryo implantation, and the coordination of these uterine contractions is equally important. OTRa have been shown to decrease uterine contractions and increase endometrial perfusion. Recently, an automated and quantitative measurement tool using transvaginal ultrasound (TVUS) to better characterise uterine contractility has been developed which can be used to quantify the effect of nolasiban on uterine contractility.

Study design, size, duration

This study is part of a completed multi-centre randomised placebo-controlled trial (IMPLANT 1 – NCT02310802) in IVF patients (n = 247) carried out in 2015. Our study retrospectively assessed a sub-set of patients with good quality TVUS recordings to evaluate their mechanical uterine motion that were randomised to receive either nolasiban 900mg (n = 39) or placebo (n = 42).

Participants/materials, setting, methods

Subjects were < 37 years, undergoing ET on Day 3 following IVF/ICSI and with evidence of uterine contractions 4 h before ET. Nolasiban was administered 4 h before ET. Patients underwent TVUS immediately before drug administration and again immediately before ET. Uterine contraction frequency, amplitude, power and coordination were measured by applying dedicated speckle tracking and strain analysis. The Shapiro–Wilk test, followed by the Wilcoxon rank-sum test were applied to compare features between treatment groups.

Main results and the role of chance

The mean (SD) frequency of uterine contractions was 1.54 (0.25) in the nolasiban group versus 1.57 (0.12) in the placebo group (p = 0.016). The mean (SD) coordination was 0.10 (0.17) in the nolasiban group versus 0.02 (0.16) in the placebo group (p = 0.034). The coordination feature was measured by assessing the presence of simultaneous movements of the anterior and posterior uterine walls, a higher value reflects increased coordination. There was no difference in contraction amplitude or power.

Limitations, reasons for caution

This was a retrospective analysis of TVUS videos. The small sample size limits the generalisability of the findings. Furthermore, our initial results do not show how the changes in uterine motion may affect pregnancy rate after ET, meaning that the clinical relevance of our results remains to be proven.

Wider implications of the findings: Our results show that in patients taking one 900mg dose of nolasiban prior to ET, beneficial uterine contractions are seen, which could be promising for embryo implantation and pregnancy in IVF patients. Our quantitative TVUS measurement tool can be applied to different patient populations to accurately quantify uterine motion.

Trial registration number

NCT02310802

P–747 Implementation of the ESHRE Congenital uterine anomaly classification into practice and clinical pregnancy outcomes at a Tertiary University Teaching Hospital Fertility department

Study question

What’s the incidence of class U1-U6 CUAs in subfertile women? What’s the clinical pregnancy rate in women with the most common anomaly, a septate uterus?

Summary answer

The incidence of CUAs is 5.9% in our subfertile population, with a septate uterus (U2) being the most common abnormality in 4.2% of the population

What is known already

Congenital uterine anomalies (CUAs) are common. A systematic review suggested an estimated overall prevalence of 5.5% in an unselected population, 8.8% in the subfertile population, 13.3% in those with a history of recurrent miscarriage and 24.5% in those with a history of subfertility and recurrent miscarriage. A septate uterus (U2) is the most common CUA and is amenable to surgical intervention although at present there is a lack of evidence suggesting benefit in subfertile patients. Women with a septate uterus are known to have poorer reproductive outcomes, including reduced conception rate and increased first trimester loss.

Study design, size, duration

All patients referred to our department for subfertility had a 2D pelvic ultrasound scan as part of their baseline investigations. Since it was established in 2016, all patients with a suspected CUA based on clinical history and investigations, were referred to the clinic and data collected prospectively. Prior to this, women with suspected CUAs required a hysteroscopy or MRI scan for confirmation of diagnosis, often leading to long waiting lists and treatment delays.

Participants/materials, setting, methods

Out of the 4716 patients referred to the department for subfertility from 2016–2018, 302 women were referred to the 3D clinic due to suspicion of a CUA. Transvaginal 3D-ultrasound scan was performed and CUAs classified according to the ESHRE/ESGE working groups. Patients diagnosed with a septate uterus were given options of conservative versus surgical treatment, in the light of unclear benefits of hysteroscopic septum resection. Clinical pregnancy data were collected about this cohort.

Main results and the role of chance

Of the 302 women referred to the service, the uteri of 25 patients were unable to be assessed accurately, most commonly as the cavity was unclear due to a thin endometrium. The remaining 277 patients were classified as having the following CUAs; Normal (U0) 63 patients, Dysmorphic (U1) 5 patients, Septate (U2) 199 patients, Bicorporeal (U3) 6 patients and Hemi uterus (U4) 4 patients. No women were classified as having an aplastic uterus (U5) or unclassified (U6).

Of the 199 women with a septate uterus, 15 women opted for surgical intervention, 143 women decided to have conservative management and 41 women were lost to follow up. The women who had hysteroscopic resection of the septum had a mean age of 35 years, 6/15 had primary subfertility and 6/15 had a history of recurrent miscarriage. The women who had conservative management had a mean age of 32.5 years, 100/143 had primary subfertility and 20/143 had a history of recurrent miscarriage. At present, 89/143 women who have had conservative management and 12/15 women who had surgical interventions have had a clinical pregnancy, 72/89 and 6/12 of these pregnancies were IVF/ICSI pregnancies respectively.

Limitations, reasons for caution

This is an observational study, these findings can be useful for patient counselling. However, ideally randomised controlled trials are needed as evidence for the different treatment options for the cohort of patients with septate uterus, which are largely lacking in the current literature, as their feasibility remains a challenge.

Wider implications of the findings: Three-dimensional transvaginal ultrasonography clinics are cost-effective one-stop services, successfully providing a diagnosis and management plan in 92% of patients referred with a suspected CUA. They increase patient satisfaction by providing an opportunity to discuss risks in future pregnancies and reducing reliance on hysteroscopy and MRI scans.

Trial registration number

Not applicable

167 The Experience and Outcomes of Elective Urgent and Cancer Surgery in A District General Hospital in The United Kingdom During Covid-19 Pandemic

Background

Many urgent and elective surgeries were postponed to cope with the Coronavirus disease (COVID-19) pandemic, with latest data found a substantial postoperative mortality risk (25·6%, 18.9%) after emergency and elective surgery, respectively.

Our institution was one of the first trust to offer essential elective surgery using a “COVID-free” designated site during the start of the pandemic.

The aim of this study is to analyse the clinical outcomes of patients who underwent essential elective procedures during the virus outbreak in the UK.

Method

Retrospective analysis of outcomes all patients who had undergone urgent elective and cancer surgery, from 30th March 2020 to 21st May 2020, using an implemented “Super Green Pathway”.

The primary endpoints were 30 days mortality and COVID related morbidities, and the secondary endpoints were surgical related complications and oncological outcomes.

Results

92 patients (Male:45%; Female:55%) across 5 surgical specialties were identified. There was no record of mortality in our cohort. Only 1 patient was tested positive for SARS-CoV-2, 18 days after the initial operation without any pulmonary complications.

Conclusions

It is possible to mitigate the high mortality risk of postoperative complications associated with COVID-19, with no delay to essential surgeries for cancer patients, thus delivering safe practice during the pandemic.

915 Post-Nephrectomy Recurrence Rates in T3 Renal Cell Carcinoma Over A 10-Year Period

Introduction

The objective of the study was to estimate the post-nephrectomy recurrence rate and assess practice around peri-op investigation and treatment.

Method

Imaging, histopathology, and clinical data were gathered using electronic and paper medical records of patients who underwent nephrectomy for T3 RCC. Recurrence defined as local recurrence.

Results

Fifty-one patients with T3 RCC were identified, 74.5% of whom were male with a median age 71 (range 45-91).

One-third had metastatic disease. The majority (96.0%) underwent radical nephrectomy with adrenalectomy (49.0%) and lymph node dissection (19.6%).

Clear cell RCC was the main histopathological type (92.2%) with chromophobe making up 3.9%.

At year one there was recurrence in 20.0% of patients at a median time of 5months (range 1-10, 90.0% grade 3, 10% grade 4).

At year five recurrence was identified in 16.7% in a median time 50months (range 41-56; 50% grade 2 and 3 each).

Ten-year follow-up identified recurrence in 85.7% at a median time 64.5 months (range 62-91; 50% grade 2 and 3 each) with the remaining patient developing jejunal metastatic recurrence in 168 months.

Adjuvant treatment was administered in 57.1%.

Conclusions

Establishing the right time to follow-up patients especially males, 17 months median recurrence time with the most frequently occurring was clear cell RCC.

Nutritive evaluation, metabolisable energy and digestible amino acid contents of different indigenous feedstuff for Nile tilapia (Oreochromis niloticus)

Three trials were executed to examine the nutritive profile, metabolisable energy and digestible amino acid (AA) contents of four indigenous feed ingredients including wheat (W), wheat middling (WM), canola meal (CM) and rapeseed meal (RSM) in Nile tilapia. Three samples of each test ingredient were collected from three different locations of Multan (MUL) and Sukkar (SKR), of Pakistan. The collected three samples were pooled thereafter to make a homogenous/ representative sample of each test ingredient from a particular study site. Nutrients composition, AA and energy digestibility of these indigenous ingredients were evaluated by using laboratory analyses and fish studies. Proximate analysis indicated variations in some of the nutrients due to location (p < 0.05). Differences were also observed in some AA including arginine, lysine, serine, cysteine, glutamic and aspartic acids, histidine, valine and glycine contents of these ingredients (p < 0.05). Digestibility of leucine, glycine and glutamic acid was higher (p < 0.05) in RSM from MUL. Among W samples from MUL, AA digestibility for lysine, threonine, and aspartic acid was higher (p < 0.05). Crude protein, arginine, alanine, serine, and aspartic acid had higher digestibility (p < 0.05), whereas digestibility was lower (p < 0.05) for threonine, valine and tyrosine in RSM from MUL. Metaboliseable energy contents did not differ among W, WM, CM and RSM regarding their origin (p > 0.05). The results indicated that nutritional profiles and their digestibility indices vary with the location for Nile tilapia.

The influence of age on the diagnostic yield of genetic testing in dilated cardiomyopathy

Background

Dilated cardiomyopathy (DCM) has an estimated population prevalence of 1/250 and is the underlying diagnosis in a third of heart failure patients. A substantial proportion of patients have familial disease caused by dominant mutations in one of more than 50 genes, but clinical practice guidelines recommend genetic testing in young patients with idiopathic DCM. There is an absence of robust data on the influence of age on the diagnostic yield of genetic testing.

Methods

The study cohort comprised 825 consecutive and unrelated patients (524 male (63.5%)) with DCM who underwent genetic testing from 2015 to 2019. Genetic variants were classified using American College of Medical Genetics (ACMG) criteria. Analyses were stratified by age and sex.

Results

173 (20.1%) patients had a positive genetic test (“pathogenic” or “likely pathogenic” variant); 292 (34.4%) had a variant of unknown significance. Mean age at genetic testing was 49.9±14.4 years. Mean age of patients with a positive test was 47.6±13.6 years. 99 (18.9%) men and 67 (22.3%) women had a positive test (p=0.246).

Mutations in the TTN gene, encoding for titin, accounted for 46.1% of positive results. 13.8% of mutations were in DSP, 8.4% in RBM20, 6% in FLNC, 4.2% in LMNA, 3.6% in BAG3 and 3.6% in MYH7.

There was a trend to declining yield with age (likelihood ratio chi-square p value = 0.047). The yield was 17.2% in the 56–65 year age group and 11.5% above 66 years of age (figure 1).

Conclusions

Approximately 1 in 5 patients with DCM had a positive genetic test. The yield declined in patients over 66 years but remained above 11%, suggesting that genetic testing should not be confined to younger patients with DCM.

Figure 1. Yield of Genetic Testing by Age

Funding Acknowledgement

Type of funding source: None

Seroprevalence of Toxoplasma gondii and associated hematological alterations in small ruminants of D.G. Khan district of Southern Punjab, Pakistan

ABSTRACT The present study was carried out to evaluate the prevalence and hematological effects of Toxoplasma gondii in sheep and goat in district Dera Ghazi Khan. Blood samples (n=204) were collected comprise goats (n=101) and sheep (n=103) alongwith age, gender and breeds of animals. Samples were collected randomly from 25 flocks of 7 different union council Viz. Vehova, Tibbi Qaisrani, Lakhani, Kohar, Tuman Qaisrani, Nutkani and Kot Qaisrani of Tehsil Taunsa Sharif at least 4 animals from each flock. All ruminants divide into three groups based on age, breed and gender. The prevalence was detected through two different kits Viz. LAT and ELISA kit. The overall prevalence suspected in goats through LAT and ELISA kit was (35.64%), (32.67%) and in sheep was (25.24%), (23.30%) respectively. The Toxoplasma gondii had a significant effect on goats in age groups and non-significant all other groups of goats and sheep. Toxoplasma gondii had a significant effect on all hematological parameters like Hemoglobin, total leukocyte cells, granulocytes, lymphocytes, platelets, and red blood cells, except monocytes. In conclusion of the current study, toxoplasmosis is prevalent among ruminants, reveals the possibility of transmission to humans on the use of host animals as protein source.

5163Predictors of adverse cardiovascular events in patients with truncating variants in the filamin c (flnc) gene

Background

Truncating variants in Filamin C (FLNCtv) are associated with arrhythmogenic (AC) and dilated cardiomyopathies (DCM). Affected patients are reported to demonstrate a high incidence of arrhythmic and heart-failure related cardiovascular events. The aim of this study was to determine factors that predict adverse events in mutation carriers.

Methods

The study cohort comprised 168 FLNCtv carriers followed at 19 European centres. Baseline and longitudinal follow-up clinical data were collected. The primary endpoint was a composite of sudden cardiac death (SCD), aborted SCD, appropriate implantable cardioverter-defibrillator (ICD) shock, cardiac transplantation (HTx) and mortality from end-stage heart failure (ESHF).

Results

47 different pathogenic or likely-pathogenic FLNCtv were identified in 60 unrelated probands. In those with baseline and longitudinal data (160 patients; 57 probands), 114 (71.3%) patients exhibited evidence of cardiac disease at initial evaluation. Gene penetrance was 85% by the age of 40 years. During a median follow-up of 1.5 years (IQR 4.1), 24 individuals (15%) reached the primary endpoint – 16 arrhythmic (SCD/aborted SCD/ICD shock) and 8 heart failure (ESHF/HTx) related-events. Univariable predictors at baseline evaluation of the composite primary endpoint included proband status (HR 4.0, 95% CI: 1.5–10.9, p=0.01), symptoms of dyspnoea (HR 2.8, 95% CI: 1.2–6.4, p=0.02), LV systolic dysfunction (LVSD) (HR 12.4, 95% CI: 2.9–53.2, p=0.001), frequent ventricular ectopy (VE>500) on 24-hour Holter (HR 9.3, 95% CI: 1.2–74.7, p=0.04) and the presence of late gadolinium enhancement on CMR (HR 8.9, 95% CI: 1.2–68.5, p=0.04).

Multivariable analysis identified LVSD (LVEF <50%) at baseline as an independent predictor of the primary endpoint with a hazard ratio of 8.6 (95% CI: 1.8–41.5, p=0.007). ROC analysis using LV systolic dysfunction to predict the primary endpoint demonstrated an area under the curve of 0.84 (95% CI: 0.76–0.91, p<0.001) and identified an optimal LVEF “cut-off” of 47% for predicting adverse events with a Youden's index of 0.61 (sensitivity 0.91; specificity 0.70).

Kaplan-Meier plot to demonstrate freedom

Conclusions

LVSD is associated with an over 8-fold increase in the hazard of a primary endpoint event in FLNCtv gene carriers indicating that these patients should be considered for implantable cardioverter-defibrillator (ICD) implantation, optimal heart failure medical therapy and close clinical follow-up.

Acknowledgement/Funding

NIHR Biomedical Research Centre; Instituto de Salud Carlos III; DETECTIN-HF project; Wellcome Trust;CIBERCV; EU Regional Development Fund; FEDER.

Hydatidiform molar pregnancy following assisted reproduction

INTRODUCTION

The use of assisted reproduction techniques (ART) is increasing; however, reports of molar pregnancy following ART remain scarce. Currently, the Human Fertility and Embryology Authority (HFEA) collates data on the molar pregnancies that have resulted through the use of ART. Recently, they have indicated that they will no longer collect these data.

AIM

This paper aimed to examine the incidence of molar pregnancy amongst patients undergoing assisted reproduction.

METHODS

We contacted HFEA and placed a request under the Freedom of Information Act (2000) for the number of molar pregnancies that resulted from fresh/frozen embryo transfer since HFEA started collecting data in 1991 to February 2018. We also asked how many patients who had suffered a molar pregnancy went on to have a normal pregnancy and how many had subsequent molar pregnancies, in subsequent treatment cycles.

RESULTS

Between 68 and 76 molar pregnancies occurred within this period using ART (n = 274,655). The incidence of molar pregnancy using fresh intracytoplasmic sperm injection (ICSI) (1/4302) and fresh in vitro fertilisation (IVF) (1/4333) was similar. The risk of recurrence of molar pregnancy following a previous molar was higher following ART compared to spontaneous conceptions.

CONCLUSION

The use of ICSI should be protective against triploidy; however, the retrospective data suggests that molar pregnancy is not eliminated with the use of ART. It is pertinent to continue to record this data, through the gestational trophoblastic disease centres, in order to ensure no further increase in incidence, appropriate follow-up, and transparency in communication.

Seroprevalence, associated risk factors and hematological impacts of toxoplasmosis in small ruminants of Multan, Punjab-Pakistan

Toxoplasmosis is a protozoal infection of zoonotic potential with worldwide geographical distribution which affects nearly all warm-blooded animals including mammals and birds. Keeping in view, this study was conducted to determine the seroprevalence of toxoplasmosis along with associated risk factors and its haematological impacts in small ruminants of district Multan, Pakistan. In this study, a total of 250 sera samples collected from sheep (n=125) and goats (n=125) from three tehsils of Multan were examined using commercially available Latex agglutination test kit for the presence of anti-T. gondii antibodies. The haematological profiles of Toxoplasma seropositive and seronegative animals were determined by using automated haematology analyser. Overall seroprevalence of toxoplasmosis in small ruminants was 42.80% with a higher prevalence rate (44.80%) in sheep as compared to goats (40.80%). Sex, existence of co-morbid conditions, feeding pattern and presence of pet cats and dogs were identified as significant (P<0.05) risk factors associated with the presence of antibodies against toxoplasmosis. The breed was found to be a significant (P=0.026) risk factor for the seroprevalence of toxoplasmosis in goats but not in sheep. Haematological analysis revealed significantly altered leukocytic counts (P<0.05) in seropositive sheep and goats as compared to seronegative ones. Our findings showed that small ruminants of the Multan District in Pakistan are toxoplasma seropositive and may pose a serious threat of public health concern in the region.