Textbook outcome following oesophagectomy for cancer: international cohort study

BACKGROUND

Textbook outcome has been proposed as a tool for the assessment of oncological surgical care. However, an international assessment in patients undergoing oesophagectomy for oesophageal cancer has not been reported. This study aimed to assess textbook outcome in an international setting.

METHODS

Patients undergoing curative resection for oesophageal cancer were identified from the international Oesophagogastric Anastomosis Audit (OGAA) from April 2018 to December 2018. Textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least 15 lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. A multivariable binary logistic regression model was used to identify factors independently associated with textbook outcome, and results are presented as odds ratio (OR) and 95 per cent confidence intervals (95 per cent c.i.).

RESULTS

Of 2159 patients with oesophageal cancer, 39.7 per cent achieved a textbook outcome. The outcome parameter 'no major postoperative complication' had the greatest negative impact on a textbook outcome for patients with oesophageal cancer, compared to other textbook outcome parameters. Multivariable analysis identified male gender and increasing Charlson comorbidity index with a significantly lower likelihood of textbook outcome. Presence of 24-hour on-call rota for oesophageal surgeons (OR 2.05, 95 per cent c.i. 1.30 to 3.22; P = 0.002) and radiology (OR 1.54, 95 per cent c.i. 1.05 to 2.24; P = 0.027), total minimally invasive oesophagectomies (OR 1.63, 95 per cent c.i. 1.27 to 2.08; P < 0.001), and chest anastomosis above azygous (OR 2.17, 95 per cent c.i. 1.58 to 2.98; P < 0.001) were independently associated with a significantly increased likelihood of textbook outcome.

CONCLUSION

Textbook outcome is achieved in less than 40 per cent of patients having oesophagectomy for cancer. Improvements in centralization, hospital resources, access to minimal access surgery, and adoption of newer techniques for improving lymph node yield could improve textbook outcome.

A cross sectional survey on the effect of COVID-19 related restrictions on undergraduate and postgraduate medical education in Qatar

BACKGROUND

COVID-19 pandemic has affected all dimensions of day to day life across the world and medical education was no exception. With this study, we aimed to understand the effect of nationwide restrictions on medical education in Qatar, the models of education adopted during this period and perceptions of participants to the same.

METHODS

We conducted a cross-sectional study utilizing an online questionnaire distributed via convenience sampling between April-October 2020. Study participants were faculty and trainees in governmental undergraduate and postgraduate medical education institutes. Two sets of questionnaires were designed for each group. They were asked a series of questions to assess pre- and post-COVID pandemic educational practices, their preferred teaching methods, and their familiarity with electronic teaching platforms. Faculty respondents were asked about their perceived barriers to delivery of medical education during the pandemic and their agreement on a 5-point Likert scale on specific elements. Trainees were asked a series of multiple-choice questions to characterize their pre- and post-COVID pandemic educational experiences. Both groups were asked open-ended questions to provide qualitative insights into their answers. Data were analysed using STATA software version 12.0.

RESULTS

Majority of trainees (58.5%) responded that the pandemic has adversely affected medical education at both the undergraduate and postgraduate levels. Trainees (58.5%) and faculty (35.7%) reported an increased reliance on e-learning. Trainees preferred face-to-face education, while faculty preferred a combination of models of education delivery (33.5% versus 37.1%, p = 0.38). Although 52.5% of the faculty had no previous experience of delivering education through e-learning modalities, 58.9% however felt confident in using e-learning software.

CONCLUSIONS

Faculty and trainees agree that the COVID-19 pandemic has had a significant impact on the provision of medical education and training in Qatar, with an increased dependence on e-learning. As trainee's prefer face-to-face models of education, we may have to consider restructuring of medical curricula in order to ensure that optimum learning is achieved via e-learning, while at the same time enhancing our use, knowledge and understanding of the e -learning methods. Further research is warranted to assess if these changes have influenced objective educational outcomes like graduation rates or board scores.

Salmonella-induced pulmonary and pericardial abscesses in a patient presenting with subacute cough

The non-typhoid Salmonella (NTS) species are commonly associated with gastroenteritis and other forms of intestinal disease. Thoraco-pulmonary infections are less commonly reported. We describe the case of a 66-year-old Qatari lady who presented with subacute cough. Chest imaging revealed multiple pulmonary and a pericardial cavitary lesion with air fluid levels. Bronchoalveolar lavage culture grew Salmonella species group D. The patient was treated with 4 weeks of appropriate antibiotics. Clinical and radiological improvement were documented on subsequent follow up. To our knowledge, this is the first reported case of pulmonary and pericardial salmonella abscesses in the state of Qatar.

Coping Strategies and Workplace Supports for Peers with Substance Use Disorders

Introduction: Substance use disorder (SUD) peers provide support and navigation through a fragmented treatment system for people who use drugs (PWUD) and those in recovery. While barriers to peers' work are well established, from role ambiguity to stigma surrounding substance use, little research has focused on factors that facilitate peers' work. Methods: We conducted in-depth semi-structured interviews (N=20) with peers as part of an evaluation of a larger project related to the opioid crisis in Western New York. Participants were recruited from a regional peer network via flyers, emails, and a brief presentation. Interviews were conducted in person or by phone, audio recorded, and transcribed. Transcripts were analyzed using thematic content analysis. Results: Peers emphasized two factors: healthy personal coping strategies and strong workplace supports. Coping strategies included a sense of community, setting appropriate boundaries, and self-care routines. At the workplace, peers valued mental and emotional support, as well as professional relationships and organizational policies that made their work easier and supported self-care. For a few peers, professional relationships included advocating on behalf of PWUD by sharing personal experiences of SUD. Conclusions: Peers valued peer colleagues and peer-led organizations, noting how shared experiences of substance use and recovery enabled a unique support system. For peers who lack such support at work, the authors suggest peer networks as an alternative. We also recommend organizational policies and practices to facilitate peers' work, such as promoting peer input and feedback, but further research is needed to measure effects on peer retention and job satisfaction.

Point Absorber Limits to Future Gravitational-Wave Detectors

High-quality optical resonant cavities require low optical loss, typically on the scale of parts per million. However, unintended micron-scale contaminants on the resonator mirrors that absorb the light circulating in the cavity can deform the surface thermoelastically and thus increase losses by scattering light out of the resonant mode. The point absorber effect is a limiting factor in some high-power cavity experiments, for example, the Advanced LIGO gravitational-wave detector. In this Letter, we present a general approach to the point absorber effect from first principles and simulate its contribution to the increased scattering. The achievable circulating power in current and future gravitational-wave detectors is calculated statistically given different point absorber configurations. Our formulation is further confirmed experimentally in comparison with the scattered power in the arm cavity of Advanced LIGO measured by in situ photodiodes. The understanding presented here provides an important tool in the global effort to design future gravitational-wave detectors that support high optical power and thus reduce quantum noise.

Pregnancy and contraception in women with Pre-Gestational diabetes in secondary Care- A questionnaire study

AIMS

To establish the knowledge of women with pre-gestational diabetes about of the risks of diabetes in pregnancy, and investigate their pregnancy plans, contraceptive choices, and preparedness for pregnancy.

METHODS

Women of reproductive age attending diabetes clinics across a single busy metropolitan NHS Trust were invited to fill in a questionnaire about pregnancy and contraception. The electronic health records of those women were also reviewed.

RESULTS

Ninety-six women completed the questionnaire. The majority of respondents (94%) had Type 1 Diabetes. Only 3% of women met the criteria of 'prepared for pregnancy'. Low efficacy contraception was used by 32% of women. Most women were only aware of a few risks to the mother and fetus in pregnancy, though the majority of women were aware of the importance of good glycaemic control before pregnancy. Previous pregnancies, or attendance at pre-conception counselling, did not improve participant knowledge.

CONCLUSIONS

Many women with diabetes of reproductive age are poorly prepared for pregnancy, but many are also using less effective contraceptive methods. These areas should be addressed if the poor pregnancy outcome in women with diabetes are to be improved, possibly through the development of an evidenced-based structured education course to target pre-conception and contraception.

Fatal hymenoptera venom anaphylaxis by undetected clonal mast cell disorder: A better identification of high risk patients is needed

Hymenoptera venom anaphylaxis is the most frequent cause of anaphylaxis and responsible for about 20% of all fatal anaphylaxis cases in adults. We report two cases of fatal hymenoptera venom anaphylaxis with undiagnosed underlying mastocytosis and review the risk factors for severe or fatal hymenoptera venom anaphylaxis, as well as the specificities of its association with mastocytosis. As hymenoptera venom allergic patients with underlying clonal mast cell disorder generally lack typical skin lesions of mastocytosis, its diagnosis can easily be missed, underscoring the importance and need for diagnostic strategies in order to correctly identify these patients. Predominant cardiovascular symptoms in the absence of urticaria or angioedema following an insect sting are suggestive of underlying clonal mast cell disorder, and should be distinguished from panic attack or vasovagal syncope. Similarly, an unexplained syncope or an "idiopathic" anaphylaxis might reveal mastocytosis or hereditary alpha-tryptasemia. Acute and basal serum tryptase measurements should always be integrated in the diagnostic work-up of an insect sting reaction or unexplained syncope or shock of any origin.

Postoperative outcomes in oesophagectomy with trainee involvement

BACKGROUND

The complexity of oesophageal surgery and the significant risk of morbidity necessitates that oesophagectomy is predominantly performed by a consultant surgeon, or a senior trainee under their supervision. The aim of this study was to determine the impact of trainee involvement in oesophagectomy on postoperative outcomes in an international multicentre setting.

METHODS

Data from the multicentre Oesophago-Gastric Anastomosis Study Group (OGAA) cohort study were analysed, which comprised prospectively collected data from patients undergoing oesophagectomy for oesophageal cancer between April 2018 and December 2018. Procedures were grouped by the level of trainee involvement, and univariable and multivariable analyses were performed to compare patient outcomes across groups.

RESULTS

Of 2232 oesophagectomies from 137 centres in 41 countries, trainees were involved in 29.1 per cent of them (n = 650), performing only the abdominal phase in 230, only the chest and/or neck phases in 130, and all phases in 315 procedures. For procedures with a chest anastomosis, those with trainee involvement had similar 90-day mortality, complication and reoperation rates to consultant-performed oesophagectomies (P = 0.451, P = 0.318, and P = 0.382, respectively), while anastomotic leak rates were significantly lower in the trainee groups (P = 0.030). Procedures with a neck anastomosis had equivalent complication, anastomotic leak, and reoperation rates (P = 0.150, P = 0.430, and P = 0.632, respectively) in trainee-involved versus consultant-performed oesophagectomies, with significantly lower 90-day mortality in the trainee groups (P = 0.005).

CONCLUSION

Trainee involvement was not found to be associated with significantly inferior postoperative outcomes for selected patients undergoing oesophagectomy. The results support continued supervised trainee involvement in oesophageal cancer surgery.

Natriuretic peptides predict future heart failure and cardiovascular death in an unselected population of patients presenting to hospital: interactions with atrial fibrillation

Aims

Natriuretic peptides are routinely quantified to diagnose heart failure (HF). Their concentrations are also elevated in atrial fibrillation (AF). To clarify their interpretation, we measured natriuretic peptides in unselected patients with cardiovascular conditions and related their concentrations to AF and HF status and to outcomes.

Methods and results

Consecutive patients with cardiovascular conditions presenting to a large teaching hospital (median age 70 [IQR 60–78] years, 40% women) underwent clinical assessment, 7-day ECG-monitoring, and echocardiography to diagnose AF and HF. N-terminal pro B-type natriuretic peptide (NT-proBNP) was centrally quantified. Clinical characteristics and NT-proBNP concentrations were related to HF hospitalization or cardiovascular death. Follow-up data was available in 1611/1616 patients (99.7%) and analysis performed at 2.5 years. Based on a literature review, four NT-proBNP groups were defined (&lt;300pg/ml, 300–999pg/ml, 1000–1999pg/ml and ≥2000pg/ml).

Multivariate Cox proportional hazards analysis of the composite outcome against AF and HF phenotype groups. This was adjusted for confounding factors including age, sex, race, body mass index, hypertension, diabetes, coronary artery disease, severe valvular heart disease, left bundle branch block, hyponatraemia, urea, haemoglobin, estimated glomerular filtration rate, NT-proBNP, medical treatment with ACE inhibitors or angiotensin receptor blockers, beta-blockers, diuretic (thiazide or loop diuretics), and anticoagulants (novel oral anticoagulant or vitamin K antagonist). Cox proportional hazards analysis adjusted for confounding variables for the composite outcome against baseline NT-proBNP concentration ranges was also performed in each patient group based on AF and HF status.

HF hospitalization or cardiovascular death increased from patients with neither AF nor HF (36/488, 3.2/100 person-years), to 55/353 (7.1/100 person-years) in patients with AF only, 91/366 (12.1/100 person-years) in patients with HF only, and, 128/404 (17.7/100 person-years) in patients with AF plus HF (p&lt;0.001). Higher NT-proBNP concentrations predicted the outcome in patients with AF only (C-statistic 0.82 [95% CI 0.77 to 0.86], p-value&lt;0.001) and in other phenotype groups (C statistic in AF plus HF 0.66 [95% CI 0.61 to 0.70], p-value&lt;0.001)). Sensitivity analyses confirmed these findings.

Conclusion

Elevated NT-proBNP concentrations predict future HF events in patients with AF irrespective of the presence of HF. In line with previous studies in HF, an NT-proBNP threshold of 1000 pg/ml is useful to identify high-risk patients with AF whether or not they are diagnosed with HF at the time of assessment. Pending external validation, these findings encourage the routine quantification of NT-proBNP in the initial assessment of patients with AF.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): 1) This study was partially supported by European Union BigData@Heart and 2) CATCH ME (Characterising Afib by Translating its Causes into Health Modifiers in the Elderly)

[The Current Therapy of Asbestos-Associated Malignant Pleural Mesothelioma - An Expert Consensus Paper]

Asbestos-related mesotheliomas belong to the group of the most frequent occupational diseases in Germany, reaching about 1,000 new cases per year. The disease has a dismal prognosis because most tumors remain asymptomatic for a long time and therefore are diagnosed as incidental findings at later stages.During the last decade the German Social Accident Insurance (DGUV) has made considerable efforts to prepone the diagnosis in order to detect the disease at earliest possible stages. These efforts resulted in new findings showing that, in a high-risk group, a combination of the biomarkers calretinin and mesothelin was able to advance the diagnosis up to 12 months.Ideally, the diagnosis of a mesothelioma at an early stage has to be accompanied by the best possible individualized therapy. Standard therapeutic strategies are surgery and chemotherapy, added by radiotherapy and psycho-oncology. In recent years, several new therapeutic avenues are being explored. This review comprehensively presents both old and new therapeutic options in mesothelioma, based on international Leitlinien and new studies.

Association of the advanced lung cancer inflammation index (ALI) with immune checkpoint inhibitor efficacy in patients with advanced non-small-cell lung cancer

Background

The advanced lung cancer inflammation index [ALI: body mass index × serum albumin/neutrophil-to-lymphocyte ratio (NLR)] reflects systemic host inflammation, and is easily reproducible. We hypothesized that ALI could assist guidance of non-small-cell lung cancer (NSCLC) treatment with immune checkpoint inhibitors (ICIs).

Patients and methods

This retrospective study included 672 stage IV NSCLC patients treated with programmed death-ligand 1 (PD-L1) inhibitors alone or in combination with chemotherapy in 25 centers in Greece and Germany, and a control cohort of 444 stage IV NSCLC patients treated with platinum-based chemotherapy without subsequent targeted or immunotherapy drugs. The association of clinical outcomes with biomarkers was analyzed with Cox regression models, including cross-validation by calculation of the Harrell's C-index.

Results

High ALI values (>18) were significantly associated with longer overall survival (OS) for patients receiving ICI monotherapy [hazard ratio (HR) = 0.402, P < 0.0001, n = 460], but not chemo-immunotherapy (HR = 0.624, P = 0.111, n = 212). Similar positive correlations for ALI were observed for objective response rate (36% versus 24%, P = 0.008) and time-on-treatment (HR = 0.52, P < 0.001), in case of ICI monotherapy only. In the control cohort of chemotherapy, the association between ALI and OS was weaker (HR = 0.694, P = 0.0002), and showed a significant interaction with the type of treatment (ICI monotherapy versus chemotherapy, P < 0.0001) upon combined analysis of the two cohorts. In multivariate analysis, ALI had a stronger predictive effect than NLR, PD-L1 tumor proportion score, lung immune prognostic index, and EPSILoN scores. Among patients with PD-L1 tumor proportion score ≥50% receiving first-line ICI monotherapy, a high ALI score >18 identified a subset with longer OS and time-on-treatment (median 35 and 16 months, respectively), similar to these under chemo-immunotherapy.

Conclusions

The ALI score is a powerful prognostic and predictive biomarker for patients with advanced NSCLC treated with PD-L1 inhibitors alone, but not in combination with chemotherapy. Its association with outcomes appears to be stronger than that of other widely used parameters. For PD-L1-high patients, an ALI score >18 could assist the selection of cases that do not need addition of chemotherapy.

•

ALI is prognostic and predictive for patients with advanced NSCLC treated with immunotherapy monotherapy, but not chemo-immunotherapy.

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Its association with outcomes is stronger than that of other parameters (PD-L1 TPS, NLR, lung immune prognostic index, EPSILoN).

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For PD-L1-high patients, an ALI score >18 could assist the selection of cases that do not need addition of chemotherapy.

A multidisciplinary early mobility model for cardiac patients in coronary intensive care unit

Funding Acknowledgements

This is an unfunded project

Background

Early mobilization is considered as a complex task in an intensive care unit (ICU) and patients are often on prolonged bed rest leading to physical deconditioning. Intensive care early mobility programs have been recognized to be safe and have shown positive outcomes. However, implementing early mobility program as a standard of care remains a challenge.

Coronary Intensive Care Unit (CICU) provides complex care for cardiac critically ill patients. In February 2018, the CICU multidisciplinary team (MDT) started a quality improvement project to implement early mobility program in the unit.

Purpose

This project aimed to investigate the feasibility of implementing an Early Mobility Protocol in CICU to increase the number of patients mobilized to more than 95%. Secondary objective was to explore the impact of the protocol on the mobility level of the patients at the time of discharge or transfer from the CICU.

Methods

A multidisciplinary mobility task force including Physicians, nurses, physiotherapists and respiratory therapists was formed to analyze the barriers in implementing an early mobility program. A staff survey was conducted to identify the need for a standard early mobility protocol. Root cause analysis and Pareto analysis was done. An evidence based early mobility protocol was developed and implemented. All non-mechanical ventilated patients were included in the first phase and all mechanical ventilated patients were included in the second phase of the project. A standard ICU Mobility scale (IMS) was used for scoring the mobility level of the patients. This quality improvement project is based on "Institute for Healthcare Improvement" model. Periodical staff education and training programs about early mobilization were conducted to improve staff confidence. Change ideas were implemented using multiple Plan Do Study Act cycles.

Results

The total number of patients included from 1st March 2018 till 31st December 2019 was 2356. This included both the genders. In March 2018, only 68% of non-mechanical ventilated patients were mobilized, that reached to 88% by November 2018. This gradually increased to 100% in May 2019 and is currently sustained at 100%.

In November 2019, only 50% of mechanical ventilated patients were mobilized which gradually increased to 66.66% and 75% in middle and end of December 2019. The mean IMS score at discharge or transfer from CICU was "8". From patient-family experience survey, 93.75% of patients perceived that the program was helpful in regaining mobility and 96.25% of patients felt that the program helped in regaining their autonomy.

Conclusion

The result shows that it is safe and feasible to implement an early mobility program in a Coronary Intensive Care Unit. A standardized mobility protocol can lead to efficient mobilization practice facilitating early transfers from ICUs without any complications. This could further enhance the collaboration of the MDT members leading to culture change in ICUs.

Pneumoperitoneum following an Endoscopic Retrograde Cholangiopancreatography (ERCP): A case report

Post Endoscopic Retrograde Cholangiopancreatography (ERCP) pneumoperitoneum is commonly associated with perforated viscus but is rarely associated with benign causes. We present a case of 29 years old lady who underwent ERCP, who was found to have benign pneumoperitoneum subsequently. She was treated conservatively and recovered without complication. Although rare, post ERCP pneumoperitoneum of benign causes should be investigated as the course of treatment and outcome differ largely.

Approaching the motional ground state of a 10-kg object

The motion of a mechanical object, even a human-sized object, should be governed by the rules of quantum mechanics. Coaxing them into a quantum state is, however, difficult because the thermal environment masks any quantum signature of the object's motion. The thermal environment also masks the effects of proposed modifications of quantum mechanics at large mass scales. We prepared the center-of-mass motion of a 10-kilogram mechanical oscillator in a state with an average phonon occupation of 10.8. The reduction in temperature, from room temperature to 77 nanokelvin, is commensurate with an 11 orders-of-magnitude suppression of quantum back-action by feedback and a 13 orders-of-magnitude increase in the mass of an object prepared close to its motional ground state. Our approach will enable the possibility of probing gravity on massive quantum systems.

Constraints on Cosmic Strings Using Data from the Third Advanced LIGO-Virgo Observing Run

We search for gravitational-wave signals produced by cosmic strings in the Advanced LIGO and Virgo full O3 dataset. Search results are presented for gravitational waves produced by cosmic string loop features such as cusps, kinks, and, for the first time, kink-kink collisions. A template-based search for short-duration transient signals does not yield a detection. We also use the stochastic gravitational-wave background energy density upper limits derived from the O3 data to constrain the cosmic string tension Gμ as a function of the number of kinks, or the number of cusps, for two cosmic string loop distribution models. Additionally, we develop and test a third model that interpolates between these two models. Our results improve upon the previous LIGO-Virgo constraints on Gμ by 1 to 2 orders of magnitude depending on the model that is tested. In particular, for the one-loop distribution model, we set the most competitive constraints to date: Gμ≲4×10^{-15}. In the case of cosmic strings formed at the end of inflation in the context of grand unified theories, these results challenge simple inflationary models.

Constraints on Cosmic Strings Using Data from the Third Advanced LIGO-Virgo Observing Run

We search for gravitational-wave signals produced by cosmic strings in the Advanced LIGO and Virgo full O3 dataset. Search results are presented for gravitational waves produced by cosmic string loop features such as cusps, kinks, and, for the first time, kink-kink collisions. A template-based search for short-duration transient signals does not yield a detection. We also use the stochastic gravitational-wave background energy density upper limits derived from the O3 data to constrain the cosmic string tension Gμ as a function of the number of kinks, or the number of cusps, for two cosmic string loop distribution models. Additionally, we develop and test a third model that interpolates between these two models. Our results improve upon the previous LIGO-Virgo constraints on Gμ by 1 to 2 orders of magnitude depending on the model that is tested. In particular, for the one-loop distribution model, we set the most competitive constraints to date: Gμ≲4×10^{-15}. In the case of cosmic strings formed at the end of inflation in the context of grand unified theories, these results challenge simple inflationary models.

513 THE INFLUENCE OF FRAILTY ON OUTCOMES FOR OLDER ADULTS ADMITTED TO HOSPITAL WITH BENIGN BILIARY AND PANCREATIC DISEASE

Introduction

The prevalence and complications of biliary disease increase with age. We describe the prevalence of frailty in older patients hospitalised with benign biliary and pancreatic disease and establish its association with mortality and duration of hospital stay.

Methods

Prospective observational cohort study of patients aged 75 years and over admitted with a diagnosis of acute biliary disease to a surgical hospital unit between 17/09/2014 and 20/03/2017. Clinical Frailty Scale (CFS) score was recorded on admission.

Results

We included 200 patients with a median age of 82 (75–99), 60% females, 89% lived in their homes, 154 (77%) were independent for personal and 99 (49.5%) for instrumental ADLs, 95% mobilised independently, 17.5% had memory impairment and 8% low mood. Acute cholecystitis was the most common diagnosis (43%) followed by acute cholangitis (36%) and acute pancreatitis (21%). 99 patients were non-frail (NF = CFS 1–4) and 101 were frail (F = CFS ≥5). 104 patients received medical treatment only. Surgery was more common in non-frail (F 2% vs. NF 11%), percutaneous drainage more frequently carried out in frail patients (15% vs. NF 5%) and endoscopic cholangiopancreatography (ERCP) was similar in both groups (F 32%vs. NF 31%). Frailty was associated with worse clinical outcomes in F vs. NF: functional deconditioning (34% vs. 11%), increased care level (19% vs 3%), length of stay (12 vs. 7 days), 90-day (8% vs. 3%) and 1 year-mortality (48% vs. 24%).

Conclusion

Half of patients in our cohort of older adults hospitalised with acute biliary disease were frail. Higher scores of frailty are associated with increased mortality. Compared with non-frail patients, individuals living with frailty were less likely to undergo surgical treatment, spent longer in hospital and were less likely to remain alive at 12 months after hospital discharge.

472 A PILOT COLORECTAL AND GERIATRIC MEDICINE (CGM) CLINIC FOR OLDER, FRAIL PATIENTS REFERRED VIA A 2 WEEK WAIT PATHWAY

Introduction

The two week wait (2ww) colorectal referral pathway was introduced to expedite referrals where cancer is suspected, facilitating prompt diagnosis +/− intervention. Older frail patients are referred via this 2ww pathway even when invasive testing and intervention may not be appropriate. These patients may benefit more from holistic assessment than a universally surgical approach. A Colorectal and Geriatric Medicine (CGM) 2ww referral clinic was piloted, delivered by an urgent referral colorectal specialist nurse and an advanced clinical practitioner in geriatric medicine.

Method

Patients &gt;65 years with a Clinical Frailty Scale (CFS) score of 5 or more at referral were directed to the CGM clinic. A telephone consultation was undertaken, incorporating both 2ww assessment and aspects of comprehensive geriatric assessment.

Results

42-patients were reviewed in the clinic. Mean age was 86.1 years and mean CFS 6. 12-patients underwent CT, and 2 CT virtual colonoscopy. No patients underwent endoscopic investigation and 28-patients declined any investigation. Of those who underwent investigation, no cancers were identified. 1 patient was referred on for endosocpic mucosal resection of polyps. 5-patients had severe diverticular disease, which accounted for their symptoms. Medication recommendations were made for 30-patients, some of which led to symptom cessation. Onward referrals were made to a community geriatrician, diabetes and continence teams, and palliative care specialists. 9-patients were identified as meeting criteria for advance care planning. This was commenced during the consultation and communicated back to the referring clinician for further action.

Conclusion

Older, frail patients are often not able, nor wish to undergo, invasive investigations but should not be disadvantaged or delayed in their pathway. Further work is needed to determine the most appropriate referral pathway for this group of patients. Holistic assessment that leads to improvement in symptoms and future planning may not be achievable through a solely surgical assessment.

Effect of timing, technique and molecular features on brain control with local therapies in oncogene-driven lung cancer

BACKGROUND

The improved efficacy of tyrosine kinase inhibitors (TKI) mandates reappraisal of local therapy (LT) for brain metastases (BM) of oncogene-driven non-small-cell lung cancer (NSCLC).

PATIENTS AND METHODS

This study included all epidermal growth factor receptor-mutated (EGFR⁺, n = 108) and anaplastic lymphoma kinase-rearranged (ALK⁺, n = 33) TKI-naive NSCLC patients diagnosed with BM in the Thoraxklinik Heidelberg between 2009 and 2019. Eighty-seven patients (62%) received early LT, while 54 (38%) received delayed (n = 34; 24%) or no LT (n = 20; 14%). LT comprised stereotactic (SRT; n = 40; 34%) or whole-brain radiotherapy (WBRT; n = 77; 66%), while neurosurgical resection was carried out in 19 cases.

RESULTS

Median overall survival (OS) was 49.1 months for ALK⁺ and 19.5 months for EGFR⁺ patients (P = 0.001), with similar median intracranial progression-free survival (icPFS) (15.7 versus 14.0 months, respectively; P = 0.80). Despite the larger and more symptomatic BM (P < 0.001) of patients undergoing early LT, these experienced longer icPFS [hazard ratio (HR) 0.52; P = 0.024], but not OS (HR 1.63; P = 0.12), regardless of the radiotherapy technique (SRT versus WBRT) and number of lesions. High-risk oncogene variants, i.e. non-del19 EGFR mutations and 'short' EML4-ALK fusions (mainly variant 3, E6:A20), were associated with earlier intracranial progression (HR 2.97; P = 0.001). The longer icPFS with early LT was also evident in separate analyses of the EGFR⁺ and ALK⁺ subsets.

CONCLUSIONS

Despite preferential use for cases with poor prognostic factors, early LT prolongs the icPFS, but not OS, in TKI-treated EGFR⁺/ALK⁺ NSCLC. Considering the lack of survival benefit, and the neurocognitive effects of WBRT, patients presenting with polytopic BM may benefit from delaying radiotherapy, or from radiosurgery of multiple or selected lesions. For SRT candidates, the improved tumor control with earlier radiotherapy should be weighed against the potential toxicity and the enhanced intracranial activity of newer TKI. High-risk EGFR/ALK variants are associated with earlier intracranial failure and identify patients who could benefit from more aggressive management.

Mortality from esophagectomy for esophageal cancer across low, middle, and high-income countries: An international cohort study

BACKGROUND

No evidence currently exists characterising global outcomes following major cancer surgery, including esophageal cancer. Therefore, this study aimed to characterise impact of high income countries (HIC) versus low and middle income countries (LMIC) on the outcomes following esophagectomy for esophageal cancer.

METHOD

This international multi-center prospective study across 137 hospitals in 41 countries included patients who underwent an esophagectomy for esophageal cancer, with 90-day follow-up. The main explanatory variable was country income, defined according to the World Bank Data classification. The primary outcome was 90-day postoperative mortality, and secondary outcomes were composite leaks (anastomotic leak or conduit necrosis) and major complications (Clavien-Dindo Grade III - V). Multivariable generalized estimating equation models were used to produce adjusted odds ratios (ORs) and 95% confidence intervals (CI95%).

RESULTS

Between April 2018 to December 2018, 2247 patients were included. Patients from HIC were more significantly older, with higher ASA grade, and more advanced tumors. Patients from LMIC had almost three-fold increase in 90-day mortality, compared to HIC (9.4% vs 3.7%, p < 0.001). On adjusted analysis, LMIC were independently associated with higher 90-day mortality (OR: 2.31, CI95%: 1.17-4.55, p = 0.015). However, LMIC were not independently associated with higher rates of anastomotic leaks (OR: 1.06, CI95%: 0.57-1.99, p = 0.9) or major complications (OR: 0.85, CI95%: 0.54-1.32, p = 0.5), compared to HIC.

CONCLUSION

Resections in LMIC were independently associated with higher 90-day postoperative mortality, likely reflecting a failure to rescue of these patients following esophagectomy, despite similar composite anastomotic leaks and major complication rates to HIC. These findings warrant further research, to identify potential issues and solutions to improve global outcomes following esophagectomy for cancer.

Standardising clinical outcomes measures for adult clinical trials in Fabry disease: A global Delphi consensus

BACKGROUND

Recent years have witnessed a considerable increase in clinical trials of new investigational agents for Fabry disease (FD). Several trials investigating different agents are currently in progress; however, lack of standardisation results in challenges to interpretation and comparison. To facilitate the standardisation of investigational programs, we have developed a common framework for future clinical trials in FD.

METHODS AND FINDINGS

A broad consensus regarding clinical outcomes and ways to measure them was obtained via the Delphi methodology. 35 FD clinical experts from 4 continents, representing 3389 FD patients, participated in 3 rounds of Delphi procedure. The aim was to reach a consensus regarding clinical trial design, best treatment comparator, clinical outcomes, measurement of those clinical outcomes and inclusion and exclusion criteria. Consensus results of this initiative included: the selection of the adaptative clinical trial as the ideal study design and agalsidase beta as ideal comparator treatment due to its longstanding use in FD. Renal and cardiac outcomes, such as glomerular filtration rate, proteinuria and left ventricular mass index, were prioritised, whereas neurological outcomes including cerebrovascular and white matter lesions were dismissed as a primary or secondary outcome measure. Besides, there was a consensus regarding the importance of patient-related outcomes such as general quality of life, pain, and gastrointestinal symptoms. Also, unity about lysoGb3 and Gb3 tissue deposits as useful surrogate markers of the disease was obtained. The group recognised that cardiac T1 mapping still has potential but requires further development before its widespread introduction in clinical trials. Finally, patients with end-stage renal disease or renal transplant should be excluded unless a particular group for them is created inside the clinical trial.

CONCLUSION

This consensus will help to shape the future of clinical trials in FD. We note that the FDA has, coincidentally, recently published draft guidelines on clinical trials in FD and welcome this contribution.