A Comparative study on the Effectiveness of Augmented Reality on Denture Tooth Selection

One of the most difficult aspects of providing removable dentures, for both the patient and the dentist, is the tooth selection process. The aim of this study was to assess the effectiveness of augmented reality (AR) on patient experience of the tooth selection process.

MATERIALS AND METHODS

3D scanning of upper anterior teeth of various shapes and sizes allowed for the creation of a virtual library that were subsequently used to programme an AR software application, 'ToothPick'. Seventeen participants were recruited to a comparative study at Leeds Dental Institute, over two clinical appointments, to trial the app and complete a 10-question survey to assess the efficacy of AR simulation. The sample size response generated outcome variables for 'perceived usefulness' and 'perceived ease of use' from the perspectives of the patient, dentist and technician.

RESULTS

By the second appointment, 86% of participants preferred the app over the conventional methods for selection of denture teeth due to increased ease of use and accuracy that AR simulation had in replicating the wax try-in.

CONCLUSION

The sample population favoured the adoption of AR technology to select denture teeth from the perspective of both the patient and the clinician.

Comparison of the prognostic value of stress and rest pulmonary transit time estimation using myocardial perfusion CMR

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): British Heart Foundation Clinical Research Training Fellowship

Background

Pulmonary transit time (PTT) is a quantitative biomarker of cardiopulmonary status. Rest PTT was previously shown to predict outcomes in specific disease models, but clinical adoption is hindered but challenges in data acquisition. Whether evaluation of PTT during stress encodes incremental prognostic information has not been previously investigated as scale.

Objectives

To compare the prognostic value of stress and rest PTT derived from a fully automated, in-line method of estimation using perfusion CMR, in a large patient cohort.

Methods

A retrospective two-center study of patients referred clinically for adenosine stress myocardial perfusion assessment using CMR. Analysis of right and left ventricular cavity arterial input function curves from first pass perfusion was performed automatically, allowing the in-line estimation of both rest and stress PTT. Association with major adverse cardiovascular events (MACE) was evaluated. MACE was defined as a composite outcome of myocardial infarction, stroke, heart failure admission and ventricular tachycardia or appropriate ICD treatment (including ICD shock and/or anti-tachycardia pacing).

Results

985 patients (67% male, median age 62 years (IQR 52,71)) were included, with median left ventricular ejection fraction (LVEF) of 62% (IQR 54-69). Median stress PTT was shorter than rest PTT 6.2 (IQR 5.1, 7.7) seconds versus 7.7 (IQR, 6.4, 9.2) seconds. Stress and rest PTT were highly correlated (r = 0.69; p < 0.001). Stress PTT also correlated with LVEF (r=-0.37), stress MBF (r=-0.31), LVEDVi (r = 0.24), LA area index (r = 0.32) (p < 0.001 for all). Over a median follow-up period of 28.6 (IQR, 22.6 35,7) months, MACE occurred in 61 (6.2%) patients. After adjusting for prognostic factors, both rest and stress PTT, independently predicted MACE, but not all-cause mortality. For every 1xSD (2.39s) increase in rest PTT the adjusted hazard ratio (HR) for MACE was 1.43 (95% CI 1.10-1.85, p = 0.007). The hazard ratio for one standard deviation (2.64s) increase in stress PTT was 1.34 (95% CI 1.048-1.723; p = 0.020) after adjusting for age, LVEF, hypertension, diabetes, sex and presence of LGE

Conclusions

In this 2-center study of 985 patients, we deploy a fully automated method of PTT estimation using perfusion mapping with CMR and show that both stress and rest PTT are independently associated with adverse cardiovascular outcomes. In this patient cohort, there is no clear incremental prognostic value of stress PTT, over its evaluation during rest.

Figure 1. Stress and Rest Pulmonary Transit Time estimation using myocardial perfusion CMR

Figure 2. Event-free survival curves for major adverse cardiovascular events (Heart failure hospitalization, myocardial infarction, stroke and ventricular tachycardia/ICD treatment) according to mean rest PTT (8.05seconds) and mean stress PTT (6.7seconds). Log-rank for both p < 0.05

Prospective case-control study of cardiovascular abnormalities six months following mild COVID-19 in healthcare workers

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): Barts Charity UCLH Charity

OnBehalf

COVIDsortium

Background

Recent CMR studies have reported cardiac abnormalities after COVID-19 are common, even after mild, non-hospitalised illness with evidence of ongoing myocardial inflammation.  Such a prevalence of chronic myocarditis after mild disease has prompted societal concerns in diverse domains, and suggests that screening should be considered post COVID-19, even in asymptomatic individuals.  Cardiovascular magnetic resonance (CMR) has proven utility for diagnosis in patients with COVID-19 infection and elevated troponin from unclear causes by measuring cardiac structure, function, myocardial scar (late gadolinium enhancement) and oedema (T1 and T2 mapping).

Objectives

We aimed to determine the prevalence and extent of late cardiac and cardiovascular sequelae after mild non-hospitalised SARS-CoV-2 infection.

Methods

Participants were recruited from COVIDsortium, a three-hospital prospective study of 731 healthcare workers who underwent first wave weekly symptom, PCR and serology assessment over 4 months, with seroconversion in 21.5% (n = 157). At 6 months post infection, 74 seropositive and 75 age-, sex-, ethnicity-matched seronegative controls were recruited for cardiovascular phenotyping (comprehensive phantom-calibrated Cardiovascular Magnetic Resonance and blood biomarkers). Analysis was blinded, using objective AI analytics where available.

Results

149 subjects (mean age 37 years, range 18-63, 58% female) were recruited. Seropositive infections had been mild with case definition/non-case definition/asymptomatic disease in 45(61%), 18(24%) and 11(15%) with one person hospitalised (for 2 days). Between seropositive and seronegative groups, there were no differences in cardiac structure (left ventricular volumes, mass; atrial area), function (ejection fraction, global longitudinal shortening, aortic distensibility), tissue characterisation (T1, T2, ECV mapping, late gadolinium enhancement) or biomarkers (troponin, NT-proBNP).  With abnormal defined by the 75 seronegatives (2 standard deviations from mean, e.g. EF < 54%, septal T1 > 1072ms, septal T2 > 52.4ms), individuals had abnormalities including reduced EF (n = 2, minimum 50%), T1 elevation (n = 6), T2 elevation (n = 9), LGE (n = 13, median 1%, max 5% of myocardium), biomarker elevation (borderline troponin elevation in 4; all NT-proBNP normal). These were distributed equally between seropositive and seronegative individuals.

Conclusions

Cardiovascular abnormalities are no more common in seropositive vs seronegative otherwise healthy, workforce representative individuals 6 months post mild SARS-CoV-2 infection.  Our study provides societal reassurance for the cardiovascular health of working-aged individuals with convalescence from mild SARS-CoV-2. Screening asymptomatic individuals following mild diseases is not indicated.

The effect of coincidental SARS-CoV-2 infection on pre-operative cardiopulmonary exercise testing

This case report demonstrates the significant impact active infection with SARS-CoV-2 can have on functional capacity evaluated by cardiopulmonary exercise testing, even in minimally symptomatic individuals. A 75-year-old man underwent cardiopulmonary exercise testing before a right hemicolectomy; SARS-CoV-2 was incidentally diagnosed following his test. The patient underwent a period of isolation and recovery before a second pre-operative cardiopulmonary exercise test 6 weeks later. His resting pulmonary function tests did not vary between tests but his peak work, anaerobic threshold, oxygen pulse, pulse oximetry nadir, ventilation perfusion matching and heart rate response to exercise all improved significantly after this recovery period. These are unique results that add to the existing knowledge of the pathophysiology and management of SARS-CoV-2 in the peri-operative setting. While our patient demonstrated dramatic improvement in his functional capacity following 6 weeks of recovery, he remained in a high-risk group for surgery according to our local guidelines. Cardiopulmonary exercise testing has a valuable role in individualised risk assessment and shared decision-making in complex, urgent surgical cases where the benefits of delaying surgery to recover from SARS-CoV-2 infection should be balanced against the potential risks.

OP0241 SERIOUS INFECTION WITH TOCILIZUMAB COMPARED TO TNF-INHIBITORS AND OTHER BDMARDS IN RHEUMATOID ARTHRITIS PATIENTS: DOES LINE OF THERAPY MATTER?

Background:

In the real-world, tocilizumab is prescribed to a population of patients different from those prescribed TNF-inhibitors, often older with longer disease duration, worse functional status and more previous b- or tsDMARDs.

Objectives:

The aim of this study was to evaluate if and how the risk of serious infection on tocilizumab and other bDMARDs differs when stratifying by line of therapy in a real-world population of rheumatoid arthritis patients.

Methods:

We included patients registered in the BSRBR-RA treated with tocilizumab, etanercept, adalimumab, infliximab, certolizumab, abatacept or rituximab, including biosimilars. Primary outcome was the occurrence of a serious infection (defined as infection requiring hospitalisation, intravenous antibiotics or resulting in death). Primary covariate of interest was line of therapy (from first to fifth line of therapy). Every change to another b- or tsDMARD was considered a new line of therapy, but not a change between a bio-original and a biosimilar.

Hazard ratios (HR) of serious infections were estimated using an inverse probability weighted Cox regression, based on a propensity score including baseline patient and disease characteristics, and adjusting for time in study (see Table). The reference group was etanercept, which included the highest number of patients. Treatment exposure was analysed without and with stratification by line of therapy.

Table.NETNTCZADAIFXCERTRTXABAN33,91610,6552,6327,8394,4301,6165,5561,188Patient-years19,1294,34214,5048,1352,72612,0091,686Infections8071926814817443374Incidence per 100 patient-years (95%CI)4.2 (3.9-4.5)4.4 (3.8-5.1)4.7 (4.4-5.1)5.9 (5.4-6.6)2.7 (2.2-3.4)3.6 (3.3-4.0)4.0 (3.2-5.1)Unadjusted HR (95%CI)Ref.1.0 (0.9-1.2)1.1 (1.0-1.2)1.4 (1.2-1.6)0.6 (0.5-0.8)0.9 (0.8-1.0)0.9 (0.7-1.2)Adjusted HR* (95% CI)All lines of therapy33,916Ref.1.2 (1.0-1.5)1.1 (1.0-1.3)1.3 (1.1-1.6)0.8 (0.6-1.0)1.0 (0.8-1.1)1.2 (0.8-1.7)1stline16,152Ref.0.9 (0.5-1.5)1.1 (1.0-1.3)1.3 (1.1-1.6)0.6 (0.5-0.9)1.6 (1.2-2.2)-2ndline10,378Ref.1.4 (1.0-2.0)1.1 (0.9-1.4)1.1 (0.7-1.6)0.9 (0.4-2.2)1.0 (0.8-1.2)0.9 (0.5-1.9)3rdline4,676Ref.1.4 (0.9-2.3)1.3 (0.8-2.2)0.9 (0.4-1.9)0.9 (0.3-2.9)0.8 (0.5-1.2)1.5 (0.7-2.9)4thline1,947Ref.1.0 (0.5-2.3)1.3 (0.4-3.7)1.4 (0.5-4.4)0.2 (0.0—2.1)1.0 (0.5.-2.2)0.9 (0.4-2.3)5thline763Ref.0.9 (0.2-3.5)2.5 (0.5-12.4)0.7 (0.1-7.1)3.3 (0.6-18.4)0.9 (0.2-3.5)0.8 (0.2-3.5)

ABA, abatacept; ADA, adalimumab; CERT, certolizumab; ETN, etanercept; HR, hazard ratio; IFX, infliximab; RTX, rituximab; TCZ, tocilizumab

*Adjusted using inverse probably weighting (with age, gender, concomitant steroids, concomitant DMARDs, comorbidities, seropositivity, smoking, disease duration, HAQ and DAS28 at baseline in the model) and time since study entry (categorised from 0 to 4, 0 starting just before or at the moment of entering study, 1 starting during the first year, 2 starting during the second year until 4 for the fourth year and more)

Results:

A total of 33,916 treatment courses were included (Table) contributing to 62,532 years of follow-up. Compared to etanercept, participants starting abatacept, tocilizumab and rituximab were older, had more previous bDMARDs, longer disease duration and more comorbidities. The crude HR of serious infections were higher with infliximab and adalimumab, lower with certolizumab and rituximab, and not significantly different for abatacept and tocilizumab compared to etanercept. After adjustment, HR of serious infections were higher with tocilizumab, adalimumab and infliximab. However, when stratified by line of therapy, HR were no longer significantly different compared to etanercept for tocilizumab, adalimumab and infliximab for most lines of therapy.

Conclusion:

Whilst initially there appears to be a difference in rates of serious infection between biologic therapies, line of therapy may be a confounding factor when comparing the risk of serious infections between bDMARDs.

Disclosure of Interests:

Kim Lauper Consultant of: Gilead-galapagos, Grant/research support from: AbbVie, Lianne Kearsley-Fleet: None declared, Rebecca Davies: None declared, Kath Watson: None declared, Mark Lunt: None declared, Kimme Hyrich Consultant of: AbbVie, Grant/research support from: Pfizer, BMS

Reduction in antimicrobial resistance prevalence in Escherichia coli from a pig farm following withdrawal of group antimicrobial treatment

An important element in the control of antimicrobial resistance (AMR) is reduction in antimicrobial usage. In the veterinary sector individual antimicrobial treatment of livestock, rather than the use of group treatment, can help achieve this goal. The aim of this study was to investigate how cessation of group antimicrobial treatment impacted the prevalence of AMR in commensal Escherichia coli in pigs at one farm over an 11-month period. Minimum inhibitory concentrations of eight antimicrobials were determined for 259 E. coli isolates collected during the study. A significant reduction in the prevalence of multidrug resistance and a significant increase in the proportion of full susceptibility to the panel of nine antimicrobials tested was seen after 11 months. Whole genome sequencing of 48 multidrug resistant isolates revealed E. coli clones that persisted across multiple visits and provided evidence for the presence of plasmids harbouring AMR genes shared across multiple E. coli lineages. E. coli were also isolated from on-farm environmental samples. Whole genome sequencing of one multidrug resistant isolate obtained from cleaning tools showed it was clonal to pig-derived E. coli that persisted on the farm for 11 months. In this study we provide evidence that withdrawal of group antimicrobial use leads to significant reductions in key indicators for AMR prevalence and the importance of the farm environment as a reservoir of resistant bacteria. These findings support policy makers and producers in the implementation of measures to control AMR and reduce antimicrobial use.

Acute kidney injury following endovascular intervention for peripheral artery disease

BACKGROUND

The incidence of, and risk factors for, acute kidney injury (AKI) after endovascular intervention for peripheral artery disease (PAD) remain unknown. The aim of this study was to assess the proportion of patients who develop AKI and explore the risk factors.

METHODS

Prospectively collected data on patients undergoing femoropopliteal endovascular intervention for symptomatic PAD across three vascular centres were analysed. The proportion of patients developing AKI (according to the Kidney Disease Improving Global Outcomes definition) within 48 h, and the proportion developing the composite Major Adverse Kidney Events (MAKE) endpoints (death, dialysis, drop in estimated glomerular filtration rate at least 25 per cent) at 30 days (MAKE30) and remains 90 days (MAKE90) were calculated. Multivariable regression analysis was used to assess predictors of AKI, and the association between AKI and death.

RESULTS

Some 2041 patients were included in the analysis. AKI developed in 239 patients (11.7 per cent), with 47 (2.3 per cent) requiring dialysis within 30 days, and 18 (0.9 per cent) requiring ongoing dialysis. The MAKE30 and MAKE90 composite endpoints were reached in 358 (17.5 per cent) and 449 (22.0 per cent) patients respectively. Risk factors for AKI were age, sex, congestive heart failure, chronic limb-threatening ischaemia, emergency procedure, and pre-existing chronic kidney disease. AKI, dementia, congestive heart failure, and major amputation were risk factors for medium-term mortality.

CONCLUSION

AKI is a common complication after intervention for PAD and is associated with medium-term mortality.

Dental school before or after core surgical training? Consideration for medically qualified junior trainees prior to embarking on - their second degree

Medical graduates who are interested in pursuing a career in oral and maxillofacial surgery require attainment of a degree in dental surgery (BDS). A common question facing this cohort of junior trainees is whether to study dentistry before or after core surgical training; both routes have advantages and disadvantages that must be considered. Here we provide our perspective into this common dilemma.

Optimal symptom combinations to aid COVID-19 case identification: Analysis from a community-based, prospective, observational cohort

Objectives

Diagnostic work-up following any COVID-19 associated symptom will lead to extensive testing, potentially overwhelming laboratory capacity whilst primarily yielding negative results. We aimed to identify optimal symptom combinations to capture most cases using fewer tests with implications for COVID-19 vaccine developers across different resource settings and public health.

Methods

UK and US users of the COVID-19 Symptom Study app who reported new-onset symptoms and an RT-PCR test within seven days of symptom onset were included. Sensitivity, specificity, and number of RT-PCR tests needed to identify one case (test per case [TPC]) were calculated for different symptom combinations. A multi-objective evolutionary algorithm was applied to generate combinations with optimal trade-offs between sensitivity and specificity.

Findings

UK and US cohorts included 122,305 (1,202 positives) and 3,162 (79 positive) individuals. Within three days of symptom onset, the COVID-19 specific symptom combination (cough, dyspnoea, fever, anosmia/ageusia) identified 69% of cases requiring 47 TPC. The combination with highest sensitivity (fatigue, anosmia/ageusia, cough, diarrhoea, headache, sore throat) identified 96% cases requiring 96 TPC.

Interpretation

We confirmed the significance of COVID-19 specific symptoms for triggering RT-PCR and identified additional symptom combinations with optimal trade-offs between sensitivity and specificity that maximize case capture given different resource settings.

Optimal symptom combinations to aid COVID-19 case identification: analysis from a community-based, prospective, observational cohort

OBJECTIVES

Diagnostic work-up following any COVID-19 associated symptom will lead to extensive testing, potentially overwhelming laboratory capacity whilst primarily yielding negative results. We aimed to identify optimal symptom combinations to capture most cases using fewer tests with implications for COVID-19 vaccine developers across different resource settings and public health.

METHODS

UK and US users of the COVID-19 Symptom Study app who reported new-onset symptoms and an RT-PCR test within seven days of symptom onset were included. Sensitivity, specificity, and number of RT-PCR tests needed to identify one case (test per case [TPC]) were calculated for different symptom combinations. A multi-objective evolutionary algorithm was applied to generate combinations with optimal trade-offs between sensitivity and specificity.

FINDINGS

UK and US cohorts included 122,305 (1,202 positives) and 3,162 (79 positive) individuals. Within three days of symptom onset, the COVID-19 specific symptom combination (cough, dyspnoea, fever, anosmia/ageusia) identified 69% of cases requiring 47 TPC. The combination with highest sensitivity (fatigue, anosmia/ageusia, cough, diarrhoea, headache, sore throat) identified 96% cases requiring 96 TPC.

INTERPRETATION

We confirmed the significance of COVID-19 specific symptoms for triggering RT-PCR and identified additional symptom combinations with optimal trade-offs between sensitivity and specificity that maximize case capture given different resource settings.

Temporal changes in the gut microbiota in farmed Atlantic cod (Gadus morhua) outweigh the response to diet supplementation with macroalgae

BACKGROUND

Aquaculture successfully meets global food demands for many fish species. However, aquaculture production of Atlantic cod (Gadus morhua) is just 2.5% of total market production. For cod farming to be a viable economic venture specific challenges on how to increase growth, health and farming productivity need to be addressed. Feed ingredients play a key role here. Macroalgae (seaweeds) have been suggested as a functional feed supplement with both health and economic benefits for terrestrial farmed animals and fish. The impact of such dietary supplements to cod gut integrity and microbiota, which contribute to overall fish robustness is unknown. The objective of this study was to supplement the diet of juvenile Atlantic cod with macroalgae and determine the impacts on fish condition and growth, gut morphology and hindgut microbiota composition (16S rRNA amplicon sequencing). Fish were fed one of three diets: control (no macroalgal inclusion), 10% inclusion of either egg wrack (Ascophyllum nodosum) or sea lettuce (Ulva rigida) macroalgae in a 12-week trial.

RESULTS

The results demonstrated there was no significant difference in fish condition, gut morphology or hindgut microbiota between the U. rigida supplemented fish group and the control group at any time-point. This trend was not observed with the A. nodosum treatment. Fish within this group were further categorised as either 'Normal' or 'Lower Growth'. 'Lower Growth' individuals found the diet unpalatable resulting in reduced weight and condition factor combined with an altered gut morphology and microbiome relative to the other treatments. Excluding this group, our results show that the hindgut microbiota was largely driven by temporal pressures with the microbial communities becoming more similar over time irrespective of dietary treatment. The core microbiome at the final time-point consisted of the orders Vibrionales (Vibrio and Photobacterium), Bacteroidales (Bacteroidetes and Macellibacteroides) and Clostridiales (Lachnoclostridium).

CONCLUSIONS

Our study indicates that U. rigida macroalgae can be supplemented at 10% inclusion levels in the diet of juvenile farmed Atlantic cod without any impact on fish condition or hindgut microbial community structure. We also conclude that 10% dietary inclusion of A. nodosum is not a suitable feed supplement in a farmed cod diet.

A change of heart: Preliminary results of the US 2018 adult heart allocation revision

In 2018, the Organ Procurement and Transplantation Network (OPTN) modified adult heart allocation to better stratify candidates and provide broader access to the most medically urgent candidates. We analyzed OPTN data that included waiting list and transplant characteristics, geographical distribution, and early outcomes 1 year before (pre: October 18, 2017-October 17, 2018) and following (post: October 18, 2018-October 17, 2019) implementation. The number of adult heart transplants increased from 2954 pre- to 3032 postimplementation. Seventy-eight percent of transplants in the post era were for the most medically urgent (statuses 1-3) compared to 68% for status 1A in the pre era. The median distance between the donor hospital and transplant center increased from 83 to 216 nautical miles, with an increase in total ischemic time from 3 to 3.4 hours (all P < .001). Waiting list mortality was not different across eras (14.8 vs 14.9 deaths per 100 patient-years pre vs post respectively). Posttransplant patient survival was not different, 93.6% pre and 92.8% post. There is early evidence that the heart allocation policy has enhanced stratification of candidates by their medical urgency and broader distribution for the most medically urgent candidates with minimal impact on overall waiting list mortality and posttransplant outcomes.

Modelling scenarios of environmental recovery after implementation of controls on emissions of persistent organic pollutants

Comparison of monitoring data with toxicologically-derived environmental quality standards (EQSs) forms the basis of assessments of the quality status of the water environment. Having established the status quo, the logical next step is to address instances of non-compliance with EQSs by applying remedial measures, including reducing the use or at least the emission of the substances of concern or by taking steps to reduce concentrations already present using technological solutions such as enhanced wastewater treatment. The selection of suitable remedial measures must be a compromise between cost, likely effectiveness and the timescale over which improvements might be acceptable. The decision on overall environmental management has also to take into account the need for demonstrable progress; this might mean that it is preferable to address some more readily achievable goal rather than to attempt to solve a more serious, but ultimately intractable problem. This paper describes the development and application of a generic modelling tool that provides a way of assessing the potential requirements for remedial actions and their likely outcomes over a timescale of up to forty years taking account of sediment partitioning, environmental degradation and biological accumulation. The tool was validated using a detailed UK wastewater treatment works effluent discharge dataset. Examples involving several chemicals that are of current concern are provided. Some substances (e.g. tributyltin, PFOS) are identified as likely to meet EQS values in sediments or biota in a relatively short timescale; others (PAHs, DEHP) appear to represent more intractable problems.

A comprehensive strategy in donor acceptance: Impact on pediatric waitlist and heart transplant outcomes

Significant inter- and intra-center practice variability is present in pediatric donor heart acceptability. This may contribute to variation in the donor refusal rate and may impact waitlist time, morbidity, mortality, and transplant rates. In order to reduce practice variability, our center developed and implemented a comprehensive strategy regarding donor acceptance in September 2017. The aim of this study was to assess the impact of this strategy on waitlist time and outcomes as well as early post-transplant outcomes. We performed a single-center, retrospective analysis of all pediatric (<18 years) patients listed for single-organ heart transplant at our center from September 2015 to September 2018. Patients were divided into those listed before (Group 1) and after implementation of the comprehensive strategy (Group 2). The primary end-point was waitlist time. Secondary end-points included waitlist removal due to death or clinical deterioration, donor refusals per listed patient, early post-transplant outcomes (graft failure, mechanical ventilation time, inotropic support, length of hospital stay) and 1-year post-transplant survival. Of 78 listed patients, 54 were transplanted (29 in Group 1), 9 were removed due to death or clinical deterioration (7 in Group 1) and 15 were removed due to clinical improvement (12 in Group 1). The waitlist time was significantly shorter in Group 2 (17 days, IQR 7-53) vs Group 1 (90 days, IQR 14-162); P = .006. The number of donor refusals was lower in Group 2 (1, IQR 0-2.2) vs Group 1 (4, IQR 2-19); P < .001. The percentage of refused donors with normal function (Left ventricular ejection fraction > 50%) was lower in Group 2 vs Group 1 (53% vs 84%; P < .001). Difference in removal from the waitlist for death or deterioration in Group 2 vs Group 1 (n = 2, 7% vs n = 7, 20%, P = .18) did not reach statistical significance. There was no difference in post-transplant outcomes between groups. The waitlist time and donor refusals significantly decreased after implementation of a comprehensive donor acceptance strategy without impacting transplant outcomes. This analysis supports the need for a comprehensive approach to donor organ acceptance within a pediatric transplant center.

Physiological performance and inflammatory markers as indicators of complications after oesophageal cancer surgery

BACKGROUND

The extent to which physiological factors influence outcome following oesophageal cancer surgery is poorly understood. This study aimed to evaluate the extent to which cardiorespiratory fitness and selected metabolic factors predicted complications after surgery for carcinoma.

METHODS

Two hundred and twenty-five consecutive patients underwent preoperative cardiopulmonary exercise testing to determine peak oxygen uptake ( V ˙ o_2peak ), anaerobic threshold and the ventilatory equivalent for carbon dioxide ( V ˙ e/ V ˙ co₂ ). Cephalic venous blood was assayed for serum C-reactive protein (CRP) and albumin levels, and a full blood count was done. The primary outcome measure was the Morbidity Severity Score (MSS).

RESULTS

One hundred and ninety-eight patients had anatomical resection. A high MSS (Clavien-Dindo grade III or above) was found in 48 patients (24·2 per cent) and was related to an increased CRP concentration (area under the receiver operating characteristic (ROC) curve (AUC) 0·62, P = 0·001) and lower V ˙ o_2peak (AUC 0·36, P = 0·003). Dichotomization of CRP levels (above 10 mg/l) and V ˙ o_2peak (below 18·6 ml per kg per min) yielded adjusted odds ratios (ORs) for a high MSS of 2·86 (P = 0·025) and 2·92 (P = 0·002) respectively. Compared with a cohort with a low Combined Inflammatory and Physiology Score (CIPS), the OR was 1·70 (95 per cent c.i. 0·85 to 3·39) for intermediate and 27·47 (3·12 to 241·69) for high CIPS (P < 0·001).

CONCLUSION

CRP and V ˙ o_2peak were independently associated with major complications after potentially curative oesophagectomy for cancer. A composite risk score identified a group of patients with a high risk of developing complications.

SAT0103 THE EFFECT OF BODYWEIGHT ON RESPONSE TO INTRAVENOUS OR SUBCUTANEOUS TOCILIZUMAB IN PATIENTS WITH RHEUMATOID ARTHRITIS

Background:

Tocilizumab is an IL-6 receptor humanised monoclonal antibody treatment option in rheumatoid arthritis (RA) who have not responded or are intolerant of disease modifying anti-rheumatic drugs (DMARDs) or other biologics. Tocilizumab was available initially as an intravenous (IV) preparation, dosed according to weight, and more recently as a subcutaneous (SC) preparation given at 162mg/weekly irrespective of bodyweight.

Obesity is highly prevalent in RA and there has been concern that starting or switching patients to SC tocilizumab could reduce its effectiveness in those patients with a higher body weight when compared to IV tocilizumab.

Objectives:

To investigate the relationship between bodyweight and DAS28 response at 6 months in tocilizumab naïve RA patients starting IV or SC tocilizumab.

Methods:

The study population comprised RA subjects recruited to the BSRBR-RA up to 30/11/2018 commencing IV or SC tocilizumab for the first time. Patients had to be tocilizumab naïve and have at least one six monthly study follow-up recorded after starting tocilizumab. Baseline characteristics at point of starting tocilizumab are described. Linear regression, fully adjusted for relevant confounders, was used to investigate the relationship between change in DAS28 score from baseline to six months and body weight per ten kilograms (kg), and in a separate analysis, as BMI category. Multiple imputation was used to handle missing data.

Results:

1241 patients starting tocilizumab (902 IV, 339 SC) were eligible for analysis. The median age was 59 years, majority were female, and had median disease duration of 11 years at baseline. Over seventy percent had prior biologic exposure. Median weight was 77kg for IV and 76kg for SC starters, and the majority of patients were categorised as normal weight (30% IV, 37% SC) or pre-obesity (31% IV & SC) according to BMI. Median DAS28 score was 5.8 (IV) and 5.5 (SC) at start of treatment with median improvement after 6-months of 1.50 and 2.02 units respectively. The fully adjusted linear regression model showed no association between body weight or BMI and change in DAS28 score at six months for patients starting IV or SC tocilizumab. (Table).

TableBaseline VariableIntravenous TCZ patients (n=902)Subcutaneous TCZ patients (n=339)Age, median (IQR)58 (50-67)60 (51-70)Gender, n (%) female708 (78)233 (74)Disease duration, median (IQR) years11 (4-21)11 (4-21)DAS28 score, median (IQR)5.8 (5.1-6.6)5.5 (4.7-6.5)Change in DAS28 score, median (IQR)-1.50 (-3.10 - -0.23)-2.02 (-3.72- -0.37)Weight in KGs, median (IQR)77 (64-91)76 (64-88)Change in DAS28, coefficient (95% CI)Body weight per 10kgs*0.04 (-0.01-0.09)-0.005 (-0.11-0.10)BMI category*Normal weightrefrefUnderweight-0.41 (-1.27-0.46)0.08 (-1.62-1.77)Pre-obesity-0.26 (-0.57-0.05)0.02 (-0.44-0.48)Obesity class I, II & III-0.03 (-0.35-0.29)0.08 (-0.40-0.55)

*Fully adjusted for age, gender, disease duration, baseline DAS28 score, baseline HAQ score, co-morbidities, and number of previous biologics

Conclusion:

Data from this study show that body weight does not appear to affect initial response to IV or SC tocilizumab. This is reassuring given that patients are likely to be given SC tocilizumab due to ease of administration and reduced hospital costs.

Disclosure of Interests:

Rebecca Davies: None declared, Arani Vivekanantham: None declared, Mark Lunt: None declared, Kath Watson: None declared, Kimme Hyrich Grant/research support from: Pfizer, UCB, BMS, Speakers bureau: Abbvie, James Bluett: None declared

Heart transplantation in an infant with Williams-Beuren syndrome and rapidly progressive ischemic cardiomyopathy

Ischemic cardiomyopathy with resultant refractory HF may occur in patients with WBS, often as the result of coronary involvement with SVAS. The rapid development of arteriopathy at a young age raises concerns regarding transplant candidacy due to progressive stenoses at other arterial sites with potential detrimental impact on long-term heart graft function. We report a 2-month-old male infant diagnosed with mild aortic stenosis during the neonatal period, but subsequently developed rapidly progressive supravalvar and coronary artery stenoses leading to cardiogenic shock due to myocardial ischemia. The presentation led to the diagnosis of WBS. He required prolonged CPR including ECMO therapy. He subsequently underwent LVAD implantation as bridge to transplant and 4 days later heart transplantation. His post-operative course was complicated by prolonged mechanical ventilation and extended intensive care unit and hospital stays. However, at follow-up 18 months post-transplant he continues to have normal graft function with mild, non-progressive residual coarctation of aorta and non-progressive moderately hypoplastic pulmonary arteries.

British Association of Oral and Maxillofacial Surgeons' National Facial Injury Surveys: hard tissue facial injuries presenting to UK emergency departments

The British Association of Oral and Maxillofacial Surgeons (BAOMS) and Saving Faces undertook two national prospective surveys 11 years apart. They recorded the facial injuries treated in UK emergency departments and collected data on 14872 patients. In this paper, which aims to act as a feasibility study for a third national survey of facial injuries, we have reviewed hard-tissue injuries and specifically focused on temporal changes in their morphology. The two sets of directly comparable, categorical, unpaired, cross-sectional data were evaluated independently for statistical significance. In 1997, there were 1977 hard-tissue facial injuries (33%) but in 2008 this had decreased to 1899 (22%) (p<0.05). In 1997, there were 1315 fractures (22%) and 662 dental injuries (11%) compared with 1462 (17%) fractures and 438 (5%) dental injuries in 2008 (p<0.05). There were proportional increases in orbital (21%), nasal (139%), and cranial fractures (340%) (p<0.05). The data showed a small reduction in the total number of hard-tissue injuries, but this was a considerable reduction as a proportion of the total injuries. Analysis of the type and subtype of injury generally pointed towards a reduction in their energy and severity, and to likely changes in mechanism. The project has proved the feasibility of a third national survey of facial injury.

Utilization and outcomes in biventricular assist device support in pediatrics

OBJECTIVE

Patients with biventricular assist devices (BiVADs) have worse outcomes than those with left ventricular assist devices (LVADs). It is unclear whether these outcomes are due to device selection or patient factors. We used propensity score matching to reduce patient heterogeneity and compare outcomes in pediatric patients supported with BiVADs with a similar LVAD cohort.

METHODS

The Pedimacs registry was queried for patients who were supported with BiVAD or LVAD. Patients were analyzed by BiVAD or LVAD at primary implant and the 2 groups were compared before and after using propensity score matching.

RESULTS

Of 363 patients who met inclusion criteria, 63 (17%) underwent primary BiVAD support. After propensity score matching, differences between cohorts were reduced. Six months after implant, in the BiVAD cohort (LVAD cohort) 52.5% (42.5%) had been transplanted; 32.5% (40%) were alive with device, and 15% (10%) had died. Survival was similar between cohorts (P = .31, log-rank), but patients with BiVADs were more likely to experience a major adverse event in the form of bleeding (P = .04, log-rank). At 1 week and 1 and 3 months' postimplant, the percentage of patients on mechanical ventilation, on dialysis, or with elevated bilirubin was similar between the 2 groups.

CONCLUSIONS

When propensity scores were used to reduce differences in patient characteristics, there were no differences in survival but more major adverse events in the patients with BiVADs, particularly bleeding. Differences in unmatched patient outcomes between LVAD and BiVAD cohorts likely represent differences in severity of illness rather than mode of support.