Assessing Detergent Residuals for Reusable Device Cleaning Validations

Cleaning chemistries are detergent-based formulations that are used during the processing of reusable medical devices. Manufacturers are responsible for demonstrating the safety of cleaning formulations when they are used during a device processing cycle, including the risk of device-associated cytotoxicity over the concentration ranges for recommended use and rinsing during cleaning. However, no regulation currently exists requiring manufacturers to demonstrate such safety. Although manufacturers' safety data sheets (SDSs) provide information on the safe use of chemicals for users, this information may not provide sufficient detail to determine the risks of residual chemicals on device surfaces. SDSs are not required to contain a comprehensive list of chemicals used, only those of risk to the user. They should be supplemented with information on the correct concentrations that should be used for cleaning, as well as instructions on the rinsing required to reduce the levels of chemicals to safe (nontoxic) levels prior to further processing. Supporting data, such as toxicity profiles or cytotoxicity data that support the instructions for use, would provide medical device manufacturers and healthcare personnel with the necessary information to make informed decisions about selection and correct use of detergents. In the current work, cytotoxicity profiles for eight commonly used cleaning formulations available internationally were studied. Although all of these products are indicated for use in the cleaning of reusable medical devices, results vary across the serial dilution curves and are not consistent among detergent types. The information presented here can be leveraged by both medical device manufacturers and processing department personnel to properly assess residual detergent risks during processing. This work also serves as a call to cleaning formulation manufacturers to provide this information for all chemistries.

Assessing Detergent Residuals for Reusable Device Cleaning Validations

Cleaning chemistries are detergent-based formulations that are used during the processing of reusable medical devices. Manufacturers are responsible for demonstrating the safety of cleaning formulations when they are used during a device processing cycle, including the risk of device-associated cytotoxicity over the concentration ranges for recommended use and rinsing during cleaning. However, no regulation currently exists requiring manufacturers to demonstrate such safety. Although manufacturers' safety data sheets (SDSs) provide information on the safe use of chemicals for users, this information may not provide sufficient detail to determine the risks of residual chemicals on device surfaces. SDSs are not required to contain a comprehensive list of chemicals used, only those of risk to the user. They should be supplemented with information on the correct concentrations that should be used for cleaning, as well as instructions on the rinsing required to reduce the levels of chemicals to safe (nontoxic) levels prior to further processing. Supporting data, such as toxicity profiles or cytotoxicity data that support the instructions for use, would provide medical device manufacturers and healthcare personnel with the necessary information to make informed decisions about selection and correct use of detergents. In the current work, cytotoxicity profiles for eight commonly used cleaning formulations available internationally were studied. Although all of these products are indicated for use in the cleaning of reusable medical devices, results vary across the serial dilution curves and are not consistent among detergent types. The information presented here can be leveraged by both medical device manufacturers and processing department personnel to properly assess residual detergent risks during processing. This work also serves as a call to cleaning formulation manufacturers to provide this information for all chemistries.

Image-based automated Psoriasis Area Severity Index scoring by Convolutional Neural Networks

Background

The Psoriasis Area and Severity Index (PASI) score is commonly used in clinical practice and research to monitor disease severity and determine treatment efficacy. Automating the PASI score with deep learning algorithms, like Convolutional Neural Networks (CNNs), could enable objective and efficient PASI scoring.

Objectives

To assess the performance of image‐based automated PASI scoring in anatomical regions by CNNs and compare the performance of CNNs to image‐based scoring by physicians.

Methods

Imaging series were matched to PASI subscores determined in real life by the treating physician. CNNs were trained using standardized imaging series of 576 trunk, 614 arm and 541 leg regions. CNNs were separately trained for each PASI subscore (erythema, desquamation, induration and area) in each anatomical region (trunk, arms and legs). The head region was excluded for anonymity. Additionally, PASI‐trained physicians retrospectively determined image‐based subscores on the test set images of the trunk. Agreement with the real‐life scores was determined with the intraclass correlation coefficient (ICC) and compared between the CNNs and physicians.

Results

Intraclass correlation coefficients between the CNN and real‐life scores of the trunk region were 0.616, 0.580, 0.580 and 0.793 for erythema, desquamation, induration and area, respectively, with similar results for the arms and legs region. PASI‐trained physicians (N = 5) were in moderate–good agreement (ICCs 0.706–0.793) with each other for image‐based PASI scoring of the trunk region. ICCs between the CNN and real‐life scores were slightly higher for erythema (0.616 vs. 0.558), induration (0.580 vs. 0.573) and area scoring (0.793 vs. 0.694) than image‐based scoring by physicians. Physicians slightly outperformed the CNN on desquamation scoring (0.580 vs. 0.589).

Conclusions

Convolutional Neural Networks have the potential to automatically and objectively perform image‐based PASI scoring at an anatomical region level. For erythema, desquamation and induration scoring, CNNs performed similar to physicians, while for area scoring CNNs outperformed physicians on image‐based PASI scoring.

The use of floating wire technique and intravascular ultrasound for precise aorto-ostial stenting

Background

Aorto-ostial interventions often lead to imprecise ostial demarcation, suboptimal stent implantation, and worse clinical outcomes when compared to non-ostial interventions. The floating wire technique (bumper or sepal wire technique) employs a second guidewire placed in the aortic root to both mark the ostium and prevent prolapse of the guide catheter past the target ostial lesion. Its use has been described in the literature and is used often in daily practice however, procedural and long-term clinical endpoints have not been assessed using the gold standard of post-implant IVUS to determine technical success. The aim of the study is therefore to objectively assess the rate of geographic miss using the floating wire technique as well as long-term clinical outcomes.

Methods

A single center retrospective study was conducted. Patients who underwent ostial lesion percutaneous coronary intervention (PCI) with the floating wire technique between January 2019 and September 2020 were identified. Procedural and clinical outcomes at 6 months follow up were investigated. The co-primary endpoints include 1) Geographic miss defined as inadequate ostial coverage by IVUS or excess stent protrusion on angiography and 2) Target lesion failure (TLF) at 6 months after PCI, defined as the composite of cardiovascular death, target-vessel myocardial infarction (MI), and target lesion revascularization.

Results

In total, 48 patients were identified. The average age was 71.7 years old, and 85.4% were male. Indication for PCI was acute coronary syndrome in about a third of patients. Twenty-six patients had left main ostial lesion, and 22 patients had right coronary artery ostial lesions. The average syntax score was 24.2. IVUS assessment was performed in 45 patients. Four (8.3%) patients had more than 2mm of excess stent proximal protrusion. Ostial miss occurred in 1 (2.2%) patient. Seven patients had loss to follow up. TLF, stroke, or major bleeding were not observed in any patients. One non-cardiovascular death, three type 2 MIs, and 1 type 4 MI were observed, which occurred in non-target vessels.

Conclusions

The floating wire technique was safe and efficient with low rates of geographic miss or adverse clinical outcomes. This is the first study to confirm precise aorto-ostial stent implantation using the floating wire technique with IVUS assessment.

Funding Acknowledgement

Type of funding sources: None. Floating Wire Technique for LM Stenting

119 The Potential of Low-fidelity Arthroscopic Simulation Training in Trauma and Orthopaedic Surgery: A Systematic Review of Experimental Studies

Aim

In an era of budget tightening and work-hour guideline reductions that have significantly reduced surgical exposure, low-fidelity arthroscopic simulators have an essential role to play in surgical training. The COVID-19 pandemic has only further amplified the need for alternative training models, as 91% of orthopaedic trainees have had elective procedures cancelled. The purpose of this systematic review is to synopsise the limited literature regarding the effectiveness of low-fidelity training models in the instruction of novices, and to formulate recommendations for future studies.

Method

The Embase, PubMed, Web of Science and Scopus databases were electronically searched. Studies from any year that described the use of orthopaedic, low-fidelity arthroscopic training models in novice populations were included. Questionnaires, case studies and review studies were excluded. Risk of bias assessments were also conducted for all studies.

Results

16 studies were identified. Using the PRISMA algorithm, 6 studies were deemed relevant. A cross-study comparison revealed low-fidelity arthroscopic simulators reduced time to completion outcomes (P < 0.05), increased ASSET scores (P < 0.01) and confirmed face validity and transfer of skills (cadaver, live patients).

Conclusions

Low-fidelity simulator training significantly improves the arthroscopic performance of novices, without the high setup costs and practical constraints of high-fidelity equivalents. Low-fidelity arthroscopic simulators remain a promising training apparatus in an era of reduced surgical exposure (COVID-19). We have identified the need for consistent outcome measures with greater sample sizes across future studies. We recommend the use of standardised pre-intervention teaching (e.g., ABOS curriculum) and further transference, construct, and face validity evaluations to support future result interpretations.

1393 The Impact of Using A Virtual Reality Surgical Curriculum to Train Scrub Practitioners in Complex Orthopaedic Surgery

Background

The training scrub practitioners receive varies considerably in comparison to their surgical counterpart, although their performance is key to a proficient surgical team. For infrequent procedures that require specific and often intricate equipment such as revision total knee arthroplasty (RTKA), their training may be limited to an initial guidance session by company representatives. This study aims to evaluate the impact of using a virtual reality (VR) curriculum to train scrub practitioners in the performance of a RTKA.

Method

Ten orthopaedic scrub practitioners were enrolled into VR training across four sessions. Each VR session consisted of training where participants were guided through the assembly of equipment and steps of the surgery. In the concluding three sessions, each training session was supplemented by an assessment session in VR without guidance. The outcomes measured in VR assessment were incorrect procedural sequence, duration of surgery and efficiency of movement. The transfer of skills outside VR were assessed pre-training and post-training by the participants performance in a sequence of tasks using real equipment.

Results

All participants enhanced their surgical performance in successive assessed VR sessions reducing their operative time by 47%, assistive prompts by 75% and dominant hand motion by 28%. Improvements in VR showed effective transfer when assessed using real equipment with participants achieving superior scores post-training (11.3% versus 83.5%).

Conclusions

VR enables safe learning and provides measurable feedback of procedural steps and technical skills of complex orthopaedic surgery. VR is an effective training tool for scrub practitioners, with transfer to the real world.

P07.04 Rapid-CNS2: Rapid comprehensive adaptive nanopore-sequencing of CNS tumors, a proof of concept study

BACKGROUND

The WHO classification 2021 includes multiple molecular markers for routine diagnostics in addition to histology. Sequencing setup for complete molecular profiling requires considerable investment, while batching samples for sequencing and methylation profiling can delay turnaround time. We introduce RAPID-CNS2, a nanopore adaptive sequencing pipeline that enables comprehensive mutational, methylation and copy number profiling of CNS tumours with a single third generation sequencing assay. It can be run for single samples and offers highly flexible target selection requiring no additional library preparation.

MATERIAL AND METHODS

Utilising ReadFish, a toolkit enabling targeted nanopore sequencing, we sequenced DNA from 22 diffuse glioma patient samples on a MinION device. Target regions comprised our Heidelberg brain tumour NGS panel and pre-selected CpG sites for methylation classification by an adapted random forest classifier. Pathognomonic alterations, copy number profiles, and methylation classes were called using a custom bioinformatics pipeline. Results were compared to their corresponding NGS panel-seq and EPIC array outputs.

RESULTS

Complete concordance with the EPIC array was found for copy number profiles from RAPID-CNS2. 94% pathognomonic mutations were congruent with NGS panel-seq. MGMT promoter status was correctly identified in all samples. Methylation families were detected with 96% congruence. Among the alterations decisive for rendering a classification-compatible integrated diagnosis, 97% of the alterations were consistent over the entire cohort (completely congruent in 19/22 cases and sufficient for unequivocal diagnosis in all).

CONCLUSION

RAPID-CNS2 provides a swift and highly flexible alternative to conventional NGS and array-based methods for SNV/Indel analysis, detection of copy number alterations and methylation classification. The turnaround time of ~4 days can be further shortened to <12h by altering target sizes. It offers a low-capital approach that would be cost-efficient for low throughput settings and invaluable in cases requiring immediate diagnoses.

Future Tail Tales: A Forward-Looking, Integrative Perspective on Tail Research

Synopsis Tails are a defining characteristic of chordates and show enormous diversity in function and shape. Although chordate tails share a common evolutionary and genetic-developmental origin, tails are extremely versatile in morphology and function. For example, tails can be short or long, thin or thick, and feathered or spiked, and they can be used for propulsion, communication, or balancing, and they mediate in predator-prey outcomes. Depending on the species of animal the tail is attached to, it can have extraordinarily multi-functional purposes. Despite its morphological diversity and broad functional roles, tails have not received similar scientific attention as, for example, the paired appendages such as legs or fins. This forward-looking review article is a first step toward interdisciplinary scientific synthesis in tail research. We discuss the importance of tail research in relation to five topics: (1) evolution and development, (2) regeneration, (3) functional morphology, (4) sensorimotor control, and (5) computational and physical models. Within each of these areas, we highlight areas of research and combinations of long-standing and new experimental approaches to move the field of tail research forward. To best advance a holistic understanding of tail evolution and function, it is imperative to embrace an interdisciplinary approach, re-integrating traditionally siloed fields around discussions on tail-related research.

Administration and monitoring of clofazimine for NTM infections in children with and without cystic fibrosis

Few studies have evaluated clofazimine (CLOF) drug monitoring and safety in children. We treated 10 children, 8 with CF, for NTM infection with multiple antimicrobials, including CLOF. All had serial blood CLOF concentrations measured and were followed for adverse events. Despite CLOF dose escalation, most children with CF did not reach a target CLOF concentration. Our data suggest that children with CF may require earlier initiation of CLOF at higher doses than is currently recommended.

Comparison between conventional CT and grayscale inversion CT images in the assessment of the post-operative spinal orthopaedic implants

AIM

To compare the accuracy of the inverted greyscale CT versus the conventional CT in the assessment of post-operative spinal orthopaedic implants and osseous fusion.

METHODS

50 patients who had CT as part of their routine spinal implant follow up were evaluated for the presence of fusion, fracture and loosening with conventional CT and with greyscale inverted CT images. 3 independent observers assessed the images 2 months apart. Diagnostic performance (sensitivity and specificity) of the conventional and greyscale inversion images relative to the reference standard were calculated. Agreement with the reference standard was assessed using Cohen's kappa for conventional and greyscale inversion images.

RESULTS

Correct classifications increased when using the greyscale inverted CT images for each reader compared to conventional CT images (40-46, 39 to 42 and 41 to 44 (out of 50)). Inverted images demonstrated better agreement with the reference standard than conventional grayscale images for assessment of fusion (kappa of 0.588 for inverted CT versus 0.484 for conventional CT) and loosening (kappa 0.386 for inverted versus 0.293 for conventional). Sensitivity was increased for assessment of fusion and loosening. McNemar's test performed for assessment of sensitivity differences showed statistical significance (p = 0.038 for fusion and p = 0.0313 for loosening).

CONCLUSION

Greyscale inversion CT is a useful adjunct which has advantages (improved sensitivity and better agreement) over conventional CT imaging in cases of fusion and loosening of metallic implants following spinal instrumentation. We recommend the use of both the greyscale inversion CT images and conventional CT imaging when assessing post-operative spinal orthopaedic implants.

Impact of enhanced personal protective equipment on surgeon workload and intraoperative patient outcomes

This work shows the need for targeted improvement to mitigate communication challenges associated with use of enhanced personal protective equipment. The data provide reassurance to surgeons and patients that there is no negative impact on surgeon workload or patient outcomes from use of enhanced personal protective equipment in the operating theatre.

GJB5 association with BRAF mutation and survival in cutaneous malignant melanoma

BACKGROUND

Gap junctional intercellular communication is crucial for epidermal cellular homeostasis. Inability to establish melanocyte-keratinocytes contacts and loss of intercellular junction's integrity may contribute to melanoma development. Connexins, laminins and desmocollins have been implicated in the control of melanoma growth, where their reduced expression has been reported in metastatic lesions.

OBJECTIVES

The aim of this study was to investigate Connexin 31.1 (GJB5) expression and identify any association with BRAF mutational status, melanoma patient prognosis and MAPK inhibitors (MAPKi) treatment.

MATERIAL AND METHODS

GJB5 expression was measured at RNA and protein level in melanoma clinical samples and established cell lines treated or not with BRAF and MEK inhibitors, as well as in cell lines which developed MAPK inhibitors resistance. Findings were further validated and confirmed by analysis of independent datasets.

RESULTS

Our analysis reveals significant downregulation of GJB5 expression in metastatic melanoma lesions compared to primary ones and in BRAF mutated versus BRAF wild-type melanomas. Likewise, GJB5 expression is significantly lower in BRAF^V600E compared with BRAF^WT cell lines and increases upon MAPKi treatment. MAPKi-resistant melanoma cells display a similar expression pattern compared to BRAF^WT cells, with increased GJB5 expression associated with morphological changes. Enhancement of BRAF^V600E expression in BRAF^WT melanoma cells significantly upregulates miR-335-5p expression with consequent downregulation of GJB5, one of its targets. Furthermore, overexpression of miR-335-5p in two BRAF^WT cell lines confirms specific GJB5 protein downregulation. RT-qPCR analysis also revealed upregulation of miR-335 in BRAF^V600E melanoma cells, which is significantly downregulated in cells resistant to MEK inhibitors. Our data were further validated using the TCGA-SKCM dataset, where BRAF mutations associate with increased miR-335 expression and inversely correlate with GJB5 expression. In clinical samples, GJB5 underexpression is also associated with patient overall worse survival, especially at early stages.

CONCLUSION

We identified a significant association between metastases / BRAF mutation and low GJB5 expression in melanoma. Our results identify a novel mechanism of Gap-junctional protein regulation, suggesting a prognostic role for GJB5 in cutaneous melanoma.

Flexible Endoscopes: Terminal Sterilization and Impact to Patient Safety

Flexible endoscopes are implicated in deaths from healthcare-associated infections (HAIs), in particular antibiotic-resistant infections. This article analyzes whether terminal sterilization should be required as part of endoscope reprocessing to reduce or eliminate HAIs and thus improve patient safety. Reusable flexible endoscopes are processed to make them ready for clinical use by the processing department of the healthcare facility. Unlike most critical and semicritical medical devices, the final step of processing an endoscope is high-level disinfection and not terminal sterilization. This is because most flexible endoscopes come in contact with mucosal membranes (versus contact with direct blood stream) and cannot withstand sterilization. However, sterilization currently is performed by a small number of U.S. healthcare facilities on reusable flexible endoscopes with the belief that they are safer for use compared to flexible endoscopes that are high-level disinfected. Based on the analysis in this article, terminal sterilization is not a required or necessary step to eliminate HAIs.

From benchtop to clinic: a translational analysis of the immune response to submicron topography and its relevance to bone healing

Proper regulation of the innate immune response to bone biomaterials after implantation is pivotal for successful bone healing. Pro-inflammatory M1 and anti-inflammatory M2 macrophages are known to have an important role in regulating the healing response to biomaterials. Materials with defined structural and topographical features have recently been found to favourably modulate the innate immune response, leading to improved healing outcomes. Calcium phosphate bone grafts with submicron-sized needle-shaped surface features have been shown to trigger a pro-healing response through upregulation of M2 polarised macrophages, leading to accelerated and enhanced bone regeneration. The present review describes the recent research on these and other materials, all the way from benchtop to the clinic, including in vitro and in vivo fundamental studies, evaluation in clinically relevant spinal fusion models and clinical validation in a case series of 77 patients with posterolateral and/or interbody fusion in the lumbar and cervical spine. This research demonstrates the feasibility of enhancing biomaterial-directed bone formation by modulating the innate immune response through topographic surface features.

Myositis ossificans revisited - The largest reported case series

INTRODUCTION

Myositis ossificans (MO) is a condition characterised by the formation of non-neoplastic heterotropic ossification in extraskeletal soft tissues.

MATERIAL AND METHODS

We performed a retrospective study of our radiology databases within our tertiary orthopaedic centre to identify all cases of MO, reported on X ray, Magnetic resonance imaging (MRI) and Computed tomography (CT) over the past 13 years (2007-2020).

RESULTS

We identified 68 cases of MO, which were included into our cohort. The average age of our patients was 36 years (range 4-84 years). 73% of cases (n = 50) were found to affect the lower limb muscles with the majority in the quadriceps.

CONCLUSION

We report the largest case series of MO and discuss the demographics, diagnoses and management.

Spinal collision lesions

Collision lesions are rare neoplasms often described in the hepatobiliary system, genitourinary system and adrenal glands. Vertebral haemangiomas (VH) are the most common lesions involving the vertebral bodies. VHs are usually asymptomatic and considered as "Do not touch" lesions. Rarely they can be symptomatic. Imaging findings of typical and atypical haemangiomas, variant forms of haemangioma such as aggressive haemangiomas are well known. Collision lesions involving VHs are extremely rare. This article presents a series of cases with collision lesions of the vertebral body involving VHs.

ADVANCES IN KNOWLEDGE

This Case series demonstrates the various collision lesions in spinal haemangioma.

617 Does Wearing Enhanced Personal Protective Equipment (PPE) In Theatre Increase Surgeon Workload and Patient Morbidity?

Introduction

Delivery of surgical services during the Covid-19 pandemic has required the use of enhanced PPE in the operating theatre. We sought to evaluate the impact of this change on surgeon workload and intraoperative patient outcomes.

Method

Surgeons performing as primary operator completed an online procedure-specific questionnaire on workload ratings for each operative case, using an extension of the validated Surgeon Task Load Index (SURG-TLX) tool (reported on a 20-point scale), together with operative details. Local approval was obtained at individual sites. Data was analysed in Stata SE v16.

Results

118 responses (17 surgeons, 7 specialties) were collected from June to September 2020. 77.1% used enhanced PPE. There was no association between enhanced PPE use and overall workload (p = 0.151) as measured with SURG-TLX, although surgeons wearing enhanced PPE commonly reported finding individual procedures harder than expected (37% vs 0%, p < 0.001). Communication was rated worse when using enhanced PPE use (MD -4.38, 95%CI -6.74 to 02.03; p < 0.001). There was no association between enhanced PPE use and intraoperative complications (p = 0.745).

Conclusions

The use of enhanced PPE is not associated with complications or increased surgeon workload assessed by SURG-TLX. It is, however, associated with difficulty in communicating, and subjectively experiencing more procedural challenge than anticipated.

25 Operative Delay in Neck of Femur Fracture Management During the COVID 19 Pandemic Lockdown; Reasons and Impact

All NOF patients beyond 24-hour window over the COVID Lockdown period From April 2020 to July 2020 were identified and causes of delay to theatre were stratified. Manual Data collection over a time period of April 2020 to July 2020, when lockdown was introduced. All patients with NOF who had surgery within 24 hours were excluded. Cases not within 24 hours were included. A total of 70 patients were included in the study. Cause for Delay beyond 24 hours included No list space 30, Medically unfit 20, Anticoagulation 18, COVID related 2 needing ventilatory support. Causes of medical Delay include chest infection (not COVID related), High anaesthetic risk, Cardiac, Anaemia, Electrolyte imbalance. Covid19 accounted for 2 % of operative delays of NOF patients. Other causes include medical optimization, theatre efficiency and use of anticoagulation. However, our study proved there is a vital requirement for robust protocols and pathways in the management of NOF especially during a global pandemic. This is important for the reduction of overall Morbidity and Mortality. Local Strategies should be put in place to address these with the importance of a MDT approach including the Anaesthetic and Orthogeriatic team.

23 Reaudit and Completing the Audit Cycle of Quality of Informed Consent for Surgery on Neck of Femur Fracture in Royal Stoke University Hospital

Using guidelines highlighted by the British Orthopaedic Association an reaudit was performed within our department to assess the adequacy of informed consent for NOF fractures to complete the audit cycle. 50 patients were included in the Audit and reaudit. Risk was classified as common, less common, rare and ‘other’. The adequacy of informed consent was evaluated by assessing the quality and accuracy of documentation. Infection, bleeding risks, clots and anaesthetic risks were documented in all patients (100%). Areas of improvement were seen in the documentation of neurovascular injuries (98%), pain (90%) and altered wound healing (87%). There was no significant change in the documentation of failure of surgery (83%) and neurovascular injuries (98%). The Poorly documented risk factors from the initial audit were seen to improve which included mortality (70%), prosthetic dislocation (90%) and limb length discrepancy (50%). There has been a significant improvement in the quality of Informed consent in the department and this could be attributed to the installation of ward posters and verbal dissemination of information to junior doctors. Recommendation for interventions would be to present in the next clinical governance meeting and presenting at the new junior doctors’ induction at August.

240 Aetiology and Outcomes of Head and Neck Free Flaps in Patients Aged ≥ 65 Years: The Cambridge Experience

Introduction

Elderly patients often present to the Head & Neck Plastic Surgery department with complex reconstructive needs, for which free flaps are the gold-standard management. In order to provide appropriate, patient-centred care, it is imperative to understand how increasing age and related factors affect long-term free flap outcomes.

Method

The authors carried out a retrospective review of all patients 65+ years who underwent free flap surgery at Addenbrooke’s Hospital from 2008-2019. Patient, operative, and flap characteristics, and outcomes, were analysed using Excel and RStudio.

Results

163 patients were identified (54F, 109M). The majority were ALT (n = 74), radial forearm (n = 35), and fibula flaps (n = 23).

Of pre-operative comorbidities, only neurological comorbidities (n = 16), were significantly associated with long-term flap failure (p = 0.016). There was no significant association between number of comorbidities and flap outcome. There was no association between age group and length of stay.

Flap site complications, and particularly venous complications, were significantly associated with later failure (p = 0.001). No other complications were statistically associated with flap failure.

Conclusions

The high success rate supports the use of free flaps in the 65+ population. This data supports a case-by-case approach to assessing fitness for free flap surgery rather than excluding patients on the basis of age or specific comorbidities.

O15: DISRUPTION OF THE BLOOD-SPINAL CORD BARRIER PREDICTS PERMANENT PARAPLEGIA AFTER THORACOABDOMINAL AORTIC ANEURYSM REPAIR

Introduction

Paraplegia post-thoracoabdominal aortic aneurysm (TAAA) repair remains both a devastating and poorly understood complication. We related temporal changes in cellular and protein composition of cerebrospinal fluid (CSF) to neurological outcomes after TAAA repair to gain mechanistic insights driving paraplegia.

Method

Patients undergoing TAAA repair (open or endovascular) with a CSF drain were prospectively recruited between 2016-2018. CSF was collected pre-operatively and 24-hourly until removal. Daily neurological examinations were performed by blinded neurologists to the study. CSF cell content was characterised by flow cytometry and proteome analysed by tandem-mass-tag proteomics. An in-vivo rat model was modified using 15 minutes of aortic occlusion to produce consistent paraplegia. Rats were analysed neuro-behaviourally and histologically.

Result

CSF was analysed from 52 patients (age: 70.27+/-11.4; 66% male; open (n=9), endovascular (n=43)). 12 developed paraplegia of whom 5 remained permanently-paraplegic. Demographics were comparable between paraplegics, those who recovered and without post-op neurology. Permanent paraplegia was associated with a significant infiltration of CSF CD45+ leucocytes (P&lt;0.0001). Levels of ADVS-1 was &gt;3-fold higher in permanent-paraplegics CSF versus those who recovered (P=0.0008). ADVS-1 &gt;15ng/ml predicted permanent paraplegia with 100% specificity. Pre-treatment with ADVS-1 inhibition significantly improved walking (&lt;0.001) and increased astrocytic staining in the lateral corticospinal, reticulospinal and rubrospinal tracts versus controls (P=0.03, 0.04, 0.04 respectively).

Conclusion

Permanent paraplegia is associated with shedding of ADVS-1 from parenchymal cord into CSF and blood/spinal-cord barrier disruption leading to cord oedema/leucocyte infiltration. Pre-treatment with ADVS-1 inhibition led to neurobehavioural and histological improvements offering translational hope for this devastating complication.

Take-home message

ADVS-1 is a novel biomarker of paraplegia where accurate biomarkers have proven challenging but more importantly it has proven a therapeutic target with genuine translational potential.

Clinical phenotypes and therapeutic responses in cutaneous-predominant sarcoidosis: 6-year experience in a tertiary referral service

BACKGROUND

There is a limited evidence base for the treatment of cutaneous sarcoidosis.

OBJECTIVE

To describe treatment modalities and responses in patients with predominantly cutaneous sarcoidosis, in addition to clinical characteristics and prevalence of systemic disease.

METHODS

Data were prospectively collected over a 6-year period. The Cutaneous Sarcoidosis Activity and Morphology Index was used to assess treatment effectiveness.

RESULTS

In total, 47 patients with biopsy-confirmed cutaneous sarcoidosis were identified. Morphologically, the most common lesions were papules (49%) and plaques (42.6%). The most commonly affected sites were the head and neck (79%); 89.4% had systemic as well as cutaneous disease; 77% received systemic corticosteroid therapy, while 87% required further steroid-sparing treatment; 40% achieved clinical remission with hydroxychloroquine (HCQ) and 88% achieved clinical remission with methotrexate (MTX). OR of achieving remission on MTX compared with HCQ was 9.8 (95% CI 2.4-40.4, P = 0.001). MTX was superior to both azathioprine (AZA) (OR = 22; 95% CI 1.7-285.9; P = 0.02) and mycophenolate mofetil (MMF) (OR = 22; 95% CI 1.7-285.9; P = 0.02) in achieving remission.

CONCLUSION

HCQ is effective and well-tolerated. MTX was associated with significantly increased probability of achieving clinical remission compared with AZA and MMF.

Utility of Prophylactic Cranial Irradiation for Limited Stage Small Cell Lung Cancer in the Modern Era with Magnetic Resonance Imaging Surveillance

AIMS

To retrospectively analyse the impact of prophylactic cranial irradiation (PCI) on survival and intracranial progression in patients with limited stage small cell lung cancer (LS-SCLC) in the modern era of widespread magnetic resonance imaging brain screening.

MATERIALS AND METHODS

Patients with LS-SCLC treated within our network between 2009 and 2020 who responded to initial therapy were stratified by receipt of PCI and stage of disease. A propensity score match analysis was carried out for stage II-III patients. Overall and neurological survival were defined as time to death and presumed death due to uncontrolled intracranial disease, respectively. Brain metastasis-free survival and symptomatic brain metastasis-free survival were defined as freedom from intracranial progression and symptomatic intracranial progression, respectively. The effect of PCI on these outcomes was assessed using Kaplan-Meier and Cox proportional hazards models.

RESULTS

In total, 243 (69.6%) of 349 patients received PCI. On multivariate analysis in the propensity matched stage II-III cohort, PCI was a significant predictor of improved neurological survival (hazard ratio 0.23, 95% confidence interval 0.08-0.65; P = 0.01), brain metastasis-free survival (hazard ratio 0.25, 95% confidence interval 0.12-0.51; P < 0.01) and symptomatic brain metastasis-free survival (hazard ratio 0.21, 95% confidence interval 0.08-0.55; P < 0.01), but not improved overall survival. Two-year neurological survival estimates within the propensity matched cohort were 96.8% (95% confidence interval 87.6-99.2%) with PCI and 77.2% (95% confidence interval 63.0-86.4%) without PCI and 1- and 2-year estimates of incidence of brain metastases were 3.9% (95% confidence interval 1.3-11.7%) and 11.7% (95% confidence interval 5.6-23.5%) in the PCI group and 31.6% (95% confidence interval 22.1-43.9%) and 40.4% (95% confidence interval 29.2-54.0%) in the no PCI group, respectively.

CONCLUSIONS

In the modern era of magnetic resonance imaging screening, PCI was associated with reduced incidence of intracranial progression in patients with stage II-III LS-SCLC who respond to initial therapy. This, importantly, translated to a decreased risk of neurological death within our propensity matched cohort, without significant improvement in overall survival.

Association of haemoglobin levels in the first trimester and at 26-30 weeks with fetal and neonatal outcomes: a secondary analysis of the Global Network for Women's and Children's Health's ASPIRIN Trial

OBJECTIVE

Limited data are available from low- and middle-income countries (LMICs) on the relationship of haemoglobin levels to adverse outcomes at different times during pregnancy. We evaluated the association of haemoglobin levels in nulliparous women at two times in pregnancy with pregnancy outcomes.

DESIGN

ASPIRIN Trial data were used to study the association between haemoglobin levels measured at 6⁺⁰ -13⁺⁶  weeks and 26⁺⁰ -30⁺⁰  weeks of gestation with fetal and neonatal outcomes.

SETTING

Obstetric care facilities in Pakistan, India, Kenya, Zambia, The Democratic Republic of the Congo and Guatemala.

POPULATION

A total of 11 976 pregnant women.

METHODS

Generalised linear models were used to obtain adjusted relative risks and 95% CI for adverse outcomes.

MAIN OUTCOME MEASURES

Preterm birth, stillbirth, neonatal death, small for gestational age (SGA) and birthweight <2500 g.

RESULTS

The mean haemoglobin levels at 6⁺⁰ -13⁺⁶  weeks and at 26-30 weeks of gestation were 116 g/l (SD 17) and 107 g/l (SD 15), respectively. In general, pregnancy outcomes were better with increasing haemoglobin. At 6⁺⁰ -13⁺⁶  weeks of gestation, stillbirth, SGA and birthweight <2500 g, were significantly associated with haemoglobin of 70-89 g/l compared with haemoglobin of 110-129 g/l The relationships of adverse pregnancy outcomes with various haemoglobin levels were more marked at 26-30 weeks of gestation.

CONCLUSIONS

Both lower and some higher haemoglobin concentrations are associated with adverse fetal and neonatal outcomes at 6⁺⁰ -13⁺⁶  weeks and at 26-30 weeks of gestation, although the relationship with low haemoglobin levels appears more consistent and generally stronger.

TWEETABLE ABSTRACT

Both lower and some higher haemoglobin concentrations were associated with adverse fetal and neonatal outcomes at 6-13 weeks and 26-30 weeks of gestation.

Modified Broström repair with suture tape augmentation for lateral ankle instability: A systematic review

BACKGROUND

There is increasing interest in augmentation of modified Broström repairs for lateral ankle instability with a prosthetic reconstruction using suture tape internal bracing. The aim of this study was to investigate if suture tape augmentation resulted in improved clinical and radiological outcomes compared to a standard modified Broström repair alone.

METHODS

A systematic review following PRISMA guidelines was undertaken. All clinical studies published in Medline, Embase, Pubmed and the Cochrane Library Database from inception until January 2020 reporting on the use of suture tape augmentation to a modified Broström repair for lateral ankle instability.

RESULTS

78 studies were identified of which 10 (assessing 333 patients) met the criteria for inclusion. Mean follow up was 24.8 months (range 6-52 months). All studies showed a statistically significant improvement across multiple clinical outcome measures post-surgery in both suture tape augmentation and modified Broström groups, however there were no statistically significant inter-group differences. Pooled results suggested there may be a reduction in recurrence of instability with suture tape augmentation when compared to modified Broström repair alone (p < 0.05). Overall quality of evidence was moderate to poor with limited data to support use of suture tape augmentation.

CONCLUSION

Clinical and radiographic outcomes using a suture tape internal bracing for lateral ankle instability are excellent, and are equivalent to standard treatment across multiple clinical and radiographic assessment measures. There is minimal evidence to suggest functional outcomes are better, or recurrence rates are lower than modified Broström repair alone.

PROSPERO REGISTRY

CRD42020169876.

LEVEL OF EVIDENCE

II.

How has COVID-19 affected the treatment of osteoporosis? An IOF-NOF-ESCEO global survey

The effects of COVID-19 have the potential to impact on the management of chronic diseases including osteoporosis. A global survey has demonstrated that these impacts include an increase in telemedicine consultations, delays in DXA scanning, interruptions in the supply of medications and reductions in parenteral medication delivery.

INTRODUCTION

The COVID-19 pandemic has had profound effects on the health of the global population both directly, via the sequelae of the infection, and indirectly, including the relative neglect of chronic disease management. Together the International Osteoporosis Foundation and National Osteoporosis Foundation sought to ascertain the impact on osteoporosis management.

METHODS

Questionnaires were electronically circulated to a sample of members of both learned bodies and included information regarding the location and specialty of respondents, current extent of face to face consultations, alterations in osteoporosis risk assessment, telemedicine experience, alterations to medication ascertainment and delivery and electronic health record (EHR) utilisation. Responses were collected, quantitative data analysed, and qualitative data assessed for recurring themes.

RESULTS

Responses were received from 209 healthcare workers from 53 countries, including 28% from Europe, 24% from North America, 19% from the Asia Pacific region, 17% from the Middle East and 12% from Latin America. Most respondents were physicians (85%) with physician assistants, physical therapists and nurses/nurse practitioners represented in the sample. The main three specialties represented included rheumatology (40%), endocrinology (22%) and orthopaedics (15%). In terms of the type of patient contact, 33% of respondents conducted telephone consultations and 21% video consultations. Bone mineral density assessment by dual-energy X-ray absorptiometry (DXA) usage was affected with only 29% able to obtain a scan as recommended. The majority of clinicians (60%) had systems in place to identify patients receiving parenteral medication, and 43% of clinicians reported difficulty in arranging appropriate osteoporosis medications during the COVID-19 crisis.

CONCLUSIONS

To conclude through surveying a global sample of osteoporosis healthcare professionals, we have observed an increase in telemedicine consultations, delays in DXA scanning, interrupted supply of medications and reductions in parenteral medication delivery.

Correction to: How has COVID-19 affected the treatment of osteoporosis? An IOF-NOF-ESCEO global survey

A Correction to this paper has been published: 10.1007/s00198-021-05905-7

Point-of-care SARS-CoV-2 serological assays for enhanced case finding in a UK inpatient population

Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2) has become a global pandemic. Case identification is currently made by real-time polymerase chain reaction (PCR) during the acute phase and largely restricted to healthcare laboratories. Serological assays are emerging but independent validation is urgently required to assess their utility. We evaluated five different point-of-care (POC) SARS-CoV-2 antibody test kits against PCR, finding concordance across the assays (n = 15). We subsequently tested 200 patients using the OrientGene COVID-19 IgG/IgM Rapid Test Cassette and find a sensitivity of 74% in the early infection period (day 5–9 post symptom onset), with 100% sensitivity not seen until day 13, demonstrating inferiority to PCR testing in the infectious period. Negative rate was 96%, but in validating the serological tests uncovered potential false-negatives from PCR testing late-presenting cases. A positive predictive value (PPV) of 37% in the general population precludes any use for general screening. Where a case definition is applied however, the PPV is substantially improved (95.4%), supporting use of serology testing in carefully targeted, high-risk populations. Larger studies in specific patient cohorts, including those with mild infection are urgently required to inform on the applicability of POC serological assays to help control the spread of SARS-CoV-2 and improve case finding of patients that may experience late complications.

Application of Processing Guidance: Case Study of Cleaning Validations on Flexible Endoscopes

In 2015, the Food and Drug Administration (FDA) updated its guidance on test methods for cleaning validations for reusable medical devices. The changes include the condition and contamination of devices, test samples and controls, cleaning process performed during validation, extraction methods, and endpoints. This article reviews the FDA's changes to cleaning validations. Examples are presented using flexible endoscopes in order to provide a practical guide to performing cleaning validations.

The novel Mechanical Ventilator Milano for the COVID-19 pandemic

This paper presents the Mechanical Ventilator Milano (MVM), a novel intensive therapy mechanical ventilator designed for rapid, large-scale, low-cost production for the COVID-19 pandemic. Free of moving mechanical parts and requiring only a source of compressed oxygen and medical air to operate, the MVM is designed to support the long-term invasive ventilation often required for COVID-19 patients and operates in pressure-regulated ventilation modes, which minimize the risk of furthering lung trauma. The MVM was extensively tested against ISO standards in the laboratory using a breathing simulator, with good agreement between input and measured breathing parameters and performing correctly in response to fault conditions and stability tests. The MVM has obtained Emergency Use Authorization by U.S. Food and Drug Administration (FDA) for use in healthcare settings during the COVID-19 pandemic and Health Canada Medical Device Authorization for Importation or Sale, under Interim Order for Use in Relation to COVID-19. Following these certifications, mass production is ongoing and distribution is under way in several countries. The MVM was designed, tested, prepared for certification, and mass produced in the space of a few months by a unique collaboration of respiratory healthcare professionals and experimental physicists, working with industrial partners, and is an excellent ventilator candidate for this pandemic anywhere in the world.

Iliotibial band enthesopathy: an unusual cause of lateral knee pain post total knee replacement

Iliotibial band (ITB) pathology is one of the main causes of lateral knee pain. The enthesopathy of the ITB at its insertion post total knee replacement (TKR) is a rare cause of lateral knee pain. We describe a series of cases of ITB enthesopathy with sonographic findings and management.

RIFM low-exposure fragrance ingredients safety assessment

The existing information supports the use of these materials as described in this safety assessment. The 167 materials identified in this assessment were evaluated for genotoxicity, repeated dose toxicity, reproductive toxicity, local respiratory toxicity, phototoxicity/photoallergenicity, skin sensitization, and environmental safety. Target data, read-across analogs and TTC show that these materials are not expected to be genotoxic. The repeated dose, reproductive, and local respiratory toxicity endpoints were evaluated using the TTC for their respective Cramer Classes (see Fig. 1 below) and the exposure to these materials is below the TTC. The skin sensitization endpoint was completed using the DST for non-reactive and reactive materials (900 μg/cm² and 64 μg/cm², respectively); exposures are below the DST. The phototoxicity/photoallergenicity endpoints were evaluated based on UV spectra; these materials are not expected to be phototoxic/photoallergenic. The environmental endpoints were evaluated; the materials were found not to be PBT as per the IFRA Environmental Standards, and their risk quotients, based on their current volume of use in Europe and North America (i.e., PEC/PNEC), are <1.

RIFM fragrance ingredient safety assessment, 3,7-dimethyl-1,3,6-octatriene, CAS registry number 13877-91-3

The existing information supports the use of this material as described in this safety assessment. 3,7-Dimethyl-1,3,6-octatriene was evaluated for genotoxicity, repeated dose toxicity, developmental and reproductive toxicity, local respiratory toxicity, phototoxicity/photoallergenicity, skin sensitization, and environmental safety. Data from 3,7-dimethyl-1,3,6-octatriene and read-across analog myrcene (β-myrcene; CAS # 123-35-3) show that 3,7-dimethyl-1,3,6-octatriene is not expected to be genotoxic and provide a calculated margin of exposure (MOE) >100 for the repeated dose toxicity and developmental and reproductive toxicity endpoints. The skin sensitization endpoint was completed using the dermal sensitization threshold (DST) for non-reactive materials (900 μg/cm 2 ); exposure is below the DST. The phototoxicity/photoallergenicity endpoints were evaluated based on ultraviolet (UV) spectra; 3,7-dimethyl-1,3,6- octatriene is not expected to be phototoxic/photoallergenic. The local respiratory toxicity endpoint was evaluated using the threshold of toxicological concern (TTC) for a Cramer Class I material, and the exposure to 3,7-dimethyl-1,3,6-octatriene is below the TTC (1.4 mg/day). The environmental endpoints were evaluated; 3,7-dimethyl-1,3,6- octatriene was found not to be persistent, bioaccumulative, and toxic (PBT) as per the International Fragrance Association (IFRA) Environmental Standards, and its risk quotients, based on its current volume of use in Europe and North America (i.e., Predicted Environmental oncentration/Predicted No Effect Concentration [PEC/PNEC]), are <1.