A multicentre, clinical evaluation of a hydro-responsive wound dressing: the Glasgow experience

OBJECTIVE

Our aim was to assess the effectiveness of hydro-responsive wound dressing (HRWD) in debridement and wound bed preparation of a variety of acute and chronic wounds that presented with devitalised tissue needing removal so that healing may proceed.

METHOD

This was a non-comparative evaluation of acute and chronic wounds that required debridement as part of their normal treatment regimen. Clinicians recorded wound changes including a subjective assessment level of devitalised tissue and wound bed preparation, presence of pain, wound status (e.g., wound size) and periwound skin condition. Data was also collected from clinicians and patients to provide information on clinical performance of the dressing.

RESULTS

We recruited 100 patients with a variety of wound types into the study. Over 90% of the clinicians reported removal of devitalised tissue to enable a healing response in both chronic and acute wounds. Specifically, over the course of the evaluation period, levels of devitalised tissue (necrosis and slough) reduced from 85.5% to 26.3%, and this was accompanied by an increase in wound bed granulation from 12.0% to 33.7%. Correspondingly, there was a 40% reduction in wound area, hence a clinically relevant healing response was seen upon treatment with HRWD. It is also noteworthy that this patient population included a significant proportion of chronic wounds (51.4%) that showed no signs of wound progression within <4 weeks before study inclusion. Of these chronic wounds, 93% demonstrated wound progression upon treatment with HRWD. Despite reported pain levels being low pre- and post-dressing change, overall wound pain improved (reduced) in 48% of patients. Periwound skin condition showed a tendency towards improvement, and the fluid management capabilities of the HRWD was reported as good to excellent in the majority of cases. Wound infections were reduced by at least 60% over the evaluation period. A simple cost-effective analysis demonstrated significant savings using HRWD (£6.33) over current standard practice regimens of a four-step debridement process (£8.05), larval therapy (£306.39) and mechanical pad debridement (£11.46).

CONCLUSION

HRWD was well tolerated and was demonstrated to be an efficient debridement tool providing rapid, effective and pain free debridement in a variety of wound types.

Help seeking for antibiotics; is the influence of a personal social network relevant?

BACKGROUND

Health policy focuses on reducing antibiotic prescribing that in order to succeed requires the public to hold similar attitudes towards judicious use. Social network influences on health behaviour and attitudes are well established and yet these influences are not sufficiently acknowledged in the UK's antibiotic stewardship programmes. Therefore, the aim of this study was to evaluate individuals' attitudes and behaviours towards antibiotics and also identify the social network influences on these in the process of help seeking for self-limiting illnesses.

METHODS

From a social network approach the methods used were a personal community mapping exercise which was carried out ahead of a semi-structured interview. A purposive sample was drawn from across the Wessex region and participants were recruited via GP practices and pharmacists. In total 14 adults, and 10 parents of children, who had received a prescription for antibiotics for a self-limiting illness within the 3 months preceding the interview were recruited and interviewed.

RESULTS

Three network types were identified; diverse, family and friend and restricted. The type of network an individual has appears to have an influence on antibiotic attitudes and behaviours. Most notably, the more diverse a network the more likely the individual will delay in help seeking from healthcare professionals as they draw upon self-care strategies advised by network members. The role of the GP varies according to network type too. Individuals' with diverse networks draw upon GP network members to provide clarity and certainty following a period of self-care. People with restricted networks are more reliant upon the GP, seek help quicker and also more likely to prioritise the GPs advice over other sources of information.

CONCLUSION

The understanding a social network approach brings to help seeking behaviour for antibiotics could help practitioners modify their consultation approach to mitigate some uncertainties and perceptions around prescribing behaviour.

Abstract P5-16-02: Enhance post-lumpectomy breast contour using oncoplastic surgery (OPS) plus a bioabsorbable 3-D tissue implant

Introduction: The appearance after breast surgery has become an important aspect of survivorship. The post lumpectomy/post radiation hollow surgical defect negatively impacts cosmesis and patient satisfaction. Oncoplastic procedures will mobilize surrounding tissues into the lumpectomy cavity but adds no volume to the breast. Use of a bioabsorbable 3-dimensional tissue implant (used for targeting radiation) has the additional benefit of adding volume to the breast and enhances the overall cosmetic appearance. Our experience over 3 years provides serial mammograms from which we may objectively categorize cosmetic contour. We report on our 2 and 3 year serial images of our treated patients compared with baseline.

Methods: Between May 2014 and June 2018, during lumpectomy for breast cancer we implanted a 3-D tissue implant marker in 170 patients, often combined with oncoplastic reconstruction and followed by radiation treatment. For long term follow-up we had 37 patients with serial mammograms at 2 or 3 years to assess cosmesis. All patients had interviews, physical exams, and serial mammograms to evaluate their cosmetic appearance. Both physician and patient graded their appearance. We also objectively measured and compared the pre-treatment mammogram and the 2-year and 3-year, post-treatment mammogram for symmetry and size using each breast as its own control. Using the post-treatment mammograms, we compared the relative anterior-posterior (depth) measurement of the quadrant bearing the implant as well as the non-cancer quadrant to the similar locations of the pre-treatment mammogram. Both mammogram positioning and radiation effects would balance. We compared the relative change from baseline in the non-cancer portion of the breast to the change from baseline in the cancer portion of the breast as a percent difference from baseline.

Results: Patients were treated with lumpectomy, oncoplastic reconstruction, and placement of a 3-D tissue implant. Three implants were removed due to positive margins. No implants were removed for any other reason. There have been no local recurrences. Overall, radiation oncologists felt the 3-D implant was useful for treatment planning in 85% of patients. Of the 37 consecutive patients who have completed an average of 27.8 months of follow-up, cosmesis was rated as excellent/good by clinicians (96%) and patients (94%). Mammograms taken at 2-3 years were compared with initial images. Whole-breast radiation effect varied among patients. Some had significant shrinkage while others had none. These changes were equal in the non-cancer post-radiation quadrants (86.2% vs 87%) demonstrating maintenance of normal breast contour. Our use of the 3-D implant and oncoplastic tissue advancement maintained the pre-operative contour of the breast after lumpectomy with radiation.

Conclusions: Breast cancer surgery and radiation is often complicated by poor cosmesis with retraction and volume loss. Using a combination of oncoplastic surgery combined with a 3-D tissue implant, we found the forward projection and contour of the breast at the lumpectomy site was preserved and patient satisfaction was good to excellent. Further investigation of the long-term cosmetic effects of breast cancer surgery should be encouraged.

Citation Format: Kaufman CS, Hall W, Behrndt VS, Wolgamot GM, Zacharias K, Rogers A, Smith A, Hill LM, Schnell N. Enhance post-lumpectomy breast contour using oncoplastic surgery (OPS) plus a bioabsorbable 3-D tissue implant [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-16-02.

ICRP Publication 135: Diagnostic Reference Levels in Medical Imaging

Abstract –

The International Commission on Radiological Protection (ICRP) first introduced the term ‘diagnostic reference level’ (DRL) in 1996 in Publication 73. The concept was subsequently developed further, and practical guidance was provided in 2001. The DRL has been proven to be an effective tool that aids in optimisation of protection in the medical exposure of patients for diagnostic and interventional procedures. However, with time, it has become evident that additional advice is needed. There are issues related to definitions of the terms used in previous guidance, determination of the values for DRLs, the appropriate interval for re-evaluating and updating these values, appropriate use of DRLs in clinical practice, methods for practical application of DRLs, and application of the DRL concept to newer imaging technologies. This publication is intended as a further source of information and guidance on these issues. Some terminology has been clarified. In addition, this publication recommends quantities for use as DRLs for various imaging modalities, and provides information on the use of DRLs for interventional procedures and in paediatric imaging. It suggests modifications in the conduct of DRL surveys that take advantage of automated reporting of radiation-dose-related quantities, and highlights the importance of including information on DRLs in training programmes for healthcare workers. The target audience for this publication is national, regional, and local authorities; professional societies; and facilities that use ionising radiation for medical purposes, and responsible staff within these facilities. A full set of the Commission’s recommendations is provided.

A Comfort-Based Approach to Smart Heating and Air Conditioning

In this article, we address the interrelated challenges of predicting user comfort and using this to reduce energy consumption in smart heating, ventilation, and air conditioning (HVAC) systems. At present, such systems use simple models of user comfort when deciding on a set-point temperature. Being built using broad population statistics, these models generally fail to represent individual users’ preferences, resulting in poor estimates of the users’ preferred temperatures. To address this issue, we propose the Bayesian Comfort Model (BCM). This personalised thermal comfort model uses a Bayesian network to learn from a user’s feedback, allowing it to adapt to the users’ individual preferences over time. We further propose an alternative to the ASHRAE 7-point scale used to assess user comfort. Using this model, we create an optimal HVAC control algorithm that minimizes energy consumption while preserving user comfort. Through an empirical evaluation based on the ASHRAE RP-884 dataset and data collected in a separate deployment by us, we show that our model is consistently 13.2% to 25.8% more accurate than current models and how using our alternative comfort scale can increase our model’s accuracy. Through simulations we show that using this model, our HVAC control algorithm can reduce energy consumption by 7.3% to 13.5% while decreasing user discomfort by 24.8% simultaneously.

Abstract PD8-03: ESR1 gene fusions drive endocrine therapy resistance and metastasis in breast cancer

Background. Dysregulation of the estrogen receptor gene (ESR1) is an established mechanism of inducing endocrine therapy resistance. We previously discovered a chromosomal translocation event generating an estrogen receptor gene fused in-frame to C-terminal sequences of YAP1 (ESR1-YAP1) that contributed to endocrine therapy resistance in estrogen receptor positive (ER+) breast cancer models. This study compares functional, transcriptional, and pharmacological properties of additional ESR1 gene fusion events of both early stage (ESR1-NOP2) late stage (ESR1-YAP1 and ESR1-PCDH11x) breast cancers to gain a better understanding of therapeutic resistance and metastasis. Understanding the role of ESR1 fusions in inducing metastasis is critical, since the primary cause of death in breast cancer patients is through metastasis to distant sites.

Methods. RNA-seq screens identified ESR1 fusions from early and late stage, endocrine therapy resistant breast tumor samples. Functional experiments were conducted using ER+ breast cancer cell lines, xenograft, and PDX models to test the ability of ESR1 fusions to induce therapeutic resistance and metastasis. ChIP-seq and RNA-seq were performed to examine transcriptional properties and differential gene expression induced by the fusions which directed subsequent pharmacological experiments with a CDK4/6 inhibitor.

Results. ESR1-YAP1 and ESR1-PCDH11x promoted estrogen-independent and fulvestrant-resistant growth in vitro and induced greater tumor growth and increased metastatic capacity to the lungs of xenografted mice. In contrast, the ESR1-NOP2 fusion was sensitive to low estrogen conditions in vitro, and did not promote tumor growth. RNA-seq profiling revealed E2F targets pathway as the most highly enriched pathway induced by the ESR1 fusions. IHC revealed higher levels of pRb in ESR1-YAP1 and ESR1-PCDH11x xenograft tumors and subsequent CDK4/6 inhibition completely blocked tumor growth in an ESR1-YAP1 PDX model. Integrating RNA-seq with ChIP-seq data, we discovered a set of EMT and metastasis genes bound by all ESR1 fusions and WT-ER, but whose expression was strongly and uniquely up-regulated only by the ESR1-YAP1 and ESR1-PCDH11x fusions. These studies also revealed gained sites bound only by the ESR1-YAP1 and ESR1-PCDH11x fusions, not bound by WT-ER nor ESR1-NOP2. Genes mapping to these sites have a role in metastatic biology and were highly up-regulated by the YAP1 and PCDH11x fusions, potentially mediated by long range transcriptional activation.

Conclusion. ESR1-YAP1 and ESR1-PCDH11x are driver fusions that occur in drug-resistant, advanced stage breast cancer and are a new class of recurrent somatic mutation that can cause acquired endocrine therapy resistance, yet can be treated with CDK4/6 inhibition. These driver fusions also confer increased metastatic ability through their ability to drive expression of genes that contribute to EMT and metastasis. In contrast, ESR1-NOP2 did not produce functional protein and appears to be a passenger event. These studies may provide pre-clinical rationale for targeting ESR1 translocated breast tumors, since the presence of an ESR1 driver fusion places a patient in a therapeutic category where none of the currently available endocrine therapies are likely to be effective.

Citation Format: Lei JT, Shao J, Zhang J, Iglesia M, Chan DW, Cao J, Anurag M, Singh P, Haricharan S, Kavuri SM, Matsunuma R, Schmidt C, Kosaka Y, Crowder R, Hoog J, Phommaly C, Goncalves R, Ramalho S, Rodrigues-Peres RM, Lai W-C, Hampton O, Rogers A, Tobias E, Parikh P, Davies S, Ma C, Suman V, Hunt K, Watson M, Hoadley KA, Thompson A, Perou CM, Creighton CJ, Maher C, Ellis MJ. ESR1 gene fusions drive endocrine therapy resistance and metastasis in breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr PD8-03.

Psychiatric Referrals from the Police

Section 136 of the Mental Health Act (MHA) 1983 authorises the police to take a mentally disordered person from ‘a place to which the public have access’ to a place of safety in order to be assessed by a doctor and an approved social worker. The person may be detained in the place of safety for up to 72 hours. Despite increasing controversy, the provision survived a heated parliamentary debate virtually unchanged from the 1959 Act. During the passage of the Mental Health Bill through Parliament, concern was expressed about the considerable variation in its use. Psychiatric examination of the provision has often been in comparison to compulsory admission provisions and the research populations have generally been confined to persons admitted to one hospital only. Although some researchers have recognised the variations in the way the provision operates, there has been no systematic examination of these variations. An important question is whether these variations result in differences in patient care and this question is largely unexplored. In the first part of a three part study of s136∗ the researchers set out to examine this question.

Linking fishes to multiple metrics of coral reef structural complexity using three-dimensional technology

Structural complexity strongly influences biodiversity and ecosystem productivity. On coral reefs, structural complexity is typically measured using a single and small-scale metric (‘rugosity’) that represents multiple spatial attributes differentially exploited by species, thus limiting a complete understanding of how fish associate with reef structure. We used a novel approach to compare relationships between fishes and previously unavailable components of reef complexity, and contrasted the results against the traditional rugosity index. This study focused on damselfish to explore relationships between fishes and reef structure. Three territorial species, with contrasting trophic habits and expected use of the reef structure, were examined to infer the potential species-specific mechanisms associated with how complexity influences habitat selection. Three-dimensional reef reconstructions from photogrammetry quantified the following metrics of habitat quality: 1) visual exposure to predators and competitors, 2) density of predation refuges and 3) substrate-related food availability. These metrics explained the species distribution better than the traditional measure of rugosity, and each species responded to different complexity components. Given that a critical effect of reef degradation is loss of structure, adopting three-dimensional technologies potentially offers a new tool to both understand species-habitat association and help forecast how fishes will be affected by the flattening of reefs.

Advanced Economic Control of Electricity-Based Space Heating Systems in Domestic Coalitions with Shared Intermittent Energy Resources

Over the past few years, Domestic Heating Automation Systems (DHASs) that optimize the domestic space heating control process with minimum user input, utilizing appropriate occupancy prediction technology, have emerged as commercial products (e.g., the smart thermostats from Nest and Honeywell). At the same time, many houses are being equipped with, potentially grid-connected, Intermittent Energy Resources (IERs), such as rooftop photovoltaic systems and/or small wind turbine generators. Now, in many regions of the world, such houses can sell energy to the grid but at a lower price than the price of buying it. In this context, and given the anticipated increase in electrification of heating, the next generation DHASs need to incorporate Advanced Economic Control (AEC). Such AEC can exploit the energy buffer that heating loads provide, in order to shift the consumption of electricity-based heating systems to follow the intermittent energy generation of the house. By so doing, the energy imported from the grid can be minimized and considerable monetary gains for the household can be achieved, without affecting the occupants’ schedule. These benefits can be amplified still further in domestic coalitions, where a number of houses come together and share their IER generation to minimize their cumulative grid energy import.

Given the above, in this work we extend a state-of-the-art DHAS, to propose AdaHeat+, a practical DHAS, that, for the first time, incorporates AEC. Our work is applicable to both individual houses and domestic coalitions and comes complete with an allocation mechanism to share the coalition gains. Importantly, we propose an effective heuristic heating schedule planning approach for collective AEC that (i) has a complexity that scales in a linear and parallelizable manner with the coalition size, and (ii) enables AdaHeat+ to handle the distinct preferences, in balancing heating cost and thermal discomfort, of the households. Our approach relies on stochastic IER power output predictions. In this context, we propose a simple and effective formulation for the site-specific calibration of such predictions based on adaptive Gaussian process modeling. Finally, we demonstrate the effectiveness of AdaHeat+ through real data evaluation, to show that collective AEC can improve heating cost-efficiency by up to 60%, compared to independent AEC (and even more when compared to no-AEC).