Maternal and fetal outcomes of pregnancy occurring after a diagnosis of immune-mediated thrombotic thrombocytopenic purpura

Pregnancy is a well-established trigger for a first episode or relapse of immune thrombotic thrombocytopenic purpura (iTTP). Other outcomes of subsequent pregnancy after a diagnosis of iTTP are less well described. We conducted this retrospective cohort study to evaluate maternal and fetal outcomes of pregnancy in women with prior iTTP from the Johns Hopkins Thrombotic Microangiopathy Cohort. Of 168 women in the cohort, 102 were of reproductive age at diagnosis. Fourteen pregnancies (in 9 women) that occurred after the initial iTTP episode were included in the analysis. iTTP relapse occurred in 9 (64%) pregnancies. Out of the 9 instances of relapse, 5 relapses occurred in 2 women. Seven pregnancies (50%) ended in fetal death or miscarriage in the setting of iTTP relapse and three were electively terminated due to fear of relapse. Four pregnancies (50% of the 8 that progressed beyond 20 weeks) were complicated by preeclampsia or HELLP syndrome, which is over ten-fold higher than that of the general population. No maternal deaths occurred. Only 4 pregnancies resulted in live births, of which, 2 were pre-term. Pregnancy in women with prior iTTP is associated with a substantial risk of iTTP relapse and fetal loss. Preeclampsia and HELLP syndrome is also more common than that in the general population. ADAMTS13 monitoring and preemptive therapy may improve pregnancy outcomes, which needs to be evaluated prospectively.

Trends in osteoporosis care patterns during the COVID-19 pandemic in Alberta, Canada

PURPOSE/INTRODUCTION

The objective of this study was to describe osteoporosis-related care patterns during the coronavirus disease 2019 (COVID-19) pandemic in Alberta, Canada, relative to the 3-year preceding.

METHODS

A repeated cross-sectional study design encompassing 3-month periods of continuous administrative health data between March 15, 2017, and September 14, 2020, described osteoporosis-related healthcare resource utilization (HCRU) and treatment patterns. Outcomes included patients with osteoporosis-related healthcare encounters, physician visits, diagnostic and laboratory test volumes, and treatment initiations and disruptions. The percent change between outcomes was calculated, averaged across the control periods (2017-2019), relative to the COVID-19 periods (2020).

RESULTS

Relative to the average control March to June period, all HCRU declined during the corresponding COVID-19 period. There was a reduction of 14% in patients with osteoporosis healthcare encounters, 13% in general practitioner visits, 9% in specialist practitioner visits, 47% in bone mineral density tests, and 13% in vitamin D tests. Treatment initiations declined 43%, 26%, and 35% for oral bisphosphonates, intravenous bisphosphonates, and denosumab, respectively. Slight increases were observed in the proportion of patients with treatment disruptions. In the subsequent June to September period, HCRU either returned to or surpassed pre-pandemic levels, when including telehealth visits accounting for 33-45% of healthcare encounters during the COVID periods. Oral bisphosphonate treatment initiations remained lower than pre-pandemic levels.

CONCLUSIONS

This study demonstrates the COVID-19 pandemic and corresponding public health lockdowns further heightened the "crisis" around the known gap in osteoporosis care and altered the provision of care (e.g., use of telehealth and initiation of treatment). Osteoporosis has a known substantial care and management disparity, which has been classified as a crisis. The COVID-19 pandemic created additional burden on osteoporosis patient care with healthcare encounters, physician visits, diagnostic and laboratory tests, and treatment initiations all declining during the initial pandemic period, relative to previous years.

Trends in osteoporotic fracture and related in-hospital complications during the COVID-19 pandemic in Alberta, Canada

Fragility fractures (i.e., low-energy fractures) account for most fractures among older Canadians and are associated with significant increases in morbidity and mortality. Study results suggest that low-energy fracture rates (associated with surgical intervention and outcomes) declined slightly, but largely remained stable in the first few months of the COVID-19 pandemic.

PURPOSE/INTRODUCTION

This study describes rates of low-energy fractures, time-to-surgery, complications, and deaths post-surgery in patients with fractures during the coronavirus disease (COVID-19) pandemic in Alberta, Canada, compared to the three years prior.

METHODS

A repeated cross-sectional study was conducted using provincial-level administrative health data. Outcomes were assessed in 3-month periods in the 3 years preceding the COVID-19 pandemic and in the first two 3-month periods after restrictions were implemented. Patterns of fracture- and hospital-related outcomes over the control years (2017-2019) and COVID-19 restrictions periods (2020) were calculated.

RESULTS

Relative to the average from the control periods, there was a slight decrease in the absolute number of low-energy fractures (n = 4733 versus n = 4308) during the first COVID-19 period, followed by a slight rise in the second COVID-19 period (n = 4520 versus n = 4831). While the absolute number of patients with low-energy fractures receiving surgery within the same episode of care decreased slightly during the COVID-19 periods, the proportion receiving surgery and the proportion receiving surgery within 24 h of admission remained stable. Across all periods, hip fractures accounted for the majority of patients with low-energy fractures receiving surgery (range: 58.9-64.2%). Patients with complications following surgery and in-hospital deaths following fracture repair decreased slightly during the COVID-19 periods.

CONCLUSIONS

These results suggest that low-energy fracture rates, associated surgeries, and surgical outcomes declined slightly, but largely remained stable in the first few months of the pandemic. Further investigation is warranted to explore patterns during subsequent COVID-19 waves when the healthcare system experienced severe strain.

Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

Clinical characteristics with inflammation profiling of long COVID and association with 1-year recovery following hospitalisation in the UK: a prospective observational study

BACKGROUND

No effective pharmacological or non-pharmacological interventions exist for patients with long COVID. We aimed to describe recovery 1 year after hospital discharge for COVID-19, identify factors associated with patient-perceived recovery, and identify potential therapeutic targets by describing the underlying inflammatory profiles of the previously described recovery clusters at 5 months after hospital discharge.

METHODS

The Post-hospitalisation COVID-19 study (PHOSP-COVID) is a prospective, longitudinal cohort study recruiting adults (aged ≥18 years) discharged from hospital with COVID-19 across the UK. Recovery was assessed using patient-reported outcome measures, physical performance, and organ function at 5 months and 1 year after hospital discharge, and stratified by both patient-perceived recovery and recovery cluster. Hierarchical logistic regression modelling was performed for patient-perceived recovery at 1 year. Cluster analysis was done using the clustering large applications k-medoids approach using clinical outcomes at 5 months. Inflammatory protein profiling was analysed from plasma at the 5-month visit. This study is registered on the ISRCTN Registry, ISRCTN10980107, and recruitment is ongoing.

FINDINGS

2320 participants discharged from hospital between March 7, 2020, and April 18, 2021, were assessed at 5 months after discharge and 807 (32·7%) participants completed both the 5-month and 1-year visits. 279 (35·6%) of these 807 patients were women and 505 (64·4%) were men, with a mean age of 58·7 (SD 12·5) years, and 224 (27·8%) had received invasive mechanical ventilation (WHO class 7-9). The proportion of patients reporting full recovery was unchanged between 5 months (501 [25·5%] of 1965) and 1 year (232 [28·9%] of 804). Factors associated with being less likely to report full recovery at 1 year were female sex (odds ratio 0·68 [95% CI 0·46-0·99]), obesity (0·50 [0·34-0·74]) and invasive mechanical ventilation (0·42 [0·23-0·76]). Cluster analysis (n=1636) corroborated the previously reported four clusters: very severe, severe, moderate with cognitive impairment, and mild, relating to the severity of physical health, mental health, and cognitive impairment at 5 months. We found increased inflammatory mediators of tissue damage and repair in both the very severe and the moderate with cognitive impairment clusters compared with the mild cluster, including IL-6 concentration, which was increased in both comparisons (n=626 participants). We found a substantial deficit in median EQ-5D-5L utility index from before COVID-19 (retrospective assessment; 0·88 [IQR 0·74-1·00]), at 5 months (0·74 [0·64-0·88]) to 1 year (0·75 [0·62-0·88]), with minimal improvements across all outcome measures at 1 year after discharge in the whole cohort and within each of the four clusters.

INTERPRETATION

The sequelae of a hospital admission with COVID-19 were substantial 1 year after discharge across a range of health domains, with the minority in our cohort feeling fully recovered. Patient-perceived health-related quality of life was reduced at 1 year compared with before hospital admission. Systematic inflammation and obesity are potential treatable traits that warrant further investigation in clinical trials.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Severity of oEsophageal Anastomotic Leak in patients after oesophagectomy: the SEAL score

Background

Anastomotic leak (AL) is a common but severe complication after oesophagectomy. It is unknown how to determine the severity of AL objectively at diagnosis. Determining leak severity may guide treatment decisions and improve future research. This study aimed to identify leak-related prognostic factors for mortality, and to develop a Severity of oEsophageal Anastomotic Leak (SEAL) score.

Methods

This international, retrospective cohort study in 71 centres worldwide included patients with AL after oesophagectomy between 2011 and 2019. The primary endpoint was 90-day mortality. Leak-related prognostic factors were identified after adjusting for confounders and were included in multivariable logistic regression to develop the SEAL score. Four classes of leak severity (mild, moderate, severe, and critical) were defined based on the risk of 90-day mortality, and the score was validated internally.

Results

Some 1509 patients with AL were included and the 90-day mortality rate was 11.7 per cent. Twelve leak-related prognostic factors were included in the SEAL score. The score showed good calibration and discrimination (c-index 0.77, 95 per cent c.i. 0.73 to 0.81). Higher classes of leak severity graded by the SEAL score were associated with a significant increase in duration of ICU stay, healing time, Comprehensive Complication Index score, and Esophagectomy Complications Consensus Group classification.

Conclusion

The SEAL score grades leak severity into four classes by combining 12 leak-related predictors and can be used to the assess severity of AL after oesophagectomy.

OP0243 OSTEOPOROSIS CASE-FINDING IN PEOPLE UNDERGOING ROUTINE DIAGNOSTIC CT SCANS ALMOST TRIPLED THE RATE OF OSTEOPOROSIS TREATMENT AT 12 MONTHS. A RANDOMISED, MULTI-CENTRE FEASIBILITY STUDY USING WAITING ROOM FRAX, OPPORTUNISTIC CT BONE DENSITY AND VERTEBRAL FRACTURE ASSESSMENT VERSUS USUAL CARE

Background

Up to 40% of all diagnostic computed tomography (CT) scans include views of the spine or hips. Among older people, osteoporosis or vertebral fractures have been found in 30% of such CT scans. Our ‘PHOENIX’ intervention repurposes CT scans taken for other reasons to identify fractures and measure bone density as an ‘added extra’. Early detection and treatment of osteoporosis in CT-attending patients could improve health outcomes.

Objectives

To determine the feasibility and efficacy of PHOENIX versus usual care in a multi-centre, randomised, pragmatic study conducted in Eastern England involving our Cambridge Specialist Hospital ‘hub’ and four regional General Hospital ‘spokes’.

Methods

Women ≥65 and men ≥75 years attending for routine diagnostic CT scans were invited to participate via a novel consent form incorporating FRAX Fracture Risk Assessment questions. After calculating their FRAX 10-year risk score, higher risk patients were block randomised (1:1:1) to Group 1) PHOENIX intervention, 2) Active Control, where the GP was sent the patients’ FRAX answers only, or 3) Usual Care where data were only analysed after 13 months had elapsed. The CT scans of high FRAX risk patients in Group 1 were retrieved by the Cambridge team using NHS Connecting for Health (Burnbank, UK). The team performed vertebral fracture assessment and measured bone density using QCT Pro (Mindways, USA). They added patient-specific treatment and investigation management advice from ‘drop down’ menus before results were reviewed by a physician, authorised and sent to general practitioners (GPs). Baseline CT scans from groups 2 and 3 were assessed in the same way after 13 months to ensure no patient with osteoporosis/fractures was neglected long term. Assuming 25% attrition, the study was powered to find a superior osteoporosis treatment rate in Group 1 (estimated 20%) versus 16% (Active Control) and 5% (Usual Care). Co-primary feasibility endpoints were the ability to a) randomise 375 patients within 10 months and b) retain 75% of survivors able to complete a 1-year bone health outcome questionnaire. Secondary outcomes included osteoporosis/vertebral fracture identification rates and osteoporosis treatment rates. Stakeholder acceptability and economic aspects will be reported separately.

Results

From 1828 invites, 595 participants consented to participate of whom 213 were excluded due to ‘low’ FRAX score. Mortality at 12 months was 20%. Both feasibility objectives were achieved: 1) 382 people were randomised within 10 months; 2) 84.4% of survivors at 1 year (95%CI: 80.5, 88.3) were successfully followed-up. Groups were well matched at baseline. The average age of 375 patients (334 female, 41 male) was 75.2 years (74.6, 75.9). Osteoporosis of the hip/spine was present in 41% of 362 analysable CT scans. From the 264 spines that were suitable for VFA, 20% (n=53) were found to have vertebral fractures, with 8.3% having multiple vertebral fractures (n=22). Osteoporosis treatment was reported in 8.5% of Usual Care group (2.9, 14.2) and 24.2% (15.4, 33.0) of PHOENIX group participants, while in the Active Control group (FRAX only) it was 18.8% (10.9, 26.6 p=0.021). In the PHOENIX group, a recommendation to treat was sent to 50 patients’ GPs at baseline. Only 18 of the 50 patients (36%) were found to be taking osteoporosis treatment 12 months after this advice was sent.

Conclusion

Osteoporosis treatment rates were almost tripled by screening patients attending for routine diagnostic CT scans with waiting room FRAX, CT-bone densitometry and vertebral fracture analysis.

Acknowledgements

This project is funded by the National Institute for Health Research (NIHR) under its Research for Patient Benefit (RfPB) Programme (Grant Reference Number PB-PG-0816-20027) and by the Cambridge NIHR Biomedical Research Centre (BRC-1215-20014). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. Funding is in place to 31.03.2022. Three individuals, Mr Jeremy Dearling, Mrs Tessa Plume and Dr Ann Frost joined our trial group as PPI representatives; they were specifically involved in patient documentation design (particularly the PHOENIX pack, informed consent form which facilitated consent without having a researcher present) and contributed to suggestions for increasing patient recruitment and follow up.

Disclosure of Interests

None declared

AB0624 Patients with vasculitis have a high prevalence of coronary microvascular dysfunction

Background

Vasculitides are a heterogenous group of diseases characterized by intense vessel wall inflammation, endothelial injury, and systemic inflammation. Several vasculitides are associated with high risk of cardiovascular (CV) disease, an important source of morbidity and mortality in this population. This excess CV risk is attributed both to a high burden of traditional risk factors and to inflammation, but this remains poorly studied. Indeed, inflammation is a known risk factor for CV disease and implicated in coronary microvascular dysfunction (CMD) which may precede obstructive coronary artery disease (CAD).

Objectives

We sought to assess whether vasculitis is associated with CMD in the absence of obstructive CAD.

Methods

We retrospectively identified subjects with systemic vasculitis who underwent symptom prompted rest/stress myocardial perfusion PET. Patients with an abnormal myocardial perfusion study (summed stress score ≥3) or LVEF<40% were excluded. Controls were identified from the same population and matched on age, gender and cardiovascular risk factors (CAD, hypertension, dyslipidemia, diabetes mellitus, and obesity). Coronary flow reserve (CFR), was calculated as the ratio of myocardial blood flow (ml/min/g) at peak stress compared to rest. CMD was defined as CFR <2.

Results

We studied 26 vasculitis cases and 66 matched controls. The most common vasculitides were giant cell arteritis (38%), ANCA-associated vasculitis (31%), and Takayasu’s arteritis (12%). Median (IQR) time between diagnosis and PET was 6.5 (2.9, 14.2) years. Seven (27%) cases had active vascultis at the time of PET. Cases and controls were well-matched on age, sex, and CV risk factors (Table 1). Despite a similar prevalence of CV risk factors, coronary flow reserve (reflected by CMD) was abnormal in 38% of vasculitis cases compared to 15% of controls (p=0.004). The mean [SD] CFR was 19% lower in vasculitis cases vs controls (2.11 [0.5] versus 2.6 [0.7], p=0.003).

Table 1.

The presence of coronary microvasculature dysfunction in patients with systemic vasculitis without obstructive coronary artery disease

Cohort characteristicsVasculitis (n=26)Control (n=66)P-valueAge at PET, years62 (18)61 (17)0.24Time from Vasculitis Diagnosis to PET, years (median, IQR)6.5 (2.9, 14.2)n/aFemale, n (%)18 (72%)43 (65%)0.99Vasculitis CharacteristicsLarge Vessel (e.g., giant cell arteritis, Takayasu’s), n(%)13 (50%)n/an/aMedium Vessel (e.g., polyarteritis nodosa, Kawasaki’s arteritis), n(%)2 (8%)n/an/aSmall Vessel (e.g., ANCA-associated vasculitis, Henoch-Schonlein Purpura), n(%)11 (42%)n/an/aCardiovascular Risk FactorsAt DiagnosisAt PETAt PETHypertension, n (%)12 (46%)20 (71%)47 (80%)0.47Obesity, n (%)3 (12%)2 (32%)2 (32%)0.84Diabetes, n (%)3 (12%)5 (20%)13 (20%)0.99Dyslipidemia, n (%)4 (15%)15 (58%)40 (61%)0.99Known CAD, n (%)0 (0%)1 (4%)1 (2%)0.48Imaging FindingsRest myocardial blood flow, ml/min/g1.0 (0.3)1.0 (0.3)0.8Stress myocardial blood flow, ml/min/g2.1 (0.6)2.6 (1.0)0.008Coronary Flow Reserve, ml/min/g*2.1 (0.5)2.6 (0.7)0.003Coronary Microvasculature Dysfunction** (CMD), n (%)10 (38%)11 (15%)0.004

Conclusion

Patients with systemic vasculitis, even in the absence of obstructive CAD, have a high prevalence of CMD compared with non-vasculitis patients. These differences were observed despite matching cases and controls on traditional CV risk factors, highlighting the importance of other factors, such as inflammation and vasculitis treatments on CMD and CV disease in this population. CMD is a known independent risk factor for CV mortality. Future prospective studies are needed to understand the relationship between vasculitis, systemic inflammation, and CMD.

Disclosure of Interests

None declared

Practical application of international recommendations and safety standards in the systematic planning and implementation of remediation of sites or areas with residual radioactive material

The IAEA fundamental safety objective is'to protect people and the environment from harmful effects of ionizing radiation'and this must be done 'without unduly limiting the operation of facilities or the conduct of activities that give rise to radiation risks', while ensuring that people and the environment, present and future are protected against radiation risks (IAEA 2006Fundamental Safety Principles, Safety FundamentalsNo. SF-1). In addition,'protective actions to reduce existing or unregulated radiation risks must be justified and optimized'(IAEA 2006Fundamental Safety Principles, Safety FundamentalsNo. SF-1). An international system of radiological protection can be applied such that processes, such as remediation, can be systematically undertaken to address the wide range of'existing exposure situations'present globally. In doing so, decisions made regarding actions undertaken can be demonstrated to be'justified'and'optimized'(i.e. balanced), such that the amount of effort should be commensurate with the risk (applying a'graded approach'). In addition, protection of people and the environment can be demonstrated by comparing the actual exposure to appropriate criteria over the lifetime of remediation. This paper provides an overview of the current IAEA safety standards on remediation of sites or areas contaminated with residual radioactive material within the international system of radiological protection and provides practical examples of their application through case studies considered in IAEA international model validation programs.

Updated soil to fruit concentration ratios for radiocaesium compiled under the IAEA MODARIA II Programme

Under the International Atomic Energy Agency (IAEA) Modelling and Data for Radiological Impact Assessments (MODARIA II) Programme, Working Group 4 activities included collating radionuclide transfer data from Japan following the Fukushima Daiichi Nuclear Power Plant accident and separately collating concentration ratio (CR) data for root uptake of radionuclides by crops grown in tropical and arid climates. In this paper, the newly compiled radiocaesium CR data for fruit from Japan, tropical and arid climates have been combined with the data originally compiled for the IAEA Technical Reports Series No. 472 (TRS 472) and additional data identified from the literature to produce an enhanced MODARIA II dataset of fruit radiocaesium CR values. Statistical analysis of the MODARIA II dataset by climate class (based on the Köppen-Geiger climate classification) indicated that the CR values for tropical climates were significantly higher (p< 0.05) than those for arid, temperate and cold climates. Statistical analysis of the MODARIA II dataset by soil group (based on soil texture) indicated that the CR values for coral sand soil (tropical climates only) and organic soil (temperate climates only) were significantly higher (p< 0.05) than those for the clay, loam and sand soil groups. Statistical analysis of the MODARIA II dataset by plant group (based on plant morphology) indicated that the CR values for non-woody trees (tropical climate bias) were significantly higher (p< 0.05) than those for herbaceous plants, shrubs and woody trees. Comparison of the MODARIA II dataset with original TRS 472 values showed only small changes in the fruit radiocaesium CR values for herbaceous plants and shrubs in temperate climates. There was a decrease in the CR values for woody trees in temperate climate across all soil groups. There was also a decrease in the CR values for tropical climates for all comparable soil groups.

Ensuring robust radiological risk assessment for wildlife: insights from the International Atomic Energy Agency EMRAS and MODARIA programmes

In response to changing international recommendations and national requirements, a number of assessment approaches, and associated tools and models, have been developed over the last circa 20 years to assess radiological risk to wildlife. In this paper, we summarise international intercomparison exercises and scenario applications of available radiological assessment models for wildlife to aid future model users and those such as regulators who interpret assessments. Through our studies, we have assessed the fitness for purpose of various models and tools, identified the major sources of uncertainty and made recommendations on how the models and tools can best be applied to suit the purposes of an assessment. We conclude that the commonly used tiered or graded assessment tools are generally fit for purpose for conducting screening-level assessments of radiological impacts to wildlife. Radiological protection of the environment (or wildlife) is still a relatively new development within the overall system of radiation protection and environmental assessment approaches are continuing to develop. Given that some new/developing approaches differ considerably from the more established models/tools and there is an increasing international interest in developing approaches that support the effective regulation of multiple stressors (including radiation), we recommend the continuation of coordinated international programmes for model development, intercomparison and scenario testing.

A research and development roadmap to support applications of the enhanced BIOMASS methodology

The International Atomic Energy Agency has coordinated an international project addressing enhancements of methods for modelling the biosphere in post-closure safety assessments of solid radioactive waste disposal. This has resulted in the enhanced BIOMASS methodology that is described elsewhere in this special issue. To a large degree, the enhancements to the BIOMASS methodology arose from experience gained in applying the original methodology, both in the context of other international projects and in assessments of existing or proposed disposal facilities for solid radioactive wastes. Here, this experience is used, together with information on the status of solid radioactive waste disposal programmes worldwide, to identify opportunities for applying the enhanced methodology and for learning from those applications. This provides a basis for identifying research and development to support application of the enhanced methodology in a variety of environmental settings. These research and development requirements include aspects related to climate change under a variety of forcing scenarios, landform development in climatic regimes ranging from cold, polar to arid, tropical, modelling of groundwater flow and contaminant transport in surface-water catchments where both fractured rock and porous sediments are present, and studies of the transport of key radioisotopes of elements central to major biogeochemical cycles, such as those of carbon, chlorine, sulphur and iodine. In addition, some remarks are made on aspects of the application of the enhanced methodology that could imply review and updating of regulations and regulatory guidance, e.g. in relation to the definition of representative persons or groups to be considered in assessments and in respect of approaches to the assessment of radiological impacts on non-human biota. Furthermore, consideration is given as to how the scientific and technical experience that has been gained and methods that have been developed in the context of solid radioactive disposal facilities could support management of contaminated sites and legacy facilities that are likely to require long-term management and stewardship.

Overview of the MODARIA programme (and comments on implications for future programmes of work). JOURNAL OF RADIOLOGICAL PROTECTION : OFFICIAL JOURNAL OF THE SOCIETY FOR RADIOLOGICAL PROTECTION 2022;42:020505. [PMID: 35343442 DOI: 10.1088/1361-6498/ac5bdd] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

The International Atomic Energy Agency (IAEA) has organised programmes on the development, comparison and testing of environmental assessment models and approaches for estimating the radiation exposure of humans and wildlife since the 1980s. The latest of these programmes was called MODARIA (Modelling and Data for Radiological Impact Assessment) and was run in two phases from 2012 to 2015 (MODARIA I) and 2016 to 2019 (MODARIA II). Both phases of the MODARIA programme had the overall objective to improve capabilities in the field of environmental transfer of radionuclides and public and non-human biota exposures assessment, by means of acquisition of improved data for model testing and comparison, reaching consensus on modelling philosophies, approaches and parameter values and building an international forum for the exchange of information. This paper provides an overview of the work undertaken during both phases of the MODARIA programme and its outputs. The overall aims and objectives of a new programme to follow on from MODARIA are described.

Adjuvant Abemaciclib Combined with Endocrine Therapy for High Risk Early Breast Cancer: Safety and Patient-Reported Outcomes From the monarchE Study

BACKGROUND

In monarchE, abemaciclib plus endocrine therapy (ET) as adjuvant treatment of hormone receptor-positive, human epidermal growth factor 2-negative, high risk, early breast cancer demonstrated a clinically meaningful improvement in invasive disease-free survival versus ET alone. Detailed safety analyses conducted at a median follow-up of 27 months and key patient-reported outcomes (PRO) are presented.

PATIENTS AND METHODS

The safety population included all patients who received at least one dose of study treatment (n=5591). Safety analyses included incidence, management, and outcomes of common and clinically relevant adverse events (AEs). Patient-reported health-related quality-of-life, ET symptoms, fatigue, and side effect burden were assessed.

RESULTS

The addition of abemaciclib to ET resulted in higher incidence of Grade≥3 AEs (49.7% vs 16.3% with ET alone), predominantly laboratory cytopenias (e.g., neutropenia [19.6%]) without clinical complications. Abemaciclib-treated patients experienced more serious adverse events (SAEs; 13.3% vs 7.8%). Discontinuation of abemaciclib and/or ET due to AEs occurred in 18.5% of patients, mainly due to Grade1/2 AEs (66.8%). AEs were managed with comedications (e.g., antidiarrheals), abemaciclib dose holds (61.7%), and/or dose reductions (43.4%). Diarrhea was generally low grade (Grade1/2: 77%); Grade2/3 events were highest in the first month (20.5%), most short-lived (≤7 days) and did not recur. Venous thromboembolic events (VTE) were higher with abemaciclib+ET (2.5%) vs ET (0.6%); in the abemaciclib arm, increased VTE risk was observed with tamoxifen vs AIs (4.3% vs 1.8%). PROs were similar between arms, including being 'bothered by side effects of treatment', except for diarrhea. At ≥3 months, most patients reporting diarrhea reported "a little bit" or "somewhat".

CONCLUSION

In patients with high risk EBC, adjuvant abemaciclib+ET has an acceptable safety profile and tolerability is supported by PRO findings. Most AEs were reversible and manageable with comedications and/or dose modifications, consistent with the known abemaciclib toxicity profile.

88 Blood Cultures on a Cardiothoracic Surgery Ward- a Quality Improvement Project

Aim

Blood cultures are an important practice when patients spike temperatures, allowing treatment to be targeted and rationalised. However, often it is missed or forgotten about when a patient is unwell. The aims of this project were: to look at the rate of blood cultures being taken after patient’s spiked temperatures and to try and improve on these rates with education.

Method

All patients on the ward had their observation charts examined. Any patient with a temperature of 38 degrees or more was noted down and seen whether blood cultures had been taken. Nurse led education then occurred between each cycle of data collection. Three cycles of data of 10 patients were collected.

Results

In the first cycle only 20% of patients had blood cultures taken. After nurse led education, this improved to 30% of patients. A crib sheet on when/why blood cultures should be taken was then distributed to nursing staff on the ward. The final cycle of results showed an improvement to 60% of patients having blood cultures taken.

Conclusions

Educating ward staff on when blood cultures should/shouldn’t be taken and why has led to a significant improvement on the proportion of pyrexic patients having blood cultures taken on the ward. However, there is still room for improvement and future work should be done to continue to improve compliance rates on the ward.

89 Covid-19 and the Impact on Oncological General Surgery at a District General Hospital

Introduction

Covid-19 has had a significant impact on all aspects of healthcare. We aimed to characterise our experience of oncological general surgery during the first 4-months of the pandemic and compare with the same period in 2019.

Method

A prospective cohort study was performed from 23/03/20 to 08/07/20. All elective oncological operations were included. Data on patient demographics, waiting times, inpatient characteristics and oncological outcomes were recorded. Statistical analysis was used to compare with retrospective data from 2019.

Results

78 patients were included in total, 38 in 2019 and 40 in 2020. There were no differences in length of stay (2.5 vs 3.5 days, p = 0.355) or waiting list time (27.2 vs 24.2 days, p = 0.574).

Oncological outcomes were comparable with no statistical difference in clear resection margin status (94.4 vs 84.6%, p = 0.168) or positive nodal status (24.1 vs 37.1%, p = 0.298).

The percentage of staging CT scans requested externally was higher in 2020 (4 vs 32%, p = &lt;0.05).

There was no difference in time from urgent referral to first assessment (30.5 vs 26.4 days, p = 0.384) or time to operation (96.6 vs 85.7 days, p = 0.618).

Conclusions

Oncological surgery during Covid-19 can be performed safely with favourable oncological outcomes. The longer-term effects from delayed diagnoses remain to be evaluated.

A GPU-accelerated framework for individualized estimation of organ doses in digital tomosynthesis

PURPOSE

Estimation of organ doses in digital tomosynthesis (DT) is challenging due to the lack of existing tools that accurately and flexibly model protocol- and view-specific collimations and motion trajectories of the source and detector for a variety of exam protocols, and the computational inefficiencies of conducting MC simulations. The purpose of this study was to overcome these limitations by developing and benchmarking a GPU-accelerated MC simulation framework compatible with patient-specific computational phantoms for individualized estimation of organ doses in DT.

MATERIALS AND METHODS

The framework for individualized estimation of dose in DT was developed as a two-step workflow: (1) a custom MATLAB code that accepts a patient-specific computational phantom and exam description (organ markers for defining the extremities of the anatomical region of interest, tube voltage, source-to-image distance, angular sweep range, number of projection views, and the pivot point to image distance - PPID) to compute the field of views (FOVs) for a clinical DT system, and (2) a MC tool (developed using MC-GPU) modeling the configuration of a clinical DT system to estimate organ doses based on the computed FOVs. Using this framework, we estimated organ doses for 28 radiosensitive organs in an adult reference patient model (M; 30 years) imaged using a commercial DT system (VolumeRad, GE Healthcare, Waukesha, WI). The estimates were benchmarked against values from a comparable organ dose estimation framework (reference dataset developed by the Advanced Laboratory for Radiation Dosimetry Studies at University of Florida) for a posterior-anterior chest exam. The resulting differences were quantified as percent relative errors and analyzed to identify any potential sources of bias and uncertainties. The timing performance (run duration in seconds) of the framework was also quantified for the same simulation to gauge the feasibility of the workflow for time-constrained clinical applications.

RESULTS

The organ dose estimates from the developed framework showed a close agreement with the reference dataset, with percent relative errors ranging from -6.9% to 5.0% and a mean absolute percent difference of 1.7% over all radiosensitive organs, with the exception of testes and eye lens, for which the percent relative errors were higher at -18.9% and -27.6%, respectively, due to their relative positioning outside the primary irradiation field, leading to fewer photons depositing energy and consequently higher errors in estimated organ doses. The run duration for the same simulation was 916.3 s, representing a substantial improvement in performance over existing nonparallelized MC tools.

CONCLUSIONS

This study successfully developed and benchmarked a GPU-accelerated framework compatible with patient-specific anthropomorphic computational phantoms for accurate individualized estimation of organ doses in DT. By enabling patient-specific estimation of organ doses, this framework can aid clinicians and researchers by providing them with tools essential for tracking the radiation burden to patients for dose monitoring purposes and identifying the trends and relationships in organ doses for a patient population to optimize existing and develop new exam protocols.