Realizing topologically ordered states on a quantum processor

[Figure: see text].

Cutaneous sarcoidosis due to immune‐checkpoint inhibition and exacerbated by a novel BRAF dimerization inhibitor

Sarcoidosis is a non‐infective granulomatous disorder of unknown aetiology, with cutaneous involvement affecting up to 30% of patients. Drug‐induced sarcoidosis has been reported secondary to modern melanoma therapies including immune‐checkpoint inhibitors and first generation BRAF inhibitors such as vemurafenib and dabrafenib. Herein, we report a case of cutaneous micropapular sarcoidosis that first developed on immune‐checkpoint inhibition with ipilimumab and nivolumab for metastatic melanoma, which was exacerbated and further complicated by pityriasis rubra pilaris‐like palmar plaques upon transition to a next‐generation BRAF‐dimerisation inhibitor. Both the micropapular eruption and palmar plaques rapidly resolved after cessation of the novel BRAF‐inhibitor and concurrent commencement of hydroxychloroquine. It is unclear how inhibition of BRAF‐dimerisation results in granuloma formation, though upregulation of T_H1/T_H17 T‐cells and impairment of T‐reg cells may be responsible. Clinicians should be aware of the potential for exacerbation of sarcoidosis when transitioning from immune‐checkpoint inhibitors to these novel BRAF‐dimerisation inhibitors, particularly as their uptake in treating cancers increases beyond clinical trials. Further studies are required to assess whether these next‐generation agents can trigger sarcoidosis de‐novo, or simply exacerbate pre‐existing sarcoidosis.

Case-based radiological anatomy instruction using cadaveric MRI imaging and delivered with extended reality web technology

PURPOSE

Extended reality (XR) technology enhances learning in medical education. The purpose of this study was to develop and apply a case-based approach for teaching radiological anatomy utilizing XR technology for improved student exploration and engagement.

METHODS

The workflow consisted of MRI scanning cadavers followed by radiological, pathological, and anatomical assessment, and finally case presentation based on XR visualizations and student interaction. Case information (Subject, History, and Physical Exam) was presented to student groups who generated and recorded hypotheses using Google Forms.

RESULTS

Use of all components of the system was voluntary and a total of 74 students responded to the survey request (response rate = 95%). Assessment of the experience was conducted through a qualitative survey comprising four Likert scale questions (1-5, 1 lowest), three binary questions, and open-ended comments. Mean, standard deviation, and overall agreement (mean ± SD, OA) showed that students found MRI scans of cadavers to be helpful for dissections (4.14 ± 1.1, 74.3%) and provided an understanding of relevant anatomy (4.32 ± 0.9, 79.7%), while 78.4% of students used the DICOM viewer to visualize scans of cadavers. The difficulty of use was found to be average (2.90 ± 1.0, 23%). zSpace visualizations were used by 40.5% of students, generally agreeing that an understanding of spatial relationships improved as a result (3.60 ± 1.0, 43.2%). More case-based sessions were favored by 97.3% of students.

CONCLUSIONS

Results suggest that cadaveric MRI radiological visualization and XR technology enhance understanding of case-based anatomical dissections and encourage student exploration and engagement.

1700 Using Intra-Operative Imaging as A Tool to Provide Peer Review, Scoring, Feedback and Education for Hand and Wrist Trauma Cases - A Quality Improvement Project

Aim

To improve the efficiency of intraoperative hand trauma x-ray review, introduce a scoring system for quality of fixation achieved and use this as an education and feedback tool for trainees.

Method

A large QI project in 2019 demonstrated that intra-operative images taken using the mini C-arm were not being reviewed. In March 2020 the first QI cycle introduced an Access database to ensure that as cases were removed from the trauma board, they were added to a review list. Each x-ray was also scored in the trauma meeting (good, acceptable, poor) to assess the radiographic quality of fixation. The second QI cycle identified the named surgeon for each case, allowing surgeon specific feedback. Finally, we trained all qualified users of the mini C-arm to upload their own images after each case, reducing the mean time to upload.

Results

This QI project has improved the review rate of mini C-arm images from 30% to 100% and every x-ray is scored. The mean time to review images has reduced from 4 days to less than 24 hours. All trainees can access their scores for imaged hand and wrist trauma and receive written constructive feedback.

Conclusions

This project ensures appropriate and prompt review of all hand and wrist trauma cases allowing early identification of any concerns. All x-rays are scored, and this process acts as an educational prompt in the trauma meeting. A final report can be printed for each trainee which can be uploaded to their portfolio to document their surgical progress.

1019 Quantified Learning Curves for Robotic Gastrointestinal Surgery

Aim

Robotic techniques are increasingly being adopted by gastrointestinal surgeons. It is important to understand the learning curves (LCs) for robotic surgery, to protect patients from harm caused by surgeon inexperience.

The aim of this study was to summarise reports of the LC for three robotic gastrointestinal procedures: cholecystectomy, oesophagectomy and Roux-en-Y gastric bypass (RYGB).

Method

Three systematic reviews were conducted by the trainee led RoboSurg Collaborative. Systematic searches identified reports of primary clinical research involving robotic cholecystectomy, oesophagectomy and RYGB. Articles were screened in duplicate by title, abstract and then full text. References to the LC were extracted and coded. Quantifications of the learning curve were summarised using descriptive statistics.

Results

259 articles were identified: 56 measured the LC, with 23 (9%) of these calculating the number of cases required to complete the LC. The mean reported number of cases at which the LC plateaued was: 16 for oesophagectomy (N = 6, SD = 3.7), 18 for cholecystectomy (N = 5, SD = 15.1), 34 for RYGB (N = 12, SD = 24.6). The reported LCs often incorporated equipment setup times, and so represents learning of the team as well as the surgeon. These values represent points on the LC that authors deemed their surgeons to have ‘completed’ learning. Definitions for when these points occurred varied greatly but largely fell in to two categories: ‘plateau of operative time’ or ‘matching operating time of laparoscopic control procedure’.

Conclusions

The heterogeneity in how LCs are defined, measured, and reported highlights the need for a more standardised approach when evaluating novel techniques such as robotics.

1028 How Has the Learning Curve Been Measured in Robotic Gastrointestinal Surgery?

Aim

Robotic surgery is increasingly being adopted by gastrointestinal surgeons. The IDEAL Collaboration has recommended evaluation of the learning curve (LC) for such surgical innovations. It is not known how learning curves have been reported for robotic gastrointestinal procedures. The aim of this study was to summarise how the LCs were measured for three robotic gastrointestinal procedures: cholecystectomy, oesophagectomy and Roux-en-Y gastric bypass (RYGB).

Method

Three systematic reviews conducted by the trainee led RoboSurg Collaborative identified primary clinical research involving robotic cholecystectomy, oesophagectomy and RYGB. Articles were screened in duplicate by title, abstract and then full text. References to the LC were extracted and coded. The techniques used to measure the LC were summarised using descriptive statistics.

Results

259 articles were identified, of which 56 (22%) actively measured the LC. The commonest surrogate marker for performance was operative time (N = 34, 63%). Several evaluated performances using the cumulative sum of the operative times (N = 8, 14%). Complications (N = 5, 8%) and time to complete a specific surgical step (N = 4, 7%) were also used. Some authors used multiple markers (N = 4, 7%). Cases were reported individually in 48 (81%) of the LCs, whereas they were grouped in 11 (19%). 19 authors (34%) provided graphical representation of the LC.

Conclusions

The reporting of LCs for robotic gastrointestinal surgery was heterogeneous and lacked standardisation. There was variation in choice of surrogate markers for performance, individual versus grouped case reporting, and graphical representations. To improve the utility of LC reports, the recommendations of the IDEAL Collaboration should be implemented.

475 An Audit to Assess Contact Information for Outpatient Emergency Trauma Patients

Aim

To recognise if there is a discrepancy between contact information on our electronic system and those obtained by the clinician.

Introduction

Patients are clerked during the orthopaedic on-call and discharged with the possibility of requiring urgent outpatient surgery. These patients are contacted by the trauma co-ordinator prior to their operation date. It is common practice in orthopaedics for the clinician to obtain the most up to date contact information during the on-call clerking. There are occasions where patients are unable to be contacted prior to surgery due to insufficient contact information. This audit is to identify if there is a discrepancy between contact information on the electronic system compared to that obtained during the clerking.

Method

Contact information for all patients clerked by the on-call team over 14 days during Nov 2019 were reviewed. They were categorised into 3 groups; ‘clinician obtained further information’, ‘electronic system had more information’ and ‘no discrepancy’.

Results

Data was collected for 71 patients. The results showed that the clinician obtained further information for 18 patients (25.3%). The electronic system had more information in 16 patients (22.5%). There was no discrepancy in 37 patients (52.1%).

Discussion

This audit has highlighted an issue, as the results show 25% of patient contact information is incomplete. Given these patients are seen in the emergency setting, this is the only opportunity to obtain correct information to continue the management of patient care. This is paramount to streamline theatre flow and optimise the use of available theatre slots.

Contamination of Air and Surfaces in Workplaces with SARS-CoV-2 Virus: A Systematic Review

OBJECTIVES

This systematic review aimed to evaluate the evidence for air and surface contamination of workplace environments with SARS-CoV-2 RNA and the quality of the methods used to identify actions necessary to improve the quality of the data.

METHODS

We searched Web of Science and Google Scholar until 24 December 2020 for relevant articles and extracted data on methodology and results.

RESULTS

The vast majority of data come from healthcare settings, with typically around 6% of samples having detectable concentrations of SARS-CoV-2 RNA and almost none of the samples collected had viable virus. There were a wide variety of methods used to measure airborne virus, although surface sampling was generally undertaken using nylon flocked swabs. Overall, the quality of the measurements was poor. Only a small number of studies reported the airborne concentration of SARS-CoV-2 virus RNA, mostly just reporting the detectable concentration values without reference to the detection limit. Imputing the geometric mean air concentration assuming the limit of detection was the lowest reported value, suggests typical concentrations in healthcare settings may be around 0.01 SARS-CoV-2 virus RNA copies m-3. Data on surface virus loading per unit area were mostly unavailable.

CONCLUSIONS

The reliability of the reported data is uncertain. The methods used for measuring SARS-CoV-2 and other respiratory viruses in work environments should be standardized to facilitate more consistent interpretation of contamination and to help reliably estimate worker exposure.

Search for a Higgs Portal Scalar Decaying to Electron-Positron Pairs in the MicroBooNE Detector

We present a search for the decays of a neutral scalar boson produced by kaons decaying at rest, in the context of the Higgs portal model, using the MicroBooNE detector. We analyze data triggered in time with the Fermilab NuMI neutrino beam spill, with an exposure of 1.93×10^{20} protons on target. We look for monoenergetic scalars that come from the direction of the NuMI hadron absorber, at a distance of 100 m from the detector, and decay to electron-positron pairs. We observe one candidate event, with a standard model background prediction of 1.9±0.8. We set an upper limit on the scalar-Higgs mixing angle of θ<(3.3-4.6)×10^{-4} at the 95% confidence level for scalar boson masses in the range (100-200)  MeV/c^{2}. We exclude, at the 95% confidence level, the remaining model parameters required to explain the central value of a possible excess of K_{L}^{0}→π^{0}νν[over ¯] decays reported by the KOTO collaboration. We also provide a model-independent limit on a new boson X produced in K→πX decays and decaying to e^{+}e^{-}.

Number of musculoskeletal pain sites leads to increased long-term healthcare contacts and healthcare related costs - a Danish population-based cohort study

BACKGROUND

People with musculoskeletal pain seek more healthcare than the general population, however little is known about the long-term effect on healthcare use. The aim of this study was to examine the consequences of number of musculoskeletal pain sites on long-term care-seeking and healthcare-related costs and explore how health anxiety influences this relationship.

METHODS

We conducted a Danish population-based longitudinal cohort study of 4883 participants combining self-reported survey data from 2008 with ten-year follow-up data from national health registers. Using a causal inference framework, we examined associations between number of pain sites (range 0-7)/level of health anxiety (high/low level) and face-to-face healthcare contacts/healthcare-related costs. Data were analyzed using negative binomial regression with generalized estimating equations. Regression models were adjusted for sex, age, duration of pain, level of education, comorbidity, personality traits, risk of depression, marital status, physical job exposure, and previous healthcare utilization.

RESULTS

For each additional pain site general healthcare contacts (Incidence Rate Ratio (IRR): 1.04 (95% CI: 1.03-1.05)), healthcare-related costs (IRR: 1.06 (95% CI: 1.03-1.08) and musculoskeletal healthcare contacts (IRR: 1.11 (95% CI:1.09-1.14) increased. Those with high levels of health anxiety at baseline had a slightly higher number of general healthcare contacts (IRR 1.06 (1.01-1.11), independent of number of pain sites. However, level of anxiety did not influence the effect of number of pain sites on any healthcare use or cost outcomes.

CONCLUSIONS

We found evidence for a causal association between increasing number of pain sites and greater healthcare use and cost, and high levels of health anxiety did not increase the strength of this association. This suggests that number of pain sites could be a potential target for biopsychosocial interventions in order to reduce the need for future care-seeking.

P–385 The relationship between systemic oestradiol and vaginal microbiota composition in miscarriage and normal pregnancy

Study question

Is there an association between serum oestradiol, vaginal microbial composition and pregnancy outcome in the early first trimester?

Summary answer

In women with a vaginal microbiome deplete of Lactobacillus species at the time of Pregnancy of Uncertain Viability (IPUV), higher serum oestradiol associates with livebirth.

What is known already

During pregnancy, oestradiol mediates vaginal mucosal properties and increases glycogen deposition in epithelial cells which is thought to support colonisation of Lactobacillus species. Low levels of Lactobacillus associates with adverse outcomes such as miscarriage and preterm birth. The direct relationship between systemic oestradiol and the vaginal microbiome has never been studied in pregnancy. However studies have shown a positive correlation between serum oestrone, vaginal glycogen and Lactobacillus abundance in menopausal women.

Study design, size, duration

This was a prospective cohort study where one-hundred women were recruited in early pregnancy at the time of IPUV and donated paired blood and vaginal samples. 40 women had an eventual miscarriage, 58 had a livebirth and two pregnancies were terminated. All 100 women donated one paired serum and vaginal sample at this time point, and 22 women with Lactobacillus depletion at the time of IPUV donated further longitudinal vaginal samples.

Participants/materials, setting, methods

Participants were recruited from an Early Pregnancy Unit and underwent transvaginal ultrasound assessment of their pregnancy. Serum samples were analysed with an immunoassay on a ROCHE COBAS E411 analyser for Oestradiol (pg/ml) and Progesterone (ng/ml). Bacterial DNA was extracted from paired vaginal swabs and sequenced using Illumina MiSeq sequencing of 16S rRNA gene amplicons.

Main results and the role of chance

Lactobacillus dominance of the vagina was associated with higher serum levels of E2 and progesterone compared to depletion (E2=398pg/ml vs 302pg/ml(p = 0.02), P4=23.1ng/ml vs 17ng/ml(p = 0.02)). E2 and P4 were positively correlated (r = 0.6, p &lt; 0.05). At species level, L. crispatus dominance associated with significantly higher levels of E2 compared to high-diversity communities (468pg/ml vs 302pg/ml(p = 0.03) but no such relationship was observed for P4. Both E2 and P4 levels were lower in women who eventually miscarried. However there was no significant difference in the vaginal bacterial composition at genera or species level at this early gestational age (P = 0.08) regardless of per vaginal bleeding. However in women with Lactobacillus depleted microbiota, livebirth was associated with significantly higher E2 levels compared to women suffering miscarriage (212pg/ml in miscarriage vs 395pg/ml in livebirth, p = 0.003) (OR = 22.4 P = 0.004). In 22 women who had Lactobacillus depletion at the time of IPUV (7 with an eventual outcome of miscarriage, and 15 with an eventual outcome of livebirth), longitudinal vaginal bacterial DNA sequencing was performed. In 7/15 women with livebirth, and higher E2 levels, the microbial composition changed to become more Lactobacillus dominant during pregnancy, whereas in those with miscarriage, only 1/7 changed to become Lactobacillus dominant.

Limitations, reasons for caution

In this study, serum oestradiol levels were compared to the local vaginal bacterial environment. The ideal would be to study local vaginal oestradiol, glycogen and the bacterial composition.

Wider implications of the findings: In contrast to previous studies in menopause where low oestrogen levels associate with the vaginal microbial composition, this study uses the high oestradiol environment of early pregnancy to study the mechanistic relationship between oestradiol and vaginal Lactobacillus abundance.

Trial registration number

NA