Comparison of Intensive Care and Trauma-specific Scoring Systems in Critically Ill Patients

INTRODUCTION

Amongst critically ill trauma patients admitted to ICU and still alive and in ICU after 24 hours, it is unclear which trauma scoring system offers the best performance in predicting in-hospital mortality.

METHODS

The Australia and New Zealand Intensive Care Society Adult Patient Database and Victorian State Trauma Registry were linked using a unique patient identification number. Six scoring systems were evaluated: the Australian and New Zealand Risk of Death (ANZROD), Acute Physiology and Chronic Health Evaluation III (APACHE III) score and associated APACHE III Risk of Death (ROD), Trauma and Injury Severity Score (TRISS), Injury Severity Score (ISS), New Injury Severity Score (NISS) and the Revised Trauma Score (RTS). Patients who were admitted to ICU for longer than 24 hours were analysed. Performance of each scoring system was assessed primarily by examining the area under the receiver operating characteristic curve (AUROC) and in addition using standardised mortality ratios, Brier score and Hosmer-Lemeshow C statistics where appropriate. Subgroup assessments were made for patients aged 65 years and older, patients between 18 and 40 years of age, major trauma centre and head injury.

RESULTS

Overall, 5,237 major trauma patients who were still alive and in ICU after 24 hours were studied from 25 ICUs in Victoria, Australia between July 2008 and January 2018. Hospital mortality was 10.7%. ANZROD (AUROC 0.91; 95% CI 0.90-0.92), APACHE III ROD (AUROC 0.88; 95% CI 0.87-0.90), and APACHE III (AUROC 0.88; 95% CI 0.87-0.89) were the best performing tools for predicting hospital mortality. TRISS had acceptable overall performance (AUROC 0.78; 95% CI 0.76-0.80) while ISS (AUROC 0.61; 95% CI 0.59-0.64), NISS (AUROC 0.68; 95% CI 0.65-0.70) and RTS (AUROC 0.69; 95% CI 0.67-0.72) performed poorly. The performance of each scoring system was highest in younger adults and poorest in older adults.

CONCLUSION

In ICU patients admitted with a trauma diagnosis and still alive and in ICU after 24 hours, ANZROD and APACHE III had a superior performance when compared with traditional trauma-specific scoring systems in predicting hospital mortality. This was observed both overall and in each of the subgroup analyses. The anatomical scoring systems all performed poorly in the ICU population of Victoria, Australia.

Assessing the Impact of Wildfires on the Use of Black Carbon as an Indicator of Traffic Exposures in Environmental Epidemiology Studies

Epidemiological studies frequently use black carbon (BC) as a proxy for traffic-related air pollution (TRAP). However, wildfire smoke (WFS) represents an important source of BC not often considered when using BC as a proxy for TRAP. Here, we examined the potential for WFS to bias TRAP exposure assessments based on BC measurements. Weekly integrated BC samples were collected across the Denver, CO region from May to November 2018. We collected 609 filters during our sampling campaigns, 35% of which were WFS-impacted. For each filter we calculated an average BC concentration. We assessed three GIS-based indicators of TRAP for each sampling location: annual average daily traffic within a 300 m buffer, the minimum distance to a highway, and the sum of the lengths of roadways within 300 m. Median BC concentrations were 9% higher for WFS-impacted filters (median = 1.14 μg/m3, IQR = 0.23 μg/m3) than nonimpacted filters (median = 1.04 μg/m3, IQR = 0.48 μg/m3). During WFS events, BC concentrations were elevated and expected spatial gradients in BC were reduced. We conducted a simulation study to estimate TRAP exposure misclassification as the result of regional WFS. Our results suggest that linear health effect estimates were biased away from the null when WFS was present. Thus, exposure assessments relying on BC as a proxy for TRAP may be biased by wildfire events. Alternative metrics that account for the influence of "brown" carbon associated with biomass burning may better isolate the effects of traffic emissions from those of other black carbon sources.

Cardiac myosin-binding protein C interaction with actin is inhibited by compounds identified in a high-throughput fluorescence lifetime screen

Cardiac myosin-binding protein C (cMyBP-C) interacts with actin and myosin to modulate cardiac muscle contractility. These interactions are disfavored by cMyBP-C phosphorylation. Heart failure patients often display decreased cMyBP-C phosphorylation, and phosphorylation in model systems has been shown to be cardioprotective against heart failure. Therefore, cMyBP-C is a potential target for heart failure drugs that mimic phosphorylation or perturb its interactions with actin/myosin. Here we have used a novel fluorescence lifetime-based assay to identify small-molecule inhibitors of actin-cMyBP-C binding. Actin was labeled with a fluorescent dye (Alexa Fluor 568, AF568) near its cMyBP-C binding sites; when combined with the cMyBP-C N-terminal fragment, C0-C2, the fluorescence lifetime of AF568-actin decreases. Using this reduction in lifetime as a readout of actin binding, a high-throughput screen of a 1280-compound library identified three reproducible hit compounds (suramin, NF023, and aurintricarboxylic acid) that reduced C0-C2 binding to actin in the micromolar range. Binding of phosphorylated C0-C2 was also blocked by these compounds. That they specifically block binding was confirmed by an actin-C0-C2 time-resolved FRET (TR-FRET) binding assay. Isothermal titration calorimetry (ITC) and transient phosphorescence anisotropy (TPA) confirmed that these compounds bind to cMyBP-C, but not to actin. TPA results were also consistent with these compounds inhibiting C0-C2 binding to actin. We conclude that the actin-cMyBP-C fluorescence lifetime assay permits detection of pharmacologically active compounds that affect cMyBP-C-actin binding. We now have, for the first time, a validated high-throughput screen focused on cMyBP-C, a regulator of cardiac muscle contractility and known key factor in heart failure.

Barriers and enablers to skill-mix in the oral health workforce: A systematic review

INTRODUCTION

In dentistry, the term "skill-mix" is used to describe the combinations of dentists and dental care professionals in delivering activities that are commonly established by their level of education, training and scope of practice. However, the literature has indicated an under-utilisation of skill-mix in the oral health care team. Further work is required to understand the poor uptake of skill-mix in oral health care and what could be done to address this issue.

OBJECTIVE

To identify and synthesise the available evidence on the barriers and enablers to skill-mix in the oral health workforce using a macro-, meso- and micro-level framework.

MATERIALS AND METHODS

The databases MEDLINE, CINAHL and Scopus between January 2010 to April 2020 were searched. Primary research studies published in English were included.

RESULTS

Thirty-two articles were included. Key barriers and enablers at each level of analysis were identified. Macro-level barriers and enablers included structural, regulatory and policy conditions and dental health care needs of populations. Meso-level barriers and enablers defined the parameters of service delivery and included workplace characteristics, referral systems and patterns, and workplace productivity and efficiency. Micro-level barriers and enablers pertained to the perceptions, attitudes, and social acceptability of stakeholders that affected the delivery of services.

CONCLUSION

Understanding the barriers and enablers from a multi-level framework requires further high-quality research to fully appreciate its importance in addressing health care needs within populations and increase generalisability to oral health settings.

O8: DIRECT MANIPULATION OF THE INTESTINAL MICROBIOME TO INFLUENCE POST-OPERATIVE OUTCOMES

Introduction

Distal feeding (DF) involves intubation of the distal limb of a loop ileostomy to feed with a prebiotic mix. Studies suggest that distally feeding patients following anterior resection prior to ileostomy closure may be beneficial as a form of bowel pre-habilitation. These pilot data examine the adaptive immune response to DF.

Method

Ten healthy controls with an intact GI tract were compared with 10 patients following rectal cancer resection and chemo/radiotherapy, prior to closure of ileostomy over 8 weeks of DF. We examined B and T cell memory responses from peripheral blood using cell proliferation assays. Cells were cultured with dead antigen to reflect the microbiota in the small and large bowel. Two negative and two positive controls were used to assess minimal and maximum cell proliferation.

Result

B cell responses prior to DF were increased in the defunctioned group compared to the normal controls to significance (p=0.0014). After 8 weeks of DF the groups were comparable. T cell responses to bacteria had significant differences in proliferation rate following DF commencement, CD4 week 0 vs 3 p=0.0001, week 3 vs 8 p=0.000034, CD8 week 0 vs 3 p=0.0001, week 3-8 p=0.00024). In individual patients, CD4 responses were shown to shift from responses to facultative aerobic species, to strict anaerobes.

Conclusion

These data suggest that distal feeding fundamentally resets peripheral circulating memory and it may be of use in pre-habilitating the bowel prior to restoration of continuity. Early clinical data suggests that distal feeding improves post-operative outcomes.

Take-home message

distal feeding is an easy pre-operative intervention that has a significant effect on cell proliferation and antigen response, which may contribute to improved post operative outcomes.

Comparing the use of direct observation, standardized patients and exit interviews in low- and middle-income countries: a systematic review of methods of assessing quality of primary care

Clinical records in primary healthcare settings in low- and middle-income countries (LMIC) are often lacking or of too poor quality to accurately assess what happens during the patient consultation. We examined the most common methods for assessing healthcare workers' clinical behaviour: direct observation, standardized patients and patient/healthcare worker exit interview. The comparative feasibility, acceptability, reliability, validity and practicalities of using these methods in this setting are unclear. We systematically review and synthesize the evidence to compare and contrast the advantages and disadvantages of each method. We include studies in LMICs where methods have been directly compared and systematic and narrative reviews of each method. We searched several electronic databases and focused on real-life (not educational) primary healthcare encounters. The most recent update to the search for direct comparison studies was November 2019. We updated the search for systematic and narrative reviews on the standardized patient method in March 2020 and expanded it to all methods. Search strategies combined indexed terms and keywords. We searched reference lists of eligible articles and sourced additional references from relevant review articles. Titles and abstracts were independently screened by two reviewers and discrepancies resolved through discussion. Data were iteratively coded according to pre-defined categories and synthesized. We included 12 direct comparison studies and eight systematic and narrative reviews. We found that no method was clearly superior to the others-each has pros and cons and may assess different aspects of quality of care provision by healthcare workers. All methods require careful preparation, though the exact domain of quality assessed and ethics and selection and training of personnel are nuanced and the methods were subject to different biases. The differential strengths suggest that individual methods should be used strategically based on the research question or in combination for comprehensive global assessments of quality.

Sexual and reproductive health (SRH) needs of women admitted to eileen skellern ward (ES1) psychiatric intensive care unit (PICU)

Introduction

PICU inpatients are likely to be at increased risk of having unmet SRH needs due to barriers to accessing services. Since May 2018, an in-reach SRH assessment has been available to all psychiatric inpatients on ES1 ward, if referred. Analysis of referrals over 15 months identified only 24 had been made during this time.

Objectives

To assess the SRH needs of women admitted to ES1 PICU, the feasibility of providing a SRH in-reach clinic, and the acceptability of delivering a nurse lead referral programme.

Methods

A bi-monthly SRH in-reach clinic and a nurse led SRH referral pathway were implemented on ES1 over a seven-month period. A staff training needs assessment was performed followed by training, a protocol was developed, staff attitudes were explored, and patient engagement was sought.

Results

A total of 41% (32/77) of patients were referred, which was a 29% increase. 53.1% (17/32) of the total referrals had a true SRH need, equating to a 10% increase and 22% (17/77) of all PICU admissions. 90% of referrals were made by nursing staff. A staff focus group (n15) highlighted the acceptability and perceived importance of offering SRH care in PICU, if interventions were appropriately timed and the patient’s individual risk profile was considered.

Conclusions

Results identify that SRH needs for PICU admissions are greater than previously realised. Providing a nurse led referral pathway for an SRH in-reach clinic is acceptable, feasible and beneficial for PICU patients. This project has resulted in service improvements including offering asymptomatic STI testing to all PICU admissions.

Disclosure

No significant relationships.

A103 PIVOTING IN A PANDEMIC: THE IMPACT OF COVID-19 ON THE PROVISION OF CARE FOR PATIENTS WITH INFLAMMATORY BOWEL DISEASE: A PRELIMINARY ANALYSIS

Background

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreak, also known as COVID-19, was declared a worldwide pandemic in March of 2020. Since the onset of the pandemic, the focus of many healthcare systems has shifted toward limiting non-essential visits to hospitals in order to prioritize and allocate resources toward treating those affected by COVID-19, and preventing further exposures. While the effect of COVID-19 has been felt amongst many patient populations, those with inflammatory bowel disease (IBD) have been particularly impacted through delayed appointments and endoscopy, which is critical in disease monitoring.

Aims

We aimed to determine how changes to the provision of IBD care due to the COVID-19 pandemic have affected IBD patients.

Methods

A retrospective cohort study was conducted using administrative data comparing IBD patients admitted to the gastroenterology ward from March 17 to August 31 2019, with IBD patients admitted from March 17 to August 31 2020 at a tertiary care centre in London, Ontario. Patients were reviewed to assess differences in care utilization and IBD-related outcomes such as hospitalization, surgery and length of stay and in-patient drug therapy.

Results

A total of 538 patients (259 in 2019 cohort and 279 in 2020 cohort) were reviewed with 48 and 60 IBD patients meeting the inclusion criteria for 2019 and 2020 respectively. Patient demographics were similar between 2019 and 2020 cohort for age, sex, rurality, disease type, and biologic exposure. A greater proportion of patients were admitted with IBD flares in 2020 (86.7% vs 75%, p=0.03). Furthermore, the 2020 cohort also had a 45% increase in in-patient surgical consultations (p=0.07), a 50% increase in in-patient IBD-related surgeries (p=0.39), a 69% increase in inpatient Remicade prescription (p=0.13) and a 70% increase in infectious complications at presentation to hospital (p=0.21). A shorter median length of stay was reported for patients in the 2020 cohort (4 days IQR 3.95 vs 5.85 IQR 4.65, p=0.09).

Conclusions

Preliminary data suggest that during the COVID-19 pandemic, we have seen more deleterious outcomes in our IBD patients such as increased flares necessitating hospital admission. There was also a non-significant trend toward increased infectious complications as well as in-patient surgeries and need for in-patient Remicade. Though these results cannot be fully interpreted due to the need for further sampling, they suggest that IBD patients may be at-risk for poor outcomes in the current climate of medical care. Completion of this study will help define the full impact of care shifts related to reducing the spread of the novel coronavirus on IBD patients and highlight areas of care that need careful assessment and consideration to protect IBD patient health.

Funding Agencies

None

A113 ANNUAL COLONOSCOPY VOLUME IS NOT PREDICTIVE OF COLONOSCOPY QUALITY - FINDINGS FROM THE SOUTHWEST ONTARIO COLONOSCOPY COHORT

Background

Performing a minimum number of colonoscopies annually has been proposed by some jurisdictions as a requirement for maintaining privileges. However, this practice is supported by limited evidence.

Aims

The objective of this study was to determine if annual colonoscopy volume was associated with colonoscopy quality metrics.

Methods

A population-based study was performed using the Southwest Ontario Colonoscopy cohort, which consists of all adult patients who underwent colonoscopy between April 2017 and Oct 2018 at 21 academic and community hospitals within the health region. Data were collected through a mandatory quality assurance form completed after each procedure and pathology reports were manually reviewed. Physician annualized colonoscopy volumes were compared by correlation analysis to each quality-related outcome, by means of the area under the receiver operating characteristics curve (AUROC), and logistic regression. The prognostic value of colonoscopy volume was also adjusted for case-mix and potential confounders in separate regression analyses for each outcome. The primary outcome was ADR. Secondary outcomes were polyp detection rate (PDR), sessile serrated polyp detection rate (SSPDR), and cecal intubation.

Results

A total of 47,195 colonoscopies were performed by 75 physicians (37.5% by gastroenterologists, 60% by general surgeons, 2.5% others). There were no clear relationships between annual colonoscopy volumes and study outcomes. Colonoscopy volume was not associated with ADR (OR 1.03, 95% CI 0.96–1.10, p=0.48) and corresponded to an AUROC not significantly different from the null (AUROC 0.52, 95% CI 0.43–0.61, p=0.65). Multi-variable regression adjusting for case-mix also demonstrated no predictive value of annual colonoscopy volume for the primary outcome (OR 1.03, 95% CI 0.94–1.12, p=0.55). Similarly, analyses of secondary outcomes failed to find an association between colonoscopy volume and PDR, SSPDR, or cecal intubation (Table 1).

Conclusions

Annual colonoscopy volumes do not predict ADR, PDR, SSPDR, or cecal intubation rate.

Results of unconditional and conditional approaches for examining the predictive value of annual colonoscopy volume for quality related outcomes.

Funding Agencies

None

A152 INVESTIGATING THE ROLE OF NOVEL NUDT15 VARIANT IN AZATHIOPRINE-RELATED MYELOTOXICITY

Background

Azathioprine (AZA), an immunosuppressant, has classically been used to treat patients with inflammatory bowel disease (IBD). AZA inhibits purine synthesis, and its metabolism occurs via a pathway involving thiopurine methyltransferase (TPMT). While standard TPMT genetic screening is conducted for IBD patients initiating AZA treatment to minimize adverse drug effects (ADE), a majority of patients experiencing ADE have wildtype TPMT. Another gene, NUDT15, has been found to be associated with AZA-related myelotoxicity

Aims

In this study we report two novel variants in NUDT15 and aim to evaluate the impact of NUDT15 variation on its gene expression. We hypothesize that the mutations found within novel NUDT15 variant are detrimental either to the gene’s expression levels or its translation process, resulting in a lower amount of NUDT15 product present and hence translating to AZA-related myelotoxicity observed clinically.

Methods

IBD patients experiencing AZA-related myelotoxicity were recruited for this study. Patients were then genotyped and the NUDT15 variants were replicated through site-directed mutagenesis. The NUDT15 variants were subsequently transformed into mammalian cell lines then E. coli cells. DNA products were isolated, and transcription levels were assessed through RT-PCR.

Results

Patient cohort consisted of 27 AZA-exposed IBD patients who developed myelotoxicity despite their TPMT wildtype genotype. Two novel NUDT15 variants were found. The mutation in one of the variants was placed in 3’ UTR, and hence further research was not pursued. Further analysis was conducted for the variant with mutation in coding region. RT-PCR was conducted to assess and compare gene transcription levels between wildtype and variant NUDT15. Wildtype NUDT15 had a relative gene expression level of 0.8x107, whereas variant NUDT15’s relative gene expression level was at 1.1x107. The two groups were not significantly different in terms of gene expression.

Conclusions

Contrary to our initial hypothesis, it appears that the mutation in the start codon for variant NUDT15 gene does not significantly impact its gene expression as compared to the wildtype gene. We are currently pursuing protein expression analysis studies to assess for translational deficits possibly present in the novel NUDT15 variant.

Funding Agencies

SRTP - Schulich School of Medicine

A117 PROPOFOL SEDATION DOES NOT IMPROVE MEASURES OF COLONOSCOPY QUALITY – FINDINGS FROM THE SOUTHWEST ONTARIO COLONOSCOPY COHORT

Background

The use of propofol during colonoscopy has gained increased popularity due to deeper anesthesia compared to conscious sedation. Prior studies examining the use of propofol sedation during colonoscopy have primarily focused on anesthesia outcomes. Whether propofol sedation is associated with improvements in colonoscopy outcomes is uncertain.

Aims

The primary outcome was adenoma detection rate (ADR). Secondary outcomes were the detection of any adenoma (conventional adenoma, sessile serrated polyp, and traditional serrated adenoma), sessile serrated polyp detection rate, polyp detection rate, cecal intubation rate, and perforation rate.

Methods

The Southwest Ontario Colonoscopy cohort consists of all patients who underwent colonoscopy between April 2017 and Oct 2018 at 21 hospitals serving a large geographic area in Southwest Ontario. Procedures performed in patients less than 18 years of age or by endoscopist who perform <50 colonoscopies/year were excluded. Data were collected through a mandatory quality assurance form that was completed by the endoscopist after each procedure. Pathology reports were manually reviewed.

Results

A total of 46,634 colonoscopies were performed by 75 physicians (37.5% by gastroenterologists, 60% by general surgeons, 2.5% others) of which 16,408 (35.2%) received propofol and 30,226 (64.8%) received conscious sedation (e.g. combination of a benzodiazepine and a narcotic). Patients who received propofol were likely to have a screening indication (49.2% vs 45.5%, p<0.0001), not have a trainee endoscopist present and be performed at a non-academic centre (32.2% vs 44.6%, p<0.0001). Compared to conscious sedation, use of propofol was associated with a lower ADR (24.6% vs. 27.0%, p<0.0001) and detection of any adenoma (27.7% vs. 29.8%, p<0.0001); no difference was observed in the detection ofsessile serrated polyps (5.0% vs. 4.7%, p=0.26), polyp detection rate (41.2% vs 41.2%, p=0.978), cecal intubation rate (97.1% vs. 96.8%, p=0.15) or perforation rate (0.04% vs. 0.06%,p=0.45). On multi-variable analysis, the use of propofol was not significantly associated with any improvement in ADR (RR=0.90, 95% CI 0.74–1.10, p=0.30), detection of any adenoma (RR=0.93, 95% CI 0.75–1.14, p=0.47), sessile serrated polyp detection rate (RR=1.20, 95%CI 0.90–1.60, p=0.22), polyp detection rate (RR=1.00, 95% CI 0.90–1.11, p=0.99), or cecal intubation rate (RR=1.00, 95%CI 0.80–1.26, p=0.99).

Conclusions

The use of propofol sedation does not improve colonoscopy quality metrics.

Funding Agencies

None

A12 PRE-TREATMENT HLADQA1-HLADRB1 TESTING FOR THE PREVENTION OF AZATHIOPRINE-INDUCED PANCREATITIS IN INFLAMMATORY BOWEL DISEASE: A PROSPECTIVE COHORT STUDY

Background

Azathioprine (AZA) therapy has a long history of use in IBD. The need to promote its safe use in this population is ensured by governmental health policy requiring IBD patients to fail low cost drugs, such as AZA, prior to approving funding for more potent biologic therapies. AZA-induced pancreatitis is an idiosyncratic and unpredictable response, occurring in up to 7% of AZA-exposed patients that can lead to patient morbidity, hospitalization, delay in effective IBD management, as well as result in substantial additional health-related costs. There are no tools in clinical practice to identify individuals at risk of AZA-induced pancreatitis. Genetic variation in the HLADQA1-HLADRB1*07:01 haplotype is strongly associated with azathioprine (AZA)-induced pancreatitis in inflammatory bowel disease (IBD).

Aims

To evaluate whether HLA DQA1-HLADRB1*07:01A>C pre-treatment genotype testing in an adult IBD population prior to AZA therapy to guide AZA selection would result in a lower incidence of AZA-induced pancreatitis.

Methods

Participants with IBD (n=599) were screened for HLADQA1-HLADRB1*07:01A>C and participants with a variant genotype were excluded from azathioprine treatment (n=271). Wildtype participants (n=328) were started on azathioprine and followed for 3 months. The incidence of pancreatitis was compared to unscreened historical controls (n=373).

Results

The minor allele frequency of HLADQA1-HLADRB1*07:01 was 30.4% and 30.0% in the screened and unscreened populations respectively. Up to 45.2% of participants were excluded from AZA therapy based on genotype in the HLADQA1-HLADRB1*07:01A>C screened cohort. HLADQA1-HLADRB1*07:01A>C screening resulted in an 11-fold reduction in the odds of azathioprine-induced pancreatitis (0.30% versus 3.4%, OR=0.085, 95%CI=0.011–0.651, p=0.002).

Conclusions

HLA DQA1-HLADRB1*07:01A>C screening substantially reduced the risk of pancreatitis during AZA treatment in patients with IBD. However, using this strategy as a tool for guiding the use of AZA therapy in IBD may eliminate a large proportion of patients from being eligible for treatment with AZA. In regions, where there is access to other IBD therapies, and given the short and long term toxicities associated with AZA, HLA DQA1-HLADRB1*07:01A>C screening may be a clinically-relevant strategy for enhancing the safe use of AZA in IBD. Additionally, cost-effectiveness analyses are needed to further solidify the utility of HLA DQA1-HLADRB1*07:01A>C-screening in IBD populations.

Funding Agencies

Academic Medical Organization of Southwestern Ontario Innovation Fund

A156 SERUM TUMOUR NECROSIS FACTOR-α ANTAGONIST DRUG CONCENTRATIONS IN PATIENTS WITH PYODERMA GANGRENOSUM ASSOSCIATED WITH INFLAMMATORY BOWEL DISEASE

Background

The utility of therapeutic drug monitoring for guiding the dosing of tumor necrosis factor-α antagonists (TNFAs) in luminal inflammatory bowel disease (IBD) is well-established and well-accepted. TNFAs, specifically infliximab and adalimumab, have become integral to the management of the rare, neutrophilic dermatosis, pyoderma gangrenosum (PG) in IBD. Little is known regarding the target serum TNFA concentrations to guide dosing to achieve resolution of PG in IBD.

Aims

To describe the serum TNFA concentrations (infliximab or adalimumab) associated with the resolution of PG lesions in patients with IBD.

Methods

Patients with IBD and associated PG treated with one of infliximab or adalimumab (collectively known as TNFAs) seen at two academic hospitals affiliated with Western University were identified. Serum TNFA concentrations were assessed at the time of PG treatment.

Results

Nine patients were identified. All patients had IBD-associated PG. Seven patients were treated with infliximab and 2 patients were treated with adalimumab. All patients received standard dosing. Eight patients had complete resolution of their PG, while one had near complete resolution at the time of last follow-up. A median serum infliximab concentration of 3.00 (IQR, 3.52) µg/ml at week 14 and a median serum adalimumab concentration of 2.02 (IQR, 0.98) µg/ml at week 12 were seen at the time of PG treatment.

Conclusions

Herein, we report low serum TNFA concentrations despite PG healing in a cohort of IBD patients. This is lower than what is in patients for successful TNFA treatment in luminal and fistulising IBD.

Funding Agencies

NoneNone.

A120 NO EVIDENCE OF A FRIDAY EFFECT ON COLONOSCOPY QUALITY OUTCOMES

Background

Colonoscopy quality may be influenced by operator fatigue. Prior studies have shown lower adenoma detection rates for procedures performed at the end of the day. However, it is unknown if colonoscopy quality is impaired at the end of the work week.

Aims

We investigated whether colonoscopy quality-related metrics differ at the end of the work week using the South West Ontario Colonoscopy Cohort.

Methods

Between April 2017 to February 2018, 45,510 consecutive colonoscopies from 20 academic and community hospitals in our health region were captured to form the cohort. In Canada, outpatient endoscopies are generally performed between Monday to Friday, taking Friday, or the last business day, as the last day of the work week compared to the rest of the work week. When a statutory holiday occurred on a Friday, Thursday was designated the last day of the work week. The primary outcome was adenoma detection rate (ADR), and secondary outcomes were sessile serrated polyp detection rate (ssPDR), polyp detection rate (PDR), and failed cecal intubation. Outcomes were presented as unadjusted and adjusted risk ratios derived from modified Poisson regression and adjusting for physician-level clustering, and characteristics of the patient (age, sex, severity), procedure (hospital setting, trainee presence, indication, sedation, bowel preparation quality) and physician (experience and specialty).

Results

During the observation period, 9,132 colonoscopies were performed on the last day of the work week compared to 36,378 procedures during the rest of the work week. No significant difference was observed for ADR (26.4% vs. 26.6%, p=0.75), ssPDR (4.5% vs. 5.0%, p=0.12), PDR (44.1% vs. 43.1%, p=0.081), or failed cecal intubation (2.8% vs. 2.9%, p=0.51) for colonoscopies performed on the last day of the work week compared to the rest of the week, respectively. After adjusting for potential confounders, there were no significant differences in the ADR (RR 1.01, 95% CI [0.88, 1.15], p=0.94), ssPDR (RR 0.90, 95% CI [0.70, 1.14], p=0.38), PDR (RR 1.00, 95% CI [0.92, 1.09], p=0.94), or failed cecal intubation (RR 0.92, 95% CI [0.72, 1.18], p=0.51) for colonoscopies performed on the last day of the work week compared to the rest of week, respectively.

Conclusions

Colonoscopy quality metrics, including ADR, ssPDR, PDR, and failed cecal intubation are not significantly different at the end of the week.

Funding Agencies

None

The FAST-M complex intervention for the detection and management of maternal sepsis in low-resource settings: a multi-site evaluation

OBJECTIVE

To evaluate whether the implementation of the FAST-M complex intervention was feasible and improved the recognition and management of maternal sepsis in a low-resource setting.

DESIGN

A before-and-after design.

SETTING

Fifteen government healthcare facilities in Malawi.

POPULATION

Women suspected of having maternal sepsis.

METHODS

The FAST-M complex intervention consisted of the following components: the FAST-M maternal sepsis treatment bundle and the FAST-M implementation programme. Performance of selected process outcomes was compared between a 2-month baseline phase and 6-month intervention phase with compliance used as a proxy measure of feasibility.

MAIN OUTCOME RESULT

Compliance with vital sign recording and use of the FAST-M maternal sepsis bundle.

RESULTS

Following implementation of the FAST-M intervention, women were more likely to have a complete set of vital signs taken on admission to the wards (0/163 [0%] versus 169/252 [67.1%], P < 0.001). Recognition of suspected maternal sepsis improved with more cases identified following the intervention (12/106 [11.3%] versus 107/166 [64.5%], P < 0.001). Sepsis management improved, with women more likely to receive all components of the FAST-M treatment bundle within 1 hour of recognition (0/12 [0%] versus 21/107 [19.6%], P = 0.091). In particular, women were more likely to receive antibiotics (3/12 [25.0%] versus 72/107 [67.3%], P = 0.004) within 1 hour of recognition of suspected sepsis.

CONCLUSION

Implementation of the FAST-M complex intervention was feasible and led to the improved recognition and management of suspected maternal sepsis in a low-resource setting such as Malawi.

TWEETABLE ABSTRACT

Implementation of a sepsis care bundle for low-resources improved recognition & management of maternal sepsis.

Measurement of the helicity asymmetry E for the reaction γ p → π 0 p : The CBELSA/TAPS Collaboration

A measurement of the double-polarization observable E for the reaction γ p → π 0 p is reported. The data were taken with the CBELSA/TAPS experiment at the ELSA facility in Bonn using the Bonn frozen-spin butanol (C4 H9 OH) target, which provided longitudinally-polarized protons. Circularly-polarized photons were produced via bremsstrahlung of longitudinally-polarized electrons. The data cover the photon energy range fromE γ = 600 to 2310 MeV and nearly the complete angular range. The results are compared to and have been included in recent partial wave analyses.

Factors affecting paramedicine students' learning about evidence-based practice: a phenomenographic study

BACKGROUND

Evidence-based practice is an important component of pre-service professional learning in medicine and allied health degrees, including new programmes in paramedicine. Despite substantial interest in this area, there is still a lack of clear understanding of how the skills and understandings needed to develop the capacity to apply evidence-based practice can best be learned. Evidence-based practice is often described as consisting of five steps: ask, acquire, appraise, apply and assess. This study focuses on paramedicine students' learning about the first three steps in a final year unit which explicitly aims to develop their skills in relation to these.

METHODS

We conducted a qualitative study of learning journals recorded by 101 of 121 students in a final year unit of a paramedicine degree (20 students either withheld consent for their journals to be used in the research or did not complete their journal entries). We used phenomenographic approaches to the data analysis in order to identify both variation in students' learning and the factors affecting this variation.

RESULTS

We observed variation in students' understanding of the purpose of literature analysis, the nature of medical research and its relationship to practice. In all three, we identify two main factors contributing to the variation in student learning outcomes: epistemological stance, and opportunities for metacognitive learning generated through peer interactions and self-reflection. We also found that as students begin to grapple with the complexity of medical research, this sometimes produced negative attitudes towards its value; such unintended outcomes need to be recognised and addressed.

CONCLUSIONS

We suggest key factors that should be considered in developing coursework intended to enhance students' understandings about the processes and application of evidence-based practice. Providing collaborative learning opportunities that address the architecture of variation we observed may be useful in overcoming epistemological and metacognitive barriers experienced by students.

Prevalence of lower limb venous disease in surgeons: a case study and results of a survey by the BAOMS Reconstruction Surgical Subspecialty Interest Group

We report a case of venous leg ulceration in a reconstructive oral and maxillofacial surgeon. An online survey was created by the British Association of Oral and Maxillofacial Surgeons (BAOMS) Reconstruction Surgical Subspecialty Interest Group (SSIG), primarily to target head and neck surgeons, to investigate the perceived risk and occurrence of venous leg disease. Two respondents had received treatment for lower limb venous disease thus compromising their ability to work, while 13 had symptoms of early venous disease. Our study shows an interesting area of concern for occupational health in surgeons, particularly in those carrying out long operations, as will be the case for members of the Reconstruction SSIG.

The PEARL study: a prospective two-group pilot PrEP promotion intervention for cisgender female sex workers living in Baltimore, MD, U.S

HIV remains elevated among female sex workers (FSW) globally, with a number of structural (e.g., poverty, access to care) factors driving these persistently high rates. Pre-exposure prophylaxis (PrEP), a user-controlled prevention method, is a promising means of empowering vulnerable populations to protect themselves and enhance agency. Yet there is a dearth of PrEP research and interventions targeting cisgender women in the United States, and even fewer aimed to reach FSW. We developed and implemented a multifaceted PrEP pilot intervention, the Promoting Empowerment And Risk Reduction (PEARL) study, to meet this gap. This paper describes the development process and nature of a community-informed intervention for tenofovir/emticitrabine (TDF/FTC) pre-exposure prophylaxis engagement among street-based cisgender FSW in Baltimore, Maryland, U.S. In the course of the study's implementation, structural, programmatic, and medical barriers have already posed significant barriers to full engagement. PEARL implemented a number of strategies in an effort to counter barriers and facilitate increased success of PrEP uptake and maintenance. The study will provide critical insights into the nature of intervention components that could help FSW to initiate PrEP and reduce PrEP care cascade gaps.

Growth patterns of the airway in Crouzon syndrome patients with different types of cranial vault suture synostosis

The severity of obstructive respiratory difficulty varies among affected Crouzon syndrome patients. The aim of this study was to investigate the correlation between the restricted airway volume in Crouzon syndrome and the associated type of cranial vault suture synostosis. Computed tomography scans of 68 unoperated Crouzon syndrome patients and 89 control subjects were subgrouped into four types: type I, bilateral coronal synostosis; type II, sagittal synostosis; type III, pansynostosis; type IV, perpendicular combinations of synostoses. Measurements were made using Mimics software. Of type I Crouzon patients, 42% had a restricted nasal airway (P=0.002), while the pharyngeal airway volume was not significantly reduced. Type II Crouzon patients grew normal segmental airway volumes. Crouzon patients of type III developed simultaneously reduced nasal and pharyngeal airway volumes in infancy, by 38% (P=0.034) and 51% (P=0.014), respectively. However, the nasal airway achieved a normal volume by 2 years of age without any intervention, while the pharyngeal airway remained significantly reduced up to 6 years of age, by 42% (P=0.013), compared to controls. Type IV Crouzon patients developed a reduced nasal airway volume (32%, P=0.048) and a non-significant restricted pharyngeal airway (18%, P=0.325). Airway compromise in Crouzon syndrome is variable when associated with different craniosynostosis fusion patterns. Type II (sagittal synostosis) Crouzon patients grew a normal nasopharyngeal airway volume. Those with types I (bicoronal synostosis) and IV (perpendicular synostoses) had significantly restricted nasal airways and a tendency towards a reduced pharyngeal volume. Type III (pansynostosis) Crouzon infants had the worst restriction of both airways, although there was some improvement with age.