Efficacy and safety of intensified versus standard prophylactic anticoagulation therapy in patients with Covid-19: a systematic review and meta-analysis

Background

Randomised controlled trials (RCTs) have reported inconsistent effects from intensified anticoagulation on clinical outcomes in Covid-19. We performed an aggregate data meta-analysis from available trials to quantify effect on non-fatal and fatal outcomes and identify subgroups who may benefit.

Methods

We searched multiple databases for RCTs comparing intensified (intermediate or therapeutic dose) versus standard prophylactic dose anticoagulation in adults with laboratory-confirmed Covid-19 through 19 January 2022. The primary efficacy outcome was all-cause mortality at end of follow-up or discharge. We used random effects meta-analysis to estimate pooled risk ratios for mortality, thrombotic, and bleeding events, and performed subgroup analysis for clinical setting and dose of intensified anticoagulation.

Results

Eleven RCTs were included (n = 5873). Intensified anticoagulation was not associated with a reduction in mortality for up to 45 days compared with prophylactic anticoagulation: 17.5% (501/2861) died in the intensified anticoagulation group and 18.8% (513/2734) died in the prophylactic anticoagulation group, relative risk (RR) 0.93; 95%CI, 0.79 - 1.10. On subgroup analysis, there was a possible signal of mortality reduction for inpatients admitted to general wards, although with low precision and high heterogeneity (5 studies; RR 0.84; 95% CI, 0.49 - 1.44; I ² = 75%) and not significantly different to studies performed in the ICU (interaction P = 0.51). Risk of venous thromboembolism was reduced with intensified anticoagulation compared with prophylaxis (8 studies; RR 0.53, 95%CI 0.41 - 0.69; I ² = 0%). This effect was driven by therapeutic rather than intermediate dosing on subgroup analysis (interaction P =0.04). Major bleeding was increased with use of intensified anticoagulation (RR 1.73, 95% CI 1.17 - 2.56) with no interaction for dosing and clinical setting.

Conclusion

Intensified anticoagulation has no effect on short term mortality among hospitalised adults with Covid-19 and is associated with increased risk of bleeding. The observed reduction in venous thromboembolism risk and trend towards reduced mortality in non-ICU hospitalised patients requires exploration in additional RCTs.

Summary

In this aggregate data meta-analysis, use of intensified anticoagulation had no effect on short term mortality among hospitalised adults with Covid-19 and was associated with increased risk of bleeding.

Syndromic Monogenic Diabetes Genes Should Be Tested in Patients With a Clinical Suspicion of Maturity-Onset Diabetes of the Young

At present, outside of infancy, genetic testing for monogenic diabetes is typically for mutations in maturity-onset diabetes of the young (MODY) genes that predominantly result in isolated diabetes. Monogenic diabetes syndromes are usually only tested for when supported by specific syndromic clinical features. How frequently patients with suspected MODY have a mutation in a monogenic syndromic diabetes gene is unknown and thus missed by present testing regimes. We performed genetic testing of 27 monogenic diabetes genes (including 18 associated with syndromic diabetes) for 1,280 patients with a clinical suspicion of MODY who were not suspected of having monogenic syndromic diabetes. We confirmed monogenic diabetes in 297 (23%) patients. Mutations in seven different syndromic diabetes genes accounted for 19% (95% CI 15-24%) of all monogenic diabetes. The mitochondrial m.3243A>G and mutations in HNF1B were responsible for the majority of mutations in syndromic diabetes genes. They were also the 4th and 5th most common causes of monogenic diabetes overall. These patients lacked typical features, and their diabetes phenotypes overlapped with patients with nonsyndromic monogenic diabetes. Syndromic monogenic diabetes genes (particularly m.3243A>G and HNF1B) should be routinely tested in patients with suspected MODY who do not have typical features of a genetic syndrome.

A220 THE IMPACT OF DIABETES AND AGE ON PERFORMANCE OF NON-INVASIVE SERUM-BASED TESTS FOR PREDICTION OF ADVANCED FIBROSIS IN BIOPSY-PROVEN NAFLD

Background

Non-alcoholic fatty liver disease (NAFLD) is now a leading cause of end-stage liver disease. Advanced stage F3-4 fibrosis predicts liver-related mortality in NAFLD patients. Simple non-invasive serum-based tests (NIT) for F3-4 are limited by indeterminate scores, necessitating secondary tests or liver biopsy. Diagnostic NIT cut-offs may vary in NAFLD patients with diabetes mellitus (DM) and the elderly. Identifying appropriate thresholds in populations in which these tests can be applied will reduce indeterminates and facilitate their broader use.

Aims

The aim of this study was to assess the impact of DM status and age on the performance of NIT for prediction of advanced fibrosis in patients with biopsy-proven NAFLD.

Methods

Patients presenting to two Canadian tertiary care centers between 2010–2018 for liver biopsy to diagnose NAFLD were included in this study. NIT including NFS, FIB4, BARD, AST-to-platelet ratio index (APRI), and AST to ALT ratio (AST/ALT) were calculated for each patient using validated cut-offs.

Results

457 patients were included in this study. Mean age was 48.8±12.9 years, 56% male, mean BMI 32.3 ± 6.7kg/m2, 69% with DM, and F3-4 prevalence 48%. Indeterminate rates for NIT were generally higher for older patients, with or without DM (27–49% and 37–52%, vs. 33–42% and 20–37%, respectively). FIB-4 and NFS both had high specificity >0.9 in DM patients <60 years (Table 1). There were no differences in AUROC for individual NITs between patients with and without DM, and those < 60 vs. ≥ 60, nor between individual NIT within these groups.

Conclusions

DM status and age, ≥ 60 vs. < 60, do not appear to have a significant impact on diagnostic performance of serum-based NIT in our cohort. Older patients had higher indeterminate results and reduced specificity, but T2DM status and age did not appear to have an impact on rate of misclassified patients. Serum-based NIT thresholds need to be optimized for older patients to reduce indeterminates and improve specificity.

Funding Agencies

None

Oral anticoagulation versus antiplatelet therapy for secondary stroke prevention in patients with embolic stroke of undetermined source: A systematic review and meta-analysis

Purpose

We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) to evaluate the efficacy and safety of direct oral anticoagulation (DOAC) compared with antiplatelet therapy for secondary stroke prevention in adult patients with embolic stroke of undetermined source (ESUS).

Method

We searched major databases (Embase, MEDLINE, CINAHL, CENTRAL, and Web of Science) for RCTs published until March 2021. The primary outcome was recurrent stroke, and the main safety outcomes were major bleeding and clinically relevant non-major bleeding (CRNB). We assessed risk of bias using the Cochrane Risk of Bias tool. We used a random-effects model to determine pooled risk ratios and 95% confidence intervals in the datasets and key subgroups.

Findings

Our search identified two RCTs, involving a total of 12,603 patients with ESUS. Anticoagulation with dabigatran or rivaroxaban compared with aspirin did not reduce the risk of recurrent stroke (RR, 0.96 [0.76–1.20]) or increase major bleeding (RR, 1.77 [0.80–3.89]) but significantly increased the composite of major or clinically relevant non-major bleeding (RR, 1.57 [1.26–1.97]). Prespecified subgroup analysis demonstrated consistent results according to age and sex. Additional post-hoc subgroup analyses demonstrated consistent results according to prior stroke and presence of a patent foramen ovale but suggested that DOACs reduced recurrent stroke in patients with an estimated glomerular filtration rate (eGFR) <50 and 50-80 ml/min but not in those with eGFR >80 ml/min (interaction P = 0.0234).

Discussion/conclusion

Direct oral anticoagulations are not more effective than aspirin in preventing stroke recurrence in patients with ESUS and increase bleeding.

Registration

PROSPERO ID: CRD42019138593

The cost savings of biosimilars can help increase patient access and lift the financial burden of health care systems

BACKGROUND

Biologics have provided improved clinical benefits to patients, but they come at a huge expense due to the high costs associated with their development and manufacturing. Biosimilars, which have been clinically studied and have demonstrated to be efficacious and safe, are more cost-effective versions of biologics, however, their uptake has been slow in the United States (US) compared to in the European Union (EU).

OBJECTIVES

In this analysis, we review the challenges to increased biosimilar use in the US and the successful strategies employed to increase biosimilar uptake in the EU.

CONCLUSIONS

Greater utilization of biosimilars in the US is an achievable goal but the federal government, pharmaceutical companies, and medical associations/institutions will need to work together to address patient and physician concerns and to remove incentives for using more expensive treatment options.

Postoperative outcomes in oesophagectomy with trainee involvement

BACKGROUND

The complexity of oesophageal surgery and the significant risk of morbidity necessitates that oesophagectomy is predominantly performed by a consultant surgeon, or a senior trainee under their supervision. The aim of this study was to determine the impact of trainee involvement in oesophagectomy on postoperative outcomes in an international multicentre setting.

METHODS

Data from the multicentre Oesophago-Gastric Anastomosis Study Group (OGAA) cohort study were analysed, which comprised prospectively collected data from patients undergoing oesophagectomy for oesophageal cancer between April 2018 and December 2018. Procedures were grouped by the level of trainee involvement, and univariable and multivariable analyses were performed to compare patient outcomes across groups.

RESULTS

Of 2232 oesophagectomies from 137 centres in 41 countries, trainees were involved in 29.1 per cent of them (n = 650), performing only the abdominal phase in 230, only the chest and/or neck phases in 130, and all phases in 315 procedures. For procedures with a chest anastomosis, those with trainee involvement had similar 90-day mortality, complication and reoperation rates to consultant-performed oesophagectomies (P = 0.451, P = 0.318, and P = 0.382, respectively), while anastomotic leak rates were significantly lower in the trainee groups (P = 0.030). Procedures with a neck anastomosis had equivalent complication, anastomotic leak, and reoperation rates (P = 0.150, P = 0.430, and P = 0.632, respectively) in trainee-involved versus consultant-performed oesophagectomies, with significantly lower 90-day mortality in the trainee groups (P = 0.005).

CONCLUSION

Trainee involvement was not found to be associated with significantly inferior postoperative outcomes for selected patients undergoing oesophagectomy. The results support continued supervised trainee involvement in oesophageal cancer surgery.

Incidental Findings of Asystole in a Patient With Complaints of Near Syncope: A Case Report on Paroxysmal Ventricular Standstill

Paroxysmal ventricular standstill (PVS) is an unusual cardiac phenomenon in which the heart experiences episodes of absent ventricular activity despite normal atrial functioning, often leading to cardiac arrest and syncope. In this case, we report the hospital stay of a 70-year-old male who was admitted to the hospital following an episode of near syncope at home. On admission, the patient’s initial electrocardiogram (ECG) showed sinus rhythm at 60 beats per minute without atrioventricular (AV) block. However, as orthostatic vitals were obtained, the patient became lightheaded for several seconds upon standing, which was noted to correspond with a nine second episode of asystole on telemetry and spontaneous return to sinus bradycardia afterward. Cardiology was immediately consulted and confirmed the diagnosis of paroxysmal ventricular standstill (PVS). Given continued episodes of PVS, the patient underwent successful urgent dual-chamber pacemaker placement, following which he became asymptomatic with resolution of bradycardia. Given the high mortality risk associated with PVS, this condition is an important differential to consider in any patient presenting with syncope or near syncope of unclear etiology.

A practical approach to bladder preservation with hypofractionated radiotherapy for localised muscle-invasive bladder cancer

Bladder preservation with trimodality treatment (TMT) is an alternative strategy to radical cystectomy (RC) for the management of localised muscle invasive bladder cancer (MIBC). TMT comprises of transurethral resection of the bladder tumour (TURBT) followed by radiotherapy with concurrent radiosensitisation. TMT studies have shown neo-adjuvant chemotherapy with cisplatin-based regimens is often given to further improve survival outcomes. A hypofractionated radiotherapy regimen is preferable due to its non-inferiority in local control and late toxicities. Radiosensitisation can comprise concurrent chemotherapy (with gemcitabine, cisplatin or combination fluorouracil and mitomycin), CON (carbogen and nicotinomide) or hyperthermic treatment. Radiotherapy techniques are continuously improving and becoming more personalised. As the bladder is a mobile structure subject to volumetric changes from filling, an adaptive approach can optimise bladder coverage and reduce dose to normal tissue. Adaptive radiotherapy (ART) is an evolving field that aims to overcome this. Improved knowledge of tumour biology and advances in imaging techniques aims to further optimise and personalise treatment.

Epstein-Barr Virus associated gastric carcinoma in a patient with germline STAT3 gain-of-function mutation

Introduction/Objective

Signal transducer and activator of transcription 3 (STAT3) is a transcription factor involved in inflammation, proliferation, differentiation and survival. STAT3 gain-of-function (GoF) disorders are characterized by immune dysregulation and present with polyendocrinopathy, enteropathy, X-linked syndrome (IPEX)- or autoimmune lymphoproliferative syndrome (ALPS)-like features. While patients with STAT-3 GoF are known to have an increased risk for hematologic malignancies, neither solid tumors nor an increased risk for EBV-associated disorders have been described. We report the first case of an EBV-associated solid organ tumor in a patient with STAT-3 GoF.

Methods/Case Report

A 21-year-old male with germline mutation in STAT3 (variant p. M329K) presented with early satiety, abdominal pain and worsening of chronic anemia. Serology showed high EBV DNA PCR levels. Endoscopy showed multiple nodular lesions in the stomach, which were biopsied to reveal EBV-associated high-grade dysplasia and intramucosal adenocarcinoma. Initiation of chemotherapy with a poor response led to a total gastrectomy. Gross examination of the specimen showed a 7.9 x 6.5 x 1.8 cm tan-brown, exophytic mass in the posterior wall of the body and antrum, involving the greater curvature. Histology revealed an adenocarcinoma with tubulovillous morphology extending into the lamina propria, without invasion into the muscularis mucosa or submucosa. EBER in-situ hybridization was diffusely positive in the tumor cells. The background mucosa showed severe chronic active and atrophic gastritis with intestinal metaplasia and low-grade dysplasia. All the seventy examined lymph nodes were negative for metastasis. Helicobacter-like organisms were not seen.

Results (if a Case Study enter NA)

NA

Conclusion

This is the first report of a solid tumor in a patient with STAT3 GoF mutation. The role of the patient’s underlying immune dysregulation disorder in the development of EBV-associated gastric adenocarcinoma is unclear and warrants further investigation. The case also highlights the importance of a close clinical follow-up in this patient population, as unexpected malignancies can develop at younger ages.

Real-world use of bevacizumab-awwb, a bevacizumab biosimilar, in US patients with metastatic colorectal cancer

Aim: Evaluated real world use of bevacizumab-awwb (MVASI^®), a bevacizumab biosimilar, for treating metastatic colorectal cancer (mCRC). Materials & methods: Adult mCRC patients who received bevacizumab-awwb during the first year after market availability were identified from the ConcertAI oncology dataset. Results: Of 304 patients, 47% initiated bevacizumab-awwb as reference product (RP) naive patients and 53% received bevacizumab-awwb with prior exposure to RP. Overall, 78% received bevacizumab-awwb as first-line therapy; the proportion was higher (91%) in RP-naive patients. Among RP-experienced patients, 83% were transitioned from RP to bevacizumab-awwb in the same line without disease progression; of those, the majority (83%) were transitioned within 28 days. Conclusion: Early evidence from US oncology practices suggests clinical adoption of bevacizumab-awwb in treating mCRC patients.

Neuromyelitis Optica in a Healthy Female After Severe Acute Respiratory Syndrome Coronavirus 2 mRNA-1273 Vaccine

Neuromyelitis optica spectrum disorder is an autoimmune demyelinating disease with high relative prevalence in the East Asian population. Clinical manifestations include optic neuritis, longitudinally extensive transverse myelitis, area postrema syndrome, brainstem syndromes, and diencephalic syndromes. In this case report, we present a case of neuromyelitis optica spectrum disorder that developed 10 days after the first dose of the severe acute respiratory syndrome coronavirus 2 mRNA-1273 vaccine. The patient was a previously healthy White female, completely independent and functional at baseline. She presented with bilateral lower-extremity numbness/tingling, weakness, and urinary retention. Although her neuromyelitis optica IgG was negative, the MRI was consistent with neuromyelitis optica involving and spanning longitudinally the C6-T2 vertebrae. She was treated with IV steroids and her symptoms improved. Given the novelty of the COVID-19 vaccines and the paucity of literature regarding their adverse effects, case reports such as ours provide unique information that aids healthcare providers in accurately diagnosing and treating patients, ultimately minimizing long-term neurologic deficits.

Computed tomography vs cardiovascular magnetic resonance imaging derived extracellular volume fraction in patients with stable new-onset chest pain

Background

Computed tomography (CT) is increasingly recognised as a diagnostic modality across a range of cardiovascular conditions and is now first-line for the investigation of stable new-onset chest pain. Determination of the myocardial extracellular volume fraction (ECV) has been shown to correlate well with the identification and prognostication of disease. Cardiovascular magnetic resonance (CMR) imaging remains the gold standard for the measurement of myocardial ECVCMR using T1-mapping, but there is increasing evidence for the use of ECV by cardiac CT (ECVCT).

Purpose

To assess the performance of ECVCT against the reference standard of ECVCMR.

Methods

Patients with a history of chest pain and no previously documented coronary disease referred for invasive angiography were recruited as part of the EVINCI Heart-QIT study. A cohort of these patients (n=33) underwent CMR at 1.5T (Siemens Aera, Siemens Healthcare, Erlangen/Germany) with T1 mapping of a mid-ventricular short axis slice (by MOdified Look-Locker Inversion recovery [MOLLI]) before and 15 minutes after a bolus of gadolinium contrast (0.1 mmol/kg gadoterate meglumine), followed by whole-heart ECVCT quantification (Somatom Force, Siemens Healthcare, Erlangen/Germany) using a 5-min post-iodine-contrast acquisition protocol. To account for data clustering on a patient level and volumetric discrepancy on a modality level, comparisons were made using mid-ventricular pooled ECVCT and ECVCMR. Bland-Altman analysis was used to determine the limits of agreement and identify systematic differences between both measures.

Results

A total of 33 patients (70% male, mean age 56.8±12.6yr) underwent the combined CMR and CT. ECVCMR and ECVCT were then analysed retrospectively (Figure 1). The average pooled ECV for the 6 mid-ventricular segments for CMR and CT were (27.6±2.4 and 26.8±2.2 respectively). Bland-Altman analysis demonstrated a marginally higher CMR-ECV (0.8±2.1) vs CT-ECV, which is in keeping with the longer delay-time encountered in CMR protocols (Figure 2).

Conclusions

ECVCT obtained from 5-minute post-contrast CT protocols show good agreement with ECVCMR in a stable chest pain patient cohort.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Siemens Helthineers Educational Grant Figure 1. CMR (L) and CT (R) ECV mapsFigure 2. Bland-Altman plot

The management of severe aortic stenosis during the COVID-19 pandemic: an observational study comparing TAVI and SAVR

Introduction

Outcomes and characteristics of patients with severe aortic stenosis (AS) treated during the COVID-19 pandemic is unknown.

Methods

This was a single-centre observational study of patients undergoing AS treatment with transcatheter (TAVI) or surgical (SAVR) therapy during the first-wave of the UK COVID-19 pandemic compared to a control cohort undergoing treatment in 2019.

Demographics, baseline echocardiogram, CT, procedural characteristics and outcome data were collated. The primary outcome was 30-day all-cause mortality. The secondary endpoint was duration of post-procedural hospitalisation.

Results

319 patients were recruited - 122 underwent intervention during the pandemic [73 TAVI; 49 SAVR] and 197 in 2019 [127 TAVI; 70 SAVR].

In 2020, TAVI patients had a higher Euroscore II (p&lt;0.001) but there were no differences in procedural complications or mortality [p=0.16] compared to TAVI 2019 cases. Duration from TAVI to discharge was shorter in 2020 (p&lt;0.001).

SAVR 2020 patients had similar baseline profile [p=0.48], surgical characteristics, mortality (p=0.68) and duration from SAVR to discharge compared to those in 2019.

During the pandemic, TAVI patients were older (p&lt;0.001) and had a higher Euroscore II (p&lt;0.001) than SAVR counterparts. TAVI patients had reduced 30-day mortality [0 (0%) vs 3 (6%); p=0.06] and were discharged more rapidly post-intervention than SAVR patients [median 1 [1] vs 7 [4] days; p&lt;0.001) translating into shorter hospitalization (p&lt;0.001).

Conclusions

TAVI and SAVR can be safely delivered with predictable resource utilisation during a pandemic. Despite the TAVI cohort incorporating higher risk, older patients, outcomes were at least as good as SAVR with a shorter length of post-procedural hospitalisation.

Funding Acknowledgement

Type of funding sources: None. Procedural Complications TAVI/SAVRDuration to discharge post TAVI/SAVR

198 Immediate Post-Operative PDE5i Therapy Improves Early Erectile Function Outcomes after Robot-Assisted Radical Prostatectomy (RARP)

Aim

To assess whether the timing of post-operative Phosphodiesterase Inhibitor (PDE5i) therapy after Robot Assisted Radical Prostatectomy (RARP) is associated with a change in early erectile function, continence, or safety outcomes.

Method

Data was prospectively collected from a single surgeon in one tertiary centre and retrospectively evaluated. 158 patients were treated with PDE5i therapy post RARP over a two-year period.

Results

There were no significant differences in pre-operative characteristics between the therapy groups. Patients that had bilateral nerve sparing had a mean drop in Erectile Function (EF) score by 5.4 compared to 8.8 in the unilateral group. Additionally, 34.9% of bilateral nerve sparing patients returned to baseline compared to 12.1% of unilateral. Drop in EF scores and percentage return to baseline for unilateral nerve sparing was respectively 9 and 11.1% of immediate (day 1-2), 7 and 14.8% of early (day 3-14) and 9.7 and 9.5% of late (day &gt;14) therapy (p = 0.9 and p = 0.6). For bilateral nerve sparing this was respectively 3.5 and 42.9% immediate therapy, 5.5 and 35.5% early therapy and 7.3 and 25% late therapy (p = 0.017 and p = 0.045). Pad free and social continence was achieved in 54% and 37% of those receiving immediate therapy, 60% and 33% for early therapy and 26% and 54% for late therapy. There were no differences in compliance, complication, or readmission outcomes.

Conclusions

Immediate PDE5i therapy should be considered in patients following nerve sparing RARP in order to maximise functional outcomes, especially in those undergoing bilateral nerve spare.

614 Elective Bariatric and Metabolic Surgery in United Kingdom During the Coronavirus Pandemic

Aim

Elective Bariatric and Metabolic Surgery (BMS) was halted in the UK during the first wave of the Coronavirus (COVID-19) pandemic. Obesity is a predictor of poor outcome in those infected with this virus. This study reports our experience resuming elective weight loss surgery safely amidst the pandemic.

Method

Guidance from national bodies (BOMSS/NICE) were reviewed and a Standard Operating Procedure (SOP) was drafted to accommodate local considerations. Data were prospectively collected on patients undergoing BMS following commencement of elective surgery after the first national lockdown.

Results

A total of 50 patients underwent BMS at our institution within six weeks of resuming the services. The median age was 41 years old and BMI was 43.8(IQR 40.0-48.8 kg/m2). Equal number of patients underwent laparoscopic Sleeve Gastrectomy (SG) and Roux en-Y Gastric Bypass (RYGB). Of these, 9 patients (18%) had revisional surgery and 48 patients (96%) were discharged within 24 hours of their surgery. The rate of readmission within thirty days of surgery was 6% (n = 3) and 1 patient returned to theatre with an obstruction proximal to the jejuno-jenunal anastomosis. None of the patients exhibited symptoms or tested positive for the COVID-19 virus.

Conclusions

With appropriate precautions and protocols, it is feasible and safe to resume BMS, with no increased risk to bariatric patients during the COVID-19 pandemic. This is particularly encouraging for other units in UK to offer BMS after the current lockdown.

684 The Standard of Emergency Operation Note Documentation at A District General Hospital Compared Against The Royal College of Surgeons of England (RCSEng) Standard

Introduction

Meticulous operation note documentation is essential for seamless, safe continuity of care in postoperative surgical patients. This study evaluated the standard of emergency operation note documentation at a district general hospital, when compared to the Royal College of Surgeons of England (RCSEng) guidelines and assessed the impact of a new operation note proforma.

Method

A retrospective review of 50 emergency operation notes was conducted between December 2019 and March 2020 and compared to RCSEng guidelines. Initial findings were presented at a local clinical governance meeting and a new electronic operation note was introduced. A further 50 emergency operation notes using the new proforma were analysed between August 2020 and December 2020.

Results

RCSEng mentions 19 main points that all operation notes must include. A total of 100 operation notes were reviewed and each given a score out of 19. Intervention of the new proforma showed significant improvement to the average score (15.64 vs 17.94; p &lt; 0.0001) when compared to RCSEng guidelines. In particular, there was significant improvement in the documentation of assistants involved in the procedure (58% vs 98%; p &lt; 0.0001), estimated blood loss (2% vs 63%; p &lt; 0.0001) and specific mention whether the operation was emergency or elective (20% vs 86%; p &lt; 0.0001).

Conclusions

Implementation of the new proforma showed significant improvement in operation note documentation when compared to the RCSEng standard. Therefore, this study emphasises the need for surgeons to familiarise themselves with the current guidelines and highlights the importance of tailoring local operation note proformas to match this national standard closely.

1384 Managing Peri-Orbital and Orbital Cellulitis: A New Multi-Specialty Care Pathway

Aim

1) To review current practice in the diagnosis and management of peri-orbital and orbital cellulitis in children at a London University Teaching Hospital. 2) To design and implement a streamlined, multi-specialty care pathway to improve the quality of care.

Background

Clinical differentiation between peri-orbital cellulitis and orbital cellulitis is often difficult, especially in young children. Early recognition and aggressive, multi-specialty treatment are required in order to prevent any vision and life-threatening sequelae.

Method

A retrospective case note analysis was performed for all paediatric patients with suspected peri-orbital or orbital cellulitis over a nineteen-month period. Extensive literature review was undertaken to ascertain current best practice in diagnosis and management. A streamlined, multi-specialty care pathway was developed, ratified by specialist departments, and introduced to optimise safety and quality of care.

Results

The results correlate with trends found in recent literature. 94.3% of patients had a blood culture taken with only 9.1% being positive. There were inadequate eye (37.1%) and endonasal (17.1%) cultures. Wide variation was noted in the criteria for imaging and in the antibiotic regimen used. 25.7% of patients received any nasal treatment. Suboptimal specialist review was identified in both orbital (60%) and peri-orbital (50.0%) cellulitis.

Conclusions

The new care pathway clearly informs investigation and empiric treatment based on initial risk stratification. The paediatric team is now the main, named care provider responsible for coordinating specialist input.

P–082 Effect of semen hyper viscosity (SHV) on blastocyst formation rate and implantation rate

Study question

Does semen hyper viscosity effects blastocyst formation rate

Summary answer

Hyper viscosity of semen sample later results in poor blastocyst formation rate and lower implantation rate.

What is known already

Normal range of semen hyper viscosity ranges between 12–29%.Highly viscous semen samples impairs the physical and chemical characteristics of seminal fluid and due to which seminal oxidative damage increases which further increases the ROS and reduces the sperm motility there are some factors that can affect the seminal viscosity out of which one is Male accessory gland infection, Hypo function of prostate seminal vesicles and varicoceles. SHV create hindrance in semen preparation.

Study design, size, duration

Retrospective study was conducted from June 2019 to Oct 2020 at IVF unit IKDRC hospital.

Participants/materials, setting, methods

142 patients were enrolled from June 2019 to Oct 2020 in IVF unit IKDRC hospital and divided into two groups. Group A (n = 83) patients with hyper semen viscosity and Group B (n = 69) patients with normal semen viscosity, inclusion and exclusion criteria’s were same for both the groups, only patient with normozoospermia were taken. Semen analysis was done by using WHO manual 2010.

Main results and the role of chance

In group A with hyper semen viscosity fertilization rate was (49.2% vs. 70% p = &lt;0.001) vs in group B with normal semen viscosity which is significantly higher in group B, Blastocyst formation rate ( 18.4% vs 35% p = &lt;0.01) and implantation rate (9.4% vs 20% p = &lt;0.005) both are significantly higher in group B . Which implies fertilization rate , blastocyst formation rate and implantation rate is significantly lower in patients with semen hyper viscosity.

Limitations, reasons for caution

Larger randomized control studies are needed to strengthen these results.

Wider implications of the findings: Our study demonstrates that patients having higher semen viscosity have poor blastocyst formation rate and implantation rate due to oxidative stress.

Trial registration number

Not applicable

P–109 Comparison between the outcome of sperm vitrification protocol and conventional slow freezing protocol for semen cryopreservation

Study question

Does sperm vitrification technique helps in increasing sperm survival and low DNA fragmentation index post warming.

Summary answer

Sperm vitrification protocol results in better motility, high progression and low DNA fragmentation index as compared to slow freezing.

What is known already

Cryopreservation is ceasing and resuming the cell metabolism, which can be achieved by different techniques like slow freezing and vitrification .Vitrification allows solidification of the cells and extracellular milieu into a glass like state without formation of ice which protects intracellular and extracellular ice formation, and further helps in avoiding different types of cryo-injuries and cellular damage. Study design, size, duration: Comparative study from July 2019 to Oct 2020 in IVF unit of IKDRC Hospital. Two hundred and ten patients were randomized by computer generated list and divided into two groups. Group 1 (n = 110) samples cryopreserved by vitrification and Group 2 (n = 100) samples cryopreserved by conventional slow freezing.

Participants/materials, setting, methods

Semen sample were analyzed by WHO 2010 laboratory manual, including all normozoospermic samples , other abnormal samples were excluded from the study . Method of semen preparation before cryopreservation is similar for both the groups, double density gradient method of preparation was used . Semen sample with high viscosity, hypo and hyper-spermia were also excluded. Similar cryovials of 2ml volume were used for both groups.

Main results and the role of chance

In group 1 where samples were cryopreserved by vitrification sperm motility was (54.3% vs 49.2%)vs in group 2 where samples were cryopreserved by slow freezing , non- significant difference were observed , but progressive motility was significantly higher in group 1 as compared to group 2 (36.8%vs17.9%) and DNA fragmentation index is significantly lower in group 1 vitrification than in group 2slow freezing ( 9.7% vs 20%).

Limitations, reasons for caution

Technical proficiency of the operator to avoid human errors and still larger randomized control studies are needed to strengthen these results

Wider implications of the findings: Our study demonstrates that vitrification is better than slow freezing of human sperm, improved survival rates with high progression were found with vitrification and low DNA fragmentation index were also observed in samples cryopreserved with vitrification protocol.

Trial registration number

Not applicable