Association of epidural analgesia in labor with neurodevelopmental outcomes in premature infants born at <29 weeks of gestational age

OBJECTIVE

To explore associations between epidural administration to mothers in labor with neurodevelopmental outcomes at 3 years corrected age in preterm infants born <29 weeks gestational age.

STUDY DESIGN

Infants born <29 weeks gestational age between 2006 and 2012 were included. Our primary outcome was a composite of death or neurodevelopmental impairment at 3 years corrected age. Infants were divided into those whose mothers did or did not receive epidural analgesia in labor. Univariable and multivariable regression was used for analysis.

RESULTS

There were 548 infants in the no epidural analgesia group and 121 in the epidural analgesia group. The adjusted odds ratio (95%CI) of neurodevelopmental impairment or death in the epidural group was 1.25 (0.82-1.93). Propensity score-matched results were 1.32 (0.79-2.22).

CONCLUSION

Preterm infants born <29 weeks gestational age to mothers who received epidural analgesia during labor were not associated with poor neurodevelopmental outcomes at 3 years corrected age.

The analgesic effect of transversalis fascia plane block after caesarean section under spinal anaesthesia with intrathecal morphine: a randomised controlled trial

We aimed to test whether bilateral injection of bupivacaine 0.25% in the transversalis fascia plane reduced 24 h opioid dose after singleton caesarean section, under spinal anaesthesia with intrathecal morphine, compared with saline 0.9% injectate. We allocated randomly 52 women to bilateral injection of 20 ml saline 0.9% on arrival in the post-anaesthesia care unit and 54 women to bilateral injection of 20 ml bupivacaine 0.25% (with adrenaline 2.5 μg.ml-1 ). Mean (SD) cumulative morphine equivalent opioid dose 24 h after saline injection was 32.3 (28.3) mg and 18.7 (20.2) mg after bupivacaine injection, a mean (95%CI) difference of 13.7 (4.1-23.2) mg (p = 0.006). Median (IQR [range]) time to first postoperative opioid dose was 3.0 (1.5-10.3 [0.0-57.4]) h after saline 0.9% and 8.2 (2.7-29.6 [0.2-55.4]) h after bupivacaine 0.25% (p = 0.054). Transversalis fascia plane with bupivacaine 0.25% with adrenaline reduced postoperative pain at rest during 48 h (0-10-point scale) by a mean (95%CI) of 0.9 (0.2-1.6) points (p = 0.013) and on movement by 1.2 (0.4-2.1) points (p = 0.004). We conclude that transversalis fascia plane bupivacaine 0.25% with adrenaline reduces pain and opioid dose after caesarean section compared with saline 0.9%.

Randomised controlled trial of analgesia for the management of acute severe pain from traumatic injury: study protocol for the paramedic analgesia comparing ketamine and morphine in trauma (PACKMaN)

BACKGROUND

Prehospital analgesia is often required after traumatic injury, currently morphine is the strongest parenteral analgesia routinely available for use by paramedics in the United Kingdom (UK) when treating patients with severe pain. This protocol describes a multi-centre, randomised, double blinded trial comparing the clinical and cost-effectiveness of ketamine and morphine for severe pain following acute traumatic injury.

METHODS

A two arm pragmatic, phase III trial working with two large NHS ambulance services, with an internal pilot. Participants will be randomised in equal numbers to either (1) morphine or (2) ketamine by IV/IO injection. We aim to recruit 446 participants over the age of 16 years old, with a self-reported pain score of 7 or above out of 10. Randomised participants will receive a maximum of 20 mg of morphine, or a maximum of 30 mg of ketamine, to manage their pain. The primary outcome will be the sum of pain intensity difference. Secondary outcomes measure the effectiveness of pain relief and overall patient experience from randomisation to arrival at hospital as well as monitoring the adverse events, resource use and cost-effectiveness outcomes.

DISCUSSION

The PACKMAN study is the first UK clinical trial addressing the clinical and cost-effectiveness of ketamine and morphine in treating acute severe pain from traumatic injury treated by NHS paramedics. The findings will inform future clinical practice and provide insights into the effectiveness of ketamine as a prehospital analgesia.

TRIAL REGISTRATION

ISRCTN, ISRCTN14124474. Registered 22 October 2020, https://www.isrctn.com/ISRCTN14124474.

Rotator cuff outcomes and mental health indices: Correlation or causation?

Background

Psychological factors such as catastrophizing, anxiety, and depression influence clinical outcomes in many conditions. Our purpose was to examine trends and associations between these and outcomes of rotator cuff surgery.

Methods

148 patients (76 W:72 M, 55.1 ± 8.2 years) with unilateral symptomatic rotator cuff syndrome were followed for 1 year after surgery. The Western Ontario Rotator Cuff Score (WORC), the Pain Catastrophizing Score (PCS), and the Hospital Anxiety and Depression Score (HADS) were administered. Evolution and associations of WORC, HADS and PCS scores were examined using uni- and multivariate analyzes.

Results

At 1 year, PCS, HADS-A, and HADS-D scores negatively correlated with WORC score (R = -0.6, -0.61, -0.69). The strength of correlation was lower between baseline PCS, HADS-A, and HADS-D scores and 1-year WORC score (R = -0.38, -0.43, -0.42). Prior anxiety diagnosis was associated with higher HADS-A scores at 2- and 6- weeks post-op (p = 0.013, 0.011). 106 participants experienced an improving HADS-D over the year of follow-up. Worse pre-op pain, WORC, PCS, HADS-A, HADS-D, cardiovascular disease and current smoking were associated with non-improving HADS-D.

Discussion

Patient-reported outcomes of rotator cuff surgery are associated with patient-reported anxiety, depression, and pain catastrophizing. In many, all outcome scores improved over time suggesting a two-way association between shoulder condition and psychological parameters.

Level of evidence

II.

Healthcare use attributable to COVID-19: a propensity-matched national electronic health records cohort study of 249,390 people in Wales, UK

BACKGROUND

To determine the extent and nature of changes associated with COVID-19 infection in terms of healthcare utilisation, this study observed healthcare contact 1 to 4 and 5 to 24 weeks following a COVID-19 diagnosis compared to propensity-matched controls.

METHODS

Two hundred forty nine thousand three hundred ninety Welsh individuals with a positive reverse transcription-polymerase chain reaction (RT-PCR) test were identified from data from national PCR test results. After elimination criteria, 98,600 positive individuals were matched to test negative and never tested controls using propensity matching. Cohorts were split on test location. Tests could be taken in either the hospital or community. Controls were those who had tested negative in their respective environments. Survival analysis was utilised for first clinical outcomes which are grouped into primary and secondary. Primary outcomes include post-viral-illness and fatigue as an indication of long-COVID. Secondary outcomes include clinical terminology concepts for embolism, respiratory conditions, mental health conditions, fit notes, or hospital attendance. Increased instantaneous risk for positive individuals was quantified using hazard ratios (HR) from Cox regression, while absolute risk (AR) and relative risk were quantified using life table analysis.

RESULTS

Analysis was conducted using all individuals and stratified by test location. Cases are compared to controls from the same test location. Fatigue (HR: 1.77, 95% CI: 1.34-2.25, p =  < 0.001) and embolism (HR: 1.50, 95% CI: 1.15-1.97, p = 0.003) were more likely to occur in all positive individuals in the first 4 weeks; however, anxiety and depression (HR: 0.83, 95% CI: 0.73-0.95, p = 0.007) were less likely. Positive individuals continued to be more at risk of fatigue (HR: 1.47, 95% CI: 1.24-1.75, p =  < 0.001) and embolism (HR: 1.51, 95% CI: 1.13-2.02, p = 0.005) after 4 weeks. All positive individuals are also at greater risk of post-viral illness (HR: 4.57, 95% CI: 1.77-11.80, p = 0.002). Despite statistical association between testing positive and several conditions, life table analysis shows that only a small minority of the study population were affected.

CONCLUSIONS

Community COVID-19 disease is associated with increased risks of post-viral-illness, fatigue, embolism, and respiratory conditions. Despite elevated risks, the absolute healthcare burden is low. Subsequently, either very small proportions of people experience adverse outcomes following COVID-19 or they are not presenting to healthcare.

Trauma-Disclosure, Meaning-Making, and Help-Seeking in Mothers Experiencing Homelessness: Results From a Trauma-Focused, Clinical Ethnographic Narrative Intervention

Mothers experiencing homelessness are seldom asked about past trauma that may be causal to housing instability and poor health. There are also few validated trauma-focused interventions in family shelters. To address this gap, we tested the feasibility and acceptability of the trauma-focused clinical ethnographic narrative intervention (CENI-TF) in increasing mothers' trauma disclosure, appraisal of its meaning in their lives, and help-seeking behaviors. We also present the qualitative findings to contextualize the intervention. Findings are organized under three major domains and nine subthemes that capture participants' voices and experiences. The CENI-TF has the potential to promote help-seeking behaviors and interrupt recurring cycles of trauma and housing instability in this at-risk population.

Disseminated protothecosis with central nervous system involvement in a dog in New Zealand

CASE HISTORY

A 1-year-old Border Terrier presented with acute onset of neurological signs and neck pain.

CLINICAL FINDINGS

Severe generalised ataxia, muscle tremors and cranial nerve deficits were noted. Multifocal brain lesions were suspected based on neurological examination. Computed tomography revealed an abdominal mass and cerebellar herniation through the foramen magnum.

LABORATORY AND PATHOLOGICAL FINDINGS

Cytological and histopathological analysis of the abdominal mass revealed necrotising and granulomatous lymphadenitis with intralesional algal elements most consistent with Prototheca spp.. Culture of a sample from the mesenteric lymph node confirmed the presence of Prototheca spp. which was identified as P. bovis based on sequencing of a DNA fragment amplified by PCR. Following inadequate response to symptomatic therapy and poor prognosis, the dog was subjected to euthanasia. Histopathological evaluation of the central nervous system lesions, identified granulomatous meningitis and ventriculitis with the presence of intralesional algae.

DIAGNOSIS

Disseminated protothecosis with granulomatous meningitis and ventriculitis caused by Prototheca bovis (formerly P. zopfii gen. 2).

CLINICAL RELEVANCE

This is the first case report of disseminated protothecosis with central nervous system involvement in a dog in New Zealand.

Allergic rhinitis: diagnosis and management

Allergic rhinitis affects 20% of the population of the UK. It confers a significant health burden upon the individual as it affects the patient's quality of life and is associated with serious comorbidities including asthma, sinusitis and conjunctivitis. Owing to its prevalence, it has a significant economic impact through its effects on education, productivity and use of healthcare resources. This review focuses on the management of allergic rhinitis and potential future treatments, because of the lack of clear national guidelines and because this illness is often misdiagnosed and mismanaged. The article provides a comprehensive overview of allergic rhinitis and illustrates the assessment criteria for various subcategories.

EPOS 4 Patients

EPOS2020 is the 4th and most recent version of the European Position Paper on Rhinosinusitis and Nasal Polyps which was first published in 2005. It aims to provide the most up to date scientifically robust information on the topic published in the literature which has been critically analysed by an international group of clinicians drawn from all disciplines dealing with these problems together with patients. The guidelines offer evidence-based recommendations and care pathways for acute and chronic rhinosinusitis in both adults and children. Management of these diseases from the patients' perspective is an important part of EPOS2020. Not only is this included in the main document but, for the first time, we have produced a separate supplement dedicated to and in collaboration with patients, EPOS4Patients, which aims to provide information in an accessible format, to answer frequently asked questions about these diseases and their treatment options as well as including useful patient resources and websites. It has never been more important for patients to be actively involved in their care. Being well informed helps you to make the best decisions together with your doctor.

Predictors of cardiac implantable electronic device infection in the United States

Background

Cardiac implantable electronic devices (CIED) are important tools for managing arrhythmias, improving hemodynamics, and preventing sudden cardiac death. Device infection (DI) remains a significant complication of CIED and is associated with high morbidity, mortality, and healthcare cost.

Purpose

To analyze predictors of DI and its in-hospital outcomes.

Methods

National Inpatient Sample 2011–2018 database was analyzed for admissions for CIED implantation or DI. Baseline and hospital level characteristics were derived. The Chi-square test and student t-test were used for comparison of categorical and continuous variables respectively. Variables with p&lt;0.20 from univariate analysis were included in the multivariate logistic regression to identify independent predictors of DI.

Results

A total of 1,604,173 admissions for CIED implantations and 71,007 (4.4%) admissions for DI were reported during 2011–2018. There was no significant change in annual admissions for DI (range 8550 to 9307, p for trend=0.98). Those with DI were more likely to be male (69.3 vs 57%, p&lt;0.001) and had higher Charlson comorbidity index score ≥3 (46.6%-vs-36.8%, p&lt;0.001). Multivariate analysis identified post-procedural hematoma (odds ratio (OR)=3.96; 95% Confidence Interval (CI)=3.46–4.54), congestive heart failure (CHF; OR=2.80, 95% CI=2.66–2.96), age group 45–60 years (OR=2.46, 95% CI=2.30–2.63), malnutrition (OR=1.99, 95% CI=1.85–2.15), coagulopathy (OR=1.75, 95% CI=1.64–1.86), end-stage renal disease (OR=1.65, 95% CI=1.53–1.78), atrial fibrillation (OR=1.42; 95% CI=1.35–1.49), non-Hispanic race (OR=1.25; 95% CI=1.16–1.36), coronary artery disease (OR=1.21; 95% CI=1.15–1.26), and thyroid disease (OR=1.15; 95% CI=1.09–1.12) [all p&lt;0.001] as independent predictors of DI. Prevalence of CHF, malnutrition, and atrial fibrillation increased in those admitted with DI over the observation period as shown in Figure 1 (p for trend &lt;0.001). Prevalence of diabetes mellitus also increased during the observation period although it was not an independent predictor of DI (p for trend &lt;0.001). Pulmonary embolism and deep vein thrombosis were most common complications in those with DI (4.1 and 3.6% respectively). Annual in-hospital mortality ranged from 3.9 to 5.7% (mean 4.4%, p for trend=0.07).

Conclusion

DI is relatively common and continues to be associated with high morbidity and mortality. Prevalence of DI has not changed significantly despite technical and technological advances in device implantation. Evaluation of risk factors for DI and management of modifiable comorbidities may be needed to reduce the incidence of this important complication of CIED implantation.

Funding Acknowledgement

Type of funding sources: None.

Transoral robotic surgery for the benefit of patients with head and neck cancer of unknown primary: our experience at St George's University Hospital, London

INTRODUCTION

Head and neck carcinoma of unknown primary represents 1-5% of all head and neck cancers and presents a diagnostic and therapeutic dilemma. In approximately 40% of cases, a primary tumour location remains unknown despite investigation. With advancements in our understanding of the role of high-risk human papilloma virus in head and neck cancer, transoral robotic surgery presents an option for diagnosis and therapy.

MATERIALS AND METHODS

This is a retrospective case series from a single centre. Case notes were reviewed for 28 patients who had transoral robotic surgery for head and neck carcinoma of unknown primary between May 2015 and July 2019.

RESULTS

Transoral robotic surgery identified an oropharyngeal primary tumour in 19 of 28 (67.8%) patients. All oropharyngeal primaries were p16 positive. The base of tongue identification rate was 63.2%. Median length of inpatient stay postoperatively was 1.0 day. Normal oral intake resumed within 48 hours in 96% (27/28) of patients. Three patients (10.3%) suffered minor postoperative bleeds that were all managed conservatively.

DISCUSSION

The base of tongue primary identification rate (63.2%) in this series is consistent with that previously reported (43-63%; 95% confidence interval). Primary tumour identification rate if a patient is p16 positive is 86.3% (19/22), with 100% of these being oropharyngeal. We suggest future investigation into p16 status as a means of stratifying patients with head and neck carcinoma of unknown primary for transoral robotic surgery.

CONCLUSION

Transoral robotic base of tongue mucosectomy (or lingual tonsillectomy) is a promising technique that offers a high yield of positive identification for the primary tumour. It is well tolerated with minimal associated morbidity. Our findings are comparable with those in the current literature.

High-volume culture and quantitative real-time PCR for the detection of Aspergillus in sputum

OBJECTIVES

Sputum culture is an insensitive method for the diagnosis of pulmonary aspergillosis. Growth of the organism allows identification of the causative species and susceptibility testing, both of which can inform treatment choices. The current practice is to culture an aliquot of diluted sputum. We assessed the value of culturing large volumes of unprocessed sputum, a method that we have termed high-volume culture (HVC).

METHODS

Specimens were processed by conventional culture (using an aliquot of homogenized, diluted sputum on Sabouraud agar at 37°C and 45°C for up to 5 days) and HVC (using undiluted sputum on Sabouraud agar at 30°C for up to 14 days). A separate specimen was tested by quantitative real-time PCR. Antifungal susceptibility testing was performed by the EUCAST standard.

RESULTS

We obtained sputum specimens from 229 individuals with the following conditions: chronic pulmonary aspergillosis (66.8%, 153/229), allergic bronchopulmonary aspergillosis (25.3%, 58/229) and Aspergillus bronchitis (7.9%, 18/229). Individuals with invasive pulmonary aspergillosis were not included. The positivity rate of conventional culture was 15.7% (36/229, 95% CI 11.6%-21.0%) and that of HVC was 54.2% (124/229, 95% CI 47.7%-60.5%) (p < 0.001). The higher positivity rate of HVC was demonstrated regardless of administration of antifungal treatment. Quantitive real-time PCR had an overall positivity rate of 49.2% (65/132, 95% CI 40.9%-57.7%), comparable to that of HVC.

CONCLUSION

Detection of Aspergillus spp. in sputum is greatly enhanced by HVC. HVC allows for detection of azole-resistant isolates that would have been missed by conventional culture. This method can be performed in any microbiology laboratory without the need for additional equipment.

C-31 A Meta-analysis Examining Fluency Measures in Depressed Elderly

Objective

Late-life depression (LLD) has been associated with cognitive impairments in domains such as memory, processing speed, and executive functions (e.g., initiation). However, it is unclear whether or not LLD is associated with language fluency difficulties that are often seen in some forms of dementia. Broadly, letter fluency is often observed to be associated with frontal deficits while category fluency is thought to be linked to temporal lobe dysfunction. Both tests are commonly used to assess language in older adults. The current meta-analysis examined potential differences between letter and category fluency in LLD and the robustness of previous findings in this population.

Data Selection

Investigators searched eight databases including PubMed and PsycINFO using terms such as “neuropsychol*,” “late-life,” and “depression.” Studies were excluded if participants were diagnosed with severe mental illness, neurological or other medical conditions that impact neurocognition.

Data Synthesis

Independent coders extracted data from 27 studies (k = 10 letter fluency, k = 17 semantic fluency). The effect size for semantic fluency was g = 0.64 (p < 0.001) with significant heterogeneity I² = 73.53% (Q = 60.45, df = 16, p < 0.001). The effect size for letter fluency was g = 0.49 (p < 0.001) also with significant heterogeneity I² = 52.08% (Q = 18.78, df = 9, p < 0.027).

Conclusions

Depressed individuals exhibited poorer performance on both category and letter fluency when compared to controls. This may indicate that depressed elderly individuals have difficulty with initiating verbal responses regardless of whether these responses rely on semantic networks or executive control.

A-25 Paced Auditory Serial Addition Test in Individuals with Cocaine Versus Methamphetamine Dependence

Objective

Research suggests that cocaine and methamphetamine differ in their impact on executive functions (EF). The Paced Auditory Serial Addition Test (PASAT) is used to assess working memory; a component of EF. The purpose of this meta-analysis was to examine the difference between the effect of these two drugs on PASAT scores.

Data Selection

Three researchers independently searched nine databases (e.g., PsycINFO, Pubmed, ProceedingsFirst), extracted required data, and calculated effect sizes. Inclusion criteria identified studies that had (a) compared cocaine or methamphetamine dependent groups to healthy controls and (b) matched groups on either age, education, or IQ (at least 2 out of 3). Studies were excluded if participants were reported to have Axis I diagnoses (other than cocaine or methamphetamine dependence) or comorbidities known to impact neuropsychological functioning. Six articles were coded and analyzed for the current study.

Data Synthesis

Cocaine studies showed a medium statistically significant effect size (g = 0.370, p = 0.020), while methamphetamine did not (g = 0.198, p = 0.172). There was no heterogeneity in effect sizes for both drugs. Subgroup analysis found no significant difference between the two drugs on the PASAT (Q-between = 0.646, p = 0.421).

Conclusions

In contrast to methamphetamine, cocaine is associated with poorer performance on PASAT. This is in line with previous studies that found that cocaine had more significant impact on EF than methamphetamine. Given the preliminary nature of this meta-analysis and the small number of studies on the topic, future primary studies should directly contrast how these two drugs impact EF.

A-17 Category Test performance in individuals with alcohol versus methamphetamine dependence

Objective

The Category Test (CT) has consistently been found to be sensitive at detecting the effects of alcohol on the brain. However, this test has not been as widely used in examining the effects of methamphetamine. The current meta-analysis compared effect sizes of studies that have examined performance on the CT in alcohol versus methamphetamine dependent participants.

Data selection

Three researchers independently searched nine databases (e.g., PsycINFO, Pubmed, ProceedingsFirst), extracted required data, and calculated effect sizes. Inclusion criteria identified studies that had (a) compared alcohol or methamphetamine dependent groups to healthy controls and (b) matched groups on either age, education, or IQ (at least 2 out of 3). Studies were excluded if participants were reported to have Axis I diagnoses (other than alcohol or methamphetamine dependence) or comorbidities known to impact neuropsychological functioning. Sixteen articles were coded and analyzed for the current study.

Data synthesis

Alcohol studies showed a large effect size (g = 0.745, p < 0.001) while methamphetamine studies evidenced a moderate effect size (g = 0.406, p = 0.001); both without statistically significant heterogeneity (I2 = 0). Subgroup analysis revealed a statistically significant difference between the effect sizes from alcohol versus methamphetamine studies (Q-between = 5.647, p = 0.017).

Conclusions

The CT is sensitive to the effects of both alcohol and methamphetamine and should be considered when examining dependent patients who might exhibit problem solving, concept formation, and set loss difficulties in everyday living.

Evaluation of a health trainer–led service for people with knee, hip and back pain

Aims:

Chronic knee, hip and back pain is extremely prevalent. Management guidelines emphasise maintaining physical activity and healthy weight to reduce pain and improve physical and mental wellbeing. Unfortunately, few people receive support to make lifestyle changes. We evaluated whether a health trainer—led ‘joint pain advice’ (JPA) service delivering person-centred lifestyle coaching was feasible, acceptable and effective for people with knee, hip and back pain.

Methods:

Feasibility of delivering a JPA service was assessed by documenting whether the health trainers could deliver JPA and its uptake. Nine health trainers delivered JPA. Participants were offered up to four appointments. At each appointment, health trainers gave people information about their condition, co-developed care plans, suggested self-management strategies and used behavioural change techniques (motivational interviewing, goal-setting and action planning) to increase physical activity and reduce body weight. Pain, function, physical activity and body mass index (BMI) were collected at baseline, 3 weeks, 6 weeks and 6 months. Focus groups captured people’s opinions of the service’s effectiveness, acceptability and usefulness.

Results:

Of the 105 people who enquired about JPA, 85 (81%) used the service, after which their physical activity and function improved, and pain, use of analgesia and BMI decreased. They felt more knowledgeable and better motivated to adopt and maintain healthier behaviours. They attributed these improvements to the JPA service, because of its better consultations and collaborative holistic approach. Only a minority attended all four appointments because they felt they received sufficient advice from the initial appointments. The health trainers gained knowledge and skills to support clients with musculoskeletal conditions.

Conclusions:

Using a holistic, patient-centred approach, health trainers can deliver lifestyle advice to people with chronic knee, hip or back pain safely, effectively and efficiently. The service was popular with recipients and health trainers, and helped people adopt healthier lifestyles that lead to reduced pain and other clinical improvements.

Can We Accurately Predict Cost Effectiveness Without Access to Overall Survival Data? The Case Study of Nivolumab in Combination with Ipilimumab for the Treatment of Patients with Advanced Melanoma in England

BACKGROUND

Nivolumab with ipilimumab (the Regimen) is the first immuno-oncology combination treatment to demonstrate long-term clinical benefit for advanced melanoma patients. We evaluated the cost effectiveness of the Regimen in this population, with and without the availability of overall survival (OS) data.

METHODS

A partitioned survival model and a Markov state-transition model were developed to estimate the lifetime costs and benefits of the Regimen versus ipilimumab. These models were built with and without the availability of OS data, as only progression-free survival data were available from the head-to-head, phase III trial against ipilimumab at the time of the National Institute for Health and Care Excellence (NICE) submission. Patient utilities and resource use data were sourced from trial data or the literature.

RESULTS

Incremental cost-effectiveness ratios (ICERs) and absolute costs were similar between the models with and without OS data, but the model with OS data generated more than 1 additional quality-adjusted life-year (QALY) across both treatment arms. In both models, based on list prices, the Regimen was the most cost-effective treatment.

CONCLUSIONS

The analyses show that the Regimen is a cost-effective treatment for advanced melanoma patients in England, and methods to overcome the lack of OS can give reasonable estimates of QALYs gained and ICERs.

Correction to: Can We Accurately Predict Cost Effectiveness Without Access to Overall Survival Data? The Case Study of Nivolumab in Combination with Ipilimumab for the Treatment of Patients with Advanced Melanoma in England

The second Key Point for Decision Makers, which reads.

Prevention of chronic rhinosinusitis

Prevention of chronicity of disease and minimising its impact with individualized treatment is a fundamental tenet of precision medicine. A review of the literature has been undertaken to explore how this may apply to chronic rhinosinusitis (CRS). Prevention may be thought of across 3 main domains. Primary prevention of CRS focuses on the avoidance of exposure to environmental factors associated with increased incidence of disease. This includes avoidance of tobacco smoke and occupational toxins. Although allergic rhinitis, respiratory infections and gastro-oesophageal reflux have been shown to be risk factors, there is no evidence as yet that treatment of these conditions is associated with reduced incidence of CRS. Secondary prevention of CRS is concerned with detecting a disease in its earliest stages, intervening to achieve disease and symptom control and preventing future exacerbations. Evidence based guidelines facilitate early diagnosis and appropriate use of medical and surgical interventions. In the future the use of endotypes to direct optimal is like to allow more clinically and cost-effective use of current and emerging treatments, such as monoclonal antibodies. Tertiary prevention aims to minimise the impact of an ongoing illness or injury that has lasting effects. Anxiety and depression have been shown to be associated with symptom amplification and may require treatment. The role of disease-related factors such as the role of the microbiome and osteo-neogenesis in the development of chronicity, and the development of severe combined upper airway disease needs further research.

Rhinitis and its impact on quality of life in swimmers

INTRODUCTION

Limited data suggest that swimmers might be affected by rhinitis significantly more often than the general population. This can have impact on quality of life but also on performance. The aim of this study was to determine the prevalence and impact of QOL of rhinitis in swimming compared to nonswimming athletes and controls.

MATERIALS AND METHODS

This was an observational case-control, questionnaire-based study involving elite (n = 101) and nonelite swimming athletes (n = 107), nonswimming athletes (n = 38) and sex- and age-matched controls (n = 50). The survey instrument consisted of a general and the miniRQLQ. Main question used to assess the prevalence of rhinitis was from the ISAAC study.

RESULTS

Rhinitis was reported significantly more often by the elite swimmers (45%) than nonelite swimmers (31%), nonswimming athletes (32%) and controls (24%). Allergic rhinitis prevalence was similar in all groups (12%-18%). The prevalence of nonallergic rhinitis (NAR) was significantly higher in elite swimmers (33%) and nonelite swimmers (22%) compared to nonswimming athletes and controls. Overall mean miniRQLQ score and all subdomains except the "eye" domain showed significantly reduced QOL in elite and nonelite swimmers compared to nonswimming athletes and controls. Regular nasal medication was used significantly less by elite swimmers (18%) compared to controls (67%) and nonswimming athletes (42%).

CONCLUSION

This study revealed a high prevalence of NAR in swimmers and related impact on QoL. These findings highlight the importance to increase the awareness towards upper airway disorders in the swimming athletes and to ensure adequate management.

Preliminary observations on clotting under three hydrocolloid dressings

Four patients with five wounds were randomly assigned to treatment with three occlusive dressings: DuoDERM®, Restore® and Comfeel Ulcus®; the dressings were left intact for 24-48 h.

When the dressings were removed, it was found that wounds that had been covered with Restore and Comfeel contained coagulated sanguinous material. Two wounds that had been covered with Comfeel and Restore, respectively, were then covered with DuoDERM, while one wound previously covered with DuoDERM was covered with Restore. Either no clotting occurred under DuoDERM or clots may have resolved.

Although these preliminary data suggest that DuoDERM gel may have fibrinolytic properties, more extensive and controlled studies are needed to assess the characteristics of this dressing.

Improving access to better care for people with knee and/or hip pain: service evaluation of allied health professional-led primary care

INTRODUCTION

Chronic knee and hip pain is prevalent, impairing mobility, function and quality of life. Allied health professions (AHPs) are better trained and have more time than general practitioners in primary care to advise and support people to adopt healthier lifestyles (maintain healthy weight, increase physical activity) that reduce joint pain. We evaluated whether AHP-led primary care delivering person-centred, practical lifestyle coaching was a feasible, effective way to manage chronic knee and/or hip pain.

METHODS

At initial assessment the 'Joint Pain Advisor' assessed pain, function, quality of life, physical activity, waist circumference and body mass, taught simple self-management strategies and used behaviour change techniques (motivational interviewing, goal setting, action/coping planning) to alter participants' lifestyles. Participants were invited for 6-week and 6-month reviews, when the Advisor reassessed clinical outcomes, fed back progress and reinforced health messages. Feasibility and effectiveness of the service was evaluated using quantitative and qualitative methods.

RESULTS

Uptake of the service was good: 498 people used the service. Between initial assessment and reviews, participants' pain, function, quality of life, weight, waist circumference and physical activity improved (p < 0.005). Service user satisfaction was high; they reported easier access to advice and support tailored to their needs that translated into clinical benefits and a more efficient pathway reducing unnecessary consultations and investigations. Relatively few people returned for a 6-month review as they considered they had received sufficient advice.

CONCLUSIONS

AHP-led care is a popular, effective, efficient and sustainable way to manage joint pain, without compromising safety or quality of care.

Abstract P2-11-06: Analysis of cardiac events among node positive breast cancer (NPBC) patients treated with three-dimensional conformal radiation therapy (3D-CRT)

Background: Regional nodal irradiation (RNI) in addition to the chest wall and/or breast can maximize local regional control and improve overall survival, but has been associated with late cardiac morbidity. We examined NPBC patients treated with RNI using 3D-CT based radiation therapy (RT) to evaluate incidence and type of cardiac events.

Methods: Between 2000 and 2007, 156 NPBC patients were treated with RNI following lumpectomy or mastectomy using 3D-CRT. In all cases, treatment target and normal tissue volumes were delineated on treatment CT scans. The heart contour included the left ventricle and the atria. Prescription dose was typically 50Gy in 25 fractions (range 44-54 Gy) to the chest wall and/or breast PTVeval. 37% received a boost to the chest wall and 73% to the lumpectomy cavity. The mean prescription dose to the axilla and supraclavicular lymph nodes was 47.6 Gy (range 43.2 – 54 Gy) and 46.8 Gy to the IMN (range 35.3 – 50.4 Gy). The dose-volume cardiac data and incidence of cardiac events is reported.

Results: Median follow-up of surviving patients was 7 years (range, 0.3-10.6). Median patient age was 50 (range, 27-91), 52% were premenopausal, 76% estrogen receptor positive, and 18% were HER-2 positive. The IMN received &gt; 40 Gy in 66%. Chemotherapy was used in 94% of patients, and it was anthracycline-based in 82.3%. At the time of RT, 12.5% smoked, 9% had diabetes, 33% with HTN, and 4.4% had a history of CAD.

Average mean heart dose for the cohort was 5.2 Gy (range, 0.2 - 25.3 Gy). Mean cardiac V25 was 5.4% (range, 0-20%), mean cardiac V45 was 1.7% (range, 0-13.3%), and mean maximum cardiac point dose was 45.4 Gy.

There was 1 (0.7% of cohort) right sided patient with cardiac events and 8 (5.1% of cohort) left experiencing cardiac events. A total of 18 cardiac diagnoses were experienced among the 9 patients: Coronary artery disease with or without myocardial infarction (4), congestive heart failure (6), cardiomyopathy (3), and arrhythmia (5).

Conclusions: The cardiac event rate among these NPBC patients treated with RNI and anthracycline-based chemotherapy was low, but more common in women with left-sided breast cancer compared to right. Additional analysis using 3DCRT volumes are important to validate these findings and better define the dose-volume parameters for cardiac toxicity.

Citation Format: Bradley JA, Sparks I, Prior P, Bergom C, Walker A, Wilson JF, Li XA, White J. Analysis of cardiac events among node positive breast cancer (NPBC) patients treated with three-dimensional conformal radiation therapy (3D-CRT) [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P2-11-06.

Meat allergy associated with galactosyl-α-(1,3)-galactose (α-Gal)-Closing diagnostic gaps by anti-α-Gal IgE immune profiling

BACKGROUND

Glycoproteins and glycolipids of some mammalian species contain the disaccharide galactosyl-α-(1,3)-galactose (α-Gal). It is known that α-Gal is immunogenic in humans and causes glycan-specific IgG and also IgE responses with clinical relevance. α-Gal is part of the IgE-reactive monoclonal therapeutic antibody cetuximab (CTX) and is associated with delayed anaphylaxis to red meat. In this study, different α-Gal-containing analytes are examined in singleplex and multiplex assays to resolve individual sensitization patterns with IgE against α-Gal.

METHODS

Three serum groups, α-Gal-associated meat allergy (MA) patients, idiopathic anaphylaxis (IA) patients with suspected MA, and non-meat-allergic healthy control individuals (HC), were analyzed via singleplex allergy diagnostics and a newly established immunoblot diagnostic system. The new dot blot detection system resolved individual IgE sensitization profiles for α-Gal-containing analytes CTX, bovine thyroglobulin (Bos d TG), and human serum albumin (HSA)-conjugated α-Gal.

RESULTS

Singleplex allergy diagnostics using the α-Gal analytes CTX and Bos d TG confirms the history of MA patients in 91% and 88% of the cases, respectively. A novel dot blot-based assay system for the detection of IgE against α-Gal reveals individual IgE sensitization profiles for α-Gal-containing analytes. An α-Gal-associated IgE cross-reactivity profile (IgE against CTX, Bos d TG, and HSA-α-Gal) was identified, which is associated with MA.

CONCLUSIONS

Detection of individual sensitization patterns with different α-Gal-containing analytes provides the basis for an individual allergy diagnosis for α-Gal-sensitized patients. Higher amounts of α-Gal in pork and beef innards compared to muscle meat as indicated by a higher staining intensity are a plausible explanation for the difference in allergic symptom severity.

A Collaborative Study to Establish the 5th International Standard for Unfractionated Heparin

Twenty-four laboratories participated in a collaborative study to calibrate a replacement for the 4th International Standard for Unfractionated Heparin (82/502). Both candidate materials A and B, gave excellent intra- and inter-laboratory variations (majority of mean %gcv <10%) when assayed against the 4th International Standard. No major differences of potency estimates were found between methods, although the USP method generally gave lower potencies than the other methods and candidate B gave a greater variation between methods than A. Overall, this study showed that the differences between the candidates are marginal. Based on its narrower molecular weight profile, higher specific activity and slightly lower inter-method variation, candidate A, 97/578, was proposed and accepted in October, 1998, by the Expert Committee on Biological Standardisation of the World Health Organisation to be the 5th International Standard for Unfractionated Heparin with an assigned potency of 2031 IU/ampoule.