Safety and efficacy of peptide receptor radionuclide therapy in neuroendocrine tumors: A single center experience

Peptide receptor radionucleotide therapy (PRRT) with 177Lu-dotatate is widely used for the treatment of patients with neuroendocrine tumors (NETs). We analyzed data from 104 patients with NETs treated with 177Lu -dotatate at a US academic center between December 2017 and October 2020 to better understand patterns of long-term efficacy, safety, and toxicity in the real-world setting. 177Lu-dotatate (200 mCi) was administered every eight weeks for four doses. The most common sites of primary disease were small intestine NETs (n = 49, 47%), pancreatic NETs (n = 32, 31%), and lung NETs (n = 7, 7%). Twenty-seven percent had Ki-67 <3%, 49% had Ki-67 between 3-20%, and 13.5% had Ki-67 >20%. The cohort had been pretreated with a median of two prior lines of treatment. Forty percent had received prior liver-directed treatment. Seventy-four percent of patients completed all four doses of treatment. The objective response rate was 18%. The median time-to-treatment failure/death was significantly longer for small-bowel NETs when compared to pancreatic NETs (37.3 months vs. 13.2 months, p = 0.001). In a multivariate model, Ki-67, primary site, and liver tumor burden ≥50% were found to independently predict time-to-treatment failure/death. Around 40% of patients experienced adverse events of ≥grade 3 severity. Treatment-related adverse events leading to discontinuation of therapy happened in 10% of patients. Preexisting mesenteric/peritoneal disease was present in 33 patients; seven of these patients developed bowel-related toxicities including two grade 5 events. We also report two cases of delayed-onset minimal change nephrotic syndrome, which occurred 14 and 27 months after the last dose of PRRT. Lastly, we describe six patients who developed rapid tumor progression in the liver leading to terminal liver failure within 7.3 months from the start of PRRT, and identify potential risk factors associated with this occurrence, which will need further study.

Multiorgan MRI findings after hospitalisation with COVID-19 in the UK (C-MORE): a prospective, multicentre, observational cohort study

INTRODUCTION

The multiorgan impact of moderate to severe coronavirus infections in the post-acute phase is still poorly understood. We aimed to evaluate the excess burden of multiorgan abnormalities after hospitalisation with COVID-19, evaluate their determinants, and explore associations with patient-related outcome measures.

METHODS

In a prospective, UK-wide, multicentre MRI follow-up study (C-MORE), adults (aged ≥18 years) discharged from hospital following COVID-19 who were included in Tier 2 of the Post-hospitalisation COVID-19 study (PHOSP-COVID) and contemporary controls with no evidence of previous COVID-19 (SARS-CoV-2 nucleocapsid antibody negative) underwent multiorgan MRI (lungs, heart, brain, liver, and kidneys) with quantitative and qualitative assessment of images and clinical adjudication when relevant. Individuals with end-stage renal failure or contraindications to MRI were excluded. Participants also underwent detailed recording of symptoms, and physiological and biochemical tests. The primary outcome was the excess burden of multiorgan abnormalities (two or more organs) relative to controls, with further adjustments for potential confounders. The C-MORE study is ongoing and is registered with ClinicalTrials.gov, NCT04510025.

FINDINGS

Of 2710 participants in Tier 2 of PHOSP-COVID, 531 were recruited across 13 UK-wide C-MORE sites. After exclusions, 259 C-MORE patients (mean age 57 years [SD 12]; 158 [61%] male and 101 [39%] female) who were discharged from hospital with PCR-confirmed or clinically diagnosed COVID-19 between March 1, 2020, and Nov 1, 2021, and 52 non-COVID-19 controls from the community (mean age 49 years [SD 14]; 30 [58%] male and 22 [42%] female) were included in the analysis. Patients were assessed at a median of 5·0 months (IQR 4·2-6·3) after hospital discharge. Compared with non-COVID-19 controls, patients were older, living with more obesity, and had more comorbidities. Multiorgan abnormalities on MRI were more frequent in patients than in controls (157 [61%] of 259 vs 14 [27%] of 52; p<0·0001) and independently associated with COVID-19 status (odds ratio [OR] 2·9 [95% CI 1·5-5·8]; padjusted=0·0023) after adjusting for relevant confounders. Compared with controls, patients were more likely to have MRI evidence of lung abnormalities (p=0·0001; parenchymal abnormalities), brain abnormalities (p<0·0001; more white matter hyperintensities and regional brain volume reduction), and kidney abnormalities (p=0·014; lower medullary T1 and loss of corticomedullary differentiation), whereas cardiac and liver MRI abnormalities were similar between patients and controls. Patients with multiorgan abnormalities were older (difference in mean age 7 years [95% CI 4-10]; mean age of 59·8 years [SD 11·7] with multiorgan abnormalities vs mean age of 52·8 years [11·9] without multiorgan abnormalities; p<0·0001), more likely to have three or more comorbidities (OR 2·47 [1·32-4·82]; padjusted=0·0059), and more likely to have a more severe acute infection (acute CRP >5mg/L, OR 3·55 [1·23-11·88]; padjusted=0·025) than those without multiorgan abnormalities. Presence of lung MRI abnormalities was associated with a two-fold higher risk of chest tightness, and multiorgan MRI abnormalities were associated with severe and very severe persistent physical and mental health impairment (PHOSP-COVID symptom clusters) after hospitalisation.

INTERPRETATION

After hospitalisation for COVID-19, people are at risk of multiorgan abnormalities in the medium term. Our findings emphasise the need for proactive multidisciplinary care pathways, with the potential for imaging to guide surveillance frequency and therapeutic stratification.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Improving antibiotic use in hospitals: development of a digital antibiotic review tracking toolkit (DARTT) using the behaviour change wheel

OBJECTIVE

To develop a theory-informed behaviour change intervention to promote appropriate hospital antibiotic use, guided by the Medical Research Council's complex interventions framework.

METHODS

A phased approach was used, including triangulation of data from meta-ethnography and two qualitative studies. Central to intervention design was the generation of a robust theoretical basis using the Behaviour Change Wheel to identify relevant determinants of behaviour change and intervention components. Intervention content was guided by APEASE (Acceptability, Practicability, Effectiveness, Affordability, Side-effects, and Equity) criteria and coded using a Behaviour Change Technique Taxonomy. Stakeholders were involved throughout.

RESULTS

From numerous modifiable prescribing behaviours identified, active 'antibiotic time-out' was selected as the target behaviour to help clinicians safely initiate antibiotic reassessment. Prescribers' capability, opportunity, and motivation were potential drivers for changing this behaviour. The design process resulted in the selection of 25 behaviour change techniques subsequently translated into intervention content. Integral to this work was the development and refinement of a Digital Antibiotic Review Tracking Toolkit.

CONCLUSION

This novel work demonstrates how the Behaviour Change Wheel can be used with the Medical Research Council framework to develop a theory-based behaviour change intervention targeting barriers to timely hospital antibiotic reassessment. Future research will evaluate the Antibiotic Toolkit's feasibility and effectiveness.

Blood pressure reduction in higher cardiovascular risk patients in the Global SYMPLICITY Registry

Background/Introduction

The Global SYMPLICITY Registry (GSR) was designed to evaluate the safety and efficacy of renal denervation (RDN) in real-world patients. Inclusion and exclusion criteria are limited to allow assessment of the effects of RDN on patients with a wide range of comorbidities. The current analysis examines blood pressure (BP) reduction after RDN in higher cardiovascular risk patients.

Purpose

To evaluate blood pressure reduction after RDN in higher cardiovascular risk patients in GSR.

Methods

GSR is a prospective all-comers registry to evaluate the safety and efficacy of RDN. Patients are enrolled in GSR and receive radiofrequency RDN using the Symplicity Flex or Symplicity Spyral catheter. Office and ambulatory BP are measured at each follow-up (3, 6, 12, 24, and 36 months). In this post-hoc analysis, changes from baseline in office and 24-hour ambulatory systolic blood pressure were assessed in patients at higher cardiovascular risk. Higher risk was defined using baseline office systolic or diastolic BP as well as additional risk factors (Figure 1).

Results

As of March 2021, there were 2621 patients characterized as higher cardiovascular risk in GSR. Baseline characteristics included mean age 60.7±12.1 years, 57.6% male, 37.9% type 2 diabetes, 35.8% hypocholesterolemia, 19.7% eGFR &lt;60 mL/min/1.73 m2, 16.2% left ventricular hypertrophy, 10.2% previous stroke and 9.3% previous myocardial infarction. Baseline office systolic BP (OSBP) was 168.8±22.7 mmHg and baseline ambulatory systolic BP (ASBP) 155.3±18.6 mmHg. Mean OSBP reductions after RDN in this higher risk population ranged from −13.1 mmHg at 3 months to −17.5 mmHg at 24 months and −18.9 mmHg at 36 months, and mean ASBP reductions ranged from −7.8 mmHg at 3 months to −9.8 mmHg at 24 months and −9.3 mmHg at 36 months (Figure).

Conclusions

Higher risk patients in GSR had sustained office and ambulatory systolic BP reductions out to 3 years after catheter-based radiofrequency RDN.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Medtronic

The impact of ventricular-arterial coupling on aerobic capacity across the heart failure spectrum

Background

Ventricular-arterial coupling (VAC) can be evaluated as the ratio between arterial stiffness (pulse wave velocity, PWV) and myocardial deformation (global longitudinal strain, GLS).

Objectives

To evaluate VAC across the spectrum of heart failure (HF).

Methods

We introduced a Doppler-derived, single-beat technique to estimate aortic arch PWV (aa-PWV) in addition to tonometry-derived carotid-femoral PWV (cf-PWV). We measured PWVs and 3D-GLS in 155 healthy controls, 75 subjects at risk of developing HF (American College of Cardiology/American Heart Association Stage A-B) and 236 patients in HF Stage C with preserved (HFpEF, n=104) or reduced ejection fraction (HFrEF, n=132). We evaluated peak oxygen consumption (VO2) and peripheral extraction (AVO2diff) using combined cardiopulmonary-echocardiography exercise stress.

Results

aa-PWV was obtainable in all subjects and significantly lower than cf-PWV in all subgroups (p&lt;0.01). PWVs were directly related and increased with age (all p&lt;0.0001). cf-PWV/3D-GLS was similarly compromised in HFrEF (1.08±0.36) and HFpEF (1.05±0.22), while aa-PWV/3D-GLS was more impaired in HFpEF (0.69±0.11) than HFrEF (0.60±0.15; p&lt;0.01). Stage A-B had values of cf-PWV/3D-GLS and aa-PWV/3D-GLS (0.66±0.25 and 0.47±0.12) higher than controls (0.47±0.10 and 0.40±0.10) but lower than Stage C (all p&lt;0.01). Peak AVO2diff was inversely related with cf-PWV/3D-GLS and aa-PWV/3D-GLS (all p&lt;0.01). cf-PWV/3D-GLS and aa-PWV/3D-GLS independently predicted peak VO2 in the overall population (adjusted R2=0.32 and 0.35; all p&lt;0.0001) but only aa-PWV/3D-GLS was independently associated with flow reserve during exercise (R2=0.51; p&lt;0.0001).

Conclusion

Abnormal VAC is directly correlated with greater severity of HF and worse functional capacity. HFpEF shows a worse VAC than HFrEF when expressed by aa-PWV/3D-GLS.

Funding Acknowledgement

Type of funding sources: None.

A behavioural intervention to increase lay-people's intentions to initiate CPR in the event of Out-of-Hospital Cardiac Arrest: results from BICeP pilot trial

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Medical Research Council

Background

Cardiopulmonary resuscitation (CPR) is the single most important factor determining survival from out of hospital cardiac arrest (OHCA). Even when trained, most lay-people don’t attempt CPR when they encounter OHCA. Working closely with intended users and CPR experts we developed a theory-based text-messaging intervention designed to increase rates of CPR. This pilot study was conducted to evaluate the acceptability of the messages, explore participant responses to them and to trial measures for a full evaluation.

Design

A before-and-after study plus qualitative interviews

Methods

Twenty lay-people from across Scotland agreed to take part and to receive the intervention (35 text-messages over approx. 6 weeks) At baseline and after participants had received intervention (approx. 6 weeks later) we measured how likely people were to perform CPR (intention) in relation to 4 scenarios and self-assessed competence and confidence about performing CPR (self-efficacy) in general. We conducted qualitative interviews with 10 participants to elicit their views of the intervention

Results

Twenty lay-people (6F, 14M; aged 20-84) participated, all providing full baseline data. 19/20 participants received at least 20 messages. 15/20 provided follow-up data and ten were interviewed. Baseline intentions to initiate CPR in CPR scenarios were high (18.1) but still greater after the intervention (19.5). Increases in theory-based predictors of intention, self-efficacy (pre:74.5 post:81.0) and self-assessed competence (pre:19.5 post:20.5) were also observed following the intervention. Qualitative data suggested the intervention was positively received and viewed as helpful in improving confidence by reinforcing and building on messages from training. Interviewees suggested additional options for delivery format and pace would be helpful.

Conclusions

A behaviour-change text-message intervention delivered after CPR training is acceptable, easily scalable and may help improve rates of lay CPR initiation. Full scale evaluation of effectiveness is planned.

Association between genetic and socioenvironmental risk for schizophrenia during upbringing in a UK longitudinal cohort

BACKGROUND

Associations of socioenvironmental features like urbanicity and neighborhood deprivation with psychosis are well-established. An enduring question, however, is whether these associations are causal. Genetic confounding could occur due to downward mobility of individuals at high genetic risk for psychiatric problems into disadvantaged environments.

METHODS

We examined correlations of five indices of genetic risk [polygenic risk scores (PRS) for schizophrenia and depression, maternal psychotic symptoms, family psychiatric history, and zygosity-based latent genetic risk] with multiple area-, neighborhood-, and family-level risks during upbringing. Data were from the Environmental Risk (E-Risk) Longitudinal Twin Study, a nationally-representative cohort of 2232 British twins born in 1994-1995 and followed to age 18 (93% retention). Socioenvironmental risks included urbanicity, air pollution, neighborhood deprivation, neighborhood crime, neighborhood disorder, social cohesion, residential mobility, family poverty, and a cumulative environmental risk scale. At age 18, participants were privately interviewed about psychotic experiences.

RESULTS

Higher genetic risk on all indices was associated with riskier environments during upbringing. For example, participants with higher schizophrenia PRS (OR = 1.19, 95% CI = 1.06-1.33), depression PRS (OR = 1.20, 95% CI = 1.08-1.34), family history (OR = 1.25, 95% CI = 1.11-1.40), and latent genetic risk (OR = 1.21, 95% CI = 1.07-1.38) had accumulated more socioenvironmental risks for schizophrenia by age 18. However, associations between socioenvironmental risks and psychotic experiences mostly remained significant after covariate adjustment for genetic risk.

CONCLUSION

Genetic risk is correlated with socioenvironmental risk for schizophrenia during upbringing, but the associations between socioenvironmental risk and adolescent psychotic experiences appear, at present, to exist above and beyond this gene-environment correlation.

Ventricular-arterial coupling derived from proximal aortic stiffness: impact on aerobic capacity across the heart failure spectrum

Funding Acknowledgements

Type of funding sources: None.

Background

Ventricular-arterial coupling (VAC) can be evaluated as the ratio between arterial stiffness (pulse wave velocity, PWV) and myocardial deformation (global longitudinal strain, GLS).

Objectives

To evaluate VAC across the spectrum of heart failure (HF).

Methods

We introduced a Doppler-derived, single-beat technique to estimate aortic arch PWV (aa-PWV) in addition to tonometry-derived carotid-femoral PWV (cf-PWV). We measured PWVs and GLS in 155 healthy controls, 75 subjects at risk of developing HF (American College of Cardiology/American Heart Association Stage A-B) and 236 patients in HF Stage C with preserved (HFpEF, n=104) or reduced ejection fraction (HFrEF, n=132). We evaluated peak oxygen consumption (VO2) and peripheral extraction (AVO2diff) using combined cardiopulmonary-echocardiography exercise stress.

Results

aa-PWV was obtainable in all subjects and significantly lower than cf-PWV in all subgroups (p&lt;0.01). PWVs were directly related and increased with age (all p&lt;0.0001). cf-PWV/GLS was similarly compromised in HFrEF (1.08±0.36) and HFpEF (1.05±0.22), while aa-PWV/GLS was more impaired in HFpEF (0.69±0.11) than HFrEF (0.60±0.15; p&lt;0.01). Stage A-B had values of cf-PWV/GLS and aa-PWV/GLS (0.66±0.25 and 0.47±0.12) higher than controls (0.47±0.10 and 0.40±0.10) but lower than Stage C (all p&lt;0.01). Peak AVO2diff was inversely related with cf-PWV/GLS and aa-PWV/GLS (all p&lt;0.01). cf-PWV/GLS and aa-PWV/GLS independently predicted peak VO2 in the overall population (adjusted R2=0.32 and 0.35; all p&lt;0.0001) but only aa-PWV/GLS was independently associated with flow reserve during exercise (R2=0.51; p&lt;0.0001).

Conclusion

Abnormal VAC is directly correlated with greater severity of HF and worse functional capacity. HFpEF shows a worse VAC than HFrEF when expressed by aa-PWV/GLS.

Enhancing clinician participation in quality improvement training: implementation and impact of an evidence-based initiative to maximise antenatal clinician participation in training regarding women’s alcohol consumption during pregnancy

Background

There are significant challenges in ensuring sufficient clinician participation in quality improvement training. Clinician capability has been identified as a barrier to the delivery of evidence-based care. Clinician training is an effective strategy to address this barrier, however, there are significant challenges in ensuring adequate clinician participation in training. This study aimed to assess the extent of participation by antenatal clinicians in evidence-based training to address alcohol consumption during pregnancy, and to assess differences in participation by profession.

Methods

A 7-month training initiative based on six evidence-based principles was implemented in a maternity service in New South Wales, Australia. Descriptive statistics described participation in training (% attending: any training; six evidence-based principles of training; all principles). Regression analyses examined differences by profession.

Results

Almost all antenatal clinicians participated in some training (182/186; 98%); 69% participated in ≥1 h of training (μ = 88.2mins, SD:56.56). The proportion of clinicians participating in training that satisfied each of the six principles ranged from 35% (training from peers and experts) to 82% (training was educational and instructional). Only 7% participated in training that satisfied all principles. A significantly higher proportion of midwifery compared to medical clinicians participated in training satisfying five of the six training principles.

Conclusions

A training initiative based on evidence-based principles resulted in almost all clinicians receiving some training and 69% participating in at least 1 h of training. Variability between professions suggests training needs to be tailored to such groups. Further research is required to determine possible associations with care delivery outcomes.

Trial registration

Australian and New Zealand Clinical Trials Registry, No. ACTRN12617000882325 (date registered: 16/06/2017).

Clinical presentation, disease course, and outcome of COVID-19 in hospitalized patients with and without pre-existing cardiac disease: a cohort study across 18 countries

AIMS

Patients with cardiac disease are considered high risk for poor outcomes following hospitalization with COVID-19. The primary aim of this study was to evaluate heterogeneity in associations between various heart disease subtypes and in-hospital mortality.

METHODS AND RESULTS

We used data from the CAPACITY-COVID registry and LEOSS study. Multivariable Poisson regression models were fitted to assess the association between different types of pre-existing heart disease and in-hospital mortality. A total of 16 511 patients with COVID-19 were included (21.1% aged 66-75 years; 40.2% female) and 31.5% had a history of heart disease. Patients with heart disease were older, predominantly male, and often had other comorbid conditions when compared with those without. Mortality was higher in patients with cardiac disease (29.7%; n = 1545 vs. 15.9%; n = 1797). However, following multivariable adjustment, this difference was not significant [adjusted risk ratio (aRR) 1.08, 95% confidence interval (CI) 1.02-1.15; P = 0.12 (corrected for multiple testing)]. Associations with in-hospital mortality by heart disease subtypes differed considerably, with the strongest association for heart failure (aRR 1.19, 95% CI 1.10-1.30; P < 0.018) particularly for severe (New York Heart Association class III/IV) heart failure (aRR 1.41, 95% CI 1.20-1.64; P < 0.018). None of the other heart disease subtypes, including ischaemic heart disease, remained significant after multivariable adjustment. Serious cardiac complications were diagnosed in <1% of patients.

CONCLUSION

Considerable heterogeneity exists in the strength of association between heart disease subtypes and in-hospital mortality. Of all patients with heart disease, those with heart failure are at greatest risk of death when hospitalized with COVID-19. Serious cardiac complications are rare during hospitalization.

Inactivation of MS2 bacteriophage on copper film deployed in high touch areas of a public transport system

Although SARS-CoV-2 is primarily an airborne risk, the COVID-19 pandemic also highlighted the need for self-disinfection surfaces that could withstand the demand of high occupant densities characteristic of public transportation systems. The aim of this study was to evaluate the durability and antiviral activity of a copper film deployed for 90 days in two high touch locations within an active metropolitan bus and railcar. The antiviral efficacy of this copper film after being deployed in transit vehicles for 90 days (deployed copper film) was then compared to new (unused) copper film to determine if frequent touches and cleaning protocols could decrease the efficacy of the copper films. Deployed copper film, new copper film, and aluminium foil (positive control) coupons were inoculated with ~1 × 10⁶ MS2 virus particles, allowed a contact time of either 5- or 10-min, and analysed for residual viral infectiousness. On both new and deployed copper films, MS2 was completely inactivated (≥5 log reduction) at both time points. These results suggest that the copper film may provide the durability demanded by high touch public spaces while maintaining the antiviral activity necessary to reduce exposure risk and viral transmission via surfaces in public transportation settings.

Validation of the Kinetik Blood Pressure Monitor-Series 1 for use in adults at home and in clinical settings, according to the 2002 European Society of Hypertension International Protocol on the validation of blood pressure devices

The aim of this study was to assess the blood pressure (BP) measurement accuracy of the Kinetik Blood Pressure Monitor-Series 1 (BPM-1) for use in home or clinical settings according to the 2002 European Society of Hypertension International Protocol (ESH-IP). Forty-two participants were recruited to fulfil the required number of systolic and diastolic BP measurements according to the ESH-IP. Nine sequential same-arm BP readings were measured and analysed for each participant using the test device and observer mercury standard readings according to the 2002 ESH-IP. Forty one participants were used to obtain 33 sets of systolic and diastolic BP readings and were included in the analysis. Mean difference between the device measurements and the observer (mercury standard) measurements was 1.1 ± 7.2/1.1 ± 6.8 mmHg (mean ± standard deviation; systolic/diastolic). The number of systolic BP differences between the test and observer measurements that fell within 5, 10 and 15 mmHg was 65, 86 and 92. For diastolic readings, the number of test-observer measurement differences within 5, 10 and 15 mmHg was 77, 91 and 94. The number of participants with at least two out of three differences within 5 mmHg was 28 for systolic and 40 for diastolic BP readings. Three participants had no differences between the test and observer measurements within 5 mmHg in both the systolic and diastolic measurement categories. The Kinetik BPM-1 device fulfilled the requirements of the ESH-IP validation procedure and can be recommended for clinical use and self-measurement within the home.

Application of win ratio methodology in the Global SYMPLICITY Registry for patients with atrial fibrillation or obstructive sleep apnea

Background/Introduction

The win ratio is a new methodology which utilizes multiple hierarchical endpoints to evaluate clinical outcomes in trials. The win ratio may have added benefit in device therapy trials like renal denervation (RDN) where anti-hypertensive medication burden can influence blood pressure (BP) changes.

Purpose

In this analysis, we applied the win ratio to patients in the Global SYMPLICITY Registry (GSR) to quantify potential differences in RDN efficacy according to different comorbidities, specifically atrial fibrillation and obstructive sleep apnea.

Methods

All patients in GSR had an RDN procedure with the Symplicity Flex or Symplicity Spyral catheter. For the win ratio analysis, ambulatory systolic BP (ASBP) measurements, office systolic BP (OSBP) measurements and the number of prescribed anti-hypertensive medications at 6 months were included as hierarchical endpoints. Patients were divided into 1 of 2 groups: with or without atrial fibrillation (AF) at baseline. Each patient was compared with every other patient in the opposing group first according to ASBP to determine “win”, “lose” or “tie” with a threshold of 5 mmHg. Then, ties from the ASBP comparison underwent the comparison using OSBP with a threshold of 10 mmHg. Any tie for a pair comparing OSBP resulted in comparison of number of anti-hypertensive medications with a threshold of 1. Comparisons of ASBP and OSBP were adjusted for baseline SBPs by using residuals from a linear regression. The analysis was repeated for patients grouped according to history of obstructive sleep apnea (OSA) at baseline.

Results

In March 2020, 336 patients with AF at baseline and 2,394 patients with no AF were compared in GSR, resulting in 336 x 2394 = 804,384 pairwise comparisons for the win ratio analysis. A total of 285,709 “wins”, indicating greater ASBP reduction, OSBP reduction, and/or fewer number of anti-hypertensive medications occurred in the AF group compared to the no AF group. Conversely, 256,511 “losses”, meaning greater BP reduction and/or number of medications occurred in the no AF group. The win ratio was thus calculated as 1.11 (95% CI: 0.98, 1.28, p=0.081) indicating similar BP reduction and medication burden after RDN in patients with or without AF in GSR (Figure). Using these methods, the win ratio for patients with and without OSA was calculated to be 0.98 (95% CI: 0.85, 1.13, p=0.81), also indicating similar RDN efficacy regardless of presence of OSA at baseline (Figure). Previously published results of the win ratio analysis of RDN and sham control patients in the SPRYAL HTN-ON MED trial reported a win ratio in favor of RDN of 2.78 (95% CI: 1.58, 5.48, p&lt;0.001).

Conclusions

Application of the win ratio methodology to patients in GSR demonstrated similar efficacy of RDN to patients regardless of whether they had comorbidities of atrial fibrillation or obstructive sleep apnea.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Medtronic

The psychological and behavioural factors associated with laypeople initiating CPR for out-of-hospital cardiac arrest: a systematic review

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Chief Scientist Office, Scottish Government

OnBehalf

BICeP Study Group

Background

Prompt, effective CPR greatly increases the chances of survival in out-of-hospital cardiac arrest. However, it is often not provided, even by people who have previously undertaken training. Psychological and behavioural factors are likely to be important in relation to CPR initiation by lay-people but have not yet been systematically identified.

Objective

To identify the psychological and behavioural factors associated with CPR initiation amongst lay-people. 

Methods  

Data sources

Cochrane Library, MEDLINE, EMBASE, CINAHL, PsycInfo and Google Scholar. 

Study eligibility criteria

Primary studies reporting psychological or behavioural factors and data on CPR initiation involving lay-people published (inception to 15th January 2020).

Study appraisal and synthesis methods

Potential studies were screened and quality assessed independently by two reviewers. Study characteristics, psychological and behavioural factors associated with CPR initiation were extracted from included studies, categorised by study type and synthesised narratively. 

Results

Ninety studies (132,429 participants) comprising various designs, populations and of mostly weak quality were identified. The strongest and most ecologically valid studies identified factors associated with CPR initiation: the overwhelming emotion of the situation, perceptions of capability, uncertainty about when CPR is appropriate, feeling unprepared  and fear of doing harm. Current evidence is limited by a preponderance of atheoretical cross-sectional surveys using unvalidated measures with relatively little formal testing of posited ‘predictors’.

Conclusions

We will present the psychological and behavioural factors that are likely useful foci for future interventions aiming to increase CPR initiation. The literature in this area would benefit from more robust study designs which make greater use of theory.

Developing a behavioural intervention to increase lay-people"s intentions to initiate CPR in the event of Out-of-Hospital Cardiac Arrest (OHCA)

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Medical Research Council

OnBehalf

BICeP Study Group

Background

Prompt, effective bystander cardiopulmonary resuscitation (CPR) is the single most important factor determining survival from out of hospital cardiac arrest (OHCA), increasing survival up to 4-fold. However only 35%-45% of people trained in CPR actually attempt it when required. This study uses psychological theory and behaviour change techniques (BCTs) to increase the proportion of bystanders who attempt CPR in a real emergency.

Design

Intervention development study

Methods

Intervention content was informed by two recent systematic reviews, which identified barriers to bystander CPR and BCTs within existing training programmes (PROSPERO CRD42018117438; CRD42019126745) and a qualitative study exploring participants’ views (n = 12) of draft text messages. A lay bystander user-involvement panel (n = 7) and an expert advisory group (comprising representatives from CPR training organisations) worked with the research team to co-produce the final intervention and agree the schedule for text message delivery.  BCT content was assessed by two independent experts. A framework analysis of interviews was undertaken. 

Results

Recognising and addressing fears, and helping people to better prepare for real-life situations were identified to be important to participants. Short, simple texts from a credible source and with a positive tone were strongly preferred, there was a strong aversion to anything "guilt-inducing". Pictures and personalisation were important, rewards less so. Regarding frequency: participants varied but around 1/week was considered adequate by most. A total of n = 35 text-messages with verified BCT content were co-developed with participants.

Conclusions

A text message intervention incorporating BCTs, which is acceptable to intended users and CPR trained individuals has been produced and will be subject to future evaluation.

Effects of Mild and Moderate Monoclonal Antibody Dose on Inflammation, Bone Loss, and Activation of the Central Nervous System in a Female Collagen Antibody-induced Arthritis Mouse Model

Induction of severe inflammatory arthritis in the collagen antibody-induced arthritis (CAIA) murine model causes extensive joint damage and pain-like behavior compromising analysis. While mild models are less severe, their reduced, variable penetrance makes assessment of treatment efficacy difficult. This study aimed to compare macroscopic and microscopic changes in the paws, along with central nervous system activation between a mild and moderate CAIA model. Balb/c mice (n=18) were allocated to control, mild, and moderate CAIA groups. Paw inflammation, bone volume (BV), and paw volume (PV) were assessed. Histologically, the front paws were assessed for joint inflammation, cartilage damage, and pre/osteoclast-like cells and the lumbar spinal cord and the periaqueductal gray (PAG) region of the brain for glial reactivity. A moderate CAIA dose induced (1) significantly greater local paw inflammation, inflammatory cell infiltration, and PV; (2) significantly more osteoclast-like cells on the bone surface and within the surrounding soft tissue; and (3) significantly greater glial reactivity within the PAG compared with the mild CAIA model. These findings support the use of a moderate CAIA model (higher dose of monoclonal antibodies with low-dose lipopolysaccharide) to induce more consistent histopathological features, without excessive joint destruction.

Specimen oriented intraoperative margin assessment in oral cavity and oropharyngeal squamous cell carcinoma

OBJECTIVE

Evaluate the oncologic outcomes and cost analysis of transitioning to a specimen oriented intraoperative margin assessment protocol from a tumour bed sampling protocol in oral cavity (OCSCC) and oropharyngeal squamous cell carcinoma (OPSCC).

STUDY DESIGN

Retrospective case series and subsequent prospective cohort study SETTING: Tertiary care academic teaching hospital SUBJECTS AND METHODS: Retrospective case series of all institutional T1-T2 OCSCC or OPSCC treated with primary surgery between January 1st 2009 - December 31st 2014. Kaplan-Meier survival estimates with log rank tests were used to compare patients based on final margin status. Cost analysis was performed for escalation of therapy due to positive final margins. Following introduction of a specimen derived margin protocol, successive prospective cohort study of T1-T4 OCSCC or OPSCC treated with primary surgery from January 1st 2017 - December 31st 2018. Analysis and comparison of both protocols included review of intraoperative margins, final pathology and treatment cost.

RESULTS

Analysis of our intra-operative tumour bed frozen section protocol revealed 15 of 116 (12.9%) patients had positive final pathology margins, resulting in post-operative escalation of therapy for 14/15 patients in the form of re-resection (7/14), radiation therapy (6/14) and chemoradiotherapy (1/14). One other patient with positive final margins received escalated therapy for additional negative prognostic factors. Recurrence free survival at 3 years was 88.4 and 50.7% for negative and positive final margins respectively (p = 0.048). Implementation of a specimen oriented frozen section protocol resulted in 1 of 111 patients (0.9%) having positive final pathology margins, a statistically significant decrease (p < 0.001). Utilizing our specimen oriented protocol, there was an absolute risk reduction for having a final positive margin of 12.0% and relative risk reduction of 93.0%. Estimated cost avoidance applying the specimen oriented protocol to our previous cohort was $412,052.812017 CAD.

CONCLUSION

Implementation of a specimen oriented intraoperative margin protocol provides a statistically significant decrease in final positive margins. This change in protocol leads to decreased patient morbidity by avoiding therapy escalation attributable only to positive margins, and avoids the economic costs of these treatments.

AB0289 PATIENT REPORTED PHYSICAL HEALTH COMPARED TO CLINICIAN RECORDED BILAG-2004 MUSCULOSKELETAL SYSTEM SCORES – DISCORDANCE BETWEEN PATIENTS AND CLINICIANS

Background:

The musculoskeletal organ system BILAG-2004 (MSK BILAG) assessment is of critical importance in SLE clinical trials. Severe active polyarthritis, MSK BILAG A, by definition includes significant impairment of basic activities of daily living (ADLs), as opposed to MSK BILAG C, D, or E where ability to perform ADLs is expected to be preserved. In clinical trials, BILAG is scored by clinicians without formal review of patient reported outcomes (PROs). The Physical Health domain of the LupusQoL (LQol PH) (range 0 – 100) can be used to assess the patient’s physical function and ADLs. LQoL PH score thresholds defining impairment severity have not been established; however, a transformed LQoL PH score ≤50 suggests more impaired function, which would not be expected in MSK BILAG C, D, or E. Conversely, a score >50 implies no major issues with ADLs, which would be contradictory to the definition of MSK BILAG A.

Objectives:

To assess correlation of patient reported LQoL PH with MSK BILAG scores recorded by clinicians at various timepoints using data from the phase 3 TULIP studies 1,2 and to investigate the percent of discordance between patients and clinicians.

Methods:

Data from TULIP 1 and 2 studies (anifrolumab 300 mg and placebo arms) were pooled to evaluate the relationship between LQoL PH and MSK BILAG scores at baseline, weeks 24 and 52 using Spearman correlations as post-hoc analysis. Mean LQoL PH scores were assessed for each MSK BILAG category at the three timepoints using one-way ANOVA. Percent of patients with MSK BILAG A and LQoL PH scores >50 and patients with MSK BILAG C, D, or E and LQoL PH scores ≤50 was calculated at baseline, week 24 and 52. MSK BILAG B was excluded from the analysis because discordance could not be easily defined for this category compared with the more extreme MSK BILAG categories.

Results:

Total of 690 patients were included in the pooled analysis (Table 1). Significant correlations between LQoL PH and MSK BILAG scores were found at each time point (nominal p<0.0001); this relationship became stronger over time. Mean LQoL PH scores were different in each MSK BILAG category, with the highest in MSK BILAG D/E and the lowest in the MSK BILAG A category, thus confirming the discriminatory ability of the LQoL PH (Table 1).

Table 1.

Correlation coefficients (CC) between LQoL PH and MSK BILAG scores, and mean LQoL PH scores with standard deviations (SD) per each MSK BILAG category at baseline, weeks 24 and 52.

BaselineWeek 24Week 52CCNCCNCCNTotal Population-0.25690-0.36626-0.41552MSK BILAGMean LQoL PH Score (SD)Mean LQoL PH Score (SD)Mean LQoL PH Score (SD)0 (D/E)69.3 (24.7)1774.2 (22.1)18674.5 (21.3)2371 (C)62.3 (25.4)6064.0 (23.9)23360.6 (22.5)1848 (B)56.6 (24.4)39855.1 (24.2)16351.3 (24.3)10512 (A)44.9 (25.8)21543.9 (25.9)4444.2 (26.2)26

At baseline, 40% of patients who were assessed by clinicians as having MSK BILAG A reported minimal impairment in physical function and ADLs (LQoL PH >50) and 24.1% who had MSK BILAG C, D, or E reported difficulties with ADLs (LQoL HP ≤50), suggesting discordance between patients and clinicians. This discordance slightly decreased over time (Figure 1).

Figure 1.

Percent of patients with MSK BILAG A and LQoL PH scores >50 and patients with MSK BILAG C, D, or E and LQoL PH scores ≤50 at baseline, weeks 24 and 52.

Conclusion:

Patient reported LQoL PH scores correlated with MSK BILAG scores and showed discriminant validity for MSK BILAG scores. Greater discordance was seen between LQoL PH and MSK BILAG A compared with C, D, or E. These findings suggest a need for further investigation of a role for PROs in MSK BILAG scoring. Formal review of PROs by clinicians during MSK BILAG assessment could be considered in future SLE clinical trials.

References:

[1]Furie R et al. Lancet 2019

[2]Morand EF et al. N Engl J Med 2020

Acknowledgements:

This study was sponsored by AstraZeneca.

Disclosure of Interests:

Ewa Olech Speakers bureau: Abbvie, Amgen, Merck, Pfizer, and UCB, Grant/research support from: BMS, Donald Stull: None declared, Betsy Williams: None declared, Stephanie Bean: None declared, Gabriel Abreu Employee of: AstraZeneca, Erik Schwetje Employee of: AstraZeneca, Raj Tummala Employee of: AstraZeneca, Sean O’Quinn Shareholder of: AstraZeneca, Employee of: AstraZeneca

Vitamin D deficiency is associated with tuberculosis disease in British children

BACKGROUND: Basic science, epidemiological and interventional research supports a link between vitamin D and tuberculosis (TB) immunity, infection and disease. We evaluated the association between vitamin D levels and TB infection and disease in UK children recruited to the National Institute for Health Research IGRA Kids Study (NIKS).METHODS: Children presenting between 2011 and 2014 were eligible if they had history of exposure to an adult case with sputum smear/culture-positive TB, or were referred and diagnosed with TB disease. Children were assessed at baseline and at 6-8 weeks for immunological evidence of TB infection (interferon-gamma release assay and/or tuberculin skin test) and evidence of TB disease. Some centres routinely measured total 25-hydroxy vitamin D (25-OHD) levels.RESULTS: A total of 166 children were included. The median 25-OHD levels were higher in non-infected children (45.5 nmol/l) than in those with tuberculous infection (36.2 nmol/l) and TB disease (20.0 nmol/l). The difference between TB infection and disease was statistically significant (P < 0.001). By logistic regression, lower vitamin D levels were associated with TB disease among participants with infection or disease, with no evidence of confounding by age, sex, bacille Calmette-Guérin vaccination status, ethnicity, non-contact referral, season or centre.CONCLUSION: Children with TB disease had lower vitamin D levels than children with infection. Implications for prevention and treatment remain to be established.

[Discharge management in pediatric and adolescent psychiatry : Expectations and realities from the parental perspective]

BACKGROUND

Interface management after inpatient care for mentally ill children and adolescents has been proven to be a breaking point in good transition of care between child and adolescent psychiatry, social welfare services, schools, job centre and the judicial system. Criteria for successful discharge management do not exist in child and adolescent psychiatry. Aim of the study ASpeKT was to survey parents on their perception of interface management and to derive recommendations for discharge management.

METHODS

Data regarding interface management were retrieved from parents (T3, n = 124, T4, n = 81) 6 months (T3) and 12 months (T4) after discharge.

RESULTS

The parents stated that accessible help after discharge from inpatient treatment is essential for stability and requires a good coordination. Parents named that they perceived helpful for successful interface management: a case manager, early round table meetings, support in returning to school, seamless access to outpatient follow-up appointments as well as information on further treatment options and contact data.

CONCLUSION

From the perspective of affected families a proactive early individual and reliable care coordination by a constant contact person is essential for a good discharge management.

Ground and In-Flight Calibration of the OSIRIS-REx Camera Suite

The OSIRIS-REx Camera Suite (OCAMS) onboard the OSIRIS-REx spacecraft is used to study the shape and surface of the mission's target, asteroid (101955) Bennu, in support of the selection of a sampling site. We present calibration methods and results for the three OCAMS cameras-MapCam, PolyCam, and SamCam-using data from pre-flight and in-flight calibration campaigns. Pre-flight calibrations established a baseline for a variety of camera properties, including bias and dark behavior, flat fields, stray light, and radiometric calibration. In-flight activities updated these calibrations where possible, allowing us to confidently measure Bennu's surface. Accurate calibration is critical not only for establishing a global understanding of Bennu, but also for enabling analyses of potential sampling locations and for providing scientific context for the returned sample.

Ground and In-Flight Calibration of the OSIRIS-REx Camera Suite

The OSIRIS-REx Camera Suite (OCAMS) onboard the OSIRIS-REx spacecraft is used to study the shape and surface of the mission's target, asteroid (101955) Bennu, in support of the selection of a sampling site. We present calibration methods and results for the three OCAMS cameras-MapCam, PolyCam, and SamCam-using data from pre-flight and in-flight calibration campaigns. Pre-flight calibrations established a baseline for a variety of camera properties, including bias and dark behavior, flat fields, stray light, and radiometric calibration. In-flight activities updated these calibrations where possible, allowing us to confidently measure Bennu's surface. Accurate calibration is critical not only for establishing a global understanding of Bennu, but also for enabling analyses of potential sampling locations and for providing scientific context for the returned sample.

1199Reduction in blood pressure following renal denervation for patients with differing baseline cardiovascular risk

Background

Lowering blood pressure (BP) reduces clinical events. Renal denervation (RDN) is under investigation for treatment of uncontrolled hypertension and might represent a particularly attractive option for patients with high cardiovascular (CV) risk. To evaluate this proposal, it is important to determine whether baseline CV risk impacts the efficacy of RDN in lowering BP.

Purpose

We evaluated whether BP changes after RDN were dependent on baseline CV risk.

Methods

AHA/ACC Atherosclerosis CV Disease (ASCVD) risk score was calculated for patients in the Global Symplicity Registry (GSR; NCT01534299), a global registry of RDN in patients with uncontrolled hypertension, using baseline office systolic BP, total/HDL cholesterol measurements, diabetic and smoking status, gender, age, and number of baseline anti-hypertensive medications. Patients were separated into 3 groups based on ASCVD risk scores: <10%, ≥10% and <20% and ≥20%. Baseline demographics and 24-hour systolic BP changes at 6 months and 1, 2 and 3 years were compared between groups, as well as rates of adverse events at 3 years.

Results

Individual ASCVD risk scores were calculated for 1,434 patients in GSR. The median ASCVD risk score was 19.4% and 403 patients had a risk score of <10%, 326 a risk score of ≥10 and <20%, and 705 a risk score ≥20%. Patients with ASCVD risk score ≥20% had a higher baseline office systolic BP, were significantly older, and had higher rates of prior myocardial infarction and/or diabetes (all p<0.0001 compared to patients with lower risk scores). RDN reduced BP similarly across all groups of patients. Changes in 24-hour systolic BP at 6 months and 1, 2 and 3 years are shown in Figure 1. Adverse events at 3 years are shown in Table 1.

Adverse events at 3 years ASCVD risk score <10% ASCVD risk score ≥10% & <20% ASCVD risk score ≥20% p-value (N=265) (N=224) (N=468) Death 3 (1.1) 5 (2.2) 41 (8.8) <0.0001 Cardiovascular death 3 (1.1) 2 (0.9) 23 (4.9) 0.0017 Myocardial infarction 6 (2.3) 6 (2.7) 11 (2.4) 0.9513 Stroke 8 (3.0) 9 (4.0) 24 (5.1) 0.3894 Hospitalization for new onset heart failure 4 (1.5) 7 (3.1) 26 (5.6) 0.0194 Values are proportions reported as n (%).

Conclusions

BP changes after RDN were similar for patients with varying baseline ASCVD risk scores, suggesting uniform BP-lowering efficacy of RDN regardless of patients' baseline CV risk. The impact of baseline risk on clinical event reduction by RDN-induced BP reduction will need to be evaluated in further studies.

Acknowledgement/Funding

The Global SYMPLICITY Registry is funded by Medtronic.

Point-of-care Hepatitis C virus testing and linkage to treatment in an Australian inner-city emergency department

BACKGROUND

In Australia, Hepatitis C Virus (HCV) treatment is declining, despite broad access to direct-acting antiviral medication. People who inject drugs are proportionally over-represented in emergency department presentations. Emergency department assessment of people who have injected drugs for HCV presents an opportunity to engage this marginalised population with treatment. We describe the outcomes of risk-based screening and point-of-care anti-HCV testing for emergency department patients, and linkage to outpatient antiviral treatment.

METHODS

During the three-month study period, consecutive adult patients who presented to the emergency department during the study times were screened for risk factors and offered the OraQuick oral HCV antibody test. Those with reactive results were offered venepuncture in the emergency department for confirmatory testing and direct-acting antiviral treatment in clinic. The main outcome measures were the number and proportion of viremic participants that were linked to the hepatitis clinic, commenced treatment and achieved a sustained viral response. Secondary outcome measures were the proportion (%) of presentations screened that were oral antibody reactive, and the prevalence and type of HCV risk factors.

RESULTS

During the study period, 2408 of the 3931 (61%) presentations to the emergency department were eligible for screening. Of these 2408 patients, 1122 (47%) participated, 307 (13%) declined participation and 977 (41%) could not be approached during their time in the emergency department. Among the 1122 participants, 378 (34%) reported at least one risk factor. Subsequently, 368 (97%) of the 378 participants underwent OraQuick anti-HCV test, and 50 (14%) had a reactive result. A risk factor of ever having injected drugs was present in 44 (88%) of participants who were sero-positive. Of the 45 that had blood tested, 30 (67%) were HCV ribonucleic acid (RNA) positive. Three participants died. Of the 27 remaining participants, 10 (37%) commenced treatment and 7 of these 10 (70%) obtained a cure. There was a high rate of homelessness (24%) among anti-HCV positive participants.

CONCLUSION

Among emergency department participants with a risk factor for HCV, positive serology was common using a rapid point-of-care test. A history of injecting drug use was identified as the risk factor with highest yield for positive HCV serology, and is suitable as a single screening question. However, linkage to care post ED presentation was low in this marginalised population. There is a need for new pathways to improve the care cascade for marginalised individuals living with HCV infection.

First real-world experience of peptide receptor radionuclide therapy (PRRT) in neuroendocrine tumors (NET) since US FDA approval

e15691

Background: PRRT using 177Lu-DOTATATE was US FDA approved in Jan 2018, and real world data in the US is lacking. Methods: We retrospectively reviewed medical records of patients who began PRRT 03/14/18 - 10/01/18 at our institution. 177Lu-DOTATATE was administered at a dose of 200mCi over 20-30 min every 8 weeks for 4 doses. Infusion of arginine-lysine 25gm/25gm in 1-liter normal saline was given over 4 hours starting 30 min prior to treatment, in addition to intravenous palonosetron 0.25mg. Results: 51 patients received at least 1 of 4 doses and 40/51 were no longer on active therapy. 28/40 received all 4 doses and 12/40 discontinued treatment after < 4 doses. 25/40 were evaluable for response per RECIST v1.1. 16/25 (64%) had GI NET, 3/25 (12%) pancreatic NET, 4/25 (16%) atypical lung carcinoid, 1/25 (4%) multifocal NET, and 1/25 (4%) had paraganglioma. 28% had grade 1, 56% grade 2, and 8% (2/25) had grade 3 (Ki 67: 25% and 40%) NET. 12/25 (48%) had received ≥2 prior systemic therapies not including somatostatin analogs, and 10/25 (40%) had ≥1 prior liver-directed therapy. Median follow-up from date of last PRRT was 61.5 days. Objective response (partial response) rate was 16% (4/25; table). 18/25 (72%) had stable disease and 3/25 (12%) had progressive disease. Most adverse events (AEs) were grade 1-2 and included fatigue, nausea, abdominal pain, and cytopenias. ≥Grade 3 AEs requiring treatment discontinuation included symptomatic gastric outlet obstruction (2/51), small bowel obstruction (1/51), ischemic enteritis (1/51), confusion/bone pains (1/51), liver failure (1/51), and severe neutropenia (1/51). All patients with ≥grade 3 AEs had a high tumor burden at baseline. Conclusions: 177Lu-DOTATATE is an effective and safe treatment in advanced NET, and our results are consistent with NETTER 1 data.[Table: see text]

Childhood adversity, mental health and suicide (CHASE): a methods protocol for a longitudinal case-control linked data study

Introduction

Suicide is a tragic outcome with devastating consequences. In 2018, Scotland experienced a 15% increase in suicide from 680 to 784 deaths. This was marked among young people, with an increase of 53% in those aged 15-24, the highest since 2007. Early intervention in those most at risk is key, but identification of individuals at risk is complex, and efforts remain largely targeted towards universal suicide prevention strategies with little evidence of effectiveness.

Recent evidence suggests childhood adversity is a predictor of subsequent poor social and health outcomes, including suicide. This protocol reports on methodology for harmonising lifespan hospital contacts for childhood adversity, mental health, and suicidal behaviour. This will inform where to 1) focus interventions, 2) prioritise trauma-informed approaches, and 3) adapt support avenues earlier in life for those most at risk.

Methods

This study will follow a case-control design. Scottish hospital data (physical health SMR01; mental health SMR04; maternity/birth record SMR02; mother’s linked data SMR01, SMR04, death records) from 1981 to as recent as available will be extracted for people who died by suicide aged 10-34, and linked on Community Health Index unique identifier. A randomly selected control population matched on age and geography at death will be extracted in a 1:10 ratio. International Classification of Disease (ICD) codes will be harmonised between ICD9-CM, ICD9, ICD10-CM and ICD10 for childhood adversity, mental health, and suicidal behaviour.

Results

ICD codes for childhood adversity from four key studies are reported in two categories, 1) Maltreatment or violence-related codes, and 2) Codes suggestive of maltreatment. ‘Clinical Classifications Software’ ICD codes to operationalise mental health codes are also reported. Harmonised lifespan ICD categories were achieved semi-automatically, but required labour-intensive supplementary manual coding. Cross-mapped codes are reported.

Conclusion

There is a dearth of evidence about touchpoints prior to suicide. This study reports methods and harmonised ICD codes along the lifespan to understand hospital contact patterns for childhood adversity, which come to the attention of hospital practitioners.

Key words

Childhood Adversity, Adverse Childhood Experiences, Mental Health, Self-harm, Suicide, Suicidality, Violence, Hospital episodes, Routine Data, Data Linkage, Study Protocol

Elevated fibrinogen, von Willebrand factor, and Factor VIII confer resistance to dilutional coagulopathy and activated protein C in normal pregnant women

BACKGROUND

Gestational changes in coagulation factor concentrations include elevations in fibrinogen, Factor VIII, and von Willebrand factor (vWF). We hypothesised that blood samples from term pregnant (TP) subjects are less prone to coagulation disturbances from haemodilution compared with those from non-pregnant (NP) females.

METHODS

Blood samples were collected from 15 NP and 15 TP subjects. In vitro haemodilution with normal saline was assessed by modified Clauss fibrinogen assay, factor activity, flow-chamber assay, and thromboelastometry. The impact of human fibrinogen concentrate (hFC), cryoprecipitate, and vWF/Factor VIII (FVIII) concentrate replacement in diluted TP and NP blood was compared. Thrombin generation and activated protein C sensitivity were assessed.

RESULTS

TP blood contained twice the concentrations of fibrinogen, FVIII, and vWF relative to NP blood (P<0.0001). Platelet thrombus formation (PTF) under flow was reduced by 99.2% and 69.2% in diluted NP and TP blood, respectively. Platelet thrombus formation was partially restored by adding vWF/FVIII, but not hFC or cryoprecipitate. Fibrin clot firmness approached the threshold of 10 mm in diluted NP blood, and clot firmness was effectively restored by hFC, but not by vWF/FVIII. In the presence of thrombomodulin, peak thrombin generation was decreased by 86.7% in NP plasma, but by 31.8% in TP plasma (P<0.0001 vs NP plasma), indicating reduced activated protein C sensitivity in TP plasma. Both elevated FVIII and haemodilution contributed to activated protein C insensitivity.

CONCLUSIONS

Our in vitro model showed relative resistance of TP blood to dilutional coagulation changes with respect to platelet adhesion, fibrin polymerisation, and thrombin generation. Careful therapeutic monitoring for different pro-haemostatic agents in pregnant women is warranted.

Cord injury after spinal anaesthesia in a patient with previously undiagnosed Klippel-Feil syndrome

This report presents an obstetric patient with no significant past medical history who underwent spinal anaesthesia for a category-three caesarean section. On examination, she had asymmetrical scapular alignment and a mild scoliosis of the lumbar spine with no functional limitation. Postoperatively the patient developed neuropathic pain symptoms in the right leg which failed to resolve with conventional analgesia. Cervical and lumbar spine magnetic resonance imaging was performed resulting in a diagnosis of a low-lying tethered spinal cord terminating at the level of L5 and congenital fusion of the C7/T1 vertebrae. A tethered spinal cord is a rare condition, which in this case had been completely asymptomatic. However, we suggest that the patient displayed musculoskeletal signs not previously widely reported, which could have indicated the presence of a potential underlying neural tube defect. Based on the imaging findings and the presence of Sprengel's deformity, the patient was diagnosed with Klippel-Feil syndrome.

Estimating Aspergillus fumigatus exposure from outdoor composting activities in England between 2005 and 14

Bioaerosols, ubiquitous in ambient air, are released in elevated concentrations from composting facilities with open-air processing areas. However, spatial and temporal variability of bioaerosols, particularly in relation to meteorology, is not well understood. Here we model relative concentrations of Aspergillus fumigatus at each postcode-weighted centroid within 4 km of 217 composting facilities in England between 2005 and 2014. Facilities were geocoded with the aid of satellite imagery. Data from existing bioaerosol modelling literature were used to build emission profiles in ADMS. Variation in input parameters between each modelled facility was reduced to a minimum. Meteorological data for each composting facility was derived from the nearest SCAIL-Agriculture validated meteorological station. According to our results, modelled exposure risk was driven primarily by wind speed, direction and time-varying emissions factors incorporating seasonal fluctuations in compostable waste. Modelled A.fumigatus concentrations decreased rapidly from the facility boundary and plateaued beyond 1.5-2.0 km. Where multiple composting facilities were within 4 km of each other, complex exposure risk patterns were evident. More long-term bioaerosol monitoring near facilities is needed to help improve exposure estimation and therefore assessment of any health risks to local populations.

Hepatic steatosis is highly prevalent across the paediatric age spectrum, including in pre-school age children

BACKGROUND

The prevalence of non-alcoholic fatty liver disease (NAFLD) in children is 8% in the general population, and 34% in the context of obesity. There is a paucity of data on the prevalence of hepatic steatosis in healthy children in Ontario.

AIMS

To determine the prevalence of hepatic steatosis using abdominal computed tomography (CT) scans in a cohort of previously healthy children across the paediatric age spectrum in Ontario, Canada, and to determine any association between measures of abdominal adiposity and hepatic steatosis.

METHODS

Retrospective review of the SickKids Trauma Database from 2004-2015. Previously healthy children ages 1-17 years having undergone an abdominal CT scan as a part of routine trauma assessment were included, and those with an intra-abdominal injury excluded. Steatosis was defined as a difference between liver and spleen attenuation ≤-25HU. The percentage of the total area occupied by abdominal subcutaneous adipose and visceral adipose tissue was measured. Anthropometrics and baseline demographics were collected.

RESULTS

A total of 503 (51% male) children with mean (±SD) age 9.5 ± 4.5 years and weight z-score of 0.37 ± 1.05 were studied. Seventy-seven (15%, 95% CI [12%-18%]) had hepatic steatosis; no differences found between sexes or across age quartiles. The abdominal subcutaneous adipose tissue area was greater in those with hepatic steatosis compared to those without (32% [22-42] vs 24% [17-36], P = 0.003). The visceral adipose tissue area was significantly greater in older children ≥9.8 years with hepatic steatosis (7.7% [5.1-10] vs 6.6% (4.9-8.5), P = 0.04).

CONCLUSION

Hepatic steatosis was highly prevalent in previously healthy children in Ontario, including children of pre-school age. We found an association between hepatic steatosis and abdominal subcutaneous adipose tissue, and in older children with visceral adipose tissue.

Who's challenging who training for staff empathy towards adults with challenging behaviour: cluster randomised controlled trial

BACKGROUND

One in five adults with intellectual disabilities (ID) known to services display challenging behaviours (CBs), and these individuals are at risk for restrictive practices and poor care. Staff attitudes may contribute to the development and/or maintenance of CBs. We investigated the effectiveness of co-produced Who's Challenging Who? training delivered by people with ID to staff.

METHOD

This study involved a cluster randomised controlled trial (RCT) of Who's Challenging Who? training with follow-up at six and 20 weeks post-randomisation.

PARTICIPANTS

two staff from each of 118 residential care settings for adults with ID at least one of whom displayed aggressive CB.

PRIMARY OUTCOME

Self-reported Staff Empathy for people with Challenging Behaviour Questionnaire.

ANALYSIS

intention to treat of all randomised settings. ISCRTN registration: ISRCTN53763600.

RESULTS

118 residential settings (including 236 staff) were randomised to either receive training (59 settings) or to receive training after a delay (59 settings). The primary analysis included data from 121 staff in 76 settings (51% of staff, 64% of settings). The adjusted mean difference on the transformed (cubed) Staff Empathy for people with Challenging Behaviour Questionnaire score at the primary end point was 1073.2 (95% CI: -938.1 to 3084.5, P = 0.296) in favour of the intervention group (effect size Cohen's d = .19).

CONCLUSIONS

This is the first large-scale RCT of a co-produced training course delivered by people with ID. Findings indicated a small positive (but statistically non-significant) effect on increased staff empathy at 20 weeks, and small to moderate effects for staff reported secondary outcomes in favour of the intervention group.

On the Pathogenesis of Syringomyelia: A Review

Discussion of the pathogenesis of syringomyelia involves considering the origin of the fluid and also the forces which cause that fluid to break down the structure of the cord. When cerebrospinal fluid (CSF) appears to be the destructive element, it commonly enters through a patent central canal running from the fourth ventricle to the inside of the syrinx. In both clinical and experimental situations pressure differences may be measured which suck on the hindbrain, particularly the cerebellar tonsils, producing deformities. These pressure differences may also suck fluid into the syrinx. In other cases, even when a communication does not appear to be patent, the hindbrain abnormalities are usually present and suck effect may usually be demonstrated and its correction be accompanied by clinical improvement. Other sources of fluid within a syrinx include liquefaction of haematomata after traumatic paraplegia and transudation of fluid from intrinsic spinal tumours. Once fluid is present within a cord cavity it may pulsate upwards and downwards in response to fluid movements in the subarachnoid space, the most energetic of which result from venous influences. Such movement, ‘slosh’, may cause the cavities to extend at either end giving rise to upward and downward extension from a post-traumatic cord cyst and sometimes to syringobulbia. Cord ischaemia, venous congestion and transport of fluid along perivascular spaces may all play a part in the maintainance of cord cavities or the progression of the clinical disabilities.

Laryngeal recurrence sites in patients previously treated with transoral laser microsurgery for squamous cell carcinoma

BACKGROUND

The laryngeal framework provides a natural barrier preventing tumour spread to extralaryngeal structures. Transoral laser microsurgery (TLM) for laryngeal squamous cell carcinoma (SCC) may violate these boundaries, altering the pathways of tumor spread for potential recurrences. Our project objective is to describe laryngeal SCC recurrence patterns and overall survival in patients requiring total laryngectomy (TL) after TLM.

METHODS

Patients undergoing TLM for laryngeal SCC requiring salvage TL were identified from a prospective CO2 laser database containing all patients undergoing TLM for head and neck malignancies at the QEII Health Sciences Center in Halifax, Nova Scotia between March 2002 - May 2014. Surgical pathology reports were analyzed for tumor characteristics, extent of recurrence and invasion of local structures. Kaplan-Meier analyses were performed to evaluate overall survival, disease specific survival (DSS) and locoregional control.

RESULTS

Fifteen patients were identified from the database as receiving salvage TL for recurrent disease after initial TLM resection for laryngeal SCC. Final pathology reports demonstrated that 67% (10/15) of patients had thyroid cartilage involvement while 53% (9/15) of patients had cricoid cartilage involvement on salvage TL pathology. 33% (5/15) of patients had perineural invasion and 27% (4/15) had lymphovascular invasion. Mean and median follow-up times were 36.7 months and 26.8 months respectively (range 3.9-112.6). The Kaplan-Meier estimate for overall survival at 36 months was 40% post TL with a standard error (SE) of 13.6%. DSS was 47% (SE 14.2%), and locoregional control was 55% (SE 14.5%) post TL.

CONCLUSIONS

Laryngeal recurrence sites following TLM seem to be consistent with historical data at known laryngeal sites of vulnerability. Treatment with TLM does not predispose patients to a lower rate of locoregional control and overall survival after total laryngectomy and salvage outcomes are consistent with literature values.

Effective macrophage delivery using RAFT copolymer derived nanoparticles

We use reversible addition fragmentation chain transfer (RAFT) polymerisation to prepare block copolymers that are subsequently assembled into nanoparticles. The prepared nanoparticles were extensively taken up by primary murine macrophages and are effective in the delivery of a cell impenetrable cargo.

Evaluation of genes associated with human myxomatous mitral valve disease in dogs with familial myxomatous mitral valve degeneration

Myxomatous mitral valve disease (MMVD) is the most common heart disease in the dog. It is believed to be heritable in Cavalier King Charles spaniels (CKCS) and Dachshunds. Myxomatous mitral valve disease is a familial disease in human beings as well and genetic mutations have been associated with its development. We hypothesized that a genetic mutation associated with the development of the human form of MMVD was associated with the development of canine MMVD. DNA was isolated from blood samples from 10 CKCS and 10 Dachshunds diagnosed with MMVD, and whole genome sequences from each animal were obtained. Variant calling from whole genome sequencing data was performed using a standardized bioinformatics pipeline for all samples. After filtering, the canine genes orthologous to the human genes known to be associated with MMVD were identified and variants were assessed for likely pathogenic implications. No variant was found in any of the genes evaluated that was present in least eight of 10 affected CKCS or Dachshunds. Although mitral valve disease in the CKCS and Dachshund is a familial disease, we did not identify genetic cause in the genes responsible for the human disease in the dogs studied here.