Radiological analysis and outcomes of isolated greater tuberosity fracture-dislocations

BACKGROUND

The purpose of this study was to investigate different radiological characteristics for isolated greater tuberosity (GT) fracture-dislocations and their effects on complication and reoperation rates.

METHODS

A two-centre, retrospective study was performed on patients with a minimum 1-year follow-up (median 4.5 years). Patients were split into two groups, Group A (<65 years old) and Group B (≥65 years old). Outcomes included initial injury characteristics (dislocation and fracture type, AC/BC ratio and distances), the reduction environment and postreduction outcomes including complications.

RESULTS

A total of 55 patients were included in this study, with a reduction in the emergency department (ED) performed in 93% of patients. Complication rates (47% overall) were similar in both groups, with an overall nonunion rate of 27%. No nonunions occurred in fractures reduced in theatre compared with 29% occurring in reductions in ED (p<0.001); 11% of patients experienced surgical neck fractures, the majority of which were in Group B (p=0.003). A larger fracture fragment (i.e. higher AC/BC or AC distances) was correlated with a higher incidence of nonunion in Group B compared with Group A (p=0.003), and a higher risk of stiffness in both groups (p=0.049); 16% of patients demonstrated delayed displacement of their GT.

CONCLUSIONS

This study highlights the high complication rates associated with these injuries. Age and specific radiological parameters should be taken into consideration when risk stratifying, as should reducing these fractures in a theatre setting. Interval radiographs are also advised to monitor GT displacement for at least 2-3 weeks.

Sexual dimorphism during integrative endocrine and immune responses to ionizing radiation in mice

Exposure to cosmic ionizing radiation is an innate risk of the spaceflight environment that can cause DNA damage and altered cellular function. In astronauts, longitudinal monitoring of physiological systems and interactions between these systems are important to consider for mitigation strategies. In addition, assessments of sex-specific biological responses in the unique environment of spaceflight are vital to support future exploration missions that include both females and males. Here we assessed sex-specific, multi-system immune and endocrine responses to simulated cosmic radiation. For this, 24-week-old, male and female C57Bl/6J mice were exposed to simplified five-ion, space-relevant galactic cosmic ray (GCRsim) radiation at 15 and 50 cGy, to simulate predicted radiation exposures that would be experienced during lunar and Martian missions, respectively. Blood and adrenal tissues were collected at 3- and 14-days post-irradiation for analysis of immune and endocrine biosignatures and pathways. Sexually dimorphic adrenal gland weights and morphology, differential total RNA expression with corresponding gene ontology, and unique immune phenotypes were altered by GCRsim. In brief, this study offers new insights into sexually dimorphic immune and endocrine kinetics following simulated cosmic radiation exposure and highlights the necessity for personalized translational approaches for astronauts during exploration missions.

A Principle-Based Approach to Visual Identification Systems for Hospitalized People with Dementia

A large proportion of hospital inpatients are affected by cognitive impairment, posing challenges in the provision of their care in busy, fast-paced acute wards. Signs and symbols, known as visual identifiers, are employed in many U.K. hospitals with the intention of helping healthcare professionals identify and respond to the needs of these patients. Although widely considered useful, these tools are used inconsistently, have not been subject to full evaluation, and attract criticism for acting as a shorthand for a routinized response. In order for visual identifiers to be used effectively in acute care settings, thorough consideration must be given to the ethical and legal issues that are engaged in this context, and their potential benefits and harms must be weighed and balanced. This paper proposes a set of legal and ethical principles that can be used to guide the implementation of visual identifiers. Together, these principles provide a framework applicable in the design and implementation phases to systematically identify relevant considerations arising from the use of these tools. We outline some tensions that arise between principles and conclude that selecting a preferred moral framework could help to guide decision-making, as does clarity around the purpose and objectives of the identifier.

The Impact of Microgravity on Immunological States

As we explore other planetary bodies, astronauts will face unique environmental and physiological challenges. The human immune system has evolved under Earth's gravitational force. Consequently, in the microgravity environment of space, immune function is altered. This can pose problematic consequences for astronauts on deep space missions where medical intervention will be limited. Studying the unique environment of microgravity has its challenges, yet current research has uncovered immunological states that are probable during exploration missions. As microgravity-induced immune states are uncovered, novel countermeasure developments and personalized mitigation programs can be designed to improve astronaut health. This can also benefit immune-related monitoring programs for disorders on Earth. This is a comprehensive review, including gaps in knowledge, of simulated and spaceflight microgravity studies in human and rodent models.

In Vivo Adaptive Bayesian Regularized Lagrangian Carotid Strain Imaging for Murine Carotid Arteries and Its Associations With Histological Findings

OBJECTIVES

Non-invasive methods for monitoring arterial health and identifying early injury to optimize treatment for patients are desirable. The objective of this study was to demonstrate the use of an adaptive Bayesian regularized Lagrangian carotid strain imaging (ABR-LCSI) algorithm for monitoring of atherogenesis in a murine model and examine associations between the ultrasound strain measures and histology.

METHODS

Ultrasound radiofrequency (RF) data were acquired from both the right and left common carotid artery (CCA) of 10 (5 male and 5 female) ApoE tm1Unc/J mice at 6, 16 and 24 wk. Lagrangian accumulated axial, lateral and shear strain images and three strain indices-maximum accumulated strain index (MASI), peak mean strain of full region of interest (ROI) index (PMSRI) and strain at peak axial displacement index (SPADI)-were estimated using the ABR-LCSI algorithm. Mice were euthanized (n = 2 at 6 and 16 wk, n = 6 at 24 wk) for histology examination.

RESULTS

Sex-specific differences in strain indices of mice at 6, 16 and 24 wk were observed. For male mice, axial PMSRI and SPADI changed significantly from 6 to 24 wk (mean axial PMSRI at 6 wk = 14.10 ± 5.33% and that at 24 wk = -3.03 ± 5.61%, p < 0.001). For female mice, lateral MASI increased significantly from 6 to 24 wk (mean lateral MASI at 6 wk = 10.26 ± 3.13% and that at 24 wk = 16.42 ± 7.15%, p = 0.048). Both cohorts exhibited strong associations with ex vivo histological findings (male mice: correlation between number of elastin fibers and axial PMSRI: rs = 0.83, p = 0.01; female mice: correlation between shear MASI and plaque score: rs = 0.77, p = 0.009).

CONCLUSION

The results indicate that ABR-LCSI can be used to measure arterial wall strain in a murine model and that changes in strain are associated with changes in arterial wall structure and plaque formation.

Changes in carotid artery texture by ultrasound and elastin features in a murine model

OBJECTIVE

In humans, arterial grayscale ultrasound texture features independently predict adverse cardiovascular disease (CVD) events and change with medical interventions. We performed this study to examine how grayscale ultrasound texture features and elastin fibers change in plaque-free segments of the arterial wall in a murine model prone to atherosclerosis.

METHODS

A total of 10 Apoetm1Unc/J mice (n = 5 male, n = 5 female) were imaged at 6, 16, and 24 weeks of age. Two mice were euthanized at 6 and 16 weeks and the remaining mice at 24 weeks. Texture features were extracted from the ultrasound images of the distal 1.0 mm of the common carotid artery wall, and elastin measures were extracted from histology images. Two-way analysis of variance was used to evaluate associations between week, sex, and grayscale texture features. Texture feature and elastin number comparisons between weeks were conducted using the sex-by-week two-way interaction contrasts. Sex-specific correlations between the number of elastin fibers and grayscale texture features were analyzed by conducting non-parametric Spearman's rank correlation analyses.

RESULTS

Arterial wall homogeneity changed significantly in male mice from 6 to 24 weeks, with a mean (SD) of 0.14 (0.03) units at 6 weeks and 0.18 (0.03) units at 24 weeks (p = 0.026). Spatial gray level dependence matrices-homogeneity (SGLD-HOM) also correlated with carotid artery plaque score (rs = 0.707, p = 0.033). Elastin fibers in the region of interest decreased from 6 to 24 weeks for both male and female mice, although only significantly in male mice. The mean (SD) number of elastin fibers for male mice was 5.32 (1.50) at 6 weeks and 3.59 (0.38) at 24 weeks (p = 0.023). For female mice, the mean (SD) number of elastin fibers was 3.98 (0.38) at 6 weeks and 3.46 (0.19) at 24 weeks (p = 0.051).

CONCLUSION

Grayscale ultrasound texture features that are associated with increased risk for CVD events in humans were used in a murine model, and the grayscale texture feature SGLD-HOM was shown to change in male mice from 6 weeks to 24 weeks. Structural alterations of the arterial wall (change in elastin fiber number) were observed during this time and may differ by sex.

Abstract P470: Total Plaque Area and Association With Stroke Risk Factors in a Native American Population

Objective: Total plaque area (TPA) has been associated with stroke risk factors; however, it has not been well studied in a Native American population. The objective of this study is to examine the relationship of TPA with stroke risk factors (RF).

Methods: Participants enrolled in the “Stroke Prevention in the Wisconsin Native American Population” (n=119) underwent a health history risk assessment, cognitive testing, carotid ultrasound to measure TPA, and a meeting with a health wellness coach. TPA for each participant was measured using the LifeQ Medical Plaque Analysis Software (Nicosia, Cyprus). Statistical analyses were performed using SPSS (SPSS, IBM Corporation, Armonk, NY, USA) and SAS (SAS Institute Inc., Cary, NC, USA). Descriptive statistics for continuous variables are reported as the median and interquartile range (IQR). Spearman rho correlation was used to examine relationships between total plaque area and stroke risk factors. Robust M—estimation was used to examine which risk factors predicted TPA after adjustment for other covariates.

Results: Of the 119 participants, 22 (18.5%) had no plaque and 97 (81.5%) had plaque, 100 (83.3%) were identified as high-risk (≥55 years with three risk factors for stroke) and 19 (15.8%) low-risk (≥55 years with fewer than three risk factors for stroke). Median participant age was 65 (IQR=11.0) years of age, 78.3% female. In univariate analyses, TPA was significantly associated with age (r s =.259;p=.005) and body mass index (BMI) (r s =-.300;p<.001). In a multivariable robust M-estimation model (including age, sex, BMI, systolic and diastolic blood pressure, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, hemoglobin A1c, physical activity, and categorical variables (yes/no) current smoker, history of high cholesterol, coronary artery disease, diabetes, hypertension, and transient ischemic attack), only age (p=.03), sex (p=.012), and hemoglobin A1c (p=.028) remained significant for predicting total plaque area (r 2 =16.5%).

Conclusion: Multivariate analysis demonstrated that age, sex, and hemoglobin A1c predicted TPA. Further work is needed to understand how both traditional and non-traditional stroke RFs may affect the risk of stroke in Native Americans.

Carotid Artery Stiffness Mechanisms in Hypertension and Their Association with Echolucency and Texture Features: The Multi-ethnic Study of Atherosclerosis (MESA)

Arterial stiffness, echolucency and texture features are altered with hypertension and associated with increased cardiovascular disease risk. The relationship between these markers and structural and load-dependent artery wall changes in hypertension are poorly understood. The Multi-ethnic Study of Atherosclerosis (MESA) is a longitudinal study of 6814 adults from six communities across the United States designed to study subclinical cardiovascular disease. From B-mode imaging of the right common carotid artery at the baseline MESA examination, we calculated carotid artery Young's elastic modulus (YEM, n = 5894) and carotid artery gray-scale texture features (n = 1403). The standard YEM calculation represented total arterial stiffness. Structural stiffness was calculated by adjusting YEM to a standard blood pressure of 120/80 mm Hg with participant-specific models. Load-dependent stiffness was the difference between total and structural stiffness. We found that load-dependent YEM was elevated in hypertensive individuals compared with normotensive individuals (35.7 ± 105.5 vs. -62.0 ± 112.4 kPa, p < 0.001) but that structural YEM was similar (425.3 ± 274.8 vs. 428.4 ± 293.0 kPa, p = 0.60). Gray-scale measures of heterogeneity in carotid artery wall texture (gray-level difference statistic contrast) had small but statistically signification correlations with carotid artery stiffness mechanisms. This association was positive for structural YEM (0.107, p < 0.001), while for load-dependent YEM, the association was negative (-0.064, p = 0.02). In conclusion, increased arterial stiffness in hypertension was owing solely to the non-linear mechanics of having higher blood pressure, not structural changes in the artery wall, and high load-dependent stiffness was associated with a more homogenous carotid artery wall texture. This is potentially related to arterial remodeling associated with subclinical atherosclerosis and future cardiovascular disease development. These results also indicate that gray-scale texture features from ultrasound imaging had a small but statistically significant association with load-dependent arterial stiffness and that gray-scale texture features may be partially load dependent.

Quality of life (QoL) in patients with heart failure with preserved ejection fraction (HFpEF): a systematic review

Introduction

Heart failure with preserved ejection fraction (HFpEF) is associated with significant clinical unmet need as mortality and morbidity rates are high despite current treatments. Patient-reported quality of life (QoL) is an important and clinically relevant endpoint in patients with HF so understanding the impact of HFpEF on QoL is essential.

Purpose

The aim of this systematic review was to identify and summarize data on QoL in HFpEF.

Methods

Systematic searches of Medline, Medline Epub Ahead of Print (In-Process & Other Non-Indexed Citations), Embase, and EBM Reviews were conducted in October 2021. Congress proceedings from the past 3 years and reference lists of included publications were also searched. Publications were screened against eligibility criteria by title/abstract and then by full text. Eligibility criteria included clinical studies of any design reporting baseline QoL in adults with HFpEF published from 2016 onwards.

Results

The electronic database search identified 6,403 articles on HFpEF. After screening, 35 full publications reporting HFpEF and QoL were included. Study designs included observational cohort (n=17), cross-sectional (n=3), and post-hoc analyses of interventional studies (n=15). Tools used to measure QoL included KCCQ (n=17), MLHFQ (n=12), EQ-5D-VAS (n=8), SF-12 (n=2), SF-36 (n=2), and EHFSQ-1 (n=1). Health-state utility values (HSUVs) were captured using EQ-5D in four studies. HSUVs in HFpEF ranged from 0.67–0.74, indicating a substantial QoL burden. Eleven studies using various instruments compared QoL in patients with HFpEF vs non-HFpEF (Table 1). Of these, five reported statistically significantly poorer QOL in HFpEF vs non-HFpEF, one reported statistically significantly poorer QOL in non-HFpEF vs HFpEF and five found no statistically significant difference between HF subtypes. Four studies compared QoL in men vs women with three reporting statistically significantly worse QoL in women. Three studies examined the impact of comorbidities, and all reported statistically significantly poorer QoL in patients with comorbid atrial fibrillation, diabetes, or metabolic syndrome. Two studies examined the effect of age; one reported that, vs elderly patients (age ≥85 years), younger patients (age ≤55 years) with HFpEF had statistically significantly worse QoL despite having fewer comorbidities; in contrast, the second study reported that younger patients (age ≤55 years) had statistically significantly better QoL than elderly patients (age ≥75 years). Two studies reported on hospitalizations, with one reporting no difference in QoL between patients who had previously been hospitalized and those who had not and the other reporting that readmission for HF correlated with QoL.

Conclusions

QoL burden among HFpEF patients is substantial. QoL may be affected by age, comorbidities, gender, and prior hospitalization, and may be associated with poorer outcomes. QoL in HFpEF is generally poorer than in non-HFpEF.

Funding Acknowledgement

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

Transcranial Color-Coded Doppler Cerebral Hemodynamics Following Aerobic Exercise Training: Outcomes From a Pilot Randomized Clinical Trial

Introduction

An active lifestyle with regular exercise is thought to decrease or delay the onset of Alzheimer dementia through increasing blood flow to the brain. We examined the mean flow velocity (MFV) and pulsatility index (PI) in the middle cerebral arteries of individuals randomized into two groups-a Usual Physical Activity (UPA) group and an Enhanced Physical Activity (EPA) exercise intervention group-to determine if exercise training is related to changes in cerebral blood flow.

Methods

We examined 23 participants, randomized into a UPA group (n=12) and an EPA group (n=11), with transcranial color-coded Doppler (TCCD) and cardiorespiratory fitness (VO2peak, mL/kg/min) testing at baseline and following a 26-week intervention. TCCD was used to measure MFV and PI. Participants in the EPA group completed supervised aerobic exercise training for 26 weeks. Kendall's tau b correlation was used to examine relationships between variables. The Wilcoxon Rank Sum tests were used to examine changes between the UPA and EPA groups.

Results

There was no significant change in MFV or PI in the UPA group or the EPA group (p-values >0.05) between baseline and 26 weeks; the change between the UPA and EPA groups was also not significant (p=0.603). There was no evidence of an association between change in VO2peak and change in MFV or PI (all p-values >0.05). Participants in the EPA group significantly increased their VO2peak compared to the UPA group (p=0.027).

Conclusion

This study did not demonstrate evidence of a significant change in the MFV in the middle cerebral arteries or evidence of a significant change in the PI between UPA and EPA groups. Future studies should be performed in larger cohorts and should consider use of personalized exercise programs to maximize understanding of how cerebrovascular hemodynamics change in structure and function with exercise for adults at risk for Alzheimer dementia.

The burden of end-stage osteoarthritis in Australia: a population-based study on the incidence of total knee replacement attributable to overweight/obesity

OBJECTIVES

To determine the risk of total knee replacement (TKR) for primary osteoarthritis (OA) associated with overweight/obesity in the Australian population.

METHODS

This population-based study analyzed 191,723 cases of TKR collected by the Australian Orthopaedic Association National Joint Registry and population data from the Australian Bureau of Statistics. The time-trend change in incidence of TKR relating to BMI was assessed between 2015 and 2018. The influence of obesity on the incidence of TKR in different age and gender groups was determined. The population attributable fraction (PAF) was then calculated to estimate the effect of obesity reduction on TKR incidence.

RESULTS

The greatest increase in incidence of TKR was seen in patients from obese class III. The incidence rate ratio for having a TKR for obesity class III was 28.683 at those aged 18-54 years but was 2.029 at those aged >75 years. Females in obesity class III were 1.7 times more likely to undergo TKR compared to similarly classified males. The PAFs of TKR associated with overweight or obesity was 35%, estimating 14,287 cases of TKR attributable to obesity in 2018. The proportion of TKRs could be reduced by 20% if overweight and obese population move down one category.

CONCLUSIONS

Obesity has resulted in a significant increase in the incidence of TKR in the youngest population in Australia. The impact of obesity is greatest in the young and the female population. Effective strategies to reduce the national obese population could potentially reduce 35% of the TKR, with over 10,000 cases being avoided.

What is the impact of dexamethasone on postoperative pain in adults undergoing general anaesthesia for elective abdominal surgery: a systematic review and meta-analysis

Background

Previous meta-analysis of heterogeneous surgical cohorts demonstrated reduction in postoperative pain with perioperative intravenous dexamethasone, but none have addressed adults undergoing elective abdominal surgery. The aim of this study was to determine the impact of intravenous perioperative dexamethasone on postoperative pain in adults undergoing elective abdominal surgery under general anaesthesia.

Methods

This review was prospectively registered on the international prospective register of systematic reviews (CRD42020176202). Electronic databases Medical Analysis and Retrieval System Online (MEDLINE), Exerpta Medica Database (EMBASE), (CINAHL) Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science and trial registries were searched to January 28 2021 for randomised controlled trials, comparing dexamethasone to placebo or alternative antiemetic, that reported pain. The primary outcome was pain score, and secondary outcomes were time to first analgesia, opioid requirements and time to post-anaesthesia care unit (PACU) discharge.

Results

Fifty-two studies (5768 participants) were included in the meta-analysis. Pain scores ≤ 4 hour (h) were reduced in patients who received dexamethasone at rest (mean difference (MD), − 0.54, 95% confidence interval (CI) − 0.72 to − 0.35, I² = 81%) and on movement (MD − 0.42, 95% CI − 0.62 to − 0.22, I² = 35). In the dexamethasone group, 4–24 h pain scores were less at rest (MD − 0.31, 95% CI − 0.47 to − 0.14, I² = 96) and on movement (MD − 0.26, 95% CI − 0.39 to − 0.13, I² = 29) and pain scores ≥ 24 h were reduced at rest (MD − 0.38, 95% CI − 0.52 to − 0.24, I² = 88) and on movement (MD − 0.38, 95% CI − 0.65 to − 0.11, I² = 71). Time to first analgesia (minutes) was increased (MD 22.92, 95% CI 11.09 to 34.75, I² = 98), opioid requirements (mg oral morphine) decreased (MD − 6.66, 95% CI − 9.38 to − 3.93, I² = 88) and no difference in time to PACU discharge (MD − 3.82, 95% CI − 10.87 to 3.23, I² = 59%).

Conclusions

Patients receiving dexamethasone had reduced pain scores, postoperative opioid requirements and longer time to first analgesia. Dexamethasone is an effective analgesic adjunct for patients undergoing abdominal surgery.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13741-022-00243-6.

341 Consenting Practices in Plastic Surgery

Introduction

Informed consent is a vital aspect of safe patient care within any surgical specialty, and if not completed thoroughly, may result in misinformation and patient dissatisfaction.

Traditional paper consent forms are notoriously poorly completed by medical professionals, with common issues ranging from ineligible handwriting, to missing key components of the form.

The aim of this audit was to assess our departments’ compliance with standard trust consent forms and compare adherence to local and national consenting policies.

Method

All elective and emergency plastic surgical procedures carried out over a one-week period from 17/05/2021 to 23/05/2021 were identified using eTrauma and Cerner operative records. In total, 40 procedures were identified. Consent forms were then reviewed and assessed for completion in key areas. 4 procedures were excluded due to the consent form not being available for review, and 1 procedure was excluded due to a cancellation.

Results

The risks and benefits of procedures were generally documented to a high standard. Providing written information to patients, confirmation of consent if the procedure was being performed on a different day, and possible additional procedures were poorly completed throughout. 90% of consent forms screened, failed to include confirmation of the surgical site within the specific section of the form.

Conclusions

Overall, the department demonstrated good compliance with completing trust consent forms. Electronic consent forms would likely address the shortcomings identified in this audit and should be adopted. Continued responsibility from the whole team should be highlighted and maintained to ensure a high standard of consenting.

Abstract TP110: Clinical Risk Factors For Stroke And Associations With Microembolic Signals On Transcranial Doppler

Introduction: Transcranial Doppler (TCD) has been used to identify microembolic signals (MES) in individuals with carotid atherosclerosis. MES are hypothesized to originate from unstable carotid plaque and have been identified in both symptomatic and asymptomatic individuals with cerebrovascular disease. The purpose of this study was to examine the relationship of clinical risk factors (CRF) for stroke and the presence of MES to further understand how clinical risk factors are associated with MES.

Method: Participants (n=89) scheduled for clinically indicated CEA (>60% stenosis NASCET and ACAS Criteria) were evaluated preoperatively for CRF for stroke and the presence MES with TCD. TCD was performed for 60 minutes examining both the right and left middle cerebral arteries. Kendall’s tau correlation coefficients were used to examine the relationship between MES and continuous CRFs. Pearson χ2 test was used to examine the relationship between MES and categorical CRFs. Logistic regression analysis with backward selection was used to examine the relationship between MES presence and CRFs (symptomatic status, age, sex, BMI, heart rate, blood pressure, hypertension, hyperlipidemia, diabetes, peripheral vascular disease, previous stroke, tobacco use, cardiac risk for MES, cancer, and taking aspirin).

Results: Participants had a median (interquartile range [IQR]) age of 71(13) years, 30(33.7%) female, and 53(59.6%) were symptomatic. MES were detected in 32 (36%) participants. There was significant evidence of association between MES with older age (p =0.026) and male sex (p =0.007). No other clinical variables showed significant association with MES (all p-values>0.05). Logistic regression (with p output 0.10) demonstrated that a model including age(p=0.018), sex(p=0.013) and hyperlipidemia(p=0.083) was significantly associated with the presence of MES(p=0.001).

Conclusion: MES were associated with age and sex in a cohort with advanced carotid atherosclerosis. Symptomatic status was not a predictor for MES in this cohort, suggesting that plaques in both symptomatic and asymptomatic individuals have the ability to release microemboli, highlighting the need for further work to be done to identify unstable plaques.

A Quality Improvement Project to Minimize COVID-19 Infections in Patients Receiving Haemodialysis and the Role of Routine Surveillance Using Nose and Throat Swabs for SARS-CoV-2 rRT-PCR and Serum Antibody Testing

Background

Patients receiving in-centre haemodialysis (ICHD) are highly vulnerable to COVID-19.

Objective

We created a quality improvement (QI) project aimed to eliminate outbreaks of COVID-19 in haemodialysis units and evaluated the utility of surveillance rRT-PCR test and SARS-CoV-2 serum antibodies for prompt identification of patients infected with COVID-19.

Methods

A multifaceted QI programme including a bundle of infection prevention control (IPC) measures was implemented across 5 ICHD units following the first wave of the pandemic in June 2020. Primary outcomes evaluated before and after QI implementation were incidence of outbreaks and severe COVID-19 illness defined as COVID-19-related death or hospitalization. Secondary outcomes included the proportion of patients identified in the pre-symptomatic/asymptomatic phase on surveillance rRT-PCR screening and the incidence and longevity of SARS-CoV-2 antibody response.

Results

Following the implementation of the QI project, there were no further outbreaks. Pre- and post-implementation comparison showed a significant reduction in COVID-19-related mortality and hospitalization (26 vs. 13 events, respectively, p < 0.001). Surveillance rRT-PCR screening identified 39 asymptomatic or pre-symptomatic cases out of a total of 59 rRT-PCR-positive patients (39/59, 66%). SARS-CoV-2 antibody levels were detected in 72/74 (97%) rRT-PCR-positive patients. Amongst rRT-PCR-positive patients diagnosed before August 2020, 96% had detectable antibodies until January 2021 (days from the rRT-PCR test to last antibody testing, 245–280).

Conclusions

Systematic implementation of a bundle of IPC measures using QI methodology and surveillance rRT-PCR eliminated outbreaks in HD facilities. Most HD patients mount and sustain antibody response to COVID-19 for over 8 months.

Perceptions of the use of artificial intelligence in the diagnosis of skin cancer: an outpatient survey

BACKGROUND

Convolutional neural networks (artificial intelligence, AI) are rapidly appearing within the field of dermatology, with diagnostic accuracy matching that of dermatologists. As technologies become available for use by both the health professionals and the general public, their uptake in healthcare will become more acceptable. National Health Service England recognizes the potential of AI for healthcare but emphasizes that patient-centred care should be at the forefront of these technological advancements.

AIM

To obtain opinions of patients on the use of AI in a dermatology setting, when aiding the diagnosis of skin cancers.

METHODS

A cross-sectional 14-point questionnaire was handed out to patients attending dermatology outpatient skin cancer clinics in two UK hospitals, between March and August 2018.

RESULTS

In total, 603 patient questionnaires were completed. Nearly half (47%; n = 282) of respondents were not concerned if AI technology was used by a skin specialist to aid skin cancer diagnosis. However, the majority (81%; n = 491) of respondents, considered it important for a dermatologist to examine and confirm a diagnosis and to be present for discussion of a cancer diagnosis.

CONCLUSION

Although the majority of respondents were not reluctant about the use of AI for skin cancer diagnosis, respondents still considered it important that dermatologists are involved in the diagnosis and/or confirmation of skin cancer. Furthermore, the study results demonstrate that personal interaction with a clinician is important. This is in keeping with proposals that AI be used as an adjunctive technology to increase accuracy of skin cancer diagnoses, but not as a substitute for a dermatologist.

AB0034 PD-1 AGONISM INHIBITS ACTIVATION OF PLASMACYTOID DENDRITIC CELLS

Background:

T cell function is regulated by complex signaling networks of interconnected activators and inhibitors. Blockade of inhibitory receptors such as programmed death-1 (PD-1) has emerged as a novel treatment for multiple forms of cancer. One of the most common adverse events associated with blockade of the endogenous PD-1/PD-L1 pathway is the induction of autoimmune pathology in multiple tissues, demonstrating that PD-1 activation is necessary for normal immune homeostasis in humans (Kostine, et al., 2018). Given this body of clinical data, we sought to develop a PD-1 agonist antibody as a therapeutic approach to restore immune homeostasis in patients living with autoimmune diseases. PD-1 expression and function has been primarily described on T cells (Ishida, et al., 1992), with additional data available from several other immune cell populations (Ohaegbulam, et al., 2015).

Objectives:

To study the effect of PD-1 agonism on plasmacytoid dendritic cell (pDC) function.

Methods:

Human PBMCs stimulated with or without toll-like receptor (TLR)-9 agonist, CpG were analyzed by flow cytometry for PD-1 expression on immune cell subsets. To assess the impact of PD-1 agonist on pDC function human PBMCs were activated by CpG in the presence or absence of PD-1 agonist. Type-I interferon (IFN) levels were quantified using ELISA from culture supernatants. The expression of interferon stimulated genes was analyzed by qPCR as a measure of type-I IFN activation.

Results:

We have discovered that TLR9 activation can induce PD-1 expression on plasmacytoid dendritic cells, which has not been previously reported. Further, we have demonstrated that PD-1 agonism inhibits TLR9-mediated activation and the effector functions of plasmacytoid dendritic cells.

Conclusion:

These data suggest the potential of PD-1 as a target for regulating diseases with pathology generated by type-I IFN.

References:

[1]Ishida, Y., Agata, Y., Shihibahara, K., & Honjo, T. (1992). Induced expression of PD-1, a novel member of the immunoglobulin gene superfamily, upon programmed cell death. EMBO J., 11(11):3887-95.

[2]Kostine, M., Rouxel, L., Barnetche, T., Veillon, R., Martin, F., Dutriaux, C., . . . Schaeverbeke, T. (2018). Rheumatic disorders associated with immune checkpoint inhibitors in patients with cancer-clinical aspects and relationship with tumour response: a single-centre prospective cohort study. Annual Rheumatic Disease, 77(3):393-398.

[3]Ohaegbulam, K. C., Assal, A., Lazar-Molnar, E., Yao, Y., & Zang, X. (2015). Human cancer immunotherapy with antibodies to the PD-1 and PD-L1 pathway. Trends in Molecular Medicine, 21(1); 24-33.

Disclosure of Interests:

Ishita Banerjee Shareholder of: Pandion Therapeutics, Employee of: Pandion Therapeutics, Lindsay Edwards Shareholder of: Pandion Therapeutics, Employee of: Pandion Therapeutics, Patrick Halvey Shareholder of: Pandion Therapeutics, Employee of: Pandion Therapeutics, Salvatore Alioto Shareholder of: Pandion Therapeutics, Employee of: Pandion Therapeutics, David Cluckley Shareholder of: Pandion Therapeutics, Employee of: Pandion Therapeutics, Caitlin Mitchell Shareholder of: Pandion Therapeutics, Employee of: Pandion Therapeutics, Christopher Cox Shareholder of: Pandion Therapeutics, Employee of: Pandion Therapeutics, Emily Lurier Shareholder of: Pandion Therapeutics, Employee of: Pandion Therapeutics, Michael Cianci Shareholder of: Pandion Therapeutics, Employee of: Pandion Therapeutics, Soumya Bengeri Shareholder of: Pandion Therapeutics, Employee of: Pandion Therapeutics, Susmita Borthakur Shareholder of: Pandion Therapeutics, Employee of: Pandion Therapeutics, Katalin Kis-Toth Shareholder of: Pandion Therapeutics, Employee of: Pandion Therapeutics, Nathan Higginson-Scott Shareholder of: Pandion Therapeutics, Consultant of: Biotech Companies, Employee of: Pandion Therapeutics, Jo Viney Shareholder of: Pandion Therapeutics, Employee of: Pandion Therapeutics, Kevin L. Otipoby Shareholder of: Pandion Therapeutics, Employee of: Pandion Therapeutics

Oxidative stress in response to heat stress in wild caught Namaqua rock mice, Micaelamys namaquensis

Modelling of anthropogenic induced climate suggests more frequent and severe heatwaves in the future, which are likely to result in the mass die-off of several species of organisms. Oxidative stress induced by severe heat stress has previously been associated with a reduction in animal cognitive performance, depressed reproduction and lower life expectancy. Little is known about the non-lethal consequences of species should they survive extreme heat exposure. We investigated the oxidative stress experienced by the Namaqua rock mouse, a nocturnal rodent, using two experimental heat stress protocols, a 6 hour acute heat stress protocol without access to water and a 3-day heatwave simulation with ad libitum water. Oxidative stress was determined in the liver, kidney and brain using malondialdehyde (MDA) and protein carbonyl (PC) as markers of oxidative damage, and superoxide dismutase (SOD) and total antioxidant capacity (TAC) as markers of antioxidant defence. Incubator heat stress (heat and dehydration stress) was brought about by increasing the body temperatures of animals to 39-40.8 °C for 6 hours. Following incubator heat stress, significantly higher levels of MDA were observed in the liver. Dehydration did not explain the variation in oxidative markers and is likely a combined effect of thermal and dehydration stress. Individual body mass was significantly negatively correlated to kidney SOD and lipid peroxidation. A heatwave was simulated using a temperature cycle that would naturally occur during a heatwave in the species' local habitat, with a maximal ambient temperature of 38 °C. Following the simulated heatwave, SOD activity of the kidney demonstrated significantly lowered activity suggesting oxidative stress. Current heat waves in this species have the potential of causing oxidative stress. Heat and dehydration stress following exacerbated temperatures are likely to incur significant oxidative stress in multiple tissues demonstrating the importance of water availability to allow for rehydration to prevent oxidative stress.

Prevalence of Salmonella spp. in translocated wild reptiles and effect of duration of quarantine on their body condition

AIMS

To assess the prevalence of carriage of Salmonella spp. in wild reptiles translocated from multiple locations to a single island, and determine changes in their body condition (BC) during quarantine.

METHODS

Between 2007 and 2009, six endemic reptile species (Oligosoma aeneum, O. moco, O. ornatum, O. smithi, Dactylocnemis pacificus, and Woodworthia maculata) were caught from several locations in the northern North Island of New Zealand. Reptiles were held in quarantine for 14-41 days while being tested for carriage of Salmonella spp. Morphometric data were collected, and scaled body mass index for each species was calculated to determine changes in BC during the quarantine.

RESULTS

Of 221 individuals tested 12 (5%) were positive for Salmonella spp. All 12 were shore skinks (O. smithi; n = 30), with a test prevalence of 0.4 (95% CI = 0.25-0.58). Eleven were carrying Salmonella enterica Warragul and one S. enterica Mississipi. There was no difference in BC at the start of quarantine of shore skinks between those that tested negative and those that tested positive for Salmonella spp. (p = 0.184). Reptiles that were quarantined for 15-20 days (three species) lost 3-5% of BC (mean proportional change 0.03-0.05), while those quarantined for >30 days increased BC by 3-13% (mean proportional change 0.03-0.13). All animals except the one individual positive for S. Mississippi were translocated to the recipient island, while the latter was returned to the source site.

CONCLUSIONS AND CLINICAL RELEVANCE

The prevalence of Salmonella spp. carriage in the translocated reptiles was low overall and consistent with other records of Salmonella spp. in wild New Zealand reptiles. However, the prevalence of 0.4 in shore skinks is the highest recorded in this species. In addition to time required for health-screening, we recommend that duration of quarantine should include time to allow animals to recover from captive stress and to provide an opportunity to increase their BC before release.

Abstract P351: Grayscale Texture Feature Angular Second Moment Correlates With Collagen Alignment in Carotid Artery Plaques

Introduction: Grayscale (GS) texture features that examine homogeneity and echogenicity have been used to identify vulnerable plaques with in vivo ultrasound imaging have been shown to correlate with plaque tissue composition. However, the relationship of collagen fiber organization to GS texture features extracted from in vivo images is a novel idea to provide additional information about plaque structure. We hypothesize that collagen fiber alignment is clinically relevant to identify vulnerable plaques. The objective of this feasibility study was to use multiscale imaging (in vivo ultrasound and high resolution optical microscopy) to determine how GS texture features are related to plaque collagen structure.

Methods: Participants (n=6) scheduled for clinically indicated carotid endarterectomy underwent in vivo carotid ultrasound imaging with texture feature extraction (spatial gray level dependence matrices method for calculating angular second moment [SGLDM-ASM] and grayscale median value [GSM]). Plaque specimens were sent to histopathology and stained with H&E. The collagen fibers in the fibrous cap of the plaque histopathology slides were imaged with liquid crystal based polarization microscopy and quantified using an established software tool (CurveAlign). Correlations between collagen alignment coefficient (range 0-1, 1 represents perfectly aligned fibers) and the texture feature SGLDM-ASM (a measure of homogeneity, higher values are more homogenous) and GSM (a measure of echogenicity higher values are more echogenic) were examined.

Results: Participants were mean (SD) 72.5 (6.1) years of age, had 71.67 (8.16) percent stenosis. The mean SGLDM-ASM was 0.0017 (0.0023), the mean SD GSM was 73.13 (30.98). SGLDM-ASM was significantly correlated to collagen alignment (r=0.83; p=0.028). There was no significant correlation detected between GSM and collagen alignment (r=-0.43;p=0.38).

Conclusion: Results of this study indicate the potential role for using high resolution optical microscopy with ultrasound to characterize collagen fiber alignment in plaques with measures of homogeneity. Future studies are needed to see how multiscale imaging can be used to inform in vivo imaging for identification of vulnerable plaque features.

Evaluating the effectiveness of a lower extremity venous phantom on developing ultrasound examination skills and confidence

Introduction

The aims of this study were: (1) Determine the effect on student ultrasound scanning skills using a lower extremity venous ultrasound phantom in addition to standard teaching methods of didactic lecture and scanning live volunteers and (2) Determine the effect of using a lower extremity venous ultrasound phantom in addition to standard teaching methods of didactic lecture and scanning live volunteers on student confidence levels in performing the lower extremity venous ultrasound examination.

Methods

Participants were first year diagnostic medical sonography students with minimal scanning experience (n = 11), which were randomized into two groups. Group 1 (n = 5) received the standard didactic lecture and attended a scan lab assessment where they performed a lower extremity venous examination on a human volunteer. Group 2 (n = 6) received the standard didactic lecture, performed three scheduled scanning sessions on an anatomic lower extremity venous phantom with flow and then attended the same scan lab assessment as Group 1, where they performed a lower extremity venous examination on a human volunteer.

Results

Scan lab assessments on day 4 of the study demonstrated a significant difference in scanning performance (p = 0.019) between the two groups. Post scan lab assessment confidence scores also demonstrated a significant difference between how participants in each group scored their confidence levels (p = 0.0260), especially in the ability to image calf veins.

Conclusions

This study suggests anatomical phantoms can be used to develop scanning skills and build confidence in ultrasound imaging of the lower extremity venous structures.

Effects of ultrasound technology advances on measurement of carotid intima-media thickness: A review

In this review, we describe how technological advances in ultrasound imaging related to transducer construction and image processing fundamentally alter generation of ultrasound images to produce better quality images with higher resolution. However, carotid intima-media thickness (IMT) measurements made from images acquired on modern ultrasound systems are not comparable to historical population nomograms that were used to determine wall thickness thresholds that inform atherosclerotic cardiovascular disease risk. Because it is nearly impossible to replicate instrumentation settings that were used to create the reference carotid IMT nomograms and to place an individual's carotid IMT value in or above a clinically relevant percentile, carotid IMT measurements have a very limited role in clinical medicine, but remain a useful research tool when instrumentation, presets, image acquisition, and measurements can be standardized. In addition to new validation studies, it would be useful for the ultrasound imaging community to reach a consensus regarding technical aspects of ultrasound imaging acquisition, processing, and display for blood vessels so standard presets and imaging approaches could reliably yield the same measurements.

Heat and dehydration induced oxidative damage and antioxidant defenses following incubator heat stress and a simulated heat wave in wild caught four-striped field mice Rhabdomys dilectus

Heat waves are known for their disastrous mass die-off effects due to dehydration and cell damage, but little is known about the non-lethal consequences of surviving severe heat exposure. Severe heat exposure can cause oxidative stress which can have negative consequences on animal cognition, reproduction and life expectancy. We investigated the current oxidative stress experienced by a mesic mouse species, the four striped field mouse, Rhabdomys dilectus through a heat wave simulation with ad lib water and a more severe temperature exposure with minimal water. Wild four striped field mice were caught between 2017 and 2019. We predicted that wild four striped field mice in the heat wave simulation would show less susceptibility to oxidative stress as compared to a more severe heat stress which is likely to occur in the future. Oxidative stress was determined in the liver, kidney and brain using malondialdehyde (MDA) and protein carbonyl (PC) as markers for oxidative damage, and superoxide dismutase (SOD) and total antioxidant capacity (TAC) as markers of antioxidant defense. Incubator heat stress was brought about by increasing the body temperatures of animals to 39-40.8°C for 6 hours. A heat wave (one hot day, followed by a 3-day heatwave) was simulated by using temperature cycle that wild four striped field mice would experience in their local habitat (determined through weather station data using temperature and humidity), with maximal ambient temperature of 39°C. The liver and kidney demonstrated no changes in the simulated heat wave, but the liver had significantly higher SOD activity and the kidney had significantly higher lipid peroxidation in the incubator experiment. Dehydration significantly contributed to the increase of these markers, as is evident from the decrease in body mass after the experiment. The brain only showed significantly higher lipid peroxidation following the simulated heat wave with no significant changes following the incubator experiment. The significant increase in lipid peroxidation was not correlated to body mass after the experiment. The magnitude and duration of heat stress, in conjunction with dehydration, played a critical role in the oxidative stress experienced by each tissue, with the results demonstrating the importance of measuring multiple tissues to determine the physiological state of an animal. Current heat waves in this species have the potential of causing oxidative stress in the brain with future heat waves to possibly stress the kidney and liver depending on the hydration state of animals.

ASE Statement on Protection of Patients and Echocardiography Service Providers During the 2019 Novel Coronavirus Outbreak: Endorsed by the American College of Cardiology

•ASE guidance for patient and provider protection during echo exams in the COVID-19 pandemic. •Triaging approach for prioritizing echo exams during the COVID-19 pandemic. •Recommended imaging approach and appropriate PPE use during echo exams.

Specific Considerations for Sonographers When Performing Echocardiography during the 2019 Novel Coronavirus Outbreak: Supplement to the American Society of Echocardiography Statement

Sonographers need to be familiar with and prepared to implement strategies for reducing the risk of exposure to and transmission of the COVID-19 virus. Strategies to employ can be grouped into three broad categories: (1) whom to scan, (2) where to scan, and (3) how to scan. Whom to scan addresses sonographer strategies for determining essential and emergent scan status. Where to scan addresses sonographer practice strategies for selecting equipment, use of rooms, portable examinations, and training personnel. How to scan addresses the topics of scanning techniques (tailored protocols, right-handed scanning, use of barrier devices) and equipment cleaning and disinfecting.

ASE Statement on Protection of Patients and Echocardiography Service Providers During the 2019 Novel Coronavirus Outbreak: Endorsed by the American College of Cardiology

•ASE guidance for patient and provider protection during echo exams in the COVID-19 pandemic. •Triaging approach for prioritizing echo exams during the COVID-19 pandemic. •Recommended imaging approach and appropriate PPE use during echo exams.

ASE Statement on the Reintroduction of Echocardiographic Services during the COVID-19 Pandemic

•

Echocardiography services have been interrupted by the COVID pandemic.

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Services are being gradually reintroduced as healthcare facilities reopen.

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Operational, workflow and prioritization considerations are suggested.

Value and learning from carer involvement in a cluster randomised controlled trial and process evaluation - Organising Support for Carers of Stroke Survivors (OSCARSS)

BACKGROUND

Patient, Carer and Public Involvement (PCPI) should be embedded in health care research. Delivering PCPI can be challenging, but even when PCPI is carried out it is rarely reported resulting in lost opportunities for learning. This paper aims to describe PCPI in the OSCARSS study, a pragmatic-cluster randomised controlled trial with an embedded economic and process evaluation.

METHODS

A carer research user group (RUG) co-developed OSCARSS to evaluate how to best deliver support to caregivers of stroke survivors. The PCPI activity involved regular meetings and preparatory work, from the initial conceptualisation of the study through to dissemination. Written reports, structured group discussions and individual interviews were carried out with the RUG and researchers to capture the added value and learning. This paper was co-authored by two of the RUG members with contributions from the wider RUG and researchers.

RESULTS

The core six members of the caregiver RUG attended the majority of the meetings alongside three researchers, one of whom was the co-chief investigator. PCPI was instrumental in changing many aspects of the research protocol, design and delivery and contributed to dissemination and sharing of good practice. There were challenges due to the emotional toll when PCPI members shared their stories and the extensive time commitment. Positive experiences of learning and fulfilment were reported by the individual researchers and PCPI members. Wider organisational administrative and financial support facilitated the PCPI. The researchers' existing positive regard for PCPI and the clear focus of the group were key to the successful co-design of this research.

CONCLUSIONS

The value and learning from the PCPI collaborative work with the researchers was of benefit to the study and the individuals involved. Specific PCPI influences were a challenge to pinpoint as successful co-design meant the researchers' and carers' contributions were intertwined and decision-making shared.

Changes in carotid artery structure with smoking cessation

Carotid artery grayscale ultrasound echogenicity and texture features predict cardiovascular disease events. We evaluated the longitudinal effects of smoking cessation on four grayscale ultrasound measures. This was a secondary analysis of data from 188 age, sex, and body mass index (BMI)-matched smokers (94 eventual abstainers [EA], 94 continued smokers [CS]) from a smoking cessation trial that had carotid ultrasound examinations at baseline and after 3 years. General linear models that included time, smoking group (EA or CS), and a time*smoking interaction term were used to examine the impact of smoking abstinence on carotid artery grayscale marker values at year 3. Participants were mean (SD) 50.3 (11.4) years old (57% female, 86% white). The baseline grayscale median value (GSM) was inversely correlated with age, BMI, insulin resistance, and smoking pack-years (r = -0.20 to -0.30, p < 0.007 for all). There was a significant time*smoking status interaction for predicting GSM at year 3: GSM decreased significantly in the EA group compared to the CS group (-3.63 [13.00] vs CS 0.39 [12.06] units; p = 0.029). BMI increased more in the EA than the CS group (2.42 [3.00] vs CS 0.35 [2.57] kg/m²; p < 0.001). After adjusting for changes in BMI, the time*smoking status interaction no longer was significant (p = 0.138). From baseline to year 3, contrast increased similarly in both groups. Entropy and angular second moment did not change significantly in either group. Changes in carotid ultrasound echogenicity and grayscale texture features during a smoking cessation attempt are modest and mostly related to weight gain. Clinicaltrials.gov Identifier: NCT01553084.

A novel discharge pathway for patients with advanced cancer requiring home parenteral nutrition

BACKGROUND

The use of home parenteral nutrition (HPN) for palliative indications is increasing internationally and is the leading indication in some countries. Discharge on HPN can be complex in metabolically unstable patients and requires intestinal failure expertise.

METHODS

Between 2012 and 2018, we performed a retrospective analysis aiming to assess the impact of a novel remote discharge pathway for palliative HPN patients. This was evaluated using a quality improvement approach.

RESULTS

One hundred and twenty-five patients with active malignancy [mean (range) age 58 (25-80) years] were referred to the intestinal failure unit (IFU) for remote discharge. Of 82 patients were discharged from the oncology Centre on HPN using the pathway. The remaining 43 patients either declined HPN or the Oncology team felt that the patient became too unwell for HPN or died prior to discharge. There was an increase in patients referred for remote discharge from 13 in 2012 to 43 in 2017. The mean number of days between receipt of referral by the IFU to discharge on HPN from the oncology centre reduced from 29.4 days to 10.1 days. Following remote discharge, the mean number of days on HPN was 215.9 days. Catheter-related blood stream infection rates in this cohort were very low at 0.169 per 1000 catheter days.

CONCLUSIONS

This is the first study to demonstrate the remote safe, effective and rapid discharge of patients requiring palliative HPN between two hospital sites. This allows patients with a short prognosis more time in their desired location.

High-brightness beam tests of the very high frequency gun at the Advanced Photo-injector EXperiment test facility at the Lawrence Berkeley National Laboratory

The very-high-frequency gun (VHF-Gun) is a new concept photo-injector developed and built at the Lawrence Berkeley National Laboratory (LBNL) for generating high-brightness electron beams capable of driving X-ray free electron lasers (FELs) at MHz-class repetition rates. The gun that purposely uses established and mature radiofrequency and mechanical technologies has demonstrated over the last many years the capability of reliably operating in continuous wave mode at the design accelerating fields and required vacuum and mechanical performance. The results of VHF-Gun technology demonstration were reported elsewhere [Sannibale et al., Phys. Rev. Spec. Top.-Accel. Beams 15, 103501 (2012)]; here in this paper, we provide and analyze examples of the experimental results of the first high-brightness beam tests performed at the Advanced Photo-injector EXperiment test facility at LBNL that demonstrated the gun capability of delivering the beam quality required for driving high repetition rate X-ray FELs.

Abstract WMP47: Traditional Doppler Measures Do Not predict Cognition in a Cohort With Advanced Atherosclerosis

Introduction: Traditional Doppler measures have been used to predict cognitive performance in patients with carotid atherosclerosis. Novel measures, such as carotid strain indices (CSI) have shown associations with cognitive performance. We hypothesized that lower mean middle cerebral artery (MCA) velocities, higher bulb-internal carotid artery (ICA) velocities, MCA pulsatility index (PI) and CSI would be associated with poorer cognitive performance in individuals with advanced atherosclerosis.

Methods: Neurocognitive testing, carotid ultrasound, transcranial Doppler and CSI were performed on 40 subjects scheduled for carotid endarterectomy. Kendall tau correlations were used to examine relationships between cognitive tests and the maximum peak systolic velocity (PSV) (from bulb, proximal, mid or distal ICA), mean MCA velocity and PI (on surgical side) and CSI (maximum axial, lateral and shear strain indices used to characterize plaque deformations with arterial pulsation). Cognitive measures included age adjusted indices of verbal fluency, verbal and visual learning/memory, psychomotor speed, auditory attention/working memory, visuoconstruction, and mental flexibility.

Results: Participants were median age 71.0 (IQR 9.75) years, 26 male (65%) and 14 female (35%). Median stenosis was 70.00 (IQR 10.00) percent. Traditional Doppler parameters, PSV, mean MCA velocity and MCA PI did not predict cognitive performance (p values all >0.05). Maximum strain values were significantly associated with cognitive performance (p<0.05). Table .

Conclusions: Traditional velocity measurements of maximum bulb-ICA PSV, mean MCA velocity and PI were not associated with cognitive performance in patients with advanced atherosclerotic disease, however maximum strain indices were associated with cognitive performance. Findings suggest that cognition may be associated with unstable plaque (plaques at greater risk for rupture) rather than blood flow.

The impact of a pharmacist on post-take ward round prescribing and medication appropriateness

Background Medication communication and prescribing on the post-take ward round following patient admission to hospital can be suboptimal leading to worse patient outcomes. Objective To evaluate the impact of clinical pharmacist participation on the post-take ward round on the appropriateness of medication prescribing, medication communication, and overall patient health care outcomes. Setting Tertiary referral teaching hospital, Brisbane, Australia. Method A pre-post intervention study was undertaken that compared the addition of a senior clinical pharmacist attending the post-take ward was compared to usual wardbase pharmacist service, with no pharmacist present of the post-take ward round. We assessed the proportion of patients with an improvement in medication appropriateness from admission to discharge, using the START/STOPP checklists. Medication communication was assessed by the mean number of brief and in-depth discussions, with health care outcomes measured by comparing length of stay and 28-day readmission rates. Main outcome measures: Medication appropriateness according to the START/STOPP list, number and type of discussions with team members and length of stay and readmission rate. Results Two hundred and sixty patients were recruited (130 pre- and 130-post-intervention), across 23 and 20 post-take ward rounds, respectively. Post-intervention, there was increase in the proportion of patients who had an improvement medication appropriateness (pre-intervention 25.4%, post-intervention 36.9%; p = 0.004), the number of in-depth discussions about patients’ medication (1.9 ± 1.7 per patient pre-intervention, 2.7 ± 1.7 per patient post-, p < 0.001), and the number relating to high-risk medications (0.71 ± 1.1 per patient pre-intervention, to 1.2 ± 1.2 per patient post-, p < 0.05). Length of stay and 28-day mortality were unchanged. Conclusion Clinical pharmacist participation on the post-take ward round leads to improved medication-related communication and improved medication appropriateness but did not significantly improve health care outcomes.

Does A Catheter over Needle System Reduce Infusate Leak in Continuous Peripheral Nerve Blockade: A Randomised Controlled Trial

Continuous peripheral nerve blockade is a common technique in the analgesic management for many procedures. Leakage of local anaesthetic from around the nerve catheter insertion site can increase the chance of catheter dislodgement, risks infective complications, and could divert anaesthetic away from the nerve causing the block to fail. We conducted a randomised controlled trial to assess whether the type of nerve catheter influenced local anaesthetic leak rate. One hundred and ten patients scheduled for elective unilateral total knee arthroplasty were randomised to receive a perineural catheter with either a catheter over needle (CON) system (Pajunk® E-Cath) (PAJUNK® GmbH, Medizintechnologie, Geisingen, Germany), or catheter through needle (CTN) system (Pajunk® SonoLong) (PAJUNK® GmbH, Medizintechnologie, Geisingen, Germany). There was no statistically significant difference in the rate of leaking catheters between groups (CON 1.8% versus CTN 3.7%; P=0.618), however, the overall leak rate was much lower than anticipated from pilot data. The CON system was on average faster to insert (CON 357 seconds versus CTN 482 seconds; P=0.004), but associated with poorer needle visibility under ultrasound (Likert scale 1–5, mean [SD], CON 3.31 [0.96] versus CTN 3.89 [0.84]; P=0.001). All seven instances of inadvertent catheter dislodgement occurred in the CTN group (P=0.006). There was no statistically significant difference between groups in the proportion of patients who had adequate analgesia on day one (CON 80% versus CTN 86.5%; P=0.294) and day two postoperatively (CON 85.5% versus CTN 91.8%; P=0.369). Our findings show the overall leak rate to be very low with both catheter systems; however, the CON system may have advantages in terms of speed of use and rate of inadvertent catheter dislodgement.

Sonar guided focused parathyroidectomy under cervical block

BACKGROUND

Presentation of hyperparathyroidism varies and is highly non-specific. The automated calcium analyzer has made the diagnosis easy. Similarly, the advent of Sestamibi scan has paved the way to minimally invasive parathyroidectomy indicated for parathyroid adenoma. There is no uniformity in the extent of minimally invasive parathyroidectomy that is done through limited incision under radio or sonar guidance and endoscopically. In this study, we are presenting the focused parathyroidectomy performed under sonar guidance and superficial cervical block (SCB). The prerequisite is concordant preoperative Sestamibi and ultrasound imaging.

METHOD

A two-year review of parathyroidectomies performed between January 2013 and December 2014.

OBJECTIVE

To reflect on the result of sonar-guided focused parathyroidectomy under SCB.

RESULTS

There was good correlation between the pre-operative imaging, the intra-operative findings and the postoperative histology result of the 15 cases analysed.

CONCLUSION

The focused parathyroidectomy under SCB yielded a good result with concordant preoperative Sestamibi and ultrasound findings.

Abstract 470: Ultrasound Carotid Plaque Features, Cardiovascular Disease Risk Factors and Events: the Multi-Ethnic Study of Atherosclerosis

Background: Grayscale ultrasound atherosclerotic plaque characteristics may predict cardiovascular disease (CVD) events, though they have not been investigated in a large primary prevention cohort. This study determined if CVD risk factors were associated with carotid plaque ultrasound characteristics and if these characteristics could predict future coronary heart disease (CHD) and stroke/transient ischemic attack (TIA) events in a multi-ethnic cohort free of known CVD at baseline.

Methods: We measured carotid artery total plaque area (TPA) and grayscale carotid plaque features (grayscale median, black areas, and discrete white areas) at baseline in participants of the Multi-Ethnic Study of Atherosclerosis that had B-mode carotid ultrasound examinations. There were 2205 participants with images available for TPA analyses and 1703 with images available for grayscale analyses. Multivariable linear regression analysis was used to examine relationships between baseline ultrasound carotid plaque features and CVD risk factors. Cox proportional hazards models were used to assess their ability to predict incident CHD and stroke/TIA events over an average follow-up of 13.3 years. The predictive characteristics of TPA and carotid plaque features were compared to carotid plaque score and coronary artery calcification (CAC) score.

Results: Participants were mean (standard deviation) 65.4 (9.6) years old, 49% male, 39% White, 28% Black, 22% Hispanic, and 11% Chinese. Mean TPA (27.7 [24.7] mm 2 ), but not grayscale plaque features, were associated with several CVD risk factors. In risk factor-adjusted models, TPA was the only plaque feature that predicted incident CHD events (HR 1.23; 95% CI 1.11-1.36; p<0.001) with C-statistics for CHD that were similar to carotid plaque score, but lower than CAC score. TPA did not independently predict stroke/TIA events. No gray scale plaque feature predicted future CHD or stroke/TIA events.

Conclusions: In middle-aged individuals free of known CVD, carotid TPA was associated with CVD risk factors and predicted incident CHD events while grayscale plaque features did not. For CHD, predictive characteristics of TPA were similar to carotid plaque score but lower than CAC score.