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.

Clinical characteristics with inflammation profiling of long COVID and association with 1-year recovery following hospitalisation in the UK: a prospective observational study

BACKGROUND

No effective pharmacological or non-pharmacological interventions exist for patients with long COVID. We aimed to describe recovery 1 year after hospital discharge for COVID-19, identify factors associated with patient-perceived recovery, and identify potential therapeutic targets by describing the underlying inflammatory profiles of the previously described recovery clusters at 5 months after hospital discharge.

METHODS

The Post-hospitalisation COVID-19 study (PHOSP-COVID) is a prospective, longitudinal cohort study recruiting adults (aged ≥18 years) discharged from hospital with COVID-19 across the UK. Recovery was assessed using patient-reported outcome measures, physical performance, and organ function at 5 months and 1 year after hospital discharge, and stratified by both patient-perceived recovery and recovery cluster. Hierarchical logistic regression modelling was performed for patient-perceived recovery at 1 year. Cluster analysis was done using the clustering large applications k-medoids approach using clinical outcomes at 5 months. Inflammatory protein profiling was analysed from plasma at the 5-month visit. This study is registered on the ISRCTN Registry, ISRCTN10980107, and recruitment is ongoing.

FINDINGS

2320 participants discharged from hospital between March 7, 2020, and April 18, 2021, were assessed at 5 months after discharge and 807 (32·7%) participants completed both the 5-month and 1-year visits. 279 (35·6%) of these 807 patients were women and 505 (64·4%) were men, with a mean age of 58·7 (SD 12·5) years, and 224 (27·8%) had received invasive mechanical ventilation (WHO class 7-9). The proportion of patients reporting full recovery was unchanged between 5 months (501 [25·5%] of 1965) and 1 year (232 [28·9%] of 804). Factors associated with being less likely to report full recovery at 1 year were female sex (odds ratio 0·68 [95% CI 0·46-0·99]), obesity (0·50 [0·34-0·74]) and invasive mechanical ventilation (0·42 [0·23-0·76]). Cluster analysis (n=1636) corroborated the previously reported four clusters: very severe, severe, moderate with cognitive impairment, and mild, relating to the severity of physical health, mental health, and cognitive impairment at 5 months. We found increased inflammatory mediators of tissue damage and repair in both the very severe and the moderate with cognitive impairment clusters compared with the mild cluster, including IL-6 concentration, which was increased in both comparisons (n=626 participants). We found a substantial deficit in median EQ-5D-5L utility index from before COVID-19 (retrospective assessment; 0·88 [IQR 0·74-1·00]), at 5 months (0·74 [0·64-0·88]) to 1 year (0·75 [0·62-0·88]), with minimal improvements across all outcome measures at 1 year after discharge in the whole cohort and within each of the four clusters.

INTERPRETATION

The sequelae of a hospital admission with COVID-19 were substantial 1 year after discharge across a range of health domains, with the minority in our cohort feeling fully recovered. Patient-perceived health-related quality of life was reduced at 1 year compared with before hospital admission. Systematic inflammation and obesity are potential treatable traits that warrant further investigation in clinical trials.

FUNDING

UK Research and Innovation and National Institute for Health Research.

124 Administration of Fascia Iliaca Block to Patients Who Have Suffered a Neck of Femur Fracture

Aim

Hip fractures are the most common serious injury affecting elderly people and are associated with a total cost to the health and social services over £1 billion per year. This injury takes approximately 1% of the NHS budget. Furthermore current 30-day mortality rate is 6.5% so has serious implications for patients. NICE recommend that nerve blocks should be used to help perioperative pain and limit the use of opioids. We audited our use of analgesia, especially fascia iliaca blocks (FIB), to see whether training could improve the management of these patients.

Method

We conducted a retrospective cohort study in which a total of 188 patients, who had sustained a hip fracture, were audited during 4 discrete periods between March 2021-July 2021. The primary outcome assessed was whether they had received a FIB preoperatively. Improvements were implemented between audit cycles to see if they achieved desired outcomes.

Results

Implementation of good quality teaching to orthopaedic juniors and emergency department registrars and juniors successfully improved rate of FIB from 2.5% to 47%. The rate of FIB was not sustained over time and declined to 22%. Factors thought to influence this decline included regular rotation of junior doctors and increasing time pressures in the emergency department.

Conclusions

Our data suggested that low rates of FIB resulted in high opioid use in the emergency department. Allocated teaching sessions on administration of FIB were a successful way to improve use of blocks and reduce opioid use.

Effect of a Multidisciplinary Pulmonary Embolism Response Team on Patient Mortality

Multidisciplinary Pulmonary Embolism Response Teams (PERTs) may improve the care of patients with a high risk of pulmonary embolism (PE). The impact of a PERT on long-term mortality has never been evaluated. An observational analysis was conducted of 137 patients before PERT implementation (between 2014 and 2015) and 231 patients after PERT implementation (between 2016 and 2019), presenting to the emergency department of an academic medical center with submassive and massive PE. The primary outcome was 6-month mortality, evaluated by univariate and multivariate analyses. PERT was associated with a sustained reduction in mortality through 6 months (6-month mortality rates of 14% post-PERT vs 24% pre-PERT, unadjusted hazard ratio of 0.57, Relative Risk Reduction of 43%, p = 0.025). There was a reduced length of stay following PERT implementation (9.1 vs 6.5 days, p = 0.007). Time from triage to a diagnosis of PE was independently predictive of mortality, and the risk of mortality was reduced by 5% for each hour earlier that the diagnosis was made. In conclusion, this study is the first to demonstrate an association between PERT implementation and a sustained reduction in 6-month mortality for patients with high-risk PE.

The safety and efficacy of systemic versus catheter-based therapies: application of a prognostic model by a pulmonary embolism response team

The decision by pulmonary embolism response teams (PERTs) to utilize anticoagulation (AC) with or without systemic thrombolysis (ST) or catheter-directed therapies (CDT) for pulmonary embolism (PE) is a balance between the desire for a positive outcome and safety. Our primary aim was to develop a predictive model of in-hospital mortality for patients with high- or intermediate-risk PE managed by PERT while externally validating this model. Our secondary aim was to compare the relative safety and efficacy of ST and CDT in this cohort. Consecutive patients hospitalized between June 2014 and January 2020 at the Cleveland Clinic Foundation and The University of Rochester with acute high- or intermediate-risk PE managed by PERT were retrospectively evaluated. Groups were stratified by treatment strategy. The primary outcome was in-hospital mortality, and secondary outcome was major bleeding. A logistic regression model to predict the primary outcome was built using the derivation cohort, with 100-fold bootstrapping for internal validation. External validation was performed and the area under the receiver operating curve (AUC) was calculated. Of 549 included patients, 421 received AC alone, 71 received ST, and 64 received CDT. Predictors of major bleeding include ESC risk category, PESI score, hypoxia, hemodynamic instability, and serum lactate. CDT trended towards lower mortality but with an increased risk of bleeding relative to ST (OR = 0.42; 95% CI [0.15, 1.17] and OR = 2.14; 95% CI [0.9, 5.06] respectively). In the multivariable logistic regression model in the derivation institution cohort, predictors of in-hospital mortality were age, cancer, hemodynamic instability requiring vasopressors, and elevated NT-proBNP (AUC = 0.86). This model was validated using the validation institution cohort (AUC = 0.88). We report an externally-validated model for predicting in-hospital mortality in patients with PE managed by PERT. The decision by PERT to initiate CDT or ST for these patients had no impact on mortality or major bleeding, yet the long-term efficacy of these interventions needs to be elucidated.

Unprofessional practice and student professionalism dilemmas: What can radiography learn from the other health professions?

OBJECTIVE

Professionalism in radiography is a complex, multidimensional concept seldom investigated. During clinical placements, students may observe or be involved in unprofessional practice/professionalism lapses which result in professionalism dilemmas. Establishing what constitutes a professionalism dilemma and what action to take may be challenging for students and also practitioners. This is due to unclear reporting pathways and fear of retribution, both deterrents to raising concerns. The aim of this integrative literature review was to investigate how and why professionalism dilemmas occur. In addition, to explore the types of dilemma students experience during clinical placement and to contextualise and reflect on these findings within radiography. Ovid MEDLINE, PubMed, Google Scholar and the grey literature were reviewed, analysed and themed.

KEY FINDINGS

Twenty-eight papers (published between 2004 and 2020) were analysed and summarised. Four themes emerged, and were discussed within the radiography context; the nature of professionalism lapses (mistreatment, verbal abuse, exclusion and intimidation), reasons for professionalism lapses (burnout and poor role modelling), student response at the time of the professionalism dilemma (accept, resist or report) and long-term impacts on students (moral/emotional distress, professional development and choice of career).

CONCLUSION

Professionalism dilemmas are not reported in the radiography literature but are cited in radiology and other health professions studies. Student experiences of such dilemmas can be profound and long lasting. Thus, research is required to investigate specifically the professional dilemmas experienced by radiography students in the unique environment in which they develop their clinical skills.

IMPLICATIONS FOR PRACTICE

The literature review findings can be used to support the development of strategies to enhance future teaching and modelling of professionalism and develop related research in radiography.

Lacan on Trauma and Causality: A Psychoanalytic Critique of Post-Traumatic Stress/Growth

This article makes the case for the largely unacknowledged relevance of the thought of the French psychoanalyst, Jacques Lacan, for the emerging field of the medical and/or health humanities. From the 1930s all the way through to the late 1970s, Lacan was deeply concerned with the ethical and political consequences of then-dominant conceptions of the human in the 'psy' disciplines. His attempt to 'humanise' these disciplines involved an emphasis on humans as symbolic beings, inevitably entangled in the structures of speech and the 'logic of the signifier.' This article explores the implications of Lacan's linguistic framework for his understanding of trauma. It argues that the Lacanian concept of trauma offers a timely antidote to dominant psychiatric notions of trauma today, linked as they are to the questionable politics of 'Post-Traumatic Stress Disorder' and, more recently, of 'Post-Traumatic Growth.'

Multiple risk behaviour and socioeconomic status during the transition from adolescence to adulthood

Background

Multiple risk behaviour (MRB) means the occurrence of two or more risk behaviours and is associated with a range of negative outcomes. What is unknown is whether MRB is associated with socioeconomic status (SES) in adulthood. This study aimed to examine the association between adolescent MRB and young adult SES and whether those who experienced early life socioeconomic disadvantage also faced greater negative impact of adolescent MRB.

Methods

Two prospective birth cohort studies; British Cohort Study 1970 (BCS70) and Avon Longitudinal Study of Parents and Children (ALSPAC), born in 1991-1992, were used. Logistic regression assessed the association between MRB and young adult SES. Three early life SES variables were examined for their moderating effect on the association using models with and without interaction parameters. Likelihood ratio tests ≤p=0.05 indicated evidence to support moderation. Multiple imputation was used to account for missing data.

Results

Adolescent MRB was negatively associated with young adult SES (university degree attainment) in BCS70 (OR 0.81, 95% CI: 0.76, 0.86) and ALSPAC (OR 0.85, 95% CI: 0.82, 0.88). There was a dose response, with each additional risk behaviour resulting in reduced odds of university degree attainment. In BCS70, maternal education (p = 0.03), parental occupation (p = 0.009) and household income (p = 0.03) moderated the effect of adolescent MRB on young adult SES. The effect of MRB on university degree attainment was stronger for those from poorer socioeconomic backgrounds. No evidence of moderation was found in ALSPAC.

Conclusions

Adolescence is a critical time to address MRB as behaviours established here may have effects in adulthood. Intervening on adolescent MRB may improve later SES and thus health outcomes later in life. Evidence for a moderation effect in the BCS70 but not ALSPAC suggests that measures should be investigated for their ability to capture the nuance of contemporary young adult SES.

Key messages

Intervening on adolescent multiple risk behaviour could improve socioeconomic life chances in young adulthood. Variables that capture the nuance of contemporary young adult socioeconomic status should be explored.

Killed in action (KIA): an analysis of military personnel who died of their injuries before reaching a definitive medical treatment facility in Afghanistan (2004-2014)

INTRODUCTION

The majority of combat deaths occur before arrival at a medical treatment facility but no previous studies have comprehensively examined this phase of care.

METHODS

The UK Joint Theatre Trauma Registry was used to identify all UK military personnel who died in Afghanistan (2004-2014). These data were linked to non-medical tactical and operational records to provide an accurate timeline of events. Cause of death was determined from records taken at postmortem review. The primary objective was to report time between injury and death in those killed in action (KIA); secondary objectives included: reporting mortality at key North Atlantic Treaty Organisation timelines (0, 10, 60, 120 min), comparison of temporal lethality for different anatomical injuries and analysing trends in the case fatality rate (CFR).

RESULTS

2413 UK personnel were injured in Afghanistan from 2004 to 2014; 448 died, with a CFR of 18.6%. 390 (87.1%) of these died prehospital (n=348 KIA, n=42 killed non-enemy action). Complete data were available for n=303 (87.1%) KIA: median Injury Severity Score 75.0 (IQR 55.5-75.0). The predominant mechanisms were improvised explosive device (n=166, 54.8%) and gunshot wound (n=96, 31.7%).In the KIA cohort, the median time to death was 0.0 (IQR 0.0-21.8) min; 173 (57.1%) died immediately (0 min). At 10, 60 and 120 min post injury, 205 (67.7%), 277 (91.4%) and 300 (99.0%) casualties were dead, respectively. Whole body primary injury had the fastest mortality. Overall prehospital CFR improved throughout the period while in-hospital CFR remained constant.

CONCLUSION

Over two-thirds of KIA deaths occurred within 10 min of injury. Improvement in the CFR in Afghanistan was predominantly in the prehospital phase.

OP0255-PARE USING AN EDUCATIONAL APPLICATION TO FACILITATE UNDERSTANDING OF THE ANATOMY AND FUNCTION OF THE BRAIN AND TO EXPLORE THE EFFECTS OF CLINICAL FATIGUE FROM A PATIENT PERSPECTIVE

Background:

Rheumatic and musculoskeletal diseases are a group of devastating autoimmune disorders that all commonly share the debilitating symptom of fatigue. Despite the fact that fatigue can often cause some of the greatest impairments to quality of life, it is frequently reported by patients as the least successfully managed symptom of these conditions.

Fatigue is routinely misunderstood within the general population, with many people using the word fatigue as a synonym for tired. Fatigue is not the same as tiredness, which is a normal state that is experienced by most of the population, therefore it is important to help the general public understand what fatigue actually is and how it imposes consequences and limitations on those who suffer from it. To aid this understanding an educational application has been created to reinforce the patient perspective of living with fatigue. Furthermore, this application will also aid the understanding of brain anatomy and function, using Augmented Reality (AR), as research has now shown that brain function may be altered in the state of fatigue.

Currently, educational AR applications show great potential for increasing comprehension and understanding of complex concepts. AR expands user engagement by enhancing the learner’s enjoyment and enriching their learning environment. We hope to utilise this technology in the education of fatigue.

Objectives:

We aimed to create an AR application that has informative content designed to educate users on the topics of basic brain anatomy and function. Furthermore, we aimed to increase the users understanding of the complete impairment of fatigue by creating a short video that describes living with fatigue from the patient’s perspective.

Methods:

The application was created using medical scan dataset, a variety of 3D modelling software, and a game engine to create a functional and interactive augmented application. The short video regarding a patient’s perspective on living with fatigue was developed in collaboration with the Glasgow Arthritis Involvement Network patient partners. In order to determine if the application met its primary objectives a pilot test was conducted on 14 participants. After consenting to taking part in the study, individuals were guided through a pre-application test, the use of the application itself and finally a post-application test.

Results:

Initial results from the pilot test showed promise in the educational potential of the application. With regards to the questions pertaining to the brain anatomy, the percentage of questions answered correctly increased from 36% in the pre-test to 60% in the post-test. Furthermore, after using the application the participants reported a significant increase in their confidence for their answers. An additional six questions ascertained a participants perceptions of fatigue. From these questions, the answer that was most significantly changed after use of the application, was in relation to the impact that fatigue has on a patient’s quality of life (t-Test p=0.02). After use of the application participants’ opinions changed to reflect the fact that fatigue can completely impair a person’s quality of life, showing an increase in their understanding of the debilitating nature of fatigue.

Conclusion:

This research explored the development and effectiveness of an AR application that was centered around fatigue and basic neuroanatomy education within the general population. From the pilot test conducted we are able to report that the application was successful in delivering educational material about brain anatomy and was successful in increasing awareness about the impact that fatigue can have on an individual’s quality of life.

Figure 1.

Augmented brain model scene using brain model as trigger

Figure 2.

Example of material change upon selection of Occipital Lobe option

Acknowledgments:

The Glasgow Arthritis Involvement Network (GAIN)

Disclosure of Interests:

None declared

Effect of platelet inhibitors on thrombus burden in patients with acute pulmonary embolism

Venous thromboembolism (VTE) whether provoked or not can be life-threatening due to an acute increase in load on the right ventricle (RV) from obstruction of the pulmonary artery (PA). Treatment for and prevention of VTE involves anti-thrombotic agents; more specifically, medications targeting the anticoagulation cascade. In spite of the widespread acceptance of anticoagulants in the treatment of VTE, there appears to be an ongoing belief that platelet reactivity contributes to thrombus burden in patients with acute pulmonary embolism (PE). This investigation of 398 patients presenting with acute PE evaluated whether anti-platelet medication use, which consisted mostly of aspirin therapy, at the time of presentation, affects PA thrombus burden, RV load, or short-term patient outcomes. We conclude that platelets may have been erroneously incriminated as direct thrombotic mediators in patients with acute PE since aspirin neither decreased PA thrombus burden, nor did aspirin improve short-term mortality following acute PE.

Characterization of an aerosol generation system to assess inhalation risks of aerosolized nano-enabled consumer products

Objective: The aerosolization of common nano-enabled consumer products such as cosmetics has significantly increased engineered nanoparticle inhalation risks. While several studies have investigated the impact of cosmetic dermal exposures, inhalation hazards of aerosolized cosmetics are much less known but could pose considerable harm to users due to potential co-exposure of nanoparticles and other product components.Materials and Methods: In this study, we developed a fully automated aerosol generation system to examine the aerosol properties of four aerosolized nano-enabled cosmetics using real-time monitoring and sampling instrumentation. Physicochemical characterization of aerosols was conducted using scanning electron microscopy coupled with energy dispersive x-ray spectroscopy (SEM-EDX). Characterization and calibration of animal exposure pods coupled to the system were also performed by measuring and comparing particle concentrations between pods.Results and Discussion: Results show peak emissions are shade dependent and varied between 12,000-22,000 particles/cm³ with modal diameters ranging from 36 nm-1.3 µm. SEM-EDX analysis determined that the original products and collected aerosols have similar morphological features consisting of micron-sized particles decorated with nanoparticles and crystalline structures. Mean total particle concentration in pods at 5 and 10 mg/m³ target levels were 2.22E + 05 #/cm³ and 4.33E + 05 #/cm³, respectively, with <10% variability between pods.Conclusions: The fully automated exposure platform described herein provides reproducible aerosol generation, conforms to recommended guidelines on chemical testing, and therefore is suitable for future in vivo toxicological assessments to examine potential respiratory hazards of aerosolized nano-enabled consumer products.

Method Validation for Determination of the 15 European-Priority Polycyclic Aromatic Hydrocarbons in Primary Smoke Condensates by Gas Chromatography/Mass Spectrometry: Interlaboratory Study

A collaborative study was conducted to validate an analytical method for quantification of the 15 polycyclic aromatic hydrocarbons (PAHs) regarded in 2002 as a health concern by the former Scientific Committee on Food of the European Commission (SCF) in primary smoke condensates. The method is based on gas chromatography/mass spectrometry of a cyclohexane extract with solid-phase cleanup through silica gel. The analytes were detected in the selected-ion monitoring mode and quantified by using 3 isotopically labeled internal standard compounds. Seventeen laboratories participated in the collaborative validation study, of which 12 reported valid results. The data were subjected to Cochran, single Grubbs, and double Grubbs tests for statistical outliers. A maximum of 2 outliers was eliminated before further statistical evaluation of the method performance characteristics. Depending on the analyte, the results showed relative standard deviations for repeatability between 4.2 and 30% and for reproducibility from 9.9 to 60%. The recoveries varied between about 50 and 85%, except those for cyclopenta[cd]pyrene, dibenzo[a,i]pyrene, and dibenzo[a,h]pyrene. Nevertheless, because Commission Directive 2005/10/EC allows for a recovery range of 50120% for (BaP) benzo[a]pyrene in various foods, it can be concluded that the method performs appropriately within the analytical range between 5 and 25 μg/kg of primary smoke condensate. For BaP the validated analytical range covered 520 μg/kg, and for benzo[a]anthracene (BaA) 1025 μg/kg. The method is suitable for monitoring BaP and BaA at their respective maximum permitted levels of 10 and 20 μg/kg. Three analytes, benzo[b]-, benzo[j]-, and benzo[k]-fluoranthene could not be separated by all of the participants and were therefore treated as the sum. Nevertheless, with this method the pattern of the respective concentrations of these 15 PAHs can be monitored in primary smoke condensate as suggested by the SCF.

Developing a national musculoskeletal core capabilities framework for first point of contact practitioners

Objective

We aimed to support service transformation by developing a core capabilities framework for first contact practitioners working with people who have musculoskeletal conditions.

Methods

We conducted a modified three-round Delphi study with a multi-professional panel of 41 experts nominated through 18 national professional and patient organizations. Qualitative data from an open-ended question in round one were analysed using a thematic approach and combined with existing literature to shape a draft framework. Participants rated their agreement with each of the proposed 142 outcomes within 14 capabilities on a 10-point Likert scale in round two. The final round combined round two results with a wider online survey.

Results

Rounds two and three of the Delphi survey were completed by 37 and 27 participants, respectively. Ninety practitioners responded to the wider online survey. The final framework contains 105 outcomes within 14 capabilities, separated into four domains (person-centred approaches; assessment, investigation and diagnosis; condition management, intervention and prevention; and service and professional development). The median agreement for all 105 outcomes was at least nine on the 10-point Likert scale in the final round.

Conclusion

The framework outlines the core capabilities required for practitioners working as the first point of contact for people with musculoskeletal conditions. It provides a standard structure and language across professions, with greater consistency and portability of musculoskeletal core capabilities. Agreement on each of the 105 outcomes was universally high amongst the expert panel, and the framework is now being disseminated by Health Education England, NHS England and Skills for Health.

Damage control resuscitation and surgery for indigenous combat casualties: a prospective observational study

INTRODUCTION

Specialist units that assist indigenous forces (IF) in their strategic aims are supported by medical teams providing point of injury emergency care for casualties, including IF and civilians (Civ). We investigated the activities of a Coalition Forces far-forward medical facility, in order to inform medical providers about the facilities and resources required for medical support to IF and Civ during such operations.

METHODS

A prospective observational study (June to August 2017) undertaken at a far-forward Coalition Forces medical support unit (12 rotating personnel) recorded patient details (IF or Civ), mechanism of injury (MOI), number of blood products used, damage control resuscitation (DCR) and damage control surgery (DCS), number of mass casualty (MASCAL) scenarios, resuscitative thoracotomy, resuscitative endovascular balloon occlusion of the aorta (REBOA) and whole blood emergency donor panels (EDP).

RESULTS

680 casualties included 478 IF and 202 Civ (45.5% of the Civ were paediatric). Most common MOIs were blast (n=425; 62.5%) and gunshot wound (n=200; 29.4%). Fifteen (2.2%) casualties died; 627 (92.2%) were transferred to local hospitals. DCR was used for 203 (29.9%), and DCS for 182 (26.8%) casualties. There were 23 MASCAL scenarios, 1220 transfusions and 32 EDPs. REBOA was performed eight times, and thoracotomy was performed 27 times.

CONCLUSIONS

A small medical team provided high-tempo emergency resuscitative care for hundreds of IF and Civ casualties within a short space of time using state-of-the-art resuscitative modalities. DCR and DCS were undertaken with a large number of EDPs, and a high survival-to-transfer rate.

Tin-oxide nanoparticles deposited from a beam: what happens to the composition?

The debate around the oxidation states occurring in laboratory-prepared tin-oxide samples has been for a long time an obstacle for an unambiguous assignment of characterization studies performed on such samples. In particular the changes in the Sn core-level energies caused by oxidation - i.e. the chemical shifts - as measured by photoelectron spectroscopy (PES) have been under discussion. The assignment problem is especially pronounced for nanoscale structures, which are important for photovoltaics, electronics, catalysis, and gas sensing. The reasons for the difficulties lie both in the natural properties of tin oxides, which can have substantial deficiencies of oxygen and tin in the lattice, and in the shortcomings of the fabrication and PES-characterization procedures themselves. Our recent PES study on tin-oxide nanoparticles fabricated by vapour-aggregation gave a chemical shift two times larger than earlier reported for Sn(iv) oxide for the Sn 4d level. The implemented fabrication technique forms an in-vacuum beam of particles whose composition can be both controlled and characterized by PES. In the present work SnO and SnO2 nanoparticles fabricated this way were deposited from the beam and probed by PES directly, as well as after exposure to air. The deposited nanoparticle films were also imaged by TEM (Transmission Electron Microscopy). The effects of the deposition process and exposure to air on the chemical composition were studied. The PES study of deposited SnO2 nanoparticles in the Sn 4d and Sn 3d core-level regions revealed the same core level shift as for unsupported nanoparticles, indicating that the chemical composition is preserved in the deposition process. The TEM study demonstrated a crystalline structure of separate SnO2 particles with lattice constants close to the macroscopic Sn(iv)-oxide. The PES study on the particles exposed to air showed changes in the composition. For the film of initially SnO particles a higher intermediate oxide was created. For the SnO2 nanoparticle film a lower, but strong, intermediate oxide was observed, likely at the surface.

Abstract P3-12-25: Dosimetric impact of patient rotation during prone breast radiotherapy

Purpose

Prone positioning has been used as a viable alternative to conventional supine position for patients receiving breast radiation therapy. However, little research has been done exploring the axial rotation of patients toward the treated breast when “sinking” into the opening of the breast board and its potentially negative effects on dosimetric outcomes, which may include increased heart and lung dose. The physician may need to move the posterior border away from the chest wall to reduce heart and lung dose.

Methodology

49 consecutive female patients with left sided early stage breast cancer treated at University of California Davis Medical Center were assessed from 2015 to 2018 (age range: 42-84 years, median age: 62 years). All patients underwent prone whole breast therapy with conventional external beam radiation therapy (EBRT) at doses of 50 Gy (n = 12) or hypofractionated at 42.56 Gy (n = 37). Treatment plans and dose volumes were retrospectively analyzed for each patient. Standard tangents were designed for each patient using clinical landmarks of the midaxillary line and midsternal line, which were then compared to the delivered tangent beams. The angle created between a vertical line centered on center sternum and a line drawn from center sternum to center spinal cord served to define degree of axial rotation. Breast depth was defined by the longest horizontal length from outer rib to edge of breast on sagittal view. Patients were divided into subgroups by degree of rotation and absolute breast depth. A two tailed paired Student's t-test was used for analysis.

Results

Overall mean heart and lung dose were 82.2 cGy and 50.43 cGy for the entire cohort, respectively. For standard tangents, patients with degree of rotation &lt; 5 degrees in the prone position (n = 23) had significant lung sparing as compared to patients with degree of rotation &gt; 5 cm (n = 26) (mean lung dose: 61.8 cGy vs 129.6 cGy, p = 0.00329). This was also seen for cardiac sparing (mean heart dose: 105.9 cGy vs 183.9 cGy, p = 0.000235). Even with reduction of posterior border for treatment delivery, there remained a significant increase in mean heart and lung dose with increased rotation (p = 0.038, p = 0.046). Although not statistically significant, for patients with &gt; 5 degrees of rotation there was a trend toward increased reduction of the posterior border of the tangent (13 mm vs. 7.5 mm, p = 0.13). A significant predictor of increased rotation was breast depth &gt; 10 cm (p = 0.01). Patients with absolute breast depth &gt; 10 cm (n = 23) in the prone position had significant lung sparing as compared to patients with absolute breast depth &lt; 10 cm (n = 26) (mean lung dose: 58.6 cGy vs 40.8 cGy, p = 0.042).

Conclusion

To our knowledge, this is the first dosimetric comparison of prone breast therapy exploring the degree of patient roll into the prone-breast setup cavity. This study demonstrates a significant increase in mean lung and heart dose when patient rotation is greater than 5 degrees. Given this, the posterior border may have to be reduced to prevent a higher than intended dose to the heart and lung. Proper attention during simulation is important to allow for optimal dose distribution and special attention should be paid to women with smaller breast size.

Citation Format: Cheng K, Hoopingarner S, Wright C, Daly M, Fragoso R, Zhao X. Dosimetric impact of patient rotation during prone breast radiotherapy [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-12-25.

Systematic review of prehospital haemostatic dressings

Introduction

Haemorrhage is one of the leading causes of battlefield and prehospital death. Haemostatic dressings are an effective method of limiting the extent of bleeding and are used by military forces extensively. A systematic review was conducted with the aim of collating the evidence on current haemostatic products and to assess whether one product was more effective than others.

Methods

A systematic search and assessment of the literature was conducted using 13 health research databases including MEDLINE and CINAHL, and a grey literature search. Two assessors independently screened the studies for eligibility and quality. English language studies using current-generation haemostatic dressings were included. Surgical studies, studies that did not include survival, initial haemostasis or rebleeding and those investigating products without prehospital potential were excluded.

Results

232 studies were initially found and, after applying exclusion criteria, 42 were included in the review. These studies included 31 animal studies and 11 clinical studies. The outcomes assessed were subject survival, initial haemostasis and rebleeding. A number of products were shown to be effective in stopping haemorrhage, with Celox, QuikClot Combat Gauze and HemCon being the most commonly used, and with no demonstrable difference in effectiveness.

Conclusions

There was a lack of high-quality clinical evidence with the majority of studies being conducted using a swine haemorrhage model. Iterations of three haemostatic dressings, Celox, HemCon and QuikClot, dominated the studies, probably because of their use by international military forces and all were shown to be effective in the arrest of haemorrhage.

For debate: on-the-person battlefield antibiotics

Wound infection has always been an important contributor to mortality and morbidity on the battlefield. On-the-person antibiotics have long been suggested as one way to help combat this, which have already been implemented by some North Atlantic Treaty Organization partners. This paper is an up-to-date review of the evidence of the efficacy of on-the-person antibiotics and whether the British military should look to use them in the near future.

"I'm obviously not dying so it's not something I need to sort out today": Considering hepatitis C treatment in the era of direct acting antivirals

BACKGROUND

People who inject drugs are the group at greatest risk of hepatitis C virus (HCV) infection. The advent of new direct-acting antiviral (DAA) treatment provides opportunities for increased uptake of therapy.

METHODS

We conducted in-depth interviews with thirty HCV positive participants from the SuperMIX cohort study. Interviews were transcribed, coded, and analysed for emerging themes and similarities between participants. General descriptions and critical interpretation of themes were generated and selective quotes extracted verbatim to best illustrate the critical themes.

RESULTS

Participants described their experiences of living with HCV, their knowledge of HCV treatment accessibility, and information on the types of support ain themes: Understanding the need for treatment; Knowledge and framing of treatment access; and Support during treatment.

CONCLUSION

The new, highly effective DAAs for the treatment of HCV are heralded as the potential beginning of HCV elimination, especially in settings where scale up is high. Our data from active PWID show that the availability of DAA medications in and of themselves is likely not to be enough to ensure that PWID will come forward for HCV treatment in sufficient numbers to drive elimination.

Association between Degree of Anaplasia and Degree of Inflammation with the Expression of COX-2 in Feline Injection Site Sarcomas

Feline injection site sarcomas (FISSs) are mesenchymal neoplasms that develop at the sites of delivery of vaccines or other injectable products. Vaccine adjuvants can trigger an intense and persistent inflammatory response that may lead to neoplastic transformation. The proinflammatory role of cyclo-oxygenase (COX)-2 is well known and its overexpression has prognostic value in multiple neoplastic processes. One hundred and seventeen FISSs were evaluated for the degree of inflammation and anaplasia. Immunohistochemistry was used to determine the expression of COX-2 in these sarcomas. There was a significant association between the degree of inflammation and the expression of COX-2 by neoplastic cells. COX-2 expression was lower in tumours with higher degrees of anaplasia. These findings may be useful in predicting the sensitivity of FISSs to treatment with COX-2 inhibitors. The potential therapeutic use of such agents could then be restricted to tumours with lower degrees of anaplasia.

British Army recruits with low serum vitamin D take longer to recover from stress fractures

BACKGROUND

Recruits undergoing military training experience a particularly high incidence of stress fractures. The role of combined calcium and vitamin D (25-OHD) deficiency and subsequent supplementation has been well described in the literature, but the role of 25-OHD deficiency alone is less well understood, particularly its influence on recovery once a stress fracture has been incurred.

METHODS

Retrospective data of recruits who had incurred stress fractures were collected (n=37). Independent-samples t-tests were conducted in Microsoft Excel to investigate the association between serum-25 OHD and the time taken to recover.

RESULTS

Significant differences (p<0.05) were found in the mean time taken to recover from stress fractures when participants were grouped according to serum 25-OHD level. Sufficient levels of serum 25-OHD (>50 nmol/L) at the time of injury resulted in shorter recovery times than all other groups.

CONCLUSION

The study demonstrated an association between serum 25-OHD level and the time taken to recover from a stress fracture. The sample population of this study was too small to contribute to the discussion about whether a minimum serum 25-OHD status should be met before entering British Army training, but a larger prospective study should be able to provide the data required for a cost benefit analysis to be conducted and a decision made.

Catastrophic haemorrhage in military major trauma patients: a retrospective database analysis of haemostatic agents used on the battlefield

Objectives

Catastrophic haemorrhage is a leading cause of morbidity and mortality in trauma, in both military and civilian settings. There are numerous studies looking at the effectiveness of different haemostatic agents in the laboratory but few in a clinical setting. This study analyses the use of haemostatic dressings used in patients injured on the battlefield and their association with survival.

Method

A retrospective database review was undertaken using the UK Joint Theatre Trauma Registry from 2003 to 2014, during combat operations in Iraq and Afghanistan. Data included patient demographics, the use of haemostatic dressings, New Injury Severity Score (NISS) and patient outcome.

Results

Of 3792 cases, a haemostatic dressing was applied in 317 (either Celox, Hemcon or Quickclot). When comparing patients who had a haemostatic dressing applied versus no haemostatic agent, there was a 7% improvement in survival. Celox was the only individual haemostatic dressing that was associated with a statistically significant improvement in survival, which was most apparent in the more severely injured (NISS 36–75).

Conclusion

We have shown an association between use of haemostatic agents and improved survival, mostly in those with more severe injuries, which is particularly evident in those administered Celox. This supports the continued use of haemostatic agents as part of initial haemorrhage control for patients injured in conflict and suggests that civilian organisations that may need to deal with patients with similar injury patterns should consider their use and implementation.

Changes in NHS Major Incident management and their relevance to the Defence Medical Services

High-profile Major Incidents in the UK civilian setting in the last few years have appropriately raised awareness of the principles and frameworks involved in the design of reliable response systems. The introduction of the Joint Emergency Services Interoperability Principles in tandem with increased investment in Major Incident Planning has supported practitioners to successfully respond to high numbers of incidents.

Defence Medical Services personnel are increasingly being asked to deploy to resource-limited 'contingency' settings where much of the established guidance relating to Major Incident response requires reconsideration and modification in the face of severely constrained space, manpower and equipment.

This editorial seeks to review contemporary theories and principles of Major Incident response and discuss how military medical personnel may need to adapt these to address the various Major Incident challenges that they may face on operations.

2 Combat use of opioid analgesia and its complications: a retrospective review of data from OP herrick

Background

On the battlefield, acute pain, particularly secondary to trauma, is a common condition which requires treatment in the pre-hospital, evacuation and hospital settings. The use of morphine to manage pain during combat has been well established since the 19th century. Despite this, there are relatively few papers reviewing analgesia use in a combat environment. This study aims to review the use and complications from morphine and other opioids during Op HERRICK.

Methods

A database search of the Joint Theatre Trauma Registry (JTTR) was carried out looking for all incidences of administration of either morphine, fentanyl or naloxone from January 2007 to September 2014. Microsoft Excel was then used to analyse the dataset and perform descriptive statistics on the data retrieved.

Results

Opioid analgesia was administered to 5801 casualties. Morphine was administered 6742 times to 3808 patients. Fentanyl was administered 9672 times to 4318 patients. Naloxone was used 18 times on 14 patients, giving a complication rate of 0.24%. Opioid doses prior to naloxone administration range from 0–72 mg of morphine and 0–100 mcg of fentanyl. 4 casualties (2 local civilian and 2 coalition forces) received naloxone despite no recorded opioids being administered. Opium abuse was prevalent amongst the local population in Afghanistan, and this could explain the rationale behind 2 local national casualties receiving naloxone without any documented opioids being given.

Conclusion

The use of opioids in a battlefield environment is extremely safe, with very few incidences of complications requiring the use of naloxone. Complication rates are comparable to previously published research. We are unable to comment on the effectiveness of opioids in relieving pain in this study, and further research is needed, particularly following the introduction of oral transmucosal fentanyl citrate (OTFC) and the availability of non-opioid analgesia.

4 Use of topical haemostatic dressings in an extended field care model of external haemorrhage

Introduction

The use of Celox gauze has been established in military practice as an adjunct in the treatment of external haemorrhage. The future character of conflict means that casualties may take longer to reach definitive care. The aim of this study was to test whether Celox Rapid, a topical haemostatic dressing, would maintain haemostasis during extended use in a junctional haemorrhage model.

Methods

An anaesthetised swine underwent simultaneous bilateral femoral arteriotomies; after 30 s of free bleeding Celox Rapid gauze was applied to the wound and pressure was maintained for 1 min. Following inspection for re-bleeding the Celox gauze was covered with standard field dressings and checked for re-bleeding every hour until the 6 hours had elapsed or the animal deceased.

Results

There was no evidence of re-bleeding at any point up to and including 6 hours. The animal was declared deceased shortly afterwards. Celox Rapid gauze maintained haemostasis in extended use in this limited single animal model. Post mortem examination revealed a stable clot at the site of the arteriotomy with no evidence of re-bleeding.

Conclusion

Celox Rapid was effective at achieving initial homeostasis and preventing re-bleeding in this limited study using a single anaesthetised swine. Its potential for use in situations where evacuation and definitive care may be delayed should be explored.

Military Prehospital Emergency Care: defining and professionalising the levels of care provided along the Operational Patient Care Pathway

The Defence Medical Services aims to provide gold standard care to ill and injured personnel in the deployed environment and its prehospital emergency care (PHEC) systems have been proven to save lives. The authors have set out to demonstrate, using existing literature, consensus and doctrine that the NHS Skills for Health framework can be reflected in military prehospital care and provides an existing model for defining the levels of care our providers can offer. In addition, we have demonstrated how these levels of care support the Operational Patient Care Pathway and add to the body of evidence for the use of specialist PHEC teams to allow the right patient to be transported on the right platform, with the right medical team, to the right place. These formalised levels allow military planners to consider the scope of practice, amount of training and appropriate equipment required to support deployed operations.

Underutilization of Donor Hearts: An Observational Study

BACKGROUND

Utilization of donor hearts remains insufficient. In this observational study, we explored the rate and reasons of rejection of cardiac donors in 1 organ procurement organization.

METHODS

Donors were enrolled in the study for 1 year, from October 5, 2014, through October 4, 2015. Data on demographics, medical history, and diagnostic tests were collected. We compared continuous variables between groups using a Mann-Whitney U test, and categorical variables using the χ²test. Multivariate logistic regression analysis was performed to identify factors predicting transplantation.

RESULTS

Of 134 adult hearts, only 39.5% were transplanted. Moreover, almost half (46.9%) of non-transplanted hearts were normal by all data available. In 12 (31.5%) of all hearts, coronary artery disease was discovered by pathology, making them unusable for transplantation. Overall, 26 normal hearts (19.4%) were not accepted for transplantation. The most common abnormality of hearts not suitable for transplantation was a decreased left ventricular ejection fraction (LVEF). In about one-fifth of donors with low LVEF on the first echocardiogram, LVEF improved on a second echocardiogram. In a majority of cases with low LVEF, echocardiogram was never repeated.

CONCLUSIONS

Almost 20% of normal donor hearts were not transplanted. Coronary artery disease was the most common abnormality in seemingly normal hearts. Coronary angiography should be performed more liberally in potential donors. Decreased LVEF was the most common reason for not using a heart. Since impaired LVEF may be reversible, repeated echocardiogram is encouraged in order to maximize the rate of transplantation.

The impact of a multi-specialty team for high risk pulmonary embolism on resident and fellow education

The impact of the Pulmonary Embolism Response Team (PERT) model on trainee physician education and autonomy over the management of high risk pulmonary embolism (PE) is unknown. A resident and fellow questionnaire was administered 1 year after PERT implementation. A total of 122 physicians were surveyed, and 73 responded. Even after 12 months of interacting with the PERT consultative service, and having formal instruction in high risk PE management, 51% and 49% of respondents underestimated the true 3-month mortality for sub-massive and massive PE, respectively, and 44% were unaware of a common physical exam finding in patients with PE. Comparing before and after PERT implementation, physicians perceived enhanced confidence in identifying ( p<0.001), and managing ( p=0.003) sub-massive/massive PE, enhanced confidence in treating patients appropriately with systemic thrombolysis ( p=0.04), and increased knowledge of indications for systemic thrombolysis and surgical embolectomy ( p=0.043 and p<0.001, respectively). Respondents self-reported an increased fund of knowledge of high risk PE pathophysiology (77%), and the perception that a multi-disciplinary team improves the care of patients with high risk PE (89%). Seventy-one percent of respondents favored broad implementation of a PERT similar to an acute myocardial infarction team. Overall, trainee physicians at a large institution perceived an enhanced educational experience while managing PE following PERT implementation, believing the team concept is better for patient care.

Ketamine for military prehospital analgesia and sedation in combat casualties

Ketamine is an effective drug for battlefield analgesia. Recent evidence suggests that it can be safely and effectively used by Level 6 Pre-Hospital Emergency Care (PHEC) practitioners. This article presents a review of the evidence, and outlines the future use of ketamine for provision of analgesia and sedation in combat casualties.

Opioid analgesia on the battlefield: a retrospective review of data from Operation HERRICK

Background

Acute pain secondary to trauma is commonly encountered on the battlefield. The use of morphine to manage pain during combat has been well established since the 19th century. Despite this, there is relatively little research on analgesia use in this environment. This study aims to review the use and complications of morphine and other opioids during Operation HERRICK.

Methods

A database search of the Joint Theatre Trauma Registry was completed looking for all incidences of morphine, fentanyl or naloxone use from February 2007 to September 2014. Microsoft Excel was used to analyse the results.

Results

Opioid analgesia was administered to 5801 casualties. Morphine was administered 6742 times to 3808 patients. Fentanyl was administered 9672 times to 4318 patients. Naloxone was used 18 times on 14 patients, giving a complication rate of 0.24%. Opioid doses prior to naloxone administration range from 0 to 72 mg of morphine and from 0 to 100 mcg of fentanyl. Four casualties (two local civilians and two coalition forces) received naloxone despite no recorded opioids being administered. Opium abuse was prevalent among the local population in Afghanistan, and this could explain the rationale behind two local national casualties receiving naloxone without any documented opioids being given.

Conclusion

The use of opioids in a battlefield environment is extremely safe. Complication rates are similar to previously published data which is reassuring. The efficacy of different opioids was not covered by this study, and further analysis is required, particularly following the introduction of oral transmucosal fentanyl citrate and the availability of novel non-opioid analgesics.