Real-World Use and Effectiveness Outcomes in Patients with Rheumatoid Arthritis Treated with Upadacitinib: An Analysis from the CorEvitas Registry

INTRODUCTION

Data assessing longer-term real-world effectiveness and treatment patterns with upadacitinib (UPA), a Janus kinase inhibitor, in rheumatoid arthritis (RA) are lacking. We assessed improvement in clinical and patient-reported outcomes and treatment patterns for up to 12 months among adult patients with RA initiating UPA.

METHODS

Data were collected from the CorEvitas® RA Registry (08/2019-04/2022). Eligible patients had moderate to severe RA (Clinical Disease Activity Index [CDAI] > 10) and follow-up visits at 6 or 12 months after UPA initiation. Outcomes were mean change from baseline, percentage achieving minimal clinically important differences (MCID) in clinical and patient-reported outcomes, and disease activity at follow-up. We evaluated clinical outcomes and therapy changes among patients with tumor necrosis factor inhibitor (TNFi) experience and among those receiving UPA as first-line therapy, as well as those receiving UPA as monotherapy versus as part of combination therapy. We further evaluated whether outcomes were similar among those that remained on therapy.

RESULTS

Patients treated with UPA (6-month cohort, N = 469; 12-month cohort, N = 263) had statistically significant improvements (p < 0.001) in mean CDAI, tender/swollen joint counts, pain, and fatigue at follow-up. At 12 months, 46.0% achieved MCID in CDAI and 40.0% achieved low disease activity/remission. Overall, 43.0% discontinued UPA at 12 months; of those receiving combination treatment (N = 90) with conventional therapies and UPA, 42.2% (N = 38) discontinued conventional therapy. Findings were similar in the 6-month cohort and among subgroups. Changes from baseline and proportions of patients achieving MCID or clinical outcomes tended to be numerically lower among patients with TNFi experience and numerically higher among those receiving UPA as first-line therapy.

CONCLUSIONS

UPA initiation was associated with improvements in clinical and patient-reported outcomes, with meaningful clinical improvements regardless of prior TNFi experience, line of therapy, or concomitant use of conventional therapies. Further research is needed to better understand sustained response of UPA over longer treatment periods.

Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Impact of socio-economic conditions and perinatal factors on risk of becoming a child looked after: a whole population cohort study using routinely collected data in Wales

OBJECTIVES

Between 1997 and 2021, the number of children looked after (CLA) in Wales, UK, increased steadily, with stark inequalities. We aimed to assess how deprivation and maternal and child perinatal characteristics influence the risk of becoming CLA in Wales.

STUDY DESIGN

We constructed a prospective longitudinal cohort of children born in Wales between April 2006 and March 2021 (n = 395,610) using linked administrative records.

METHODS

Survival models examined the risk of CLA from birth by small-area deprivation and maternal and child perinatal characteristics. Population attributable fractions quantify the potential impact of action on modifiable risk factors.

RESULTS

Children from the most deprived fifth of the population were 3.4 times more likely to enter care than those in the least deprived (demographic adjusted hazard ratios [aHRs] 3.40, 95% confidence interval [CI] 3.08, 3.74). Maternal mental health problems in pregnancy (fully aHR, 2.03, 95% CI 1.88, 2.19) and behavioural factors, such as smoking (aHR 2.46, 95% CI 2.34-2.60), alcohol problems (aHR 2.35, 95% CI 1.70-3.23) and substance use in pregnancy (aHR 5.72, 95% CI 5.03-6.51), as well as child congenital anomalies (aHR 1.46, 95% CI 1.16-1.84), low birth weight (aHR 1.28, 95% CI 1.17, 1.39) and preterm birth (aHR 1.16, 95% CI 1.06, 1.26), were associated with higher risk of CLA status. The risk of CLA in the population may be reduced by 35% (95% CI 0.33, 0.38) if children in the two most deprived fifths of the population experienced the conditions of those in the least deprived.

CONCLUSIONS

Deprivation and perinatal maternal health are important modifiable risk factors for children becoming CLA. Our analysis provides insight into the mechanisms of intergenerational transfer of disadvantage in a vulnerable section of the child population and identifies targets for public health action.

Collagen Type IV Alpha 5 Chain in Bronchiolitis Obliterans Syndrome After Lung Transplant: The First Evidence

INTRODUCTION

Bronchiolitis obliterans syndrome (BOS) is the most common form of CLAD and is characterized by airflow limitation and an obstructive spirometry pattern without parenchymal opacities. The protein signature of BOS lesions concerns extracellular matrix organization and aberrant basement membrane composition. In this pilot study, we investigated the presence of COL4A5 in the serum of patients with BOS.

METHODS

41 patients who had undergone LTX were enrolled. Of these, 27 developed BOS and 14 (control group) were considered stable at the time of serum sampling. Of BOS patients, serum samples were analysed at the time of BOS diagnosis and before the clinical diagnosis (pre-BOS). COL4A5 levels were detected through the ELISA kit.

RESULTS

Serum concentrations of COL4A5 were higher in pre-BOS than in stable patients (40.5 ± 13.9 and 24.8 ± 11.4, respectively, p = 0.048). This protein is not influenced by comorbidities, such as acute rejection or infections, or by therapies. Survival analysis also reveals that a higher level of COL4A5 was also associated with less probability of survival. Our data showed a correlation between concentrations of COL4A5 and FEV1 at the time of diagnosis of BOS.

CONCLUSION

Serum concentrations of COL4A5 can be considered a good prognostic marker due to their association with survival and correlation with functional parameters.

Radiographers' perspectives on clinical supervision of students in Ireland

INTRODUCTION

Optimising clinical education in radiography is crucial to ensure competent graduates provide safe and effective patient care. Radiographers play a vital role in student supervision undertaken in the complex clinical environment. A greater understanding of factors influencing their ability to undertake this role effectively is needed. The study aimed to explore radiographers' attitudes and perceptions of confidence in undertaking clinical supervision and perceived barriers in a 'real-life' clinical department.

METHODS

The lens of Bandura's social-cognitive theory was utilised to assist the exploration of the desired constructs. An anonymous online survey was developed and circulated among qualified radiographers in Ireland. Descriptive (frequencies and percentages) and inferential statistical testing was undertaken. Thematic analysis was conducted on optional free-text comments.

RESULTS

217 responses were received. Although most radiographers reported a positive attitude (73.3%), a significant minority reported not being confident across survey items related to the tasks required (ranging from 20.7%-29.1%). Time pressures from clinical workload, perceived lack of organisational support, and lack of guidance on expectations were highlighted challenges.

CONCLUSION

The survey has enabled first-hand identification of some challenges radiographers encounter in undertaking students' clinical supervision. Radiographers must be supported to optimise the clinical learning environment where both students and educators are valued.

IMPLICATIONS FOR PRACTICE

The findings highlight impact on educational support, practice, policy and future research. Effective clinical supervision is dependent on collaborative engagement and support being evident at all levels, including the clinical department, academic and healthcare institutions, and national organisations.

The influence of anastomotic techniques on postoperative anastomotic complications: Results of the Oesophago-Gastric Anastomosis Audit

BACKGROUND

The optimal anastomotic techniques in esophagectomy to minimize rates of anastomotic leakage and conduit necrosis are not known. The aim of this study was to assess whether the anastomotic technique was associated with anastomotic failure after esophagectomy in the international Oesophago-Gastric Anastomosis Audit cohort.

METHODS

This prospective observational multicenter cohort study included patients undergoing esophagectomy for esophageal cancer over 9 months during 2018. The primary exposure was the anastomotic technique, classified as handsewn, linear stapled, or circular stapled. The primary outcome was anastomotic failure, namely a composite of anastomotic leakage and conduit necrosis, as defined by the Esophageal Complications Consensus Group. Multivariable logistic regression modeling was used to identify the association between anastomotic techniques and anastomotic failure, after adjustment for confounders.

RESULTS

Of the 2238 esophagectomies, the anastomosis was handsewn in 27.1%, linear stapled in 21.0%, and circular stapled in 51.9%. Anastomotic techniques differed significantly by the anastomosis sites (P < .001), with the majority of neck anastomoses being handsewn (69.9%), whereas most chest anastomoses were stapled (66.3% circular stapled and 19.3% linear stapled). Rates of anastomotic failure differed significantly among the anastomotic techniques (P < .001), from 19.3% in handsewn anastomoses, to 14.0% in linear stapled anastomoses, and 12.1% in circular stapled anastomoses. This effect remained significant after adjustment for confounding factors on multivariable analysis, with an odds ratio of 0.63 (95% CI, 0.46-0.86; P = .004) for circular stapled versus handsewn anastomosis. However, subgroup analysis by anastomosis site suggested that this effect was predominantly present in neck anastomoses, with anastomotic failure rates of 23.2% versus 14.6% versus 5.9% for handsewn versus linear stapled anastomoses versus circular stapled neck anastomoses, compared with 13.7% versus 13.8% versus 12.2% for chest anastomoses.

CONCLUSIONS

Handsewn anastomoses appear to be independently associated with higher rates of anastomotic failure compared with stapled anastomoses. However, this effect seems to be largely confined to neck anastomoses, with minimal differences between techniques observed for chest anastomoses. Further research into standardization of anastomotic approach and techniques may further improve outcomes.

Understanding Racial Attitudes Among Students and Teachers in a Ethnically/Racially Diverse High School

This study examined the role of racial attitudes in a diverse high school setting. Teachers and students were recruited from a public charter high school in Albuquerque, New Mexico. The final sample consisted of 19 students and 10 teachers who participated in face-to-face interviews regarding racial attitudes and racial bias in the academic setting. Three themes emerged among the teacher interviews: rejecting racial inequalities, contradicting thoughts and color-blind explanations, and racially conscious explanations. For the student interviews, two themes emerged: color-blind racial attitudes and witnessing/experiencing bias. These findings yield evidence that color-blind racial attitudes are prevalent in diverse schools among students and teachers, presenting a challenge to intervention efforts in schools aimed at promoting racial justice.

POS1218 RELAPSES OF IDIOPATHIC INFLAMMATORY MYOPATHIES AFTER VACCINATION AGAINST COVID19: A REAL-LIFE ITALIAN STUDY

Background

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination plays a crucial role as pivotal strategies to curb the coronavirus disease-19 (COVID-19) pandemic. Despite the mass-scale vaccination, literature data about the incidence of disease flares in IIM patients are still not reported as well as the immunological condition.

Objectives

The present study aimed to describe the clinical status of patients affected by IIM after vaccination against COVID19 in order to assess the number of relapses or immune-mediated reactions in a cohort of Italian patients with such disease.

Methods

We included all patients affected by IIM and followed by Myositis Clinic, Rheumatology and Respiratory Diseases Units, Siena University Hospital, Bari University Hospital, Policlinico Umberto I, Sapienza University, Rome, and Policlinico Paolo Giaccone, Palermo. Inclusion criteria were a recent (<3 months) clinical and serological assessment before the survey and a definite diagnosis of dermatomyositis, polymyositis and anti-synthetase syndrome. All patients underwent a telephone survey in order to establish their clinical status and potential relapses after vaccination.

Results

A total of 119 IIM patients (median, IQR 58 (47-66) years; 32 males) were consecutively enrolled. Fifty had a diagnosis of DM, 39 had PM and 30 had ASS. The median months of disease duration was 79.62±83.98. According to number of organs involvement, forty-two had only one, 45 had two organs involvement, 20 had three, 11 had four and one had five. The majority of them received two doses of COVID-19 vaccine, except four patients who refused the vaccination: 94 (78.9%) Cominarty, 16 (13.4%) Moderna, 5 (0.04%) AZ. Seven (0.06%) patients had flare after vaccination, the majority of them were mild except one major with three organs involved and one life-threatening with systemic involvement. In order to understand or predict the effect of demographic and clinical features on the flare development after vaccination, a logistic regression analysis was performed. The goodness-of-fit statistics showed a Chi2 associated with the Log ratio (L.R.) of 0.045. From the probability associated with the Chi-square tests, the Type II analysis showed the variable that most influences the development of flare was the number of organs involved (p=0.047).

Sixty-eight patients received the third dose of COVID-19 vaccination: 51 (75%) Cominarty and 17 (25%) Moderna. Only one (0.01%) patient (the same who had life-threatening flare with systemic involvement after two doses) had flare after third dose and eventually died.

Conclusion

Vaccines against SARS-CoV2 have provided, both in registratory studies and in preliminary real-life evidence, an overall good efficacy and safety. Nevertheless, only scanty data are available for rheumatic patients in general and the ones affected by IIM in particular. To the best of our knowledge, ours represent the largest cohort of IIM patients in which immunogenicity of anti-SARS-CoV2 vaccine was assessed. In line with real-life data from other diseases, we found a non-statistically significant risk of relapse in our patients, which occurred seldom, usually mild and in patients with a more severe and aggressive course of disease.

ParametersFlare after two doses (n=7)No-flare after two doses (n=108)P valueAge (years)55 (51-68)59 (47-67)NSGender (M/F)2/530/82NSDiagnosis (DM/PM/ASS)2/2/348/36/28NSAntibodiesJo1225PL7-3PL12-1Ku-2Mi217PM/Scl15Ro5217TIG1g-5MDA5-6SRP-1SAE-2cN1a--NPX-1SSA-12Ds-DNA-1ANA (only positivity)-3negative227Length of disease (months)50 (19-200)60 (24-108)NSNumber of organs involved:One0360.0004Two243Three319Four110Five10Type of vaccination:Cominarty688NSModerna115AZ05Disease activity (PhGA≥2/PhGA<2)3/427/81NSMDI3 (1-6.5)2 (1-4)NSCRP (mg/dL)0.1 (0.01-0.3)0.99 (0.3-2.9)0.0041ESR32 (14-39)15.5 (8-27.5)NSCPK111 (63-905)97.5 (63-158)NSTreatment at time of vaccination: GCs010NS Immunosuppressive319 Biologic12 Combination365 no-treatment-12

Disclosure of Interests

None declared

099 High relapse rate with steroid monotherapy in non-systemic vasculitic neuropathy

Introduction

Historically, single tissue vasculitis has been managed with steroid monotherapy. Recent data from large longitudinal databases on systemic vasculitis suggest Non-Systemic Vasculitic Neuropathy (NSVN) has higher rates of relapse, recommending that more aggressive immunotherapy is employed.

Aim

To investigate the relapse rate in NSVN in response to steroid monotherapy.

Methods

A retrospective case note review of clinically and/or pathologically defined cases of (Systemic Vasculitic Neuropathy) SVN and NSVN in two London specialist peripheral nerve centres, between 2005

- 2012 and 2015 - 2019.

Results

32 cases of SVN and 34 cases of NSVN were identified. In each group 14 individuals were treated first-line with steroid monotherapy, and 8 with cyclophosphamide. 8 SVN and 9 NSVN cases received steroids plus azathioprine. 15/32 SVN and 13/34 NSVN relapsed after first-line therapy (10/14 and 9/14 on steroid monotherapy, 3/8 and 3/9 on steroids and azathioprine, 2/8 and 1/8 on cyclophosphamide). 10 individuals stabilised with the addition of azathioprine, 13 with cyclophosphamide and 4 with Rituximab.

Conclusion

This representative case series suggests that steroid monotherapy is inadequate in the treatment of NSVN and supports an approach akin to that recommended in SVN, even if nerve is the only tissue clinically involved.

e.bunting@nhs.net

Determinants of exclusive breastfeeding for wāhine Māori

AIM

Breastfeeding is a fundamental aspect of tikanga Māori (Māori cultural traditions/practices) requiring protection and promotion. This study identifies determinants of exclusive breastfeeding in wāhine Māori.

METHODS

Wāhine Māori enrolled in the Growing Up in New Zealand child cohort study participated (n=1060). Exclusive breastfeeding duration was self-reported. Hierarchical regression analyses were framed by a model of Māori health and wellbeing.

RESULTS

Most wāhine Māori initiated breastfeeding (96%), with 12% exclusively breastfeeding for six or more months. Wāhine Māori had increased odds of exclusively breastfeeding for six or more months if they: thought it best to breastfeed for >6 months (adjusted odds ratio (aOR)=1.94, 95% confidence interval (CI)=1.05-3.78); thought returning to work would not (aOR=2.17, 95% CI=1.17-4.24) or may (aOR=4.25, 95% CI=1.86-9.85) limit breastfeeding; were experienced mothers (aOR=2.55, 95% CI=1.35-5.06); or were undecided about vaccination (aOR=3.16, 95% CI=1.55-6.39). Exclusive breastfeeding for six or more months was less likely if mothers experienced depression during pregnancy (aOR=0.47, 95% CI=0.20-0.99) or viewed cultural traditions/practices as "fairly important" (aOR=0.53, 95% CI=0.27-0.99), compared to "very important".

CONCLUSION

Determinants of exclusive breastfeeding in wāhine Māori are knowledge of breastfeeding recommendations, return to work, motherhood experience, connection to Te Ao Māori (Māori worldview) and tikanga Māori, antenatal depression and vaccine indecision. Interventions delivered within a Kaupapa Māori framework will best address breastfeeding inequities in Aotearoa New Zealand.

Textbook outcome following oesophagectomy for cancer: international cohort study

Background

Textbook outcome has been proposed as a tool for the assessment of oncological surgical care. However, an international assessment in patients undergoing oesophagectomy for oesophageal cancer has not been reported. This study aimed to assess textbook outcome in an international setting.

Methods

Patients undergoing curative resection for oesophageal cancer were identified from the international Oesophagogastric Anastomosis Audit (OGAA) from April 2018 to December 2018. Textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least 15 lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. A multivariable binary logistic regression model was used to identify factors independently associated with textbook outcome, and results are presented as odds ratio (OR) and 95 per cent confidence intervals (95 per cent c.i.).

Results

Of 2159 patients with oesophageal cancer, 39.7 per cent achieved a textbook outcome. The outcome parameter ‘no major postoperative complication’ had the greatest negative impact on a textbook outcome for patients with oesophageal cancer, compared to other textbook outcome parameters. Multivariable analysis identified male gender and increasing Charlson comorbidity index with a significantly lower likelihood of textbook outcome. Presence of 24-hour on-call rota for oesophageal surgeons (OR 2.05, 95 per cent c.i. 1.30 to 3.22; P = 0.002) and radiology (OR 1.54, 95 per cent c.i. 1.05 to 2.24; P = 0.027), total minimally invasive oesophagectomies (OR 1.63, 95 per cent c.i. 1.27 to 2.08; P &lt; 0.001), and chest anastomosis above azygous (OR 2.17, 95 per cent c.i. 1.58 to 2.98; P &lt; 0.001) were independently associated with a significantly increased likelihood of textbook outcome.

Conclusion

Textbook outcome is achieved in less than 40 per cent of patients having oesophagectomy for cancer. Improvements in centralization, hospital resources, access to minimal access surgery, and adoption of newer techniques for improving lymph node yield could improve textbook outcome.

Textbook outcome following oesophagectomy for cancer: international cohort study

BACKGROUND

Textbook outcome has been proposed as a tool for the assessment of oncological surgical care. However, an international assessment in patients undergoing oesophagectomy for oesophageal cancer has not been reported. This study aimed to assess textbook outcome in an international setting.

METHODS

Patients undergoing curative resection for oesophageal cancer were identified from the international Oesophagogastric Anastomosis Audit (OGAA) from April 2018 to December 2018. Textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least 15 lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. A multivariable binary logistic regression model was used to identify factors independently associated with textbook outcome, and results are presented as odds ratio (OR) and 95 per cent confidence intervals (95 per cent c.i.).

RESULTS

Of 2159 patients with oesophageal cancer, 39.7 per cent achieved a textbook outcome. The outcome parameter 'no major postoperative complication' had the greatest negative impact on a textbook outcome for patients with oesophageal cancer, compared to other textbook outcome parameters. Multivariable analysis identified male gender and increasing Charlson comorbidity index with a significantly lower likelihood of textbook outcome. Presence of 24-hour on-call rota for oesophageal surgeons (OR 2.05, 95 per cent c.i. 1.30 to 3.22; P = 0.002) and radiology (OR 1.54, 95 per cent c.i. 1.05 to 2.24; P = 0.027), total minimally invasive oesophagectomies (OR 1.63, 95 per cent c.i. 1.27 to 2.08; P < 0.001), and chest anastomosis above azygous (OR 2.17, 95 per cent c.i. 1.58 to 2.98; P < 0.001) were independently associated with a significantly increased likelihood of textbook outcome.

CONCLUSION

Textbook outcome is achieved in less than 40 per cent of patients having oesophagectomy for cancer. Improvements in centralization, hospital resources, access to minimal access surgery, and adoption of newer techniques for improving lymph node yield could improve textbook outcome.

The impact of islet mass, number of transplants, and time between transplants on graft function in a national islet transplant program

The UK islet allotransplant program is nationally funded to deliver one or two transplants over 12 months to individuals with type 1 diabetes and recurrent severe hypoglycemia. Analyses were undertaken 10 years after program inception to evaluate associations between transplanted mass; single versus two transplants; time between two transplants and graft survival (stimulated C-peptide >50 pmol/L) and function. In total, 84 islet transplant recipients were studied. Uninterrupted graft survival over 12 months was attained in 23 (68%) single and 47 (94%) (p = .002) two transplant recipients (separated by [median (IQR)] 6 (3-8) months). 64% recipients of one or two transplants with uninterrupted function at 12 months sustained graft function at 6 years. Total transplanted mass was associated with Mixed Meal Tolerance Test stimulated C-peptide at 12 months (p < .01). Despite 1.9-fold greater transplanted mass in recipients of two versus one islet infusion (12 218 [9291-15 417] vs. 6442 [5156-7639] IEQ/kg; p < .0001), stimulated C-peptide was not significantly higher. Shorter time between transplants was associated with greater insulin dose reduction at 12 months (beta -0.35; p = .02). Graft survival over the first 12 months was greater in recipients of two versus one islet transplant in the UK program, although function at 1 and 6 years was comparable. Minimizing the interval between 2 islet infusions may maximize cumulative impact on graft function.

Postoperative outcomes in oesophagectomy with trainee involvement

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Incidence and risk factors for respiratory tract bacterial colonization and infection in lung transplant recipients

To evaluate incidence of and risk factors for respiratory bacterial colonization and infections within 30 days from lung transplantation (LT). We retrospectively analyzed microbiological and clinical data from 94 patients transplanted for indications other than cystic fibrosis, focusing on the occurrence of bacterial respiratory colonization or infection during 1 month of follow-up after LT. Thirty-three percent of patients developed lower respiratory bacterial colonization. Bilateral LT and chronic heart diseases were independently associated to a higher risk of overall bacterial colonization. Peptic diseases conferred a higher risk of multi-drug resistant (MDR) colonization, while longer duration of aerosol prophylaxis was associated with a lower risk. Overall, 35% of lung recipients developed bacterial pneumonia. COPD (when compared to idiopathic pulmonary fibrosis, IPF) and higher BMI were associated to a lower risk of bacterial infection. A higher risk of MDR infection was observed in IPF and in patients with pre-transplant colonization and infections. The risk of post-LT respiratory infections could be stratified by considering several factors (indication for LT, type of LT, presence of certain comorbidities, and microbiologic assessment before LT). A wider use of early nebulized therapies could be useful to prevent MDR colonization, thus potentially lowering infectious risk.

Mortality from esophagectomy for esophageal cancer across low, middle, and high-income countries: An international cohort study

BACKGROUND

No evidence currently exists characterising global outcomes following major cancer surgery, including esophageal cancer. Therefore, this study aimed to characterise impact of high income countries (HIC) versus low and middle income countries (LMIC) on the outcomes following esophagectomy for esophageal cancer.

METHOD

This international multi-center prospective study across 137 hospitals in 41 countries included patients who underwent an esophagectomy for esophageal cancer, with 90-day follow-up. The main explanatory variable was country income, defined according to the World Bank Data classification. The primary outcome was 90-day postoperative mortality, and secondary outcomes were composite leaks (anastomotic leak or conduit necrosis) and major complications (Clavien-Dindo Grade III - V). Multivariable generalized estimating equation models were used to produce adjusted odds ratios (ORs) and 95% confidence intervals (CI95%).

RESULTS

Between April 2018 to December 2018, 2247 patients were included. Patients from HIC were more significantly older, with higher ASA grade, and more advanced tumors. Patients from LMIC had almost three-fold increase in 90-day mortality, compared to HIC (9.4% vs 3.7%, p < 0.001). On adjusted analysis, LMIC were independently associated with higher 90-day mortality (OR: 2.31, CI95%: 1.17-4.55, p = 0.015). However, LMIC were not independently associated with higher rates of anastomotic leaks (OR: 1.06, CI95%: 0.57-1.99, p = 0.9) or major complications (OR: 0.85, CI95%: 0.54-1.32, p = 0.5), compared to HIC.

CONCLUSION

Resections in LMIC were independently associated with higher 90-day postoperative mortality, likely reflecting a failure to rescue of these patients following esophagectomy, despite similar composite anastomotic leaks and major complication rates to HIC. These findings warrant further research, to identify potential issues and solutions to improve global outcomes following esophagectomy for cancer.

Comparison of short-term outcomes from the International Oesophago-Gastric Anastomosis Audit (OGAA), the Esophagectomy Complications Consensus Group (ECCG), and the Dutch Upper Gastrointestinal Cancer Audit (DUCA)

BACKGROUND

The Esophagectomy Complications Consensus Group (ECCG) and the Dutch Upper Gastrointestinal Cancer Audit (DUCA) have set standards in reporting outcomes after oesophagectomy. Reporting outcomes from selected high-volume centres or centralized national cancer programmes may not, however, be reflective of the true global prevalence of complications. This study aimed to compare complication rates after oesophagectomy from these existing sources with those of an unselected international cohort from the Oesophago-Gastric Anastomosis Audit (OGAA).

METHODS

The OGAA was a prospective multicentre cohort study coordinated by the West Midlands Research Collaborative, and included patients undergoing oesophagectomy for oesophageal cancer between April and December 2018, with 90 days of follow-up.

RESULTS

The OGAA study included 2247 oesophagectomies across 137 hospitals in 41 countries. Comparisons with the ECCG and DUCA found differences in baseline demographics between the three cohorts, including age, ASA grade, and rates of chronic pulmonary disease. The OGAA had the lowest rates of neoadjuvant treatment (OGAA 75.1 per cent, ECCG 78.9 per cent, DUCA 93.5 per cent; P < 0.001). DUCA exhibited the highest rates of minimally invasive surgery (OGAA 57.2 per cent, ECCG 47.9 per cent, DUCA 85.8 per cent; P < 0.001). Overall complication rates were similar in the three cohorts (OGAA 63.6 per cent, ECCG 59.0 per cent, DUCA 62.2 per cent), with no statistically significant difference in Clavien-Dindo grades (P = 0.752). However, a significant difference in 30-day mortality was observed, with DUCA reporting the lowest rate (OGAA 3.2 per cent, ECCG 2.4 per cent, DUCA 1.7 per cent; P = 0.013).

CONCLUSION

Despite differences in rates of co-morbidities, oncological treatment strategies, and access to minimal-access surgery, overall complication rates were similar in the three cohorts.

Medicine, media and the law: The effect on training in obstetrics and gynaecology

The inextricable link between medicine and the legal profession has flourished in the 21st century, with countless newspaper articles and social media content on medical cases visible at every juncture. This is particularly true in the speciality of obstetrics and gynaecology, with one of the highest rates of litigation of all medical specialities. We aimed to evaluate the influence of media and the legal environment on the career of trainees in obstetrics and gynaecology. Under the auspices of the Irish national training body, we distributed a 26-item questionnaire to doctors-in-training (DIT) working in obstetrics and gynaecology in the Republic of Ireland. Descriptive statistics and Chi-squared analyses were performed on the anonymised data. 151 DIT responded to the questionnaire, with a response rate of 86.2 % (sample size = 175). The majority were female (79.9 %, n = 121), Irish (85.5 %, n = 106) and had no children (67.0 %, n = 83). 86.7 % (n = 131) felt that the media did not have a positive impact on patients receiving care, and, further, unfairly represented the speciality (94.1 %; n = 142). Additionally, DIT felt that medico-legal issues had a negative impact on issues such as retention and recruitment. These two areas were implicated in over three quarters of DIT considering leaving the speciality. This study demonstrates that DIT perceive media scrutiny and litigation to have a negative effect on the speciality of obstetrics and gynaecology. Further support integrated into specialist training, is needed to ensure that trainees are adequately equipped to deal with both mainstream and social media as well as interactions they may have with the legal profession as they progress through their career.

Genetic susceptibility, elevated blood pressure and risk of atrial fibrillation

Background

Whether elevated blood pressure (BP) is a modifiable risk factor for atrial fibrillation (AF) is not established.

Purpose

We tested (1) whether the association between BP and risk of AF is causal, (2) whether it varies according to individual's genetic susceptibility for AF, and (3) the extent to which specific BP-lowering drugs are expected to reduce this risk.

Methods

First, causality of association was assessed through two-sample Mendelian Randomization (MR), using data from two independent genome-wide association studies that included a total of one million European population. Second, UK Biobank individual participant data of 329,237 participants at baseline was used to study the effect of BP on AF according to genetic susceptibility of developing AF. Third, a possible treatment effect with BP-lowering drug classes on AF risk was predicted through genetic variants in druggable genes that code proteins related to the function of each drug class. Estimated drug effects were compared with effects on incident coronary heart disease, for which direct trial evidence exists.

Results

The two-sample MR analysis indicated that on average each 10-mm Hg increment in systolic BP increased the risk of AF (odds ratio [OR]: 1.23 [1.11 to 1.36]). This association was replicated in the UK biobank using individual participant data. However, in a further genetic risk-stratified analysis, there was evidence for a linear gradient in the relative effects of systolic BP on AF; while there was no conclusive evidence of an effect in those with low genetic risk, a strong effect was observed among those with high genetic susceptibility for AF (Figure). The indirect comparison of predicted treatment effects using genetic proxies for three main drug classes (angiotensin-converting enzyme inhibitors, beta-blockers and calcium channel blockers) suggested similar average effects for prevention of atrial fibrillation and coronary heart disease.

Conclusions

The association between elevated BP and higher risk of AF is likely to be causal, suggesting that BP-lowering treatment may be effective in AF prevention. However, average effects masked clinically important variations, with a more pronounced effect in individuals with high genetic susceptibility.

Figure 1

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): British Heart Foundation

0900 Obstructive Sleep Apnea Severity, Symptoms Of Attention Deficit Hyperactivity Disorder And Other Comorbid Psychiatric Disorders In Children And Adolescents: A Retrospective Data Analysis

Introduction

Children and adolescents with obstructive sleep apnea (OSA) are often diagnosed with attention deficit hyperactivity disorder (ADHD). However, the connection between the severity of Apnea/Hypopnea Index (AHI) and ADHD is controversial with research evidence pointing in opposing directions.

Methods

A retrospective study was conducted in a pediatric sleep center at a university hospital setting to investigate the effect between AHI severity, ADHD and/or other comorbid psychiatric disorders. One hundred and thirty-eight participants between the age of 6 and 18 were examined in terms of AHI severity level and their correlation with scores from the Child Behavior Checklist (CBCL) using SPSS program.

Results

A negative correlation between AHI scores and Attention Problems for the entire group of participants was found. Additionally, female adolescents had positive correlations between AHI scores and several affective disorder variables from the CBCL, while male adolescents had negative correlations between AHI levels and several CBCL scores that are typically associated with ADHD and Anxiety disorders.

Conclusion

This study suggests a relationship between OSA severity and psychiatric conditions. However, this relationship can vary depending on age, gender and AHI severity. More research is required to understand this relationship.

Support

Chervin, R.D. How many children with ADHD have sleep apnea or periodic leg movements on polysomnography? Sleep. 2005: 28(9): 1041-1042.

Sedky K, Bennett DS, Carvalho KS. Attention deficit hyperactivity disorder and sleep disordered breathing in pediatric populations: A meta-analysis. Sleep Medicine Reviews. 2014; 18: 349-356

β-Cell and renal transplantation options for diabetes

Despite major advances in structured education, insulin delivery and glucose monitoring, diabetes self-management remains an unremitting challenge. Insulin therapy is inextricably linked to risk of dangerous hypoglycaemia and sustained hyperglycaemia remains a leading cause of renal failure. This review sets out to demystify transplantation for diabetes multidisciplinary teams, facilitating consideration and incorporation within holistic overall person-centred management. Deceased and living donor kidney, whole pancreas and isolated islet transplant procedures, indications and potential benefits are described, in addition to outcomes within the integrated UK transplant programme.

Parenthood and risk of hip fracture: a 10-year follow-up prospective study of middle-aged women and men in China

This prospective study of Chinese adults demonstrated an inverse J-shaped association of number of children with risk of hip fracture in both men and postmenopausal women aged 50 years or older. Women with 2 or 3 children and men with 4 children had the lowest risk of hip fracture.

INTRODUCTION

Women have higher absolute risks of fracture than men, which is believed to reflect differences in oestrogen exposure. The aim of this study was to compare the associations of number of children with risk of hip fracture between men and women aged over 50 years.

METHODS

The China Kadoorie Biobank (CKB) recruited 133,399 women and 110,296 men, aged 50 years or older between 2004 and 2008. During 10-year follow-up, 2068 participants (1394 women and 674 men) suffered a hip fracture. Cox regression analysis was used to estimate sex-specific adjusted hazard ratios (HRs) and 95% CI for incident hip fracture.

RESULTS

Over 98% of both subsets of men and women aged 50 or older reported having children. Women who had 2 or 3 children had the lowest risks of hip fracture compared with other groups. Compared with nulliparous women, the adjusted HR for hip fracture were 0.89 (95% CI; 0.72, 1.10) for 1 child, 0.79 (0.70, 0.90) for 2 children, 0.79 (0.72, 0.87) for 3 children, 0.81 (0.72, 0.91) for 4 children, and 0.95 (0.83, 1.10) for those with 5 or more children. The associations of number of children with hip fracture were broadly consistent in men of a similar age.

CONCLUSIONS

The concordant effects of the number of children with risk of hip fracture between men and women suggest that the lower risks in multiparous women are not due to differences in oestrogen exposure or other biological effects, but may reflect residual confounding by socioeconomic or lifestyle factors.

Publisher Correction: Parenthood and risk of hip fracture: a 10-year follow-up prospective study of middle-aged women and men in China

The original version of this article, published on 25 November 2019, unfortunately contained a mistake.

Characterization of pre-transplant psychosocial burden in an integrated national islet transplant program

The psychological burden experienced by people with diabetes prior to islet transplantation is recognized but has not been studied comprehensively, especially in relation to glycemia. Therefore, we conducted a rigorous pre-operative psychosocial profile of UK islet transplant recipients, and compared groups with higher/lower HbA1 c to test the null hypothesis that pre-transplant hypoglycemia awareness and psychosocial burden would not be related to baseline HbA1 c in this high-risk cohort. Pre-transplant, recipients (n = 44) completed validated hypoglycemia awareness questionnaires and generic/diabetes-specific measures of psychological traits and states. Scores were compared in groups, dichotomized by HbA1 c (≤8% versus >8%). Participants were aged (mean±SD) 53 ± 10 years; 64% were women; with HbA1 c 8.3 ± 1.7%. Median rate of severe hypoglycemia over the preceding 12 months was 13 events/person-year and 90% had impaired awareness of hypoglycemia (Gold/Clarke score ≥4). Participants had elevated fear of hypoglycemia (HFS-II Worry), impaired diabetes-specific quality of life (DQoL) and low generic health status (SF-36; EQ-5D). One quarter reported scores indicating likely anxiety/depression (HAD). Dispositional optimism (LOT-R) and generalized self-efficacy (GSE) were within published 'norms.' Despite negative perceptions of diabetes (including low personal control), participants were confident that islet transplantation would help (BIPQ). Hypoglycemia awareness and psychosocial profile were comparable in lower (n = 24) and higher (n = 20) HbA1 c groups. Islet transplant candidates report sub-optimal generic psychological states (anxiety/depressive symptoms), health status and diabetes-specific psychological states (fear of hypoglycemia, diabetes-specific quality of life). While their generic psychological traits (optimism, self-efficacy) are comparable with the general population, they are highly optimistic about forthcoming transplant. HbA1 c is not a proxy measure of psychosocial burden, which requires the use of validated questionnaires to systematically identify those who may benefit most from psychological assessment and support.

Classification of Trauma-Associated Invasive Fungal Infections to Support Wound Treatment Decisions

The proposed classification, based on diagnostic certainty, provides a framework for determining initial empiric and subsequent targeted therapy.

To evaluate a classification system to support clinical decisions for treatment of contaminated deep wounds at risk for an invasive fungal infection (IFI), we studied 246 US service members (413 wounds) injured in Afghanistan (2009–2014) who had laboratory evidence of fungal infection. A total of 143 wounds with persistent necrosis and laboratory evidence were classified as IFI; 120 wounds not meeting IFI criteria were classified as high suspicion (patients had localized infection signs/symptoms and had received antifungal medication for >10 days), and 150 were classified as low suspicion (failed to meet these criteria). IFI patients received more blood than other patients and had more severe injuries than patients in the low-suspicion group. Fungi of the order Mucorales were more frequently isolated from IFI (39%) and high-suspicion (21%) wounds than from low-suspicion (9%) wounds. Wounds that did not require immediate antifungal therapy lacked necrosis and localized signs/symptoms of infection and contained fungi from orders other than Mucorales.

P6231Iron status and risk of cardio-metabolic diseases in European adults: a Mendelian randomization study

Background

Observational studies have reported conflicting results about the associations of iron status with risk of cardio-metabolic diseases but such studies are constrained by confounding and reverse causality.

Purpose

To assess the causal relevance of iron status biomarkers (transferrin, serum iron, and ferritin) for risk of coronary artery diseases (CAD), ischaemic stroke (IS), and type 2 diabetes (T2D), using Mendelian randomization (MR).

Methods

Effect size estimates for genetic variants associated with iron status biomarkers were obtained from the Genetics of Iron Status consortium (transferrin saturation, serum iron, and ferritin: n=48,972). The corresponding effects of these variants on the risk of CAD, IS and T2D were obtained from a meta-analysis of unrelated participants of European ancestry in the UK Biobank (UKB), together with previously recruited participants in CARDIOGRAMplusC4D (total n=90,377 CAD cases), MEGASTROKE (total n=43,381 IS cases) and DIAGRAM (total n=74,124 T2D cases), respectively. The main analysis used a two-sample inverse-variance weighted MR, while the sensitivity analyses used weighted-median, weighted-mode, MR-PRESSO, and MR-Egger approaches.

Results

MR analysis demonstrated significant inverse association of each of the three genetically-instrumented iron status biomarker with risk of CAD (transferrin saturation OR=0.96 [95% CI: 0.92–0.99], p=0.02; serum iron OR=0.93 [0.89–0.97], p=0.001; and ferritin OR=0.86 (0.79–0.94), p=0.001, per 1 SD higher level). In contrast, these iron status biomarkers showed positive associations with risk of T2D (transferrin saturation OR=1.06 [1.01–1.11], p=0.01; serum iron OR=1.06 [0.99–1.13], p=0.07; and ferritin OR=1.12 [0.99–1.26], p=0.06, per 1 SD higher level). There was positive, but non-significant, association of IS with each of the iron status biomarker analysed. Sensitivity analyses using several different MR approaches yielded concordant results.

Conclusions

Among European adults, iron status appeared to have causal associations, but in opposite directions, with the risk of CHD and T2D. Our findings highlight the need for caution about strategies for advocating iron supplementation in individuals with normal haemoglobin levels for prevention of CAD.

Acknowledgement/Funding

British Heart Found, Medical Research Council, Wellcome Trust, NIHR Biomedical Research Centre, Oxford

Improving Patient Flow: Analysis of an Initiative to Improve Early Discharge

BACKGROUND

Discharge delays adversely affect hospital bed availability and thus patient flow.

OBJECTIVE

We aimed to increase the percentage of early discharges (EDCs; before 11 am). We hypothesized that obtaining at least 25% EDCs would decrease emergency department (ED) and postanesthesia care unit (PACU) hospital bed wait times.

DESIGN

This study used a pre/postintervention retrospective analysis.

SETTING

All acute care units in a quaternary care academic children's hospital were included in this study.

PATIENTS

The patient sample included all discharges from the acute care units and all hospital admissions from the ED and PACU from January 1, 2014, to December 31, 2016.

INTERVENTION

A multidisciplinary team identified EDC barriers, including poor identification of EDC candidates, accountability issues, and lack of team incentives. A total of three successive interventions were implemented using Plan-Do-Check-Act (PDCA) cycles over 10 months between 2015 and 2016 addressing these barriers. Interventions included EDC identification and communication, early rounding on EDCs, and modest incentives.

MEASUREMENTS

Calendar month EDC percentage, ED (from time bed requested to the time patient left ED) and PACU (from time patient ready to leave to time patient left PACU) wait times were measured.

RESULTS

EDCs increased from an average 8.8% before the start of interventions (May 2015) to 15.8% after interventions (February 2016). Using an interrupted time series, both the jump and the slope increase were significant (3.9%, P = .02 and 0.48%, P < .01, respectively). Wait times decreased from a median of 221 to 133 minutes (P < .001) for ED and from 56 to 36 minutes per patient (P = .002) for PACU.

CONCLUSION

A multimodal intervention was associated with more EDCs and decreased PACU and ED bed wait times.

2053. Tissue-Based Molecular Diagnostics: A Sensitive and Specific Way for the Identification of Invasive Fungal Infections in the Combat-Related Setting

Background

Combat-associated invasive fungal infections (IFI) of the deep skin and soft tissue are an infectious disease. Reliance on conventional techniques to diagnose IFIs has limitations as culture is insensitive and time-delayed and histopathology cannot provide a species-level or even a genus-level identification (ID). Molecular-based methods are rapid, provide species-level ID, and have been studied to a limited extent in the trauma setting although they may prove overly sensitive as soil (thereby fungal) contamination is common. In this study, we examined the performance characteristics of a panfungal PCR for the diagnosis of IFI among subjects injured in Afghanistan operations.

Methods

Formalin-fixed paraffin-embedded (FFPE) tissue samples obtained during debridement from IFI cases with angioinvasion (AI) and controls (combat-injured with negative histopathology) were evaluated with a panfungal PCR targeting the internal transcribed spacer (ITS 1 and ITS 2) of the fungal genome.

Results

We assessed 41 injury sites where culture, histopathology, and FFPE specimens were available contemporaneously. Fungus was cultured from 32 sites (78%) with the order Mucorales represented in 18 sites (44%, five sites with Saksenaea spp.), and Aspergillus spp. in six (15%) sites. Using PCR, a fungus was identified from 33 sites (81%) with order Mucorales identified from 28 sites (68%, 20 with Saksenaea spp.) and Aspergillus spp. from five (12%) sites. When compared with the gold standard (histopathology), the sensitivity, negative, and positive predictive value were 83, 94, and 98%, respectively. Specificity was calculated to be 99.2% based upon the identification of one false-positive among 118 controls.

Conclusion

Concerns about PCR being overly sensitive for the diagnosis of trauma-related IFI are not upheld. The PCR-based method was sensitive, specific, and had a high negative predictive value for the diagnosis of AI IFI. Re-demonstrated is the inability of culture to identify fungi of the order Mucorales and the need for antifungal coverage targeting fungi of the order Mucorales and Aspergillus in AI IFI. As Saksenaea is the dominant fungus identified in this setting, study of the virulence characteristics and antifungal susceptibility is warranted.

Disclosures

All authors: No reported disclosures.

The widespread use of topical antimicrobials enriches for resistance in Staphylococcus aureus isolated from patients with atopic dermatitis

BACKGROUND

Carriage rates of Staphylococcus aureus on affected skin in atopic dermatitis (AD) are approximately 70%. Increasing disease severity during flares and overall disease severity correlate with increased burden of S. aureus. Treatment in AD therefore often targets S. aureus with topical and systemic antimicrobials.

OBJECTIVES

To determine whether antimicrobial sensitivities and genetic determinants of resistance differed in S. aureus isolates from the skin of children with AD and healthy child nasal carriers.

METHODS

In this case-control study, we compared S. aureus isolates from children with AD (n = 50) attending a hospital dermatology department against nasal carriage isolates from children without skin disease (n = 49) attending a hospital emergency department for noninfective conditions. Using whole genome sequencing we generated a phylogenetic framework for the isolates based on variation in the core genome, then compared antimicrobial resistance phenotypes and genotypes between disease groups.

RESULTS

Staphylococcus aureus from cases and controls had on average similar numbers of phenotypic resistances per isolate. Case isolates differed in their resistance patterns, with fusidic acid resistance (Fus^R ) being significantly more frequent in AD (P = 0·009). The genetic basis of Fus^R also differentiated the populations, with chromosomal mutations in fusA predominating in AD (P = 0·049). Analysis revealed that Fus^R evolved multiple times and via multiple mechanism in the population. Carriage of plasmid-derived qac genes, which have been associated with reduced susceptibility to antiseptics, was eight times more frequent in AD (P = 0·016).

CONCLUSIONS

The results suggest that strong selective pressure drives the emergence and maintenance of specific resistances in AD.

Sex-specific relevance of diabetes to occlusive vascular and other mortality: a collaborative meta-analysis of individual data from 980 793 adults from 68 prospective studies

BACKGROUND

Several studies have shown that diabetes confers a higher relative risk of vascular mortality among women than among men, but whether this increased relative risk in women exists across age groups and within defined levels of other risk factors is uncertain. We aimed to determine whether differences in established risk factors, such as blood pressure, BMI, smoking, and cholesterol, explain the higher relative risks of vascular mortality among women than among men.

METHODS

In our meta-analysis, we obtained individual participant-level data from studies included in the Prospective Studies Collaboration and the Asia Pacific Cohort Studies Collaboration that had obtained baseline information on age, sex, diabetes, total cholesterol, blood pressure, tobacco use, height, and weight. Data on causes of death were obtained from medical death certificates. We used Cox regression models to assess the relevance of diabetes (any type) to occlusive vascular mortality (ischaemic heart disease, ischaemic stroke, or other atherosclerotic deaths) by age, sex, and other major vascular risk factors, and to assess whether the associations of blood pressure, total cholesterol, and body-mass index (BMI) to occlusive vascular mortality are modified by diabetes.

RESULTS

Individual participant-level data were analysed from 980 793 adults. During 9·8 million person-years of follow-up, among participants aged between 35 and 89 years, 19 686 (25·6%) of 76 965 deaths were attributed to occlusive vascular disease. After controlling for major vascular risk factors, diabetes roughly doubled occlusive vascular mortality risk among men (death rate ratio [RR] 2·10, 95% CI 1·97-2·24) and tripled risk among women (3·00, 2·71-3·33; χ2 test for heterogeneity p<0·0001). For both sexes combined, the occlusive vascular death RRs were higher in younger individuals (aged 35-59 years: 2·60, 2·30-2·94) than in older individuals (aged 70-89 years: 2·01, 1·85-2·19; p=0·0001 for trend across age groups), and, across age groups, the death RRs were higher among women than among men. Therefore, women aged 35-59 years had the highest death RR across all age and sex groups (5·55, 4·15-7·44). However, since underlying confounder-adjusted occlusive vascular mortality rates at any age were higher in men than in women, the adjusted absolute excess occlusive vascular mortality associated with diabetes was similar for men and women. At ages 35-59 years, the excess absolute risk was 0·05% (95% CI 0·03-0·07) per year in women compared with 0·08% (0·05-0·10) per year in men; the corresponding excess at ages 70-89 years was 1·08% (0·84-1·32) per year in women and 0·91% (0·77-1·05) per year in men. Total cholesterol, blood pressure, and BMI each showed continuous log-linear associations with occlusive vascular mortality that were similar among individuals with and without diabetes across both sexes.

INTERPRETATION

Independent of other major vascular risk factors, diabetes substantially increased vascular risk in both men and women. Lifestyle changes to reduce smoking and obesity and use of cost-effective drugs that target major vascular risks (eg, statins and antihypertensive drugs) are important in both men and women with diabetes, but might not reduce the relative excess risk of occlusive vascular disease in women with diabetes, which remains unexplained.

FUNDING

UK Medical Research Council, British Heart Foundation, Cancer Research UK, European Union BIOMED programme, and National Institute on Aging (US National Institutes of Health).

Burnout and Physical Activity in Medical Students

Burnout is associated with increased levels of stress and lower productivity; however, it is unclear what factors contribute to its development. This study aims to quantify levels of burnout in UCC medical students and to investigate whether physical activity levels are associated with burnout in medical students. Medical students (n=383) at University College Cork were surveyed and the collected data analysed. On the Maslach Burnout Inventory-Student Survey (MBI-SS), 44.8% of students reported high levels of Emotional Exhaustion (EE), 25.6% reported high levels of Cynicism (CY), and 51.2% reported low levels of Professional Efficacy (PE). On the International Physical Activity Questionnaire (IPAQ), 53.2% of respondents were found to engage in Health-Enhancing Physical Activity (HEFA-active). Gender, year group and nationality group appear to be associated with the prevalence of burnout and physical activity levels. Higher levels of physical activity are associated with higher professional efficacy but this relationship requires further research.

Thirteen Pancarpal Arthrodeses Using 2.7/3.5 mm Hybrid Dynamic Compression Plates

Thirteen pancarpal arthrodeses were performed in eleven dogs at the University of Glasgow Veterinary School. All of the animals were presented as referral patients. Two of the eleven dogs had the procedure carried out in both carpi. The arthrodeses were carried out using a 2.7/3.5 mm hybrid dynamic compression platea. The animals were between 1 year and 11 years of age. Their weight ranged from 15 kg to 38 kg. Two cases had associated soft tissue trauma/infection prior to the surgery; these two dogs together with one other developed post-operative soft tissue problems. The soft tissue problems had resolved by the time of radiographic arthrodesis. The plate was removed in three cases due to persistent lameness. The animals were followed up for a period of at least eight weeks postoperatively; the maximum follow-up time was fourteen months. Arthrodesis occurred in all thirteen antebrachio-carpal joints. The hybrid plate can thus be recommended for carpal arthrodesis in the dog and has many advantages over a conventional dynamic compression plate.

Pancarpal arthrodeses were performed in dogs using custom made 2.7/3.5 mm Hybrid Dynamic Compression Plates instead of conventional AO/ASIF Dynamic Compression Plates (DCP). The implantation of the plates was facilitated by their profile and the usage of smaller 2.7 mm screws in the metacarpal regions. All of the carpi went on to full arthrodesis within the follow-up period. The rate of complications associated with the use of this plate compares favourably against previous similar studies using the conventional DCP.

Polyarthritis following vaccination in four dogs

The purpose of this study was to describe four dogs that developed polyarthritis (PA) shortly after vaccination.

Between 1996–1999, 27 dogs were admitted to the Clinic for Small Animals, University of Berlin with clinical signs of PA. Based on the history, clinical findings, results of routine laboratory tests, radiography and ultrasonography, synovial fluid analysis, serum titers for rheumatoid factors, infectious disease and immunological serum titers nine dogs were diagnosed with idiopathic PA type I and 14 dogs with other forms of polyarthritis. Vaccine-associated PA (VAPA) was suspected in four dogs of different breeds (1.3–2.4 years old) which showed a sudden onset of lameness with several painful and swollen joints three – 15 days (mean 11) after vaccination. Synovial fluid analysis revealed nucleated cell counts ranging from 4,000-72,000/μl (mean 30,000) with 30–90% (mean 80) neutrophils. Treatment consisted of NSAIDs and doxycycline. The VAPA dogs quickly recovered in one to two days, three had not experienced a recurrent arthritic episode, one dog developed arthritic signs 12 days after revaccination. An accurate vaccination history is important on all dogs presenting with PA. In accordance with anecdotal reports the signs of disease in VAPA can spontaneously resolve.

Kinematics of the elbow and stifle joints in greyhounds during treadmill trotting An investigation of familiarisation

We studied the familiarisation time required to obtain reliable sagittal plane kinematics for the elbow and stifle joints in eleven treadmill-naïve greyhounds trotting on a treadmill. Motion analysis software was used to measure sagittal elbow and stifle joint movements and to calculate joint angular velocities. After a twominute walking initiation period, the dogs trotted for two and a half minutes. Three trials of three seconds (27 to 30, 72 to 75 and 117 to 120 seconds) trotting, each comprising four complete strides, were analysed. The angle versus time and angular velocity versus time graphs were plotted. For each stride, angular velocity and angular velocity data at key points during the gait cycle were recorded. These angles corresponded with the flexion and extension angles and the peak angular velocities of the elbow and stifle joints during stance and swing phase. Reliable elbow and stifle joint kinematics were obtained within 30 seconds of trotting, which did not differ significantly over the twominute test period indicating that the dogs had familiarised to the treadmill.

Mandibular fracture repair in dogs and cats using epoxy resin and acrylic external skeletal fixation

Mandibular fractures in 17 dogs and in eight cats were managed using external skeletal fixation (ESF) with acrylic or epoxy resin connecting bars. In order to maintain dental occlusion during fracture repair pha- ryngostomy or tracheostomy was performed in 12 dogs and in six cats to permit inhalational anaesthesia during surgery. All of the fractures healed with the exception of fractures in two dogs. Mandibular external skeletal fixation was well tolerated and there was not any evidence of iatrogenic damage to teeth nor to neurovascular structures within the mandible. Implant loosening was commonly observed at the time of fixator removal, but it did not affect the outcome.

Homicide, inquiries and scapegoating

Homicide is in the news and community care is being blamed, a view not justified by the facts. Much has been written about the homicides of Johnathan Zito and Georgina Robinson and there has rightly been considerable public and professional concern. There have been other reports on the murder of Johnathan Newby in October 1993 and William Bennett in July 1994. Yet another case is currently the subject of an inquiry and again the press is expressing indignation and horror. The anxiety and concern are natural but the reactions are not justified.

U.S. Combat-related Invasive Fungal Wound Infection (IFI) Epidemiology and Wound Microbiology: Afghanistan Theater 2009–2014

Background

Culturing combat-related wounds often yields both fungi and bacteria. It is difficult to differentiate fungal contamination from infection, and objective criteria that identify patients at risk for IFI are needed. This study was designed to characterize IFI among US combat casualties in the Afghanistan Theater.

Methods

This retrospective study includes subjects with any labortory evidence of fungi (either histopathology or cultures). Wounds with ongoing necrosis and labortory evidence of infection were classified as IFI). Wounds with labortory evidence of fungal infection, but without ongoing necrosis were classified as either highly suspicious wounds based on objective clinical criteria (i.e., presence of systemic and local signs of infection and use of antifungals for ≥10 days) or non-IFI wounds if they failed to meet clinical criteria.

Results

Of 1932 subjects, 246 (12.7%) had labortory evidence of fungal infection. There were a total of 143 IFI wounds (n = 94), 157 non-IFI wounds (n = 96), and 113 high suspicion wounds (n = 56). IFI subjects had significantly higher injury severity scores (ISS median: 39.5 vs. 33), Sequential Organ Failure Assessment (SOFA) scores (7 vs. 2) and were more likely to require mechanical ventilation (66 vs. 28%). IFI patients also had higher ISS (93 vs. 84% with ISS >25) and SOFA scores (7 vs. 4) compared with the subjects with high suspicion wounds. IFI wounds often grew molds belonging to the order Mucorales compared with high suspicion (19 vs. 10%, P = 0.04) and non-IFI wounds (19 vs. 7%, P = 0.02). About half of the IF wounds grew fungi of the order Mucorales either isolated alone or in conjunction with other fungi, in comparison, 25% of the high suspicion wounds and 11% of the non-IFI wounds grew fungi of the order Mucorales. Three groups of fungi belonging to the order Mucorales, genus Aspergillus and Fusarium accounted for 83% of the IFI wounds and 74% of the high suspicion wounds.

Conclusion

Labortory evidence of fungal infection is common among combat casualties. Clinical characteristics and wound microbiology allows us to group subjects into groups at low and high risk of IFI. Fungi of the order Mucorales, genus Aspergillus and Fusarium should not be considered contaminants. The presence of these fungi should obligate close clinical follow-up and debridement as needed.

Disclosures

All authors: No reported disclosures.

Survey of Irish general practitioners' preferences for continuing professional development

BACKGROUND

Doctors' continuing professional development (CPD) training needs are known to be strongly influenced by national and local contextual characteristics. Given the changing national demographic profile and government-mandated changes to primary care health care provision, this study aimed to investigate Irish General Practitioners' (GPs) perceptions of, and preferences for, current and future CPD programmes.

METHODS

A cross-sectional questionnaire, using closed- and open-ended questions, was administered to Irish GPs, focusing on training needs analysis; CPD course content; preferred format and the learning environment.

RESULTS

The response rate was 719/1000 (71.9%). GPs identified doctor-patient communication as the most important and best-performed GP skill. Discrepancies between perceived importance (high) and current performance (low) emerged for time/workload management, practice finance and business skills. GPs identified clinically-relevant primary care topics and non-clinical topics (stress management, business skills, practice management) as preferences for future CPD. Flexible methods for CPD delivery were important. Gender and practice location (urban or rural) significantly influenced CPD participation and future course preference.

CONCLUSION

The increasing diversity of services offered in the Irish primary care setting, in both clinical and non-clinical areas, should be tailored based to include GP practice location and structure.

Sensory integration deficits support a dimensional view of psychosis and are not limited to schizophrenia

Visual dysfunction is commonplace in schizophrenia and occurs alongside cognitive, psychotic and affective symptoms of the disorder. Psychophysical evidence suggests that this dysfunction results from impairments in the integration of low-level neural signals into complex cortical representations, which may also be associated with symptom formation. Despite the symptoms of schizophrenia occurring in a range of disorders, the integration deficit has not been tested in broader patient populations. Moreover, it remains unclear whether such deficits generalize across other sensory modalities. The present study assessed patients with a range of psychotic and nonpsychotic disorders and healthy controls on visual contrast detection, visual motion integration, auditory tone detection and auditory tone integration. The sample comprised a total of 249 participants (schizophrenia spectrum disorder n=98; bipolar affective disorder n=35; major depression n=31; other psychiatric conditions n=31; and healthy controls n=54), of whom 178 completed one or more visual task and 71 completed auditory tasks. Compared with healthy controls and nonpsychotic patients, psychotic patients trans-diagnostically were impaired on both visual and auditory integration, but unimpaired in simple visual or auditory detection. Impairment in visual motion integration was correlated with the severity of positive symptoms, and could not be accounted for by a reduction in processing speed, inattention or medication effects. Our results demonstrate that impaired sensory integration is not specific to schizophrenia, as has previously been assumed. Instead, sensory deficits are closely related to the presence of positive symptoms independent of diagnosis. The finding that equivalent integrative sensory processing is impaired in audition is consistent with hypotheses that propose a generalized deficit of neural integration in psychotic disorders.

Patterns and correlates of major depression in Chinese adults: a cross-sectional study of 0.5 million men and women

BACKGROUND

Worldwide 350 million people suffer from major depression, with the majority of cases occurring in low- and middle-income countries. We examined the patterns, correlates and care-seeking behaviour of adults suffering from major depressive episode (MDE) in China.

METHOD

A nationwide study recruited 512 891 adults aged 30-79 years from 10 provinces across China during 2004-2008. The 12-month prevalence of MDE was assessed by the Modified Composite International Diagnostic Interview-short form. Logistic regression yielded adjusted odds ratios (ORs) of MDE associated with socio-economic, lifestyle and health-related factors and major stressful life events.

RESULTS

Overall, 0.7% of participants had MDE and a further 2.4% had major depressive symptoms. Stressful life events were strongly associated with MDE [adjusted OR 14.7, 95% confidence interval (CI) 13.7-15.7], with a dose-response relationship with the number of such events experienced. Family conflict had the highest OR for MDE (18.9, 95% CI 16.8-21.2) among the 10 stressful life events. The risk of MDE was also positively associated with rural residency (OR 1.5, 95% CI 1.4-1.7), low income (OR 2.3, 95% CI 2.1-2.4), living alone (OR 2.6, 95% CI 2.3-3.0), smoking (OR 1.4, 95% CI 1.3-1.6) and certain other mental disorders (e.g. anxiety, phobia). Similar, albeit weaker, associations were observed with depressive symptoms. Among those with MDE, about 15% sought medical help or took psychiatric medication, 15% reported having suicidal ideation and 6% reported attempting suicide.

CONCLUSIONS

Among Chinese adults, the patterns and correlates of MDE were generally consistent with those observed in the West. The low rates of seeking professional help and treatment highlight the great gap in mental health services in China.