Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

BACKGROUND

Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.

METHODS

This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.

RESULTS

The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P < 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (β coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.

CONCLUSION

Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely.

Genetic analysis of the emerging citrus yellow vein clearing virus reveals a divergent virus population in American isolates

Citrus yellow vein clearing virus (CYVCV) is a previously reported citrus virus from Asia with widespread distribution in China. In 2022 the California Department of Food and Agriculture (CDFA) conducted a multi-pest citrus survey targeting multiple citrus pathogens including CYVCV. In March 2022, a lemon tree with symptoms of vein clearing, chlorosis and mottling in a private garden in the city of Tulare, California tested positive for CYVCV, which triggered an intensive survey in the surrounding areas. A total of 3,019 plant samples, including citrus and non-citrus species, were collected, and tested for CYVCV using conventional RT-PCR, RT-qPCR, and Sanger sequencing. Five hundred eighty-six citrus trees tested positive for CYVCV, including eight citrus species not previously recorded infected under field conditions. Comparative genomic studies were conducted using seventeen complete viral genomes. Sequence analysis revealed two major phylogenetic groups. Known Asian isolates and five California isolates from this study comprised the first group, whereas all other CYVCV isolates from California formed a second group, distinct from all worldwide isolates. Overall, CYVCV population shows rapid expansion and high differentiation indicating a population bottleneck typical of a recent introduction into a new geographic area. .

High-intensity interval training in cardiac rehabilitation (HIIT or MISS UK): A multi-centre randomised controlled trial

BACKGROUND

There is a lack of international consensus regarding the prescription of high-intensity interval exercise training (HIIT) for people with coronary artery disease (CAD) attending cardiac rehabilitation (CR).

AIM

To assess the clinical effectiveness and safety of low-volume HIIT compared with moderate intensity steady-state (MISS) exercise training for people with CAD.

METHODS

We conducted a multi-centre RCT, recruiting 382 patients from 6 outpatient CR centres. Participants were randomised to twice-weekly HIIT (n = 187) or MISS (n = 195) for 8 weeks. HIIT consisted of 10 × 1-minute intervals of vigorous exercise (>85% maximum capacity) interspersed with 1-minute periods of recovery. MISS was 20-40 minutes of moderate intensity continuous exercise (60-80% maximum capacity). The primary outcome was the change in cardiorespiratory fitness (peak oxygen uptake, VO2 peak) at 8-week follow-up. Secondary outcomes included cardiovascular disease risk markers, cardiac structure and function, adverse events, and health-related quality of life.

RESULTS

At 8 weeks, VO2  peak improved more with HIIT (2.37 mL.kg-1.min-1; SD, 3.11) compared with MISS (1.32 mL.kg-1.min-1; SD, 2.66). After adjusting for age, sex and study site, the difference between arms was 1.04 mL.kg-1.min-1 (95% CI, 0.38 to 1.69; p = 0.002). Only 1 serious adverse event was possibly related to HIIT.

CONCLUSIONS

In stable CAD, low-volume HIIT improved cardiorespiratory fitness more than MISS by a clinically meaningful margin. Low-volume HIIT is a safe, well tolerated, and clinically effective intervention that produces short-term improvement in cardiorespiratory fitness. It should be considered by all CR programmes as an adjunct or alternative to MISS.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02784873. https://clinicaltrials.gov/ct2/show/NCT02784873.

Population estimates of obstructive and non-obstructive hypertrophic cardiomyopathy in the UK and Germany

Background

While numerous publications have estimated the prevalence of diagnosed hypertrophic cardiomyopathy (HCM), none have quantified the real-world proportion of obstructive and non-obstructive HCM using nationally representative data sources in any European countries.

Purpose

To estimate the prevalence of diagnosed HCM and its subtypes in the UK and Germany.

Methods

Patients with HCM were identified in the UK from 01 Apr 2009 to 30 Oct 2020 and Germany from 2011 to 2019. UK patients with HCM were identified using electronic health records from the Clinical Practice Research Datalink (CPRD) primary care data linked with Hospital Episode Statistics (HES) secondary care data using ICD-10 (I42.1, I42.2), Read, Medcode, SNOMED, and OPCS codes. German patients with HCM were identified using a nationally representative administrative claims data pool (WIG2 Benchmark database) from several German Statutory Health Insurance (SHI)-insurances using ICD-10 and OPS codes. Obstructive HCM was identified as any obstructive HCM diagnosis, any HCM diagnosis with septal reduction therapy, and any HCM diagnosis and left ventricular outflow tract obstruction (LVOTO; not in German claims data). Non-obstructive HCM was any non-obstructive or unspecified HCM diagnosis without evidence of any obstructive HCM. Annual prevalence was calculated for each year in the respective study periods and average annual prevalence across the study period.

Results

The average annual prevalence rate of HCM was 4.15/10,000 in the UK and 8.61/10,000 in Germany, while the average annual prevalence rate of obstructive HCM was 2.84/10,000 in the UK and 4.18/10,000 in Germany (Table). The proportion of HCM that was obstructive HCM was 68% in the UK and 49% in Germany. The prevalence rates of diagnosed HCM and obstructive HCM tended to increase over time (Figure).

Conclusion

The prevalence of HCM, obstructive HCM and the proportion of HCM that is obstructive varied between the UK and Germany. The prevalence of HCM was generally consistent with previously published estimates. Although there are limitations with coding in administrative data, it is important to differentiate obstructive HCM from non-obstructive HCM given their unique treatments and disease progression and management, especially since at least 49–68% of HCM is obstructive.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Bristol Myers-Squibb

Transcriptome Analysis of Citrus Dwarfing Viroid Induced Dwarfing Phenotype of Sweet Orange on Trifoliate Orange Rootstock

Dwarfed citrus trees for high-density plantings or mechanized production systems will be key for future sustainable citrus production. Citrus trees consist of two different species of scion and rootstock. Therefore, any observed phenotype results from gene expression in both species. Dwarfed sweet orange trees on trifoliate rootstock have been produced using citrus dwarfing viroid (CDVd). We performed RNA-seq transcriptome analysis of CDVd-infected stems and roots and compared them to non-infected controls. The identified differentially expressed genes validated with RT-qPCR corresponded to various physiological and developmental processes that could be associated with the dwarfing phenotype. For example, the transcription factors MYB13 and MADS-box, which regulate meristem functions and activate stress responses, were upregulated in the stems. Conversely, a calcium-dependent lipid-binding protein that regulates membrane transporters was downregulated in the roots. Most transcriptome reprogramming occurred in the scion rather than in the rootstock; this agrees with previous observations of CDVd affecting the growth of sweet orange stems while not affecting the trifoliate rootstock. Furthermore, the lack of alterations in the pathogen defense transcriptome supports the term “Transmissible small nuclear ribonucleic acid,” which describes CDVd as a modifying agent of tree performance with desirable agronomic traits rather than a disease-causing pathogen.

Outcomes of a Pharmacy Internship Program at a Quaternary Care Hospital

OBJECTIVE

To design, implement, and evaluate a Hospital-based Pharmacy Internship Program that meets the educational requirements of  pharmacy graduates to register as competent pharmacists in the United Arab  Emirates.

METHOD

The Pharmacy Internship Program was designed as a 6-month, full- time, competency-based program. Intern performance was assessed through  monthly continuous evaluations. Interns who successfully completed the  program were eligible to take the Department of Health Licensing Examination. Pharmacy intern surveys were collected to assess their overall satisfaction with the program.

RESULTS

Over the previous 5 years, the program has trained 53 interns. All  interns completed the 6-month training program. Of the 53 graduates, 45  completed the post-internship survey. Interns reported a high level of satisfaction with the program structure and content.

CONCLUSIONS

The Pharmacy Internship Program structure was successful in its first 5 years of implementation and was both feasible and sustainable. The  program was viewed as highly beneficial for the professional and personal  growth of pharmacy interns and provided them with the necessary competencies and skills to successfully enter the workforce.

High-Throughput RNA Extraction from Citrus Tissues for the Detection of Viroids

High-throughput nucleic acid extraction is critical for the implementation of modern viroid detection assays. Successful large-scale nursery, field surveys, and other regulatory, quarantine, or research diagnostic programs are increasingly dependent on high-throughput tissue pulverization and nucleic acid extraction protocols. Magnetic bead-based approaches using semi-automated robotic equipment allow high-throughput extraction and purification of high-quality uniform total nucleic acids for each individual sample. Here, we describe a streamlined and optimized protocol for citrus tissue processing and RNA extraction that can be used for downstream applications such as viroid detection by reverse transcription-quantitative polymerase chain reaction.

Real-Time Detection of Viroids Using Singleplex and Multiplex Quantitative Polymerase Chain Reaction

Multiplex quantitative polymerase chain reaction (multiplex qPCR) enables the amplification of more than one target in a single reaction using different reporter dyes with distinct fluorescent spectra. The number of reporter fluorophores is typically restricted to three or four, depending upon the capability of the real-time PCR platform and software used. Each target is amplified by a different set of primers and a uniquely labeled probe that distinguishes each PCR amplicon. Thus, the levels of several targets of interest can be quantified in real time. By combining several reactions in a single tube, multiplex qPCR reduces the quantity, and cost of reagents needed to screen a sample for multiple targets. Specificity and efficiency are not affected by the inclusion of the three assays in a multiplex reaction.

Real-world evaluation of follow up strategies after implantable cardiac-defibrillator therapies in patients with ventricular tachycardia (REFINE-VT)

Introduction

Implantable cardiac-defibrillators (ICD) can prevent sudden cardiac death but the risk of recurrent ventricular arrhythmia (VA) and ICD therapies persists. Established strategies to minimize such risks include medication optimization, device reprogramming or ventricular tachycardia (VT) catheter ablation (CA). However, the timing and choice of these strategies at ICD follow-up may not be as consistent in the real-world as the regulated conditions of clinical trials. Furthermore, whether these decisions at follow-up are influenced by the type of arrhythmia, ICD therapy or patient characteristics remain unclear.

Purpose

We evaluated ICD follow-up strategies in patients with ischaemic (ICM) and non-ischaemic cardiomyopathy (NICM) to refine the outpatient management of these complex patients and ultimately improve overall patient outcome.

Methods

REFINE-VT is a retrospective study of 514 patients with ICD/CRT-D who attended ICD follow-up between June 2018 to September 2019 at the University Hospital Coventry & Warwickshire (UHCW) tertiary cardiology department. All follow-ups were face-to-face. Patients were divided into 2 groups according to the absence or presence of sustained VA (e.g. &gt;30 seconds of VT and/or appropriate ICD therapy), described as “negative event” and “positive event” groups respectively. The type of strategy employed in response to a positive event were categorized into 4 groups: (1) Medication change only (2) Device programming +/− medication (3) Referral for VT CA (4) No intervention

Results

514 consecutive patients with ICD (52%) or CRT-D (48%) were analysed. Overall mean age was 67±14 years with 79% male patients. ICM was diagnosed in 329 (64%) patient and NICM in 185 (36%). 437 (85%) patients had no significant VA and/or ICD therapy referred to as the negative group. A total of 77 patients (15%) suffered VA and/or ICD therapies, of whom 22 patients (26%) experienced a second event. 31% (n=24) of this positive event group received no preventative strategy (Table 1). We observed an inconsistent approach to the choice of strategies across different types of arrhythmias and ICD therapies. E.g. the odds of intervening were significantly higher if ICD shock was detected compared to anti-tachycardia pacing (OR 8.4, 95% CI 1.7–39.6, p=0.007). Even in patients with two events, the rate of referral for VT ablation and escalation of antiarrhythmics were similarly as low as patients with a single event (Table 2).

Conclusion

This is the first contemporary study that has evaluated how strategies that reduce the risk of recurrent ICD events are executed in a real-world population. We have demonstrated that the decision to intervene and choices of strategy remain inconsistent and partially biased by the type of arrhythmia and ICD therapy at follow-up. This supports the need for an evidence-driven multi-disciplinary VT clinic to refine and standardize our approach to this heterogeneous population.

Funding Acknowledgement

Type of funding sources: None.

Complete Nucleotide Sequence, Genome Organization, and Comparative Genomic Analyses of Citrus Yellow-Vein Associated Virus (CYVaV)

Citrus yellow-vein disease (CYVD) was first reported in California in 1957. We now report that CYVD is associated with a virus-like agent, provisionally named citrus yellow-vein associated virus (CYVaV). The CYVaV RNA genome has 2,692 nucleotides and codes for two discernable open reading frames (ORFs). ORF1 encodes a protein of 190 amino acid (aa) whereas ORF2 is presumably generated by a −1 ribosomal frameshifting event just upstream of the ORF1 termination signal. The frameshift product (717 aa) encodes the RNA-dependent RNA polymerase (RdRp). Phylogenetic analyses suggest that CYVaV is closely related to unclassified virus-like RNAs in the family Tombusviridae. Bio-indexing and RNA-seq experiments indicate that CYVaV can induce yellow vein symptoms independently of known citrus viruses or viroids.

Genome analysis of Spiroplasma citri strains from different host plants and its leafhopper vectors

BACKGROUND

Spiroplasma citri comprises a bacterial complex that cause diseases in citrus, horseradish, carrot, sesame, and also infects a wide array of ornamental and weed species. S. citri is transmitted in a persistent propagative manner by the beet leafhopper, Neoaliturus tenellus in North America and Circulifer haematoceps in the Mediterranean region. Leafhopper transmission and the pathogen's wide host range serve as drivers of genetic diversity. This diversity was examined in silico by comparing the genome sequences of seven S. citri strains from the United States (BR12, CC-2, C5, C189, LB 319, BLH-13, and BLH-MB) collected from different hosts and times with other publicly available spiroplasmas.

RESULTS

Phylogenetic analysis using 16S rRNA sequences from 39 spiroplasmas obtained from NCBI database showed that S. citri strains, along with S. kunkelii and S. phoeniceum, two other plant pathogenic spiroplasmas, formed a monophyletic group. To refine genetic relationships among S. citri strains, phylogenetic analyses with 863 core orthologous sequences were performed. Strains that clustered together were: CC-2 and C5; C189 and R8-A2; BR12, BLH-MB, BLH-13 and LB 319. Strain GII3-3X remained in a separate branch. Sequence rearrangements were observed among S. citri strains, predominantly in the center of the chromosome. One to nine plasmids were identified in the seven S. citri strains analyzed in this study. Plasmids were most abundant in strains isolated from the beet leafhopper, followed by strains from carrot, Chinese cabbage, horseradish, and citrus, respectively. All these S. citri strains contained one plasmid with high similarity to plasmid pSci6 from S. citri strain GII3-3X which is known to confer insect transmissibility. Additionally, 17 to 25 prophage-like elements were identified in these genomes, which may promote rearrangements and contribute to repetitive regions.

CONCLUSIONS

The genome of seven S. citri strains were found to contain a single circularized chromosome, ranging from 1.58 Mbp to 1.74 Mbp and 1597-2232 protein-coding genes. These strains possessed a plasmid similar to pSci6 from the GII3-3X strain associated with leafhopper transmission. Prophage sequences found in the S. citri genomes may contribute to the extension of its host range. These findings increase our understanding of S. citri genetic diversity.

Treatment outcomes in patients with drug-resistant TB-HIV co-infection treated with bedaquiline and linezolid

BACKGROUND: Bedaquiline (BDQ) has not been extensively studied among patients co-infected with HIV drug-resistant tuberculosis (DR-TB). We compared treatment outcomes in DR-TB patients treated with BDQ- and linezolid (LZD) containing regimens to historic controls treated with second-line injectable-containing regimens.METHODS: Retrospective cohort study of consecutive DR-TB patients initiated on BDQ- and LZD-containing regimens at a TB referral hospital in KwaZulu-Natal, South Africa. Participants were prospectively followed through 24 months for treatment outcome and adverse events. Outcomes were compared to a historic control cohort of DR-TB HIV patients enrolled at the same facility prior to BDQ introduction.RESULTS: Adult DR-TB patients initiating BDQ between January 2014 and November 2015 were enrolled (n = 151). The majority of patients were female (52%), HIV co-infected (77%) and on antiretroviral therapy (100%). End of treatment outcomes included cure (63%), TB culture conversion (83%), completion (0.7%), loss to follow-up (15%), treatment failure (5%), and death (17%). Compared to historic controls (n = 105), patients treated with BDQ experienced significantly higher TB culture conversion and cure, with significantly lower mortality. Adverse effects were common (92%), and most frequently attributed to LZD (24.1%). QT segment prolongation was common but without clinical sequelae.CONCLUSION: Treatment with BDQ- and LZD-containing regimens was associated with improved treatment outcomes and survival in DR-TB HIV patients.

Understanding the future research needs in Postural Orthostatic Tachycardia Syndrome (POTS): Evidence mapping the POTS adult literature

POTS is under diagnosed with an estimated prevalence of 0.2%. North American and Australian researchers, as well as patient groups have called for more research into POTS. However, there has been no comprehensive appraisal of the current POTS evidence base.

AIM

To map the POTS evidence base.

METHODS

Two reviewers systematically searched 12 databases until July 1st 2019 using the search term "Postural Tachycardia Syndrome" (n = 7280) and categorised the literature. Inclusion criteria included all adult published literature with no language restrictions. 779 papers are analysed and mapped.

RESULTS

Seven themes were identified: symptomology and quality of life 16.8% (n = 132), biomedical topics 16.5% (n = 130), co-morbidities 10.3% (n = 81), non-pharmacological management 9.8% (n = 77), aetiologies 6.9% (n = 53), pharmacological management 6.7% (n = 53), and clinical management 6.6% (n = 52). There 45 subthemes. Quality appraisal of the research studies (n = 233) evaluated design, sample size, outcome measures, data analysis and research biases. 74.8% (n = 175) were observational designs and 25.2% (n = 59) were experimental designs (16 using a randomised controlled design, 11 of which had a sample size greater than 21). 47.4% (n = 111) of studies only measured duration of effect for <1 day. 11.5% (n = 27) of studies reported outcomes using an unvalidated subjective measurement tool.

CONCLUSION

The volume of adult POTS literature is small and the validity and reliability of the research lacks rigour. The evidence map methodology provides POTS researchers with a benchmark for research thus far. This paper adds an in-depth research appraisal to the broad calls for action, highlighting the pressing need for multicentre, good quality research in POTS, to support guidelines and consensus development in the future.

The fundamentals of health economics and its application in the provision of vascular surgery in the UK

Health economics offers a lifeline to policymakers as a way of improving health outcomes in the face of increased monetary constraints. Doctors are uniquely placed in healthcare delivery where they have a pertinent influence on both supply and demand for healthcare provisions. Every clinical decision made by doctors is also an economic decision, and the true cost of offering a scarce healthcare resource includes not being able to fund alternative therapies and hence, foregoing its benefit. Technology and innovation in medicine is seeing an increase in potential therapies; however, how well do they perform against the current gold standard and are they worth the additional cost? A personalized and patient-centered approach to medicine has paved the way for a holistic health outcome measure, quality-adjusted life years, which is predominately used by United Kingdom resource allocators. Aortic surgical interventions are resource-intensive, and recent trends have shown the growing economic burden as yearly costs continue to climb. Health economic models are not without their weaknesses and it is important that future analyses assess the impact on society, distributional consequences, and the value of collecting more information to reduce the uncertainty of the economic result.

Factors Associated with Self-Reported Dysphagia in Older Adults Receiving Meal Support

OBJECTIVES

Dysphagia is common in older adults. However, there are no current estimates of dysphagia in community-dwelling older adults those receiving meal support. It is unknown whether dysphagia is associated with other measures of physical function (activities of daily living [ADL] ability or nutrition status). The study purposes were to determine the prevalence of self-reported dysphagia and to identify factors associated with self-reported dysphagia in community-dwelling older adults receiving meal support.

DESIGN

A cross-sectional study.

SETTING AND PARTICIPANTS

476 community-dwelling older adults (78.5±0.51 years) across five Elder Nutrition Program meal services in Wisconsin participated in the study.

MEASUREMENTS

Data were collected through administration of validated ADL and nutrition questionnaires (nutritional status, functional status with ADLs, chewing ability, dental conditions, and prior diagnoses of dysphagia, pneumonia, and dementia). For self-reported dysphagia, the validated 10-item eating assessment tool (EAT-10) was used.

RESULTS

The prevalence of self-reported dysphagia (EAT-10 score of ≥ 3) was 20.4%. Multivariate logistic regression results indicated that poor nutritional status (OR=3.1, p=0.04), difficulty chewing (OR=2.2, p=0.03), prior dysphagia diagnosis (OR=34.8, p<0.001), prior pneumonia diagnosis (OR=2.1, p=0.04), and meal service site (OR=2.68, p=0.02) were associated with self-reported dysphagia.

CONCLUSION

Approximately one in five community-dwelling older adults receiving meal support had self-reported dysphagia. Increased risk for poor nutrition, reduced chewing ability, prior dysphagia and pneumonia diagnosis, and meal service site were identified as factors associated with dysphagia on the EAT-10. Results highlight the need for further studies across more sites to identify dysphagia risk indicators in community-dwelling older adults receiving meal support state-wide.

COVID-19: The rising cost of cardiac surgery and disease

The coronavirus disease 19 (COVID-19) pandemic has resulted in widespread economic, health and social disruptions. The delivery of cardiovascular care has been stifled during the pandemic to adhere to infection control measures as a way of protecting patients and the workforce at large. This cautious approach has been protective since individuals with COVID-19 and cardiovascular disease are anticipated to have poorer outcomes and an increased risk of death. The combination of postponing elective cardiovascular surgeries, reduced acute care and long-term cardiac damage directly resulting from COVID-19 will likely have increased the demand for cardiac care, particularly from patients presenting with more severe symptoms. The combination of increased demand and inhibited supply will likely result in huge backlog of unmet patients' needs. The novelty, virulence and infectivity of severe acute respiratory syndrome coronavirus 2 has caused substantial morbidity and mortality, thus necessitating modifications to the UK government's healthcare strategy. Without improving cost efficiency, the UK's ageing population will likely need an increasing spend on cardiac surgery simply to maintain the same level of service. However, the government's short-term increase in spending is unsustainable especially in the face of ongoing economic uncertainty. This means that the long-term impact of COVID-19 will only increase the need to find innovative ways of delivering equivalent or superior cardiac care at a reduced unit cost.

Undergraduate exposure to patient presentations on the acute medical placement: a prospective study in a London teaching hospital

OBJECTIVES

To identify the availability and variability of learning opportunities through patient presentations on an acute medical placement at a teaching hospital.

DESIGN

A prospective study evaluating all acute admissions to the Acute Medical Unit over 14 days (336 hours). Clinical presentations and the day and time of admission were recorded and compared with the learning outcomes specified in the medical school curriculum.

SETTING

An Acute Medical Unit at a London teaching hospital.

OUTCOMES

(1) Number of clinical presentations to the Acute Medical Unit over 14 days and (2) differences between the availability and variation of admissions and presentations between in-hours and out-of-hours.

RESULTS

There were 359 admissions, representing 1318 presentations. Of those presentations, 76.6% were admitted out-of-hours and 23.4% in-hours. Gastrointestinal bleeding, tachycardia, oedema and raised inflammatory markers were over three times more common per hour out-of-hours than in-hours. Hypoxia was only seen out-of-hours. Important clinical presentations in the curriculum such as chest pain and hemiparesis were not commonly seen.

CONCLUSIONS

There is greater availability of presentations seen out-of-hours and a changing landscape of presentations seen in-hours. The out-of-hours presentation profile may be due to expanded community and specialist services. Medical schools need to carefully consider the timing and location of their clinical placements to maximise undergraduate learning opportunities.

'I felt like a human being' – An exploratory, multi-method study of refugee involvement in the development of mental health intervention research

The purpose of this study was to pilot and methodologically appraise innovative patient and public involvement (PPI) evaluation tools and to describe a case study of refugee involvement in the development of mental health intervention research. 'Refugee Advisors' were involved in the development of a randomised controlled trial protocol evaluating a brief group intervention for refugee children experiencing symptoms of post-traumatic stress in Sweden. During an 8-hour research meeting, observation and questionnaire data were collected using the Active Involvement of Users in Research Observation Schedule and Questionnaire, followed by a focus group discussion. The multi-method approach demonstrated good feasibility. There were clear examples of how the advisors influenced research development e.g. recruitment strategy, cultural brokerage among study group participants, outcome measure validation. The advisors described a perceived impact on the research, equality and acceptance, and knowledge gain. A sense of appreciation and empowerment was also interpreted. However, potential issues relating to the relevance of contributions and use of an interpreter were identified.

Effectiveness of a school-based intervention for adolescents and teachers to promote mental health among refugee and migrant adolescents

Refugee youth have often experienced trauma during relocation and continue to face adversity in their host country in the form of acculturation stress, residence insecurity, social isolation, and experiences of discrimination. These experiences are associated with a significant risk of developing mental health problems such as post-traumatic stress disorder (PTSD). This cluster randomised trial aims to evaluate the effectiveness of a school-based intervention that provides a manualized, trauma-focussed programme called Teaching Recovery Techniques (TRT) to target refugee and migrant youth and an In-Service Teacher Training (INSETT) programme to teachers. The study will consider the impact of the intervention on the mental health of adolescent refugees and their guardians who participate in the TRT programme. It will also consider the intervention's impact on the interrelationships between teachers and parents and teachers' cultural competence, as well as the social support and school belonging experienced by adolescents who do not participate in TRT but whose teachers receive INSETT training. Further details on TRT and INSETT, trial design and preliminary findings will be presented at the workshop.

Meaningful patient and public involvement to advance healthcare equity, quality and accessibility

Background

A large part of public health is promoting healthcare equity, quality and accessibility. Patient and public involvement (PPI) is a powerful tool to support this goal. It can lead to a richer understanding of public health research topics, improve data quality and analysis, increase trust in and dissemination of research findings, and ultimately achieve health services that are useful, useable and desirable. However, this all relies on PPI being conducted in a meaningful, respectful and inclusive way. Guidance is available on how to conduct, report and evaluate PPI activities. However, evaluative data are often brief, narrative descriptions, which reflects the lack of robust tools specifically developed to assess PPI. The purpose of this study was to develop and pilot tools to objectively assess PPI in the context of research project meetings.

Methods

PPI and group dynamics literature was used to guide the construction of an observation protocol and questionnaire. The research tools were piloted within a randomised trial of a community intervention for refugee children reporting symptoms of posttraumatic stress.

Results

The Active Involvement of Users in Research Observation Schedule is a semi-structured observation protocol, which consists of 12 observable behaviours relating to the interpersonal relations between researchers and PPI advisors; the nature of advisor contributions; and how the advisors guide research development. Each category consists of positive and negative behaviours. There is an accompanying paper-based assessment form that allows attendees to independently and anonymously grade the meeting on a list of items that correspond to those on the observation pro-forma. Preliminary inter-rater reliability for the observation protocol is good (ICC=0.833; 95% CI: 0.569-0.947).

Conclusions

Although the research tools require further refinement and validation, the methodological approach offers a promising, rigorous way to evaluate PPI.

Key messages

A large part of public health is promoting healthcare equity, quality and accessibility. Patient and public involvement (PPI) is a powerful tool to support this goal. The Active Involvement of Users in Research Observation Schedule and Questionnaire offer a promising, rigorous way to evaluate PPI and promote meaningful involvement to advance public health research.

Whole genome sequence of five strains of Spiroplasma citri isolated from different host plants and its leafhopper vector

Objectives

Spiroplasma citri is a bacterium with a wide host range and is the causal agent of citrus stubborn and brittle root diseases of citrus and horseradish, respectively. S. citri is transmitted in a circulative, persistent manner by the beet leafhopper, Neoaliturus (Circulifer) tenellus (Baker), in North America. Five strains of S. citri were cultured from citrus, horseradish, and N. tenellus from different habitats and times. DNA from cultures were sequenced and genome assembled to expand the database to improve detection assays and better understand its genetics and evolution.

Data description

The whole genome sequence of five strains of S. citri are described herein. The S. citri chromosome was circularized for all five strains and ranged from 1,576,550 to 1,742,208 bp with a G + C content of 25.4–25.6%. Characterization of extrachromosomal DNAs resulted in identification of one or two plasmids, with a G + C content of 23.3 to 27.6%, from plant hosts; and eight or nine plasmids, with a G + C content of 21.65 to 29.19%, from N. tenellus. Total genome size ranged from 1,611,714 to 1,832,173 bp from plants and 1,968,976 to 2,155,613 bp from the leafhopper. All sequence data has been deposited in DDBJ/ENA/GenBank under the accession numbers CP046368-CP046373 and CP047426-CP047446.

Breast ultrasound region of interest detection and lesion localisation

In current breast ultrasound computer aided diagnosis systems, the radiologist preselects a region of interest (ROI) as an input for computerised breast ultrasound image analysis. This task is time consuming and there is inconsistency among human experts. Researchers attempting to automate the process of obtaining the ROIs have been relying on image processing and conventional machine learning methods. We propose the use of a deep learning method for breast ultrasound ROI detection and lesion localisation. We use the most accurate object detection deep learning framework - Faster-RCNN with Inception-ResNet-v2 - as our deep learning network. Due to the lack of datasets, we use transfer learning and propose a new 3-channel artificial RGB method to improve the overall performance. We evaluate and compare the performance of our proposed methods on two datasets (namely, Dataset A and Dataset B), i.e. within individual datasets and composite dataset. We report the lesion detection results with two types of analysis: (1) detected point (centre of the segmented region or the detected bounding box) and (2) Intersection over Union (IoU). Our results demonstrate that the proposed methods achieved comparable results on detected point but with notable improvement on IoU. In addition, our proposed 3-channel artificial RGB method improves the recall of Dataset A. Finally, we outline some future directions for the research.

Genome Sequence Resource for Spiroplasma citri, Strain CC-2, Associated with Citrus Stubborn Disease in California

Spiroplasma citri is a bacterium that causes stubborn disease of citrus and infects other crops, ornamentals, and weeds. It is transmitted by leafhoppers in a circulative manner. Due to limited sequence data on S. citri, the bacterium was isolated from naturally infected Chinese cabbage grown on a farm in Fresno County, CA. DNA from S. citri CC-2 was extracted from a pure culture in LD8 and subjected to PacBio sequencing. Four contigs were obtained with a single circular chromosome of 1,709,192 bp and three plasmids of 40,210, 39,313, and 2,921 bp in size. The genome developed herein extends the sequence database of S. citri and is the first whole-genome sequence record of S. citri from California.

Full genome characterization of 12 citrus tatter leaf virus isolates for the development of a detection assay

Citrus tatter leaf virus (CTLV) threatens citrus production worldwide because it induces bud-union crease on the commercially important Citrange (Poncirus trifoliata × Citrus sinensis) rootstocks. However, little is known about its genomic diversity and how such diversity may influence virus detection. In this study, full-length genome sequences of 12 CTLV isolates from different geographical areas, intercepted and maintained for the past 60 years at the Citrus Clonal Protection Program (CCPP), University of California, Riverside, were characterized using next generation sequencing. Genome structure and sequence for all CTLV isolates were similar to Apple stem grooving virus (ASGV), the type species of Capillovirus genus of the Betaflexiviridae family. Phylogenetic analysis highlighted CTLV’s point of origin in Asia, the virus spillover to different plant species and the bottleneck event of its introduction in the United States of America (USA). A reverse transcription quantitative polymerase chain reaction assay was designed at the most conserved genome area between the coat protein and the 3’-untranslated region (UTR), as identified by the full genome analysis. The assay was validated with different parameters (e.g. specificity, sensitivity, transferability and robustness) using multiple CTLV isolates from various citrus growing regions and it was compared with other published assays. This study proposes that in the era of powerful affordable sequencing platforms the presented approach of systematic full-genome sequence analysis of multiple virus isolates, and not only a small genome area of a small number of isolates, becomes a guideline for the design and validation of molecular virus detection assays, especially for use in high value germplasm programs.

P2837Day-case complex left atrial ablation is safe and cost-effective: experience from a UK tertiary centre

Background

Day-case standard catheter ablation is becoming routine. However, patients having complex left atrial ablation for atrial fibrillation (AF) or left atrial tachycardia (LAT) often stay overnight. We have been performing day-case complex left atrial ablation since 2015.

Purpose

To evaluate the safety, efficacy and cost-effectiveness of day-case complex left atrial ablation compared with those who stayed overnight.

Methods

A retrospective analysis of all consecutive complex left atrial ablations performed in a UK tertiary cardiac centre between 2010–2018. Data were collected on baseline parameters, procedure details including mapping technique, ablation strategy, immediate efficacy, and acute complications.

Results

A total of 830 complex left atrial catheter ablations were performed; mean age±SD=60±12 years, 63% male. The majority were AF ablation (n=804, 96.9%), with the rest being LAT/left-atrial flutter. Of the AF cases, 545 were paroxysmal (≤7 days), 212 persistent (>7 days) and 47 long-standing (>1yr); 98% of cases were elective. Pulmonary vein isolation was performed in all; additional LA lines were done in 163, CTI ablation in 129 and CFAEs in 33. 3D-mapping (Carto/Precision)=44.7% (with contact sensing=38.0%), PVAC=18.7%, PVI cryo-balloon=36.6%. Of the cohort 331 (39.9%) were done as day-case. Acute success= 94.9%, acute complications=4.58% (femoral site complications, n=12; pericardial effusion, n=19 (9 needing drain); stroke/cerebral embolus, n=3; phrenic nerve palsy, n=5; first degree heart block, n=1). Comparison of day-case vs non day-case revealed no significant difference in number of complications (Table 1). An overnight stay at out hospital costs £350. During the period of study our institution saved £115.850 (∼140,000 euros).

Day-case vs non day-case ablation Parameters Day-case (n=331) Non day-case (n=499) p-value Mean age ± SD (years) 61.2±11.6 59.1±11.9 0.009 Males (n, %) 205 (61.9%) 321 (64.3%) 0.484 Normal heart (n, %) 243 (73.4%) 383 (76.8%) 0.276 Paroxysmal AF (n, %) 218 (65.9%) 327 (65.5%) 0.928 Fluoroscopy time (mins) 23.8±13.9 27.0±14.5 0.001 Procedure time (mins) 150±89.6 163±68.2 0.025 % with 3D-mapping 30.8% 56.9% <0.001 Acute complications (n, %) 12 (3.63%) 26 (5.21%) 0.285

Conclusions

Day-case complex left atrial cardiac ablation is safe and effective. It is associated with good clinical outcomes and leads to significant cost savings as an overnight stay is not needed.

P6561Diagnostic yield of implantable loop recorders: a comparison of arrhythmia nurse specialists versus clinicians

Background

Implantable loop recorders (ILR) are recommended in guidelines to determine symptom-rhythm correlation. Arrhythmia Nurse Specialists (ANS) play a critical role in the assessment of such patients. Their effectiveness at risk stratification for ILR implantation is unknown. The ESC 2018 Syncope guidelines recommend more research in this field.

Aim

To evaluate the diagnostic yield of consecutive ILR implants at a tertiary centre over a 2year period and compare ANS versus Clinicians.

Methods

A retrospective study of all patients undergoing ILR implant between April 2016 and April 2018. Data collected included baseline patient demographics, referral source and management changes made by ILR findings.

Results

305 patients had an ILR; median age was 71yrs (interquartile range 52–81), 55% male. Median follow-up time was 15months. Referrals were from general cardiology (GC) = 98 (32%), electrophysiology (EP) = 105 (34%), and ANS-led syncope clinic = 102 (34%). Indications for ILR implant were syncope = 203 (65.9%), palpitation = 21 (6.9%), pre-syncope = 16 (5.2%), cryptogenic stroke = 35 (11.5%) and others 7 (8.9%) (falls, channelopathies). Of the entire cohort, 102 (34.0%) experienced arrhythmias recorded on the ILR that resulted in a change of management. This included: pacemaker implant = 49 (16.1%), complex-device implant = 7 (2.3%), AF=28 (9.2%), SVT=14 (4.6%), VT=1 (0.3%). Of those with a syncope indication (n=203), findings on ILR altered management in 73patients (36.0%) over a median follow-up of 18months; a pacing indication in this syncope group was present in 44 (21.9%) patients (median time to diagnosis: 2.7 months) with 24 receiving a pacemaker indication within 3 months of ILR insertion. ANS had a higher pacemaker implant rate. Overall, an ILR resulted in a diagnostic yield of 34.1% (n=104). Specialist nurse referral resulted in an overall greater trend towards change of management in 38.2% of patients compared with GC (32.7%) and EP (31.0%) (p=0.593 nurse vs. consultant).

Conclusion

The overall diagnostic yield of ILR insertion was 34% in our study. ANS had a trend towards a greater diagnostic yield compared with clinicians, and significantly more pacemaker indications. Our data suggests that ANS patient selection for ILR insertion are at least comparable to clinicians.

One-step multiplex RT-qPCR detects three citrus viroids from different genera in a wide range of hosts

A one-step multiplex reverse transcription real-time quantitative polymerase chain reaction (RT-qPCR) based on species-specific minor groove binding (MGB) probes, was developed for the simultaneous detection, identification, and quantification of three citrus viroids belonging to different genera. Citrus exocortis viroid (Pospiviroid), Hop stunt viroid (Hostuviroid), and Citrus bark cracking viroid (Cocadviroid) cause a variety of maladies in agriculturally significant crops. Therefore, reliable assays for their detection are essential tools for various government and industry organizations implementing disease management programs. Singleplex qPCR primers and MGB probes were designed individually for the detection of the three targeted viroids, and subsequently combined in a one-step multiplex RT-qPCR reaction. A wide host range of woody plants, including citrus, grapevines, apricots, plums and herbaceous plants such as tomato, cucumber, eggplant and chrysanthemum different world regions were used to validate the assay. Single, double and triple viroid infections were identified in the tested samples. The developed multiplex RT-qPCR assay was compared with a previously reported SYBR Green I RT-qPCR for the universal detection of citrus viroids. Both assays accurately identified all citrus viroid infected samples. The multiplex assay complemented the SYBR Green I universal detection assay by differentiating among citrus viroid species in the positive samples. The developed multiplex RT-qPCR assay has the potential to simultaneously detect each targeted viroid and could be used in high throughput screenings for citrus viroids in field surveys, germplasm banks, nurseries and other viroid disease management programs.

Detection of Grapevine leafroll-associated virus 7 using real time qRT-PCR and conventional RT-PCR

Nine isolates of Grapevine leafroll-associated virus 7 (GLRaV-7) from diverse geographical regions were sequenced to design more sensitive molecular diagnostic tools. The coat protein (CP) and heat shock protein 70 homologue (HSP70h) genes of these nine isolates were sequenced. Sequences were then used to design more sensitive molecular diagnostic tools. Sequence identity among these isolates ranged between 90 to 100% at the nucleotide and amino acid levels. One RT-PCR and two qRT-PCR assays were used to survey 86 different grapevines from the University of California, Davis Grapevine Virus Collection, the Foundation Plant Services collection and the USDA National Clonal Germplasm Repository, Davis, CA with primers designed in conserved regions of the CP and HSP70h genes. Results revealed that qRT-PCR assays designed in the HSP70h gene was more sensitive (29.07% positives) than that designed in the CP gene (22.09% positives) and both qRT-PCR assays proved to be more sensitive than RT-PCR.

Vitis californica and Vitis californica × Vitis vinifera Hybrids are Hosts for Grapevine leafroll-associated virus-2 and -3 and Grapevine virus A and B

Vitis and non-Vitis spp. surrounding nine Napa Valley vineyards were surveyed for Grapevine leafroll-associated virus (GLRaV)-1 to -5 and -9, Grapevine virus A (GVA), Grapevine virus B (GVB), and Grapevine virus D (GVD). Vitis spp. from three riparian areas not adjacent to vineyards were also included. DNA fingerprinting and probability analyses indicated that the Vitis samples consisted primarily of Vitis californica followed by V. californica × V. vinifera hybrids. Single and mixed infections of GLRaV-2, -3, GVA, or GVB were detected by conventional or quantitative reverse-transcription polymerase chain reaction in 6 of the 66 V. californica and 11 of the 19 V. californica × V. vinifera hybrids. GLRaV-1, -4, -5, -9, and GVD were not detected. Phylogenetic analysis of GLRaV-2 and -3 partial coat protein gene nucleotide sequences indicated that the isolates from V. californica and V. californica × V. vinifera hybrids were closely related to isolates from V. vinifera.

Ureteral motility

The pyeloureteral function is to transport urine from the kidneys into the ureter toward the urinary bladder for storage until micturition. A set of mechanisms collaborates to achieve this purpose: the basic process regulating ureteral peristalsis is myogenic, initiated by active pacemaker cells located in the renal pelvis. Great emphasis has been given to hydrodynamic factors, such as urine flow rate in determining the size and pattern of urine boluses which, in turn, affect the mechanical aspects of peristaltic rhythm, rate, amplitude, and baseline pressure. Neurogenic contribution is thought to be limited to play a modulatory role in ureteral peristalsis. The myogenic theory of ureteral peristalsis can be traced back to Engelmann (1) who was able to localize the peristaltic pressure wave's origin in the renal pelvis and suggested that the ureteral contraction impulse passes from one ureteral cell to another, the whole ureter working as a functional syncitium. Recent studies of ureteral biomechanics, smooth muscle cell electrophysiology, membrane ionic currents, cytoskeletal components and pharmacophysiology much improved our understanding of the mechanism of how the urine bolus is propelled, how this process is disturbed in pathological states, and what could be done to improve it.

Comparison of low-density arrays, RT-PCR and real-time TaqMan RT-PCR in detection of grapevine viruses

Low-density arrays (LDA) have been designed based on the real-time RT-PCR (TaqMan) assays for the specific detection of 13 viruses that infect Grapevines in addition to the housekeeping gene 18S rRNA. The viruses included in the study are Grapevine leafroll associated viruses 1, 2, 3, 4, 5, and 9, Grapevine leafroll associated virus-2 Redglobe (GLRaV-2RG) strain, Ruspestris stem pitting associated virus, Grapevine vitivirus A, Grapevine vitivirus B, Grapevine fanleaf virus, Tomato ringspot virus (ToRSV), and Grapevine fleck virus (GFkV). This study includes three new TaqMan RT-PCR assays that have been developed for GLRaV-2RG, GFkV and ToRSV and have been included in the TaqMan RT-PCR and LDA detection. The LDAs were evaluated against a wide range of isolates distributed geographically. Geographical locations included Africa, Europe, Australia, Asia, Latin America and the United States. High-throughput detection of these viruses using LDAs was compared to RT-PCR and real-time TaqMan RT-PCR. The efficiency of different RNA extraction methodologies and buffers were compared for use in low-density array detection. In addition improving the RNA extraction technique and testing the quality of the RNA using the 18S ribosomal RNA TaqMan assay as an RNA specific internal control proved to generate better diagnostic assays. This is the first report on the use of LDA for the detection of plant viruses.

Toxicological evaluation of some Malaysian locally processed raw food products

Malaysian locally processed raw food products are widely used as main ingredients in local cooking. Previous studies showed that these food products have a positive correlation with the incidence of cancer. The cytotoxicity effect was evaluated using MTT assay (3-(4,5-dimetil-2-thiazolil)-2,5-diphenyl-2H-tetrazolium bromide) against Chang liver cells at 2000 microg/ml following 72 h incubation. Findings showed all methanol extracts caused a tremendous drop in the percentage of cell viability at 2000 microg/ml (shrimp paste - 41.69+/-3.36%, salted fish - 37.2+/-1.06%, dried shrimp - 40.32+/-1.8%, p<0.05). To detect DNA damage in a single cell, alkaline Comet Assay was used. None of the extracts caused DNA damage to the Chang liver cells at 62.5 microg/ml following 24 h incubation, as compared to the positive control, hydrogen peroxide (tail moment - 9.50+/-1.50; tail intensity - 30.50+/-2.50). Proximate analysis which was used for the evaluation of macronutrients in food showed that shrimp paste did not comply with the protein requirement (<25%) as in Food Act 1983. Salt was found in every sample with the highest percentage being detected in shrimp paste which exceeded 20%. Following heavy metal analysis (arsenic, cadmium, lead and mercury), arsenic was found in every sample with dried shrimps showing the highest value as compared to the other samples (6.16 mg/kg). In conclusion, several food extracts showed cytotoxic effect but did not cause DNA damage against Chang liver cells. Salt was found as the main additive and arsenic was present in every sample, which could be the probable cause of the toxicity effects observed.

Real-time RT-PCR (TaqMan) assays for the detection of Grapevine Leafroll associated viruses 1-5 and 9

Real-time RT-PCR (TaqMan) assays were developed for the specific detection of Grapevine Leafroll associated viruses 1-5 and 9 (GLRaV-1-5 and -9). The assays were evaluated against a wide range of geographically distributed isolates. Geographical locations included South Africa, Europe, Australia, Asia, Latin America and the United States. Sequences were piled up from the most conserved regions of these geographically diverse isolates and TaqMan primers and probes were designed, targeting the regions with 100% sequence identity. Improving the RNA extraction technique and testing the quality of the RNA using the 18S ribosomal RNA TaqMan assay as an RNA specific internal control to validate the quality of the extracted RNA proved to generate better diagnostic assays. The real-time TaqMan RT-PCR assays were compared to the conventional RT-PCR assays for the detection of viruses using purified total RNA as well as crude extract. The data showed that when using total RNA extracted either by the Qiagen RNeasy method or by an ABI automated system more isolates were detected in comparison to crude extract. The optimum volume of crude extract prepared in GES for use in real-time TaqMan RT-PCR cocktail was determined to be 1 microl per reaction. In addition this report showed that TaqMan RT-PCR was more sensitive than conventional one-step RT-PCR for testing different isolates of these viruses either using RNA or crude tissue extract.