ST6GAL1 is associated with poor response to chemoradiation in rectal cancer

INTRODUCTION

Colorectal cancer is the third most common cause of cancer death. Rectal cancer makes up a third of all colorectal cases. Treatment for locally advanced rectal cancer includes chemoradiation followed by surgery. We have previously identified ST6GAL1 as a cause of resistance to chemoradiation in vitro and hypothesized that it would be correlated with poor response in human derived models and human tissues.

METHODS

Five organoid models were created from primary human rectal cancers and ST6GAL1 was knocked down via lentivirus transduction in one model. ST6GAL1 and Cleaved Caspase-3 (CC3) were assessed after chemoradiation via immunostaining. A tissue microarray (TMA) was created from twenty-six patients who underwent chemoradiation and had pre- and post-treatment specimens of rectal adenocarcinoma available at our institution. Immunohistochemistry was performed for ST6GAL1 and percent positive cancer cell staining was assessed and correlation with pathological grade of response was measured.

RESULTS

Organoid models were treated with chemoradiation and both ST6GAL1 mRNA and protein significantly increased after treatment. The organoid model targeted with ST6GAL1 knockdown was found to have increased CC3 after treatment. In the tissue microarray, 42 percent of patient samples had an increase in percent tumor cell staining for ST6GAL1 after treatment. Post-treatment percent staining was associated with a worse grade of treatment response (p = 0.01) and increased staining post-treatment compared to pre-treatment was also associated with a worse response (p = 0.01).

CONCLUSION

ST6GAL1 is associated with resistance to treatment in human rectal cancer and knockdown in an organoid model abrogated resistance to apoptosis caused by chemoradiation.

Modified realist evaluation of a complex, multi-centred, multi-intervention programme

Well North was a complex, multi-intervention health improvement programme spanning 10 sites across the North of England. The aim was to address inequalities by improving the health of the poorest fastest, increasing resilience and reducing levels of worklessness. The intention of the programme was for all sites to have freedom and flexibility to conduct different interventions reflecting local priorities. Evaluation ran concurrently with the programme, and an iterative approach was required to ensure constant feedback, allowing the programme to be adapted and improved as necessary. Realist methodology was chosen for evaluation, as it provides insight into what works, for whom and in what circumstances. Due to the complex nature of the programme and diverse approaches, it was necessary to adapt the methodology to meet the needs of the evaluation. The Evaluation Team utilized a range of qualitative and quantitative techniques within the context of a Rapid Cycle Evaluation framework. For each project, Contexts, Mechanisms and Outcomes (CMOs) were identified at three stages and were incorporated into the CMO configuration, leading to the development of a middle range theory. Validation and testing of theory took place at every stage. Realist methodology was the most appropriate existing method. However, it still necessitated modification.

Strategies of nanoparticles integration in polymer fibers to achieve antibacterial effect and enhance cell proliferation with collagen production in tissue engineering scaffolds

Current design strategies for biomedical tissue scaffolds are focused on multifunctionality to provide beneficial microenvironments to support tissue growth. We have developed a simple yet effective approach to create core-shell fibers of poly(3-hydroxybuty-rate-co-3-hydroxyvalerate) (PHBV), which are homogenously covered with titanium dioxide (TiO2) nanoparticles. Unlike the blend process, co-axial electrospinning enabled the uniform distribution of nanoparticles without the formation of large aggregates. We observed 5 orders of magnitude reduction in Escherichia coli survival after contact with electrospun scaffolds compared to the non-material control. In addition, our hybrid cores-shell structure supported significantly higher osteoblast proliferation after 7 days of cell culture and profound generation of 3D networked collagen fibers after 14 days. The organic-inorganic composite scaffold produced in this study demonstrates a unique combination of antibacterial properties and increased bone regeneration properties. In summary, the multifunctionality of the presented core-shell cPHBV+sTiO2 scaffolds shows great promise for biomedical applications.

Aerosol Particle Size Influences the Infectious Dose and Disease Severity in a Golden Syrian Hamster Model of Inhalational COVID-19

Background: Significant evidence suggests that SARS-CoV-2 can be transmitted via respiratory aerosols, which are known to vary as a function of respiratory activity. Most animal models examine disease presentation following inhalation of small-particle aerosols similar to those generated during quiet breathing or speaking. However, despite evidence that particle size can influence dose-infectivity relationships and disease presentation for other microorganisms, no studies have examined the infectivity of SARS-CoV-2 contained in larger particle aerosols similar to those produced during coughing, singing, or talking. Therefore, the aim of the present study was to assess the influence of aerodynamic diameter on the infectivity and virulence of aerosols containing SARS-CoV-2 in a hamster model of inhalational COVID-19. Methods: Dose-response relationships were assessed for two different aerosol particle size distributions, with mass median aerodynamic diameters (MMADs) of 1.3 and 5.2 μm in groups of Syrian hamsters exposed to aerosols containing SARS-CoV-2. Results: Disease was characterized by viral shedding in oropharyngeal swabs, increased respiratory rate, decreased activity, and decreased weight gain. Aerosol particle size significantly influenced the median doses to induce seroconversion and viral shedding, with both increasing ∼30-fold when the MMAD was increased. In addition, disease presentation was dose-dependent, with seroconversion and viral shedding occurring at lower doses than symptomatic disease characterized by increased respiratory rate and decreased activity. Conclusions: These results suggest that aerosol particle size may be an important factor influencing the risk of COVID-19 transmission and needs to be considered when developing animal models of disease. This result agrees with numerous previous studies with other microorganisms and animal species, suggesting that it would be generally translatable across different species. However, it should be noted that the absolute magnitude of the observed shifts in the median doses obtained with the specific particle sizes utilized herein may not be directly applicable to other species.

Integrating EM and Patch-seq data: Synaptic connectivity and target specificity of predicted Sst transcriptomic types

Neural circuit function is shaped both by the cell types that comprise the circuit and the connections between those cell types ¹ . Neural cell types have previously been defined by morphology ^{2, 3} , electrophysiology ^{4, 5} , transcriptomic expression ^6-8 , connectivity ^9-13 , or even a combination of such modalities ^14-16 . More recently, the Patch-seq technique has enabled the characterization of morphology (M), electrophysiology (E), and transcriptomic (T) properties from individual cells ^17-20 . Using this technique, these properties were integrated to define 28, inhibitory multimodal, MET-types in mouse primary visual cortex ²¹ . It is unknown how these MET-types connect within the broader cortical circuitry however. Here we show that we can predict the MET-type identity of inhibitory cells within a large-scale electron microscopy (EM) dataset and these MET-types have distinct ultrastructural features and synapse connectivity patterns. We found that EM Martinotti cells, a well defined morphological cell type ^{22, 23} known to be Somatostatin positive (Sst+) ^{24, 25} , were successfully predicted to belong to Sst+ MET-types. Each identified MET-type had distinct axon myelination patterns and synapsed onto specific excitatory targets. Our results demonstrate that morphological features can be used to link cell type identities across imaging modalities, which enables further comparison of connectivity in relation to transcriptomic or electrophysiological properties. Furthermore, our results show that MET-types have distinct connectivity patterns, supporting the use of MET-types and connectivity to meaningfully define cell types.

Current issues and future directions in gymnastics research: biomechanics, motor control and coaching interface

The sport of gymnastics is undergoing a global examination of its culture and the relationship between the gymnast, coach and environment is a central focus. The aim of this review is to explore biomechanics and motor control research in skill development and technique selection in artistic gymnastics with a focus on the underlying concepts and scientific principles that allow performance enhancement, skill development and injury risk reduction. The current review examines peer reviewed papers from 2000 onwards, with a focus on contemporary approaches in the field of gymnastics research, and highlights several key directions for future gymnastics research. Based on our review and the integration of the models of Newell (1986) and Irwin et al. (2005), we recommend that future gymnastics research should embrace at the very least a multidisciplinary approach and aim for an interdisciplinary paradigm.

Health workforce governance during the COVID-19 pandemic: learning lessons from Europe

Background

This study considers some of the effective governance tools that have been utilised to mobilise, redeploy and repurpose the health workforce during the COVID-19 pandemic to create surge capacity, protect workforce health and wellbeing and ensure effective implementation of vaccination programmes.

Methods

Data were systematically extracted from the Observatory/WHO Europe/European Commission Health System and Response Monitor, covering the period from March 2020 to May 2021 with a focus on four dimensions of health workforce governance: national/regional government policies; legislation; regulation; the role and remit of employers and management.

Results

A wide-range of governance actions across all levels were required to ensure the health workforce could provide effective pandemic responses. Creating surge capacity, for example, often required adoption of emergency legislation to facilitate exceptional hiring procedures and the changing of (re-)registration requirements, as well as additional training and development of new competencies among other actions. Putting in place physical and mental health support meanwhile required defining infection control policies, monitoring PPE supply and distribution, ensuring access to free mental health support, and implementation of breaks. Some countries also allowed “new” types of workers to vaccinate; online or in person training; adjustments to payment mechanisms; and creating new supervision requirements.

Conclusions

Pandemic responses have broken up sclerotic governance structures which have hampered past health workforce development and reform, new training programmes have been rapidly developed, leadership roles have been delegated to a wider-range of health professionals than before and monitoring systems that provide more rapid data on staffing levels have been put into place. Learning from and evaluating these changes will be important to help inform future pandemic responses.

A comparison of the kinematics and kinetics of barefoot and shod running in children with cerebral palsy

BACKGROUND

The biomechanics of barefoot and shod running are different for typically developing children but unknown for children with cerebral palsy (CP). Such differences may have implications for injury and performance.

AIMS

The primary aims of this study were to compare the lower limb biomechanics of barefoot and shod running in children with CP, and to determine whether any differences were the same in GMFCS levels I and II.

METHODS

This cross-sectional study examined 38 children with CP (n = 24 (GMFCS) level I; n = 14 GMFCS II), running overground at 3 speeds (jog, run, sprint) in barefoot and shod conditions. Marker trajectories and force plate data were recorded, and lower limb kinematics, kinetics and spatiotemporal variables were derived. Differences between barefoot and shod running were analysed using linear mixed models.

RESULTS

For both GMFCS levels, barefoot running resulted in higher loading rates, but smaller impact peaks at all speeds. Barefoot running was associated with greater hip and knee power; less ankle dorsiflexion and hip flexion at initial contact, and less ankle and knee range of motion during stance, compared to shod running, at all speeds. Barefoot stride length was shortened, and cadence increased compared to shod during jogging and running but not sprinting. For GMFCS level I only, barefoot running involved a higher incidence of forefoot strike, greater ankle power generation and less hip range of motion during stance.

SIGNIFICANCE

Running barefoot may facilitate running performance by increasing power generation at the ankle in children with CP, GMFCS level I. Higher barefoot loading rates may have implications for performance and injury.

Incisional hernia following colorectal cancer surgery according to suture technique: Hughes Abdominal Repair Randomized Trial (HART)

BACKGROUND

Incisional hernias cause morbidity and may require further surgery. HART (Hughes Abdominal Repair Trial) assessed the effect of an alternative suture method on the incidence of incisional hernia following colorectal cancer surgery.

METHODS

A pragmatic multicentre single-blind RCT allocated patients undergoing midline incision for colorectal cancer to either Hughes closure (double far-near-near-far sutures of 1 nylon suture at 2-cm intervals along the fascia combined with conventional mass closure) or the surgeon's standard closure. The primary outcome was the incidence of incisional hernia at 1 year assessed by clinical examination. An intention-to-treat analysis was performed.

RESULTS

Between August 2014 and February 2018, 802 patients were randomized to either Hughes closure (401) or the standard mass closure group (401). At 1 year after surgery, 672 patients (83.7 per cent) were included in the primary outcome analysis; 50 of 339 patients (14.8 per cent) in the Hughes group and 57 of 333 (17.1 per cent) in the standard closure group had incisional hernia (OR 0.84, 95 per cent c.i. 0.55 to 1.27; P = 0.402). At 2 years, 78 patients (28.7 per cent) in the Hughes repair group and 84 (31.8 per cent) in the standard closure group had incisional hernia (OR 0.86, 0.59 to 1.25; P = 0.429). Adverse events were similar in the two groups, apart from the rate of surgical-site infection, which was higher in the Hughes group (13.2 versus 7.7 per cent; OR 1.82, 1.14 to 2.91; P = 0.011).

CONCLUSION

The incidence of incisional hernia after colorectal cancer surgery is high. There was no statistical difference in incidence between Hughes closure and mass closure at 1 or 2 years.

REGISTRATION NUMBER

ISRCTN25616490 (http://www.controlled-trials.com).

Comparison of oral minoxidil, finasteride, and dutasteride for treating androgenetic alopecia

Background Androgenetic alopecia (AGA) is the most common cause of hair loss, often challenging to treat. While oral finasteride (1 mg/day) is an FDA-approved treatment for male AGA, oral minoxidil and oral dutasteride are not approved yet. However, clinicians have been increasingly using these two drugs off-label for hair loss. Recently, Japan and South Korea have approved oral dutasteride (0.5 mg/day) for male AGA.Efficacy and safety A probable efficacy ranking, in decreasing order, is- dutasteride 0.5 mg/day, finasteride 5 mg/day, minoxidil 5 mg/day, finasteride 1 mg/day, followed by minoxidil 0.25 mg/day. Oral minoxidil predominantly causes hypertrichosis and cardiovascular system (CVS) symptoms/signs in a dose-dependent manner, whereas oral finasteride and dutasteride are associated with sexual dysfunction and neuropsychiatric side effects.Pharmacokinetics and pharmacodynamics The average plasma half-lives of minoxidil, finasteride, and dutasteride are ∼4 hours, ∼4.5 hours, and ∼5 weeks, respectively. Minoxidil acts through multiple pathways to promote hair growth. It has been shown as a vasodilator, an anti-inflammatory agent, a Wnt/β-catenin signaling inducer, and an antiandrogen. Finasteride inhibits 5 α-reductase (5AR) type II isoenzyme, while dutasteride inhibits both type I and type II. Thus, dutasteride suppresses DHT levels more than finasteride in the serum and scalp.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Transcriptional analysis of peripheral memory T cells reveals Parkinson's disease-specific gene signatures

Parkinson's disease (PD) is a multi-stage neurodegenerative disorder with largely unknown etiology. Recent findings have identified PD-associated autoimmune features including roles for T cells. To further characterize the role of T cells in PD, we performed RNA sequencing on PBMC and peripheral CD4 and CD8 memory T cell subsets derived from PD patients and age-matched healthy controls. When the groups were stratified by their T cell responsiveness to alpha-synuclein (α-syn) as a proxy for an ongoing inflammatory autoimmune response, the study revealed a broad differential gene expression profile in memory T cell subsets and a specific PD associated gene signature. We identified significant enrichment of transcriptomic signatures previously associated with PD, including for oxidative stress, phosphorylation, autophagy of mitochondria, cholesterol metabolism and inflammation, and the chemokine signaling proteins CX3CR1, CCR5, and CCR1. In addition, we identified genes in these peripheral cells that have previously been shown to be involved in PD pathogenesis and expressed in neurons, such as LRRK2, LAMP3, and aquaporin. Together, these findings suggest that features of circulating T cells with α-syn-specific responses in PD patients provide insights into the interactive processes that occur during PD pathogenesis and suggest potential intervention targets.

Inhibition of DNA-PK may improve response to neoadjuvant chemoradiotherapy in rectal cancer

Treatment of locally advanced rectal cancer includes chemoradiation and surgery, but patient response to treatment is variable. Patients who have a complete response have improved outcomes; therefore, there is a critical need to identify mechanisms of resistance to circumvent them. DNA-PK is involved in the repair of DNA double-strand breaks caused by radiation, which we found to be increased in rectal cancer after treatment. We hypothesized that inhibiting this complex with a DNA-PK inhibitor, Peposertib (M3814), would improve treatment response.

We assessed pDNA-PK in a rectal cancer cell line and mouse model utilizing western blotting, viability assays, γH2AX staining, and treatment response. The three treatment groups were: standard of care (SOC) (5-fluorouracil (5FU) with radiation), M3814 with radiation, and M3814 with SOC.

SOC treatment of rectal cancer cells increased pDNA-PK protein and increased γH2AX foci, but this was abrogated by the addition of M3814. Mice with CT26 tumors treated with M3814 with SOC did not differ in average tumor size but individual tumor response varied. The clinical complete response rate improved significantly with the addition of M3814 but pathological complete response did not. We investigated alterations in DNA repair and found that Kap1 and pATM are increased after M3814 addition suggesting this may mediate resistance.

When the DNA-PK inhibitor, M3814, is combined with SOC treatment, response improved in some rectal cancer models but an increase in other repair mechanisms likely diminishes the effect. A clinical trial is ongoing to further explore the role of DNA-PK inhibition in rectal cancer treatment.

A122 OUTCOMES OF COLD SNARE POLYPECTOMY FOR POLYPS GREATER THAN 20 MM: DATA FROM AN ACADEMIC CENTER

Background

Cold snare polypectomy (CSP) is widely utilized for resection of small polyps (less than 10mm), due to the technique’s favourable safety profile. However, Hot Snare Endoscopic Mucosal Resection (HSEMR) remains the standard of care for large polyps greater than or equal to 20mm. HSEMR carries an increased risk of complications. These include delayed bleeding, perforation, and post-polypectomy syndrome, along with residual or recurrent adenomatous (RRA).

More recently, Cold Snare Endoscopic Mucosal Resection (CSEMR) technique has been used selectively for polyps greater than 20mm. Published studies have demonstrated a significantly lower adverse event rate of complications as compared with HSEMR. RRA utilizing CSP remains a concern, with a recent publication reporting a recurrence of 34.8% on follow-up endoscopy. We present the experience at a single Canadian academic centre with patients undergoing CSEMR for polyps greater than 20mm.

Aims

To demonstrate the efficacy and safety of cold snare endoscopic mucosal resection CSEMR of large (greater than or equal to 20mm) polyps at a single Canadian academic centre.

Methods

We retrospectively reviewed colonoscopies performed by endoscopists employing this technique at our centre from January 2020 to August 2021. 15 total cases were identified for patients with polyps greater than or equal to 20 mm, removed by CSEMR technique.

Results

Patient age ranged from 41 to 76, with a median patient age was 66. There were 10 males and 5 females. There were no adverse events intraoperatively. 15/15 (100%) polyps were successfully resected using CSEMR technique. Polyp size ranged from 2 cm to 7 cm, and there was a median polyp size of 3 cm. 14/15 (93%) polyps were proximal to the splenic flexure, with 1/15 (7%) polyp in the rectum. 6/15 (40%) patients received snare tip soft coagulation to the edges of the polypectomy site. Polyp histology included 7 tubular adenomas, 3 tubulovillous adenomas, 4 sessile serrated polyps, and one hyperplastic polyp. Two patients were on aspirin 81 mg daily, and there were zero patients on any other antiplatelets or anticoagulation. 1/15 patient presented with late bleeding requiring emergent colonoscopy. There were no immediate or delayed perforations or other serious adverse events recorded.

Approximately 50% of patients have had follow-up colonoscopy within 3–6 months of their initial procedure. Follow-up ranged from 12 to 252 days, with a median time to follow up of 171 days. 3/7 (43%) patients had histologic evidence of recurrence at follow-up colonoscopy, all of which were successfully treated endoscopically.

Conclusions

Selective CSEMR is a safe and effective technique, with a low risk of complications. There may be a higher rate of residual polyp at follow-up colonoscopy compared to HSEMR. This data will need further validation with a larger sample size.

Funding Agencies

None

Sialyltransferase ST6GAL-1 mediates resistance to chemoradiation in rectal cancer

Locally advanced rectal cancer is typically treated with chemoradiotherapy followed by surgery. Most patients do not display a complete response to chemoradiotherapy, but resistance mechanisms are poorly understood. ST6GAL-1 is a sialyltransferase that adds the negatively charged sugar, sialic acid (Sia), to cell surface proteins in the Golgi, altering their function. We therefore hypothesized that ST6GAL-1 could mediate resistance to chemoradiation in rectal cancer by inhibiting apoptosis. Patient-derived xenograft and organoid models of rectal cancer and rectal cancer cell lines were assessed for ST6GAL-1 protein with and without chemoradiation treatment. ST6GAL-1 mRNA was assessed in untreated human rectal adenocarcinoma by PCR assays. Samples were further assessed by Western blotting, Caspase-Glo apoptosis assays, and colony formation assays. The presence of functional ST6GAL-1 was assessed via flow cytometry using the Sambucus nigra lectin, which specifically binds cell surface α2,6-linked Sia, and via lectin precipitation. In patient-derived xenograft models of rectal cancer, we found that ST6GAL-1 protein was increased after chemoradiation in a subset of samples. Rectal cancer cell lines demonstrated increased ST6GAL-1 protein and cell surface Sia after chemoradiation. ST6GAL-1 was also increased in rectal cancer organoids after treatment. ST6GAL-1 knockdown in rectal cancer cell lines resulted in increased apoptosis and decreased survival after treatment. We concluded that ST6GAL-1 promotes resistance to chemoradiotherapy by inhibiting apoptosis in rectal cancer cell lines. More research will be needed to further elucidate the importance and mechanism of ST6GAL-1-mediated resistance.

Drug connectivity mapping and functional analysis reveal therapeutic small molecules that differentially modulate myelination

Disruption or loss of oligodendrocytes (OLs) and myelin has devastating effects on CNS function and integrity, which occur in diverse neurological disorders, including Multiple Sclerosis (MS), Alzheimer's disease and neuropsychiatric disorders. Hence, there is a need to develop new therapies that promote oligodendrocyte regeneration and myelin repair. A promising approach is drug repurposing, but most agents have potentially contrasting biological actions depending on the cellular context and their dose-dependent effects on intracellular pathways. Here, we have used a combined systems biology and neurobiological approach to identify compounds that exert positive and negative effects on oligodendroglia, depending on concentration. Notably, next generation pharmacogenomic analysis identified the PI3K/Akt modulator LY294002 as the most highly ranked small molecule with both pro- and anti-oligodendroglial concentration-dependent effects. We validated these in silico findings using multidisciplinary approaches to reveal a profoundly bipartite effect of LY294002 on the generation of OPCs and their differentiation into myelinating oligodendrocytes in both postnatal and adult contexts. Finally, we employed transcriptional profiling and signalling pathway activity assays to determine cell-specific mechanisms of action of LY294002 on oligodendrocytes and resolve optimal in vivo conditions required to promote myelin repair. These results demonstrate the power of multidisciplinary strategies in determining the therapeutic potential of small molecules in neurodegenerative disorders.

Mobilizing human resources

The COVID-19 pandemic has confronted health systems with extraordinary changes in demand for health services, which magnified underlying disparities in the health workforce. Initial health workforce capacities were critical, as health systems only have two options to increase workforce level: increasing capacity among the existing workforce or mobilising/recruiting additional personnel. Workforce capacity became a limiting factor in an effective pandemic response, particularly in countries with acute workforce shortages. Countries in Europe have pursued various strategies to rapidly surge the numbers of health workers and using their existing human resources differently, including by introducing or expanding on alternative and flexible approaches such as task shifting and other skill-mix changes. The pressure to provide services across the continuum of care, from prevention and vaccination to specialist and inpatient care, led several countries to re-evaluate the distribution of tasks among the health workforce. In the best cases, multidisciplinary team-based staffing models combined the skills of multiple health professionals, enabling provision of the right care at the right time. This presentation will provide an overview of strategies to increase capacity for surges in human resources requirements, as well as supporting measures that help recognise the key role of health workers in the pandemic response. A brief overview of key metrics to assess resilience in the area of human resources will also be provided.

Mind the gap: population ageing and health financing sustainability

Background

Models used to forecast the effects of population ageing on health financing usually only explore effects on health spending, while neglecting effects on health revenues.

Methods

Using publicly available data, we construct simulation models to project how changes in the population age mix affect both public sector health revenues and expenditures across a range of countries representing a diverse mix of health financing systems in Europe as well as the Western Pacific (Australia, Bulgaria, Japan, Slovenia, United Kingdom and Vietnam).

Results

By 2100, the largest gap between health revenues and expenditures due to population ageing under current health financing arrangements is expected in Vietnam; the majority of that health financing gap (87.1%) is attributable to expected growth in health expenditures. In Slovenia and Japan, the financing gaps are forecast to reach less than half that of Vietnam by 2100; however, the reasons for the increases in gaps vary. In Slovenia, nearly half of the increase in the gap (44.2%) is due to reductions in health revenues compared with just under one-third (28.7%) in Japan.

Conclusions

There is a perception that population ageing will have deleterious effects on the sustainability of public sector health financing. However, this is highly dependent on how financing systems are designed. Our simulation models demonstrate that comparative analyses that give equal attention to both health expenditures and revenues provide decision makers a balanced set of policy options for addressing the challenges of population ageing. The options range from targeting expenditures and utilization of services to diversifying revenue generation.

How are countries supporting health workers? Data from the COVID-19 Health System Response Monitor

Background

Health workers have been at the forefront of treating and caring for patients with COVID-19. They were often under immense pressure to care for severely ill patients with a new disease, under strict hygiene conditions and with lockdown measures creating practical barriers to working. This study aims to explore the range of mental health, financial and other practical support measures that 36 countries in Europe and Canada have put in place to support health workers and enable them to do their job.

Methods

We use data extracted from the COVID-19 Health Systems Response Monitor (HSRM). We only consider initiatives implemented outside of clinical settings where COVID-19 patients are treated, and therefore exclude workplace provisions such as availability of personal protective equipment, working time limits or mandatory rest periods.

Results

We show that countries have implemented a range of measures, ranging from mental health and well-being support initiatives, to providing bonuses and temporary salary increases. Practical measures such as childcare provision and free transport and accommodation have also been implemented to ensure health workers can get to their workplace and have their children looked after. Other initiatives such as offering continuing professional development credits for knowledge learnt during the crisis were also offered in some countries, albeit less frequently.

Conclusions

While a large number of initiatives have been introduced, often as ad-hoc measures, their effectiveness in helping staff is unknown in most countries. The effectiveness of these initiatives should be evaluated to inform future crisis responses and strategies for health workforce development.

A cross-country comparison on providing health services effectively during the first wave of COVID-19

At the onset of the COVID-19 pandemic, health care providers had to abruptly change their way of providing care in order to simultaneously plan for and manage a rise of COVID-19 cases while maintaining essential health services. Even the most well-resourced health systems faced pressures from new challenges brought on by COVID-19, and every country had to make difficult choices about how to maintain access to essential care while treating a novel communicable disease. Using the information available on the HSRM platform from the early phases of the pandemic, we analyze how countries planned services for potential surge capacity, designed patient flows ensuring separation between COVID-19 and non-COVID-19 patients, and maintained routine services in both hospital and outpatient settings. Many country responses displayed striking similarities despite very real differences in the organization of health and care services. These include transitioning the management of COVID-19 mild cases from hospitals to outpatient settings, increasing the use of remote consultations, and cancelling or postponing non-urgent services during the height of the first wave. In the immediate future, countries will have to continue balancing care for COVID-19 and non-COVID-19 patients to minimize adverse health outcomes, ideally with supporting guidelines and COVID-19-specific care zones. Many countries expect to operate at lower capacity for routinely provided care, which will impact patient access and waiting times. Looking forward, policymakers will have to consider whether strategies adopted during the COVID-19 pandemic will become permanent features of care provision.

"Lest we forget": An overview of Australia's response to the recovery and identification of unrecovered historic military remains

The Australian Defence Force (ADF) is responsible for the recovery and identification of its historic casualties. With over 30,000 still unrecovered from past conflicts including World War One (WW1) and World War Two (WWII), the Australian Army and Royal Australian Air Force have teams that research, recover, identify and oversee the burial (or reburial) of the remains of soldiers and airmen who continue to be found each year. The Royal Australian Navy is also responsible for its unrecovered casualties. Collectively the priorities of the various services within the ADF are the respectful recovery and treatment of the dead, thorough forensic identification efforts, resolution for families and honouring the ADF's proud history of service and sacrifice. What is unique about the approach of the ADF is that the respective services retain responsibility for their historic losses, while a joint approach is taken on policies and in the utilisation of the pool of forensic specialists. Section One describes the process undertaken by the Australian Army in the recovery, identification and burial or repatriation of soldiers through its specialised unit Unrecovered War Casualties - Army (UWC-A). Section Two describes the role of the Royal Australian Air Force in the recovery of aircraft and service personnel through their specialised unit Historic Unrecovered War Casualties - Air Force (HUWC-AF). An overview of the operations of each service and case studies is presented for each section.

732 Delay to Elective Colorectal Cancer Surgery and its Potential Implications During the Covid-19 Pandemic: A Systematic Review and Metanalysis

Aim

The ongoing Covid-19 pandemic has interrupted the surgical treatment of colorectal cancer (CRC). This systematic review will assess literature concerning the risk of delay of elective surgery for CRC patients, focusing on overall survival (OS) and disease-free survival (DFS).

Method

A systematic review was performed as per PRISMA guidelines (PROSPERO ID: CRD42020189158). Medline, EMBASE and Scopus were searched. Delay to elective surgery was defined as the period between CRC diagnosis and the day of surgery. Metanalyses of the outcome’s OS and DFS were conducted. Forest plots, funnel plots, and tests of heterogeneity were produced. An estimated Number Needed to Harm (NNH) was calculated for statistically significant pooled Hazard Ratios (HRs).

Results

Of 3753 articles identified, seven met the inclusion criteria. Encompassing 314560 patients, three of the seven studies showed that a delay to elective resection is associated with poorer OS or DFS. OS was assessed at a one-month delay, the HR for six datasets was 1.13 (95%CI 1.02-1.26, p = 0.020) and at three months the pooled HR for three datasets was 1.57 (95%CI 1.16-2.12, p = 0.004). Estimated NNHs for a delay at one month and three months were 35 and 10 respectively. Delay was non-significantly negatively associated with DFS on meta-analysis.

Conclusions

This review recommends that elective surgery for CRC patients is not postponed, as evidence suggests delays from diagnosis are associated with poorer outcomes. Focused research is essential so that patient groups can be prioritized based on risk factors for future pandemics.

The effect of a low-load plyometric running intervention on leg stiffness in youth with cerebral palsy: A randomised controlled trial

AIM

To determine whether a running intervention utilising plyometric activities improved leg stiffness in youth with cerebral palsy (CP), GMFCS levels I and II.

METHOD

This stratified randomised controlled trial examined the lower limb kinetics and kinematics of a sample of youths with CP during sub-maximal hopping and running, prior to and immediately following a 12-week running intervention that incorporated low load plyometric training. Included participants were 13 in the control group (mean age 13 years 2 months [SD 2 years 7 months]; six males; nine GMFCS level I; six unilateral) and 18 in the intervention group (mean age 12 years 9 months [SD 2 years 10 months]; 13 males; 11 GMFCS level I; nine unilateral). Derived variables included three-dimensional leg stiffness as well as resultant ground reaction force and change in leg length. Generalised linear mixed models were developed for statistical analysis.

RESULTS

At follow-up the intervention group had greater leg stiffness than the control group during submaximal hopping (Intervention median = 3278Nm^-1; Control median = 1556Nm^-1; p < 0.01). At follow-up, participants in the intervention group in GMFCS Level I had greater leg stiffness than the control group during jogging (Intervention mean=38.84 (SD=25.55); Control mean=29.38 (SD=11.11); t = 2.61 p = 0.01).

INTERPRETATION

A running training intervention which includes plyometric activities can improve leg stiffness in young people with CP, especially those in GMFCS level I.

Exploring the active ingredients of workplace physical and psychological wellbeing programs: a systematic review

Previous reviews have established that workplace wellbeing initiatives are effective at promoting wellbeing, but less is known about which intervention characteristics or "active ingredients" underpin this effectiveness (i.e., behavior change techniques [BCTs]). This review aims to illuminate the connections between the types of BCTs and the level of intervention intensity with intervention effectiveness. A systematic search for peer-reviewed studies evaluating a workplace wellbeing initiative was undertaken across five databases: Medline, Scopus, PsycInfo, and CINAHL (Ovid Emcare). Eligible studies included those that evaluated the effect of a workplace wellbeing initiative on participants' physical wellbeing (e.g., physical activity and quality of life) and psychological wellbeing (e.g., mental health and stress), were published between 2009 and September 2019, and utilized a comparator (e.g., control group or prepost change). Studies were screened in independent duplicate to minimize bias. Effect sizes were calculated. Following removal of duplicates, 1,541 studies were identified and screened for eligibility. Of these, 23 studies reporting 28 comparisons were deemed to meet eligibility criteria. Just over 50% of these studies reported evidence of either a strong or moderate effect across a physical and a psychological outcome, providing a positive indication that workplace wellbeing programs can promote physical and psychological wellbeing in workers. Interventions tended to employ multiple BCTs (mean range 8.1-9.4), however, no discernible patterns between the types or numbers of BCTs employed and intervention effectiveness was found. Further experimental work is required that compares and contrasts workplace wellbeing initiatives to enable a better understanding of how to develop and implement highly effective programs.

Seroconversion and fever are dose-dependent in a nonhuman primate model of inhalational COVID-19

While evidence exists supporting the potential for aerosol transmission of SARS-CoV-2, the infectious dose by inhalation remains unknown. In the present study, the probability of infection following inhalation of SARS-CoV-2 was dose-dependent in a nonhuman primate model of inhalational COVID-19. The median infectious dose, assessed by seroconversion, was 52 TCID50 (95% CI: 23-363 TCID50), and was significantly lower than the median dose for fever (256 TCID50, 95% CI: 102-603 TCID50), resulting in a group of animals that developed an immune response post-exposure but did not develop fever or other clinical signs of infection. In a subset of these animals, virus was detected in nasopharyngeal and/or oropharyngeal swabs, suggesting that infected animals without signs of disease are able to shed virus and may be infectious, which is consistent with reports of asymptomatic spread in human cases of COVID-19. These results suggest that differences in exposure dose may be a factor influencing disease presentation in humans, and reinforce the importance of public health measures that limit exposure dose, such as social distancing, masking, and increased ventilation. The dose-response data provided by this study are important to inform disease transmission and hazard modeling, and, ultimately, mitigation strategies. Additionally, these data will be useful to inform dose selection in future studies examining the efficacy of therapeutics and vaccines against inhalational COVID-19, and as a baseline in healthy, young adult animals for assessment of the importance of other factors, such as age, comorbidities, and viral variant, on the infectious dose and disease presentation.

Improved outcomes with minimally invasive pancreaticoduodenectomy in patients with dilated pancreatic ducts: a prospective study

Background

Little is known about what factors predict better outcomes for patients who undergo minimally invasive pancreaticoduodenectomy (MIPD) versus open pancreaticoduodenectomy (OPD). We hypothesized that patients with dilated pancreatic ducts have improved postoperative outcomes with MIPD compared to OPD.

Methods

All patients undergoing pancreaticoduodenectomy were prospectively followed over a time period of 47 months, and perioperative and pathologic covariates and outcomes were compared. Ideal outcome after PD was defined as follows: (1) no complications, (2) postoperative length of stay < 7 days, and (3) negative (R0) margins on pathology. Patients with dilated pancreatic ducts (≥ 3 mm) who underwent MIPD were 1:3 propensity score-matched to patients with dilated ducts who underwent OPD and outcomes compared. Likewise, patients with non-dilated pancreatic ducts (< 3 mm) who underwent MIPD were 1:3 propensity score-matched to patients with non-dilated ducts who underwent OPD and outcomes were compared.

Results

371 patients underwent PD—74 (19.9%) MIPD and 297 (80.1%) underwent OPD. Overall, patients who underwent MIPD had significantly less intraoperative blood loss. After 1:3 propensity score matching, patients with dilated pancreatic ducts who underwent MIPD (n = 45) had significantly lower overall complication and 90-day readmission rates compared to matched OPD patients (n = 135) with dilated ducts. Patients with dilated duct who underwent MIPD were more likely to have an ideal outcome than patients with OPD (29 vs 15%, p = 0.035). There were no significant differences in postoperative outcomes among propensity score-matched patients with non-dilated pancreatic ducts who underwent MIPD (n = 29) compared to matched patients undergoing OPD (n = 87) with non-dilated ducts.

Conclusions

MIPD is safe with comparable perioperative outcomes to OPD. Patients with pancreatic ducts ≥ 3 mm appear to derive the most benefit from MIPD in terms of fewer complications, lower readmission rates, and higher likelihood of ideal outcome.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00464-021-08611-x.

467 Impact of the Coronavirus Pandemic on Acute Surgical Patients’ Discharge Summaries

Background

The emergence of the Coronavirus pandemic has placed increased demands on the NHS workforce, especially in medical and intensive care units. The subsequent redistribution of surgical house officers to accommodate this in a single centre has possibly negatively impacted on the effective discharge notification of acute surgical patients.

Methods:

Discharge summaries of all patients discharged from a Surgical Assessment Unit were collected and analysed, to identify the date of completion and grade of responsible clinician. Data collection was carried out over three weeks before the initiation of lockdown measures and continued for a further three weeks during the peak of the Coronavirus pandemic with a three-week interventional period in between.

Results

In the initial audit, 36.2% of the 246 patients had delayed discharge summaries with an average of 7 days to complete. On re-evaluation, 45.3% of the 223 patients had delayed discharge summaries, with an average of 12 days to complete. A survey conducted post-re-audit identified that the most common reason for this was due to time constraints.

Conclusions

The reallocation of surgical staff has affected communication between primary and secondary care. Given the potential repercussions of these delays, healthcare systems should be made aware of this consequence, especially in preparation for any future resurgences.

Comparison of the performance of aerosol sampling devices for measuring infectious SARS-CoV-2 aerosols

To assess the risk of aerosol transmission of SARS-CoV-2, measurements of the airborne viral concentrations in proximity to infected individuals, the persistence of the virus in aerosols, and the dose of the virus needed to cause infection following inhalation are required. For studies aimed at quantifying these parameters, an aerosol sampling device needs to be employed. A number of recent studies have reported the detection of both genetic material and infectious SARS-CoV-2 virus in air samples collected in clinical settings. Previous studies have demonstrated that the efficiency of different samplers for collection and preservation of the infectivity of microorganisms can vary as a function of the specific microorganism. In the present study, the performance of eight common low-flow aerosol sampling devices were compared for their ability to collect and preserve the infectivity of airborne SARS-CoV-2 contained in small particle aerosols. The influence of sampling duration on recovery of infectious virus was also evaluated. Similar concentrations of infectious SARS-CoV-2 were measured in aerosols for the majority of the samplers tested, with the exception of the midget impingers, which measured significantly lower concentrations of SARS-CoV-2. Additionally, in three of the four impingers tested, additional clean airflow through the device following collection of infectious virus resulted in a decrease of the infectious concentration of virus over time, suggesting that virus was being inactivated and these devices may not be suitable for sampling for long durations. Further, RNA copies in the samples over time did not correspond with the losses of infectious SARS-CoV-2 observed in the impingers samples. These data can be utilized to inform interpretation of current studies on the SARS-CoV-2 viral loads in air samples, as well as inform sampling device selection in future studies.

The stability of an isolate of the SARS-CoV-2 B.1.1.7 lineage in aerosols is similar to three earlier isolates

Background

Our laboratory previously examined the influence of environmental conditions on the stability of an early isolate of SARS-CoV-2 (hCoV-19/USA/WA-1/2020) in aerosols generated from culture medium or simulated saliva. However, genetic differences have emerged among SARS-CoV-2 lineages, and it is possible that these differences may affect environmental stability and the potential for aerosol transmission.

Methods

The influence of temperature, relative humidity, and simulated sunlight on the decay of four SARS-CoV-2 isolates in aerosols, including one belonging to the recently emerged B.1.1.7 lineage, were compared in a rotating drum chamber. Aerosols were generated from simulated respiratory tract lining fluid to represent aerosols originating from the deep lung.

Results

No differences in the stability of the isolates were observed in the absence of simulated sunlight at either 20°C or 40°C. However, a small but statistically significant difference in the stability was observed between some isolates in simulated sunlight at 20°C and 20% relative humidity. .

Conclusions

The stability of SARS-CoV-2 in aerosols does not vary greatly among currently circulating lineages, including B.1.1.7, suggesting that the increased transmissibility associated with recent SARS-CoV-2 lineages is not due to enhanced survival in the environment.

Predicting Outcomes in Patients Undergoing Pancreatectomy Using Wearable Technology and Machine Learning: Prospective Cohort Study

Background

Pancreatic cancer is the third leading cause of cancer-related deaths, and although pancreatectomy is currently the only curative treatment, it is associated with significant morbidity.

Objective

The objective of this study was to evaluate the utility of wearable telemonitoring technologies to predict treatment outcomes using patient activity metrics and machine learning.

Methods

In this prospective, single-center, single-cohort study, patients scheduled for pancreatectomy were provided with a wearable telemonitoring device to be worn prior to surgery. Patient clinical data were collected and all patients were evaluated using the American College of Surgeons National Surgical Quality Improvement Program surgical risk calculator (ACS-NSQIP SRC). Machine learning models were developed to predict whether patients would have a textbook outcome and compared with the ACS-NSQIP SRC using area under the receiver operating characteristic (AUROC) curves.

Results

Between February 2019 and February 2020, 48 patients completed the study. Patient activity metrics were collected over an average of 27.8 days before surgery. Patients took an average of 4162.1 (SD 4052.6) steps per day and had an average heart rate of 75.6 (SD 14.8) beats per minute. Twenty-eight (58%) patients had a textbook outcome after pancreatectomy. The group of 20 (42%) patients who did not have a textbook outcome included 14 patients with severe complications and 11 patients requiring readmission. The ACS-NSQIP SRC had an AUROC curve of 0.6333 to predict failure to achieve a textbook outcome, while our model combining patient clinical characteristics and patient activity data achieved the highest performance with an AUROC curve of 0.7875.

Conclusions

Machine learning models outperformed ACS-NSQIP SRC estimates in predicting textbook outcomes after pancreatectomy. The highest performance was observed when machine learning models incorporated patient clinical characteristics and activity metrics.

NEVBD Pesticide Resistance Monitoring Network: Establishing a Centralized Network to Increase Regional Capacity for Pesticide Resistance Detection and Monitoring

Pesticide resistance in arthropod vectors of disease agents is a growing issue globally. Despite the importance of resistance monitoring to inform mosquito control programs, no regional monitoring programs exist in the United States. The Northeastern Regional Center for Excellence in Vector-Borne Diseases (NEVBD) is a consortium of researchers and public health practitioners with a primary goal of supporting regional vector control activities. NEVBD initiated a pesticide resistance monitoring program to detect resistant mosquito populations throughout the northeastern United States. A regionwide survey was distributed to vector control agencies to determine needs and refine program development and in response, a specimen submission system was established, allowing agencies to submit Culex pipiens (L.) (Diptera:Culicidae) and Aedes albopictus (Skuse) (Diptera: Culicidae) for pesticide resistance testing. NEVBD also established larvicide resistance diagnostics for Bacillus thuringiensis israelensis (Bti) and methoprene. Additional diagnostics were developed for Cx. pipiens resistance to Lysinibacillus sphaericus. We received 58 survey responses, representing at least one agency from each of the 13 northeastern U.S. states. Results indicated that larvicides were deployed more frequently than adulticides, but rarely paired with resistance monitoring. Over 18,000 mosquitoes were tested from six states. Widespread low-level (1 × LC-99) methoprene resistance was detected in Cx. pipiens, but not in Ae. albopictus. No resistance to Bti or L. sphaericus was detected. Resistance to pyrethroids was detected in many locations for both species. Our results highlight the need for increased pesticide resistance testing in the United States and we provide guidance for building a centralized pesticide resistance testing program.

A109 LINKING PRIMARY AND SPECIALTY CARE FOR THE MANAGEMENT OF DIGESTIVE HEALTH CONDITIONS: AN EVALUATION OF GUT LINK IMPLEMENTATION

Background

Severe restrictions on in-person encounters and endoscopic procedures for digestive care have occurred as a result of the COVID-19 pandemic. This has exacerbated pre-existing barriers in access to gastroenterology (GI) care across Nova Scotia (NS) for patients and primary healthcare providers (PHCPs). In response, a provincial PHCP-GI consultative service (GUT LINK) was implemented at a single tertiary care center with the goal of supporting PHCPs in the management of non-urgent GI referral conditions.

Aims

To implement and evaluate the acceptability, feasibility, appropriateness, and early effectiveness of the GUT LINK PHCP-GI consultation service.

Methods

This is an ongoing prospective observational cohort study. All referrals received through the EMR-based referral and triage management system between May and November 2020 that were deemed to be amenable to management within primary care with specialist support were returned to the PHCP with the suggestion to arrange a GUT LINK telephone consultation. GUT LINK appointments were scheduled through an administrative support telephone line with the PHCP and a GI specialist. A post-consultation e-questionnaire was distributed to PHCPs who consented to participate. Feasibility (number of and indication for referrals, PHCP participation rates), acceptability and appropriateness (satisfaction, future use, likelihood to recommend) metrics and outcomes (case resolution, re-referrals, proportion requiring endoscopic investigations) were recorded. Patient charts were reviewed to determine whether the patient ultimately required GI speciality care. Analyses were descriptive and expressed as frequencies, means (+/-SD), medians (+/-SE), and proportions (%).

Results

A total of 45 GUT LINK consultations were completed between May and November 2020. Of these, 20% required GI specialist care and 80% have remained within primary care, with a median follow-up of 101 (+/-9.1) days. The indications for GUT LINK consultation included lower GI symptoms (64%), abnormal imaging or investigations (17%), and upper GI symptoms (19%).

To date, 21 PHCP agreed to be contacted for the post-consultation survey and 10 have been completed. All PHCPs reported that GUT LINK consultation was easy to access, while 90% found the advice helpful and 80% reported that that it resolved the issue. Following the GUT LINK appointment, 80% felt they would not need to refer their patient to GI.

Conclusions

The implementation of GUT LINK was acceptable, feasible, and improved access to specialist support for management of undifferentiated GI symptoms. Future research will focus on comprehensive stakeholder engagement in order to design, implement, and evaluate GUT LINK PHCP care pathways.

Funding Agencies

CAG

A85 THE CLINICAL IMPACT OF COVID-19 DELAYS ON PLASTIC BILIARY STENT REMOVAL IN NOVA SCOTIA

Background

The COVID-2019 pandemic continues to restrict access to endoscopy, resulting in delays or cancellation of non-urgent endoscopic procedures. A delay in the removal or exchange of plastic biliary stents may lead to stent occlusion with consensus recommendation of stent removal or exchange at three-month intervals [1–4]. We postulated that delayed plastic biliary stent removal (DPBSR) would increase complication rates.

Aims

We aim to report our single-centre experience with complications arising from DPBSR.

Methods

This was a retrospective, single-center, observational cohort study. All subjects who had ERCP-guided plastic biliary stent placement in Halifax, Nova Scotia between Dec 2019 and June 2020 were included in the study. DPBSR was defined as stent removal &gt;=90 days from insertion. Four endpoints were assigned to patients: 1. Stent removed endoscopically, 2. Died with stent in-situ (measured from stent placement to documented date of death/last clinical encounter before death), 3. Pending removal (subjects clinically well, no liver enzyme elevation, not expired, endpoint 1 Nov 2020), and 4. Complication requiring urgent reintervention. Kaplan-Meier survival analysis was used to represent duration of stent patency (Fig.1).

Results

102 (47.2%) had plastic biliary stents placed between 2/12/2019 and 29/6/2020. 49 (48%) were female, and the median age was 68 (R 16–91). Median follow-up was 167.5 days, 60 (58.8%) subjects had stent removal, 12 (11.8%) died before replacement, 21 (20.6%) were awaiting stent removal with no complications (median 230d, R 30–332), 9 (8.8%) had complications requiring urgent ERCP. Based on death reports, no deaths were related to stent-related complications.

72(70.6%) of patients had stents in-situ for &gt;= 90 days. In this population, median time to removal was 211.5d (R 91-441d). 3 (4.2%) subjects had stent-related complications requiring urgent ERCP, mean time to complication was 218.3d (R 94–441). Stent removal &gt;=90 days was not associated with complications such as occlusion, cholangitis, and migration (p=1.0). Days of stent in-situ was not associated with occlusion, cholangitis, and migration (p=0.57). Sex (p=0.275), cholecystectomy (p=1.0), cholangiocarcinoma (p=1.0), cholangitis (p=0.68) or pancreatitis (p=1.0) six weeks prior to ERCP, benign vs. malignant etiology (p=1.0) were not significantly associated with stent-related complications.

Conclusions

Plastic biliary stent longevity may have been previously underestimated. The findings of this study agree with CAG framework recommendations [5] that stent removal be prioritized as elective (P3). Limitations include small sample size that could affect Kaplan-Meier survival analysis. Despite prolonged indwelling stent time as a result of COVID-19, we did not observe an increased incidence of stent occlusion or other complications.

Funding Agencies

None

A rare report on 18-month survival of a dog born with multiple anomalies including atresia ani

Long term survival of animals with major congenital anomalies is very rare. This report documents the 18-month survival of a dog with multiple anomalies including atresia ani. An 18-month-old black Cocker Spaniel bitch was presented for evaluation of prolapsed glands of the third eyelid involving both the eyes. Clinical examination revealed a single perineal opening, fecal matter in the vestibule, distended abdomen, hypoplastic vulva, and the absence of a tail without any neurological deficits. Abdominal contrast radiography revealed a distended colon with fecal stasis, rectovestibular fistula, termination of the rectum as a blind pouch, lumbar scoliosis due to block vertebrae, and the presence of only two hypoplastic coccygeal vertebrae. The case was diagnosed as atresia ani type II with rectovestibular fistula, hypoplastic vulva, lumbar scoliosis, and anury, in the global context of a caudal regression syndrome. The wide aperture fistula, connected to the vestibule, undamaged spinal cord and sacrum without any neurological deficits were the favorable prognostic factors that maintained continence and allowed the dog to survive to adult life with these anomalies. Thus, an appropriate bowel management program and specialty care can improve the quality of life and longevity of this animal.

Panniculitis at the Site of Injection: Infection or Foreign Body Reaction?

Introduction/Objective

A 63 year old diabetic female presented to the dermatology clinic with painful abdominal nodules. The nodules seemed to wax and wane every 1–2 weeks and appeared in different locations on the abdomen. The lesions were subcutaneous, tender, firm, and mobile with no discoloration. The patient had diabetes treated with injectable exenatide but no other significant medical or travel history.

Methods

The differential diagnoses included mycobacterial infection, mechanical insult from injectable diabetes medication, erythema nodosum, erythema induratum, and lupus panniculitis. Ultrasound was indicative of panniculitis. A biopsy of the active lesion was performed.

Results

The biopsy showed septal and lobular panniculitis with mixed inflammation and multinucleated giant cells. Small, circular, non-polarizable pink amphorous material was associated with the infiltrate. The amphorous material was strongly acid fast. The patient had a negative quantiferon-TB test. Scanning electron microscopy with energy dispersive x-ray analysis showed that the material contained more oxygen and less carbon than surrounding tissue, but no abnormal elements were identified. Infrared spectroscopy of the foreign material most closely matched poly(L- lactide-co-glycolide).

Conclusion

The diagnosis of exenatide induced granulomatous panniculitis was made. The patient had recently started using this injectable glucagon-like peptide-1 receptor agonist, which has been associated with panniculitis. The injectable formulation is loaded onto microspheres composed of poly (DL-lactic-co-glycolic acid), which is closely related to poly(L-lactide-co-glycolide). This material has been shown to stain strongly acid fast. This case of granulomatous panniculitis due to injectable diabetic medication highlights an important potential pitfall that pathologists should be aware of, especially in cases where mycobacterial infection is in the differential.

Does PD-L1 Positivity in Inflammatory Cells Correlate with PD-L1 Expression in Tumor Cells in Colorectal Adenocarcinoma?

Introduction/Objective

Drugs targeting the programmed death-1 (PD-1) and programmed death-ligand 1 (PD-L1) checkpoint is an important type of novel immunotherapy. These checkpoint inhibitors are being used in a wide variety of cancers, including colorectal carcinoma (CRC). PD-L1 expression on tumor cells in CRC is predictive of good response to checkpoint inhibitor therapies. PD-L1 expression on tumor infiltrating immune cells (TIIC) is increasingly observed and independently portends good prognosis. The relationship between PD-L1 positivity in TIIC and tumor cells is not well established. In this study, the relationship and correlation of PD-L1 positivity in TIIC and tumor cells were retrospectively reviewed.

Methods

197 sections of CRC from 33 cases (mean of 6 sections/case) with heterogeneous expression of PD-L1 on tumor cells were stained for PD-L1 with immunohistochemistry. None of the patients had received neo-adjuvant therapy. The presence of tumor cells and immune cells with positive PD-L1 expression was noted for each section.

Results

Immune cells were positive in 79% of the sections examined. TIIC were positive in 56% of the sections examined. A Cohen’s correlation study showed correlation between tumor cells and TIIC in 77% of the cases (k=0.51, moderate agreement). There was at least one section with PD-L1 positive TIIC in 97% of cases.

Conclusion

This study shows that PD-L1 is expressed in TIIC in the vast majority of CRC cases designated PD-L1 positive and that PD-L1 is positive in TIIC at a higher rate than in tumor cells. The moderate correlation is interesting, perhaps suggesting that if TIIC are noted to be positive for PD-L1 and tumor cells are not, additional sections of tumor should be stained.

Heterogeneity and Geographical Patterns of PD-L1 Positive Tumor Infiltrating Immune Cells in Colonic Adenocarcinoma

Introduction/Objective

Programmed death-ligand 1 (PD-L1) status is an important prognostic and predictive biomarker. PD-L1 status is difficult to accurately assess in tumor cells (TCs) due to tumor heterogeneity and lack of standardized histologic evaluation. PD-L1 expression by tumor infiltrating immune cells (TIICs) is an independent prognostic marker and may provide fewer diagnostic challenges, as TIICs appear less heterogeneous. We examined the geographical patterns of PD-L1 expression in TCs and TIICs in order to evaluate heterogeneity and ease of histological evaluation.

Methods

197 blocks of colonic adenocarcinoma from 33 patients were retrospectively reviewed and stained for PD- L1. PD-L1 was interpreted as positive or negative in the TCs and TIICs. Geographical patterns of expression were recorded for the TCs and the TIICs at the surface, center of tumor, and invasive margin. Geographical patterns were compared using a chi-square test.

Results

56% of blocks had PD-L1 positive TCs. 42.7% showed positive TCs at the invasive margin. 38.2% had positive TCs at the invasive margin and surface. No blocks had positive TCs at the center of the tumor. 79% of blocks had PD-L1 positive TIICs. 20% showed positive TIICs at the invasive margin. 37.4% had positive TIICs at the surface and invasive margin. 15.5% of TIICs expressed PD-L1 throughout the tumor. There was a statistically significant difference in PD-L1 expression on TCs versus TIICs in 4 of the 7 geographic patterns.

Conclusion

PD-L1 expression on TCs of colonic adenocarcinoma is more heterogeneous than PD-L1 expression by TIICs. TIICs express PD-L1 more consistently throughout the tumor and are easier to identify and report. PD-L1 expression by TIICs is an independent prognostic indicator and may be more useful than TCs when evaluating the tumor microenvironment and determining PD-L1 status.

Safety and feasibility of initiating a hepatic artery infusion pump chemotherapy program for unresectable colorectal liver metastases: A multicenter, retrospective cohort study

INTRODUCTION

Hepatic artery infusion pump (HAIP) chemotherapy is a specialized therapy for patients with unresectable colorectal liver metastases (uCRLM). Its effectiveness was demonstrated from a high volume center, with uncertainty regarding the feasibility and safety at other centers. Therefore, we sought to assess the safety and feasibility of HAIP for the management of uCRLM at other centers.

METHODS

We conducted a multicenter retrospective cohort study of patients with uCRLM treated with HAIP from January 2003 to December 2017 at six North American centers initiating the HAIP program. Outcomes included the safety and feasibility of HAIP chemotherapy.

RESULTS

We identified 154 patients with HAIP insertion and the median age of 54 (48-61) years. The burden of disease was >10 intra-hepatic metastatic foci in 59 (38.3%) patients. Patients received at least one cycle of systemic chemotherapy before HAIP insertion. Major complications occurred in 7 (4.6%) patients during their hospitalization and 13 (8.4%) patients developed biliary sclerosis during follow-up. A total of 148 patients (96.1%) received at least one-dose of HAIP chemotherapy with a median of 5 (4-7) cycles. 78 patients (56.5%) had a complete or partial response and 12 (7.8%) received a curative liver resection.

CONCLUSION

HAIP programs can be safely and effectively initiated in previously inexperienced centers with good response.

Health professional mobility and the Global Code of Practice: joint EUROSTAT/OECD/WHO survey data

Background

This study assesses the impact and continuing relevance of the Code of Practice on the International Recruitment of Health Personnel in the WHO Europe region by analysing trends over time in intra- and inter-regional health worker mobility.

Methods

Data from the joint EUROSTAT/OECD/WHO questionnaire are analysed to determine 1) the proportion of foreign-born and foreign-trained doctors and nurses working in WHO Europe Member States, 2) trends in health workforce mobility over time by country of origin and destination, and 3) how the Global Code has impacted mobility patterns.

Results

The size of the foreign-trained health workforce in Europe varies widely, with foreign-trained doctors comprising over a quarter of the workforce in Norway, Switzerland and the UK, but below 2% in Estonia and Serbia. While annual in-flows across the region have been stable since 2009, the share of foreign-trained doctors and nurses have both increased by over 30%. Mobility between The Commonwealth of Independent States has remained steady, but an increase in East-West and South-North migration is observed, driven by European Union expansion in 2004 and the economic crisis. Migration of health workers into Europe from developing countries covered by the Code has fluctuated, with increased numbers seen from some origin countries (e.g. Nigeria, Pakistan). Some Western countries remain reliant on a foreign-trained health workforce. This contributes to a high outward flow of health professionals from other European countries and creates challenges for sustainable workforce development.

Conclusions

The Global Code remains highly relevant, but other factors have more impact on migration flows, such as free movement in the EU. Health workforce mobility data can be improved to support a 'whole of workforce' approach to policy and planning by including more professional groups, and by adding qualitative indicators, e.g. individual perceptions and intention to leave.