Vascular access surgery training in the United Kingdom is currently perceived (by trainees) to be inadequate

INTRODUCTION

Vascular access surgery (VAS) involves the creation and maintenance of arteriovenous access to facilitate haemodialysis. The prevalence of haemodialysis is rising despite increases in kidney transplants on a yearly basis. There is currently only one access surgery fellowship accredited by the Royal College of Surgeons of England. We aimed to establish the experience and perceived competence in access surgery of senior vascular surgery trainees.

METHODS

A short questionnaire (SurveyMonkey) was used to survey all senior (ST6-ST8) vascular surgery trainees in Health Education England (HEE) vascular surgery training programmes. The short survey asked trainees to report their: (1) training grade; (2) training deanery; (3) experience of access surgery; and (4) whether senior trainees thought they would be able to independently undertake primary access surgery post-completion of training (post Certificate of Completion of Training). The survey was circulated via HEE deaneries and the vascular surgery trainees' society: the Rouleaux Club.

RESULTS

Twenty-eight senior (ST6-ST8) vascular surgery trainees responded to the survey: 29.6% were ST6 level, 33.3% were ST7 and 37.1% were ST8. Deanery respondence was evenly spread, although London was overrepresented (37.1%). In total, 28.6% had been involved in fewer than 10 cases, 35.7% in 10-25 cases, and 35.7% in more than 25 cases. Almost 54% of senior vascular surgery trainees believed they would not be able to undertake independent access surgery once they had completed training.

CONCLUSIONS

Competence in access surgery is an increasing requirement of a consultant vascular surgeon. More formalised training is required to adequately train the next generation of vascular surgeons.

Vascular access surgery training in the United Kingdom is currently perceived (by trainees) to be inadequate

INTRODUCTION

Vascular access surgery (VAS) involves the creation and maintenance of arteriovenous access to facilitate haemodialysis. The prevalence of haemodialysis is rising despite increases in kidney transplants on a yearly basis. There is currently only one access surgery fellowship accredited by the Royal College of Surgeons of England. We aimed to establish the experience and perceived competence in access surgery of senior vascular surgery trainees.

METHODS

A short questionnaire (SurveyMonkey) was used to survey all senior (ST6-ST8) vascular surgery trainees in Health Education England (HEE) vascular surgery training programmes. The short survey asked trainees to report their: (1) training grade; (2) training deanery; (3) experience of access surgery; and (4) whether senior trainees thought they would be able to independently undertake primary access surgery post-completion of training (post Certificate of Completion of Training). The survey was circulated via HEE deaneries and the vascular surgery trainees' society: the Rouleaux Club.

RESULTS

Twenty-eight senior (ST6-ST8) vascular surgery trainees responded to the survey: 29.6% were ST6 level, 33.3% were ST7 and 37.1% were ST8. Deanery respondence was evenly spread, although London was overrepresented (37.1%). In total, 28.6% had been involved in fewer than 10 cases, 35.7% in 10-25 cases, and 35.7% in more than 25 cases. Almost 54% of senior vascular surgery trainees believed they would not be able to undertake independent access surgery once they had completed training.

CONCLUSIONS

Competence in access surgery is an increasing requirement of a consultant vascular surgeon. More formalised training is required to adequately train the next generation of vascular surgeons.

Fertility Potential and Gonadal Function in Survivors of Reduced-Intensity Hematopoietic Stem Cell Transplantation

The use of reduced-intensity conditioning (RIC) regimens has increased in an effort to minimize hematopoietic stem cell transplantation (HCT) end-organ toxicity, including gonadal toxicity. We aimed to describe the incidence of fertility potential and gonadal function impairment in adolescent and young adult survivors of HCT and to identify risk factors (including conditioning intensity) for impairment. We performed a multi-institutional, international retrospective cohort study of patients age 10 to 40 years who underwent first allogeneic HCT before December 1, 2019, and who were alive, in remission, and available for follow-up at 1 to 2 years post-HCT. For females, an AMH level of ≥.5 ng/mL defined preserved fertility potential; an AMH level of ≥.03 ng/mL was considered detectable. Gonadal failure was defined for females as an elevated follicle-stimulating hormone (FSH) level >30 mIU/mL with an estradiol (E2) level <17 pg/mL or current use of hormone replacement therapy (regardless of specific indication or intent). For males, gonadal failure was defined as an FSH level >10.4 mIU/mL or current use of hormone replacement therapy. A total of 326 patients (147 females) were available for analysis from 17 programs (13 pediatric, 4 adult). At 1 to 2 years post-HCT, 114 females (77.6%) had available FSH and E2 levels and 71 (48.3%) had available AMH levels. FSH levels were reported for 125 males (69.8%). Nearly all female HCT recipients had very low levels of AMH. One of 45 (2.2%) recipients of myeloablative conditioning (MAC) and four of 26 (15.4%) recipients of reduced-intensity conditioning (RIC) (P = .06) had an AMH ≥.5 ng/m, and 8 of 45 MAC recipients (17.8%) and 12 of 26 RIC recipients (46.2%) (P = .015) had a detectable AMH level. Total body irradiation (TBI) dose and cyclophosphamide equivalent dose (CED) were not associated with detectable AMH. The incidence of female gonadal hormone failure was 55.3%. In univariate analysis, older age at HCT was associated with greater likelihood of gonadal failure (median age, 17.6 versus 13.9; P < .0001), whereas conditioning intensity (RIC versus MAC), TBI, chronic graft-versus-host disease requiring systemic therapy, and CED were not significantly associated with gonadal function. In multivariable analysis, age remained statistically significant (odds ratio [OR]. 1.11; 95% confidence interval [CI], 1.03 to 1.22) for each year increase; P = .012), Forty-four percent of the males had gonadal failure. In univariate analysis, older age (median, 16.2 years versus 14.4 years; P = .0005) and TBI dose (P = .002) were both associated with gonadal failure, whereas conditioning intensity (RIC versus MAC; P = .06) and CED (P = .07) were not statistically significant. In multivariable analysis, age (OR, 1.16; 95% CI, 1.06-1.27 for each year increase; P = .0016) and TBI ≥600 cGy (OR, 6.23; 95% CI, 2.21 to 19.15; P = .0008) remained significantly associated with gonadal failure. Our data indicate that RIC does not significantly mitigate the risk for gonadal failure in females or males. Age at HCT and (specifically in males) TBI use seem to be independent predictors of post-transplantation gonadal function and fertility status. All patients should receive pre-HCT infertility counseling and be offered appropriate fertility preservation options and be screened post-HCT for gonadal failure.

Association of MiRNA and Bone Tumors: Future Therapeutic Inroads

Small endogenous non-coding RNA molecules known as micro-ribonucleic acids (miRNAs) control post-transcriptional gene regulation. A change in miRNA expression is related to various diseases, including bone tumors. Benign bone tumors are categorized based on matrix production and predominant cell type. Osteochondromas and giant cell tumors are among the most common bone tumors. Interestingly, miRNAs can function as either tumor suppressor genes or oncogenes, thereby determining the fate of a tumor. In the present review, we discuss various bone tumors with regard to their prognosis, pathogenesis, and diagnosis. The association between miRNAs and bone tumors, such as osteosarcoma, Ewing's sarcoma, chondrosarcoma, and giant-cell tumors, is also discussed. Moreover, miRNA may play an important role in tumor proliferation, growth, and metastasis. Knowledge of the dysregulation, amplification, and deletion of miRNA can be beneficial for the treatment of various bone cancers. The miRNAs could be beneficial for prognosis, treatment, future drug design, and treatment of resistant cases of bone cancer.

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

BACKGROUND

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

METHODS

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

FINDINGS

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

INTERPRETATION

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

FUNDING

Boehringer Ingelheim and Eli Lilly.

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

BACKGROUND

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

METHODS

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

FINDINGS

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

INTERPRETATION

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

FUNDING

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

Niacin-Induced Syncope in a Middle-Aged Male: When an Over-the-Counter Vitamin Goes Wrong

Niacin is an essential vitamin with lipid-modifying properties. It is readily available in many over-the-counter (OTC) supplements. However, the use of niacin can lead to undesirable adverse reactions, including flushing, nausea, hyperglycemia, etc. Here, we present a rare case of niacin-induced syncope caused by a sudden increase in dosage in a middle-aged male. Extensive history, examination, and cardiovascular investigation were obtained to rule out various common etiologies of syncope. We also discuss the utility of niacin as a nutritional supplement, as most individuals obtain sufficient niacin intake from foods and beverages. As a treatment for dyslipidemia, niacin no longer exhibits cardiovascular benefits in the contemporary statin era. We argue that an additional niacin supplement is both unnecessary and potentially harmful. Therefore, niacin supplementation should be cautiously taken with no additional health benefits and frequent deleterious effects.

Hepatocyte-specific regulation of autophagy and inflammasome activation via MyD88 during lethal Ehrlichia infection

Hepatocytes play a crucial role in host response to infection. Ehrlichia is an obligate intracellular bacterium that causes potentially life-threatening human monocytic ehrlichiosis (HME) characterized by an initial liver injury followed by sepsis and multi-organ failure. We previously showed that infection with highly virulent Ehrlichia japonica (E. japonica) induces liver damage and fatal ehrlichiosis in mice via deleterious MyD88-dependent activation of CASP11 and inhibition of autophagy in macrophage. While macrophages are major target cells for Ehrlichia, the role of hepatocytes (HCs) in ehrlichiosis remains unclear. We investigated here the role of MyD88 signaling in HCs during infection with E. japonica using primary cells from wild-type (WT) and MyD88-/- mice, along with pharmacologic inhibitors of MyD88 in a murine HC cell line. Similar to macrophages, MyD88 signaling in infected HCs led to deleterious CASP11 activation, cleavage of Gasdermin D, secretion of high mobility group box 1, IL-6 production, and inflammatory cell death, while controlling bacterial replication. Unlike macrophages, MyD88 signaling in Ehrlichia-infected HCs attenuated CASP1 activation but activated CASP3. Mechanistically, active CASP1/canonical inflammasome pathway negatively regulated the activation of CASP3 in infected MyD88-/- HCs. Further, MyD88 promoted autophagy induction in HCs, which was surprisingly associated with the activation of the mammalian target of rapamycin complex 1 (mTORC1), a known negative regulator of autophagy. Pharmacologic blocking mTORC1 activation in E. japonica-infected WT, but not infected MyD88-/- HCs, resulted in significant induction of autophagy, suggesting that MyD88 promotes autophagy during Ehrlichia infection not only in an mTORC1-indpenedent manner, but also abrogates mTORC1-mediated inhibition of autophagy in HCs. In conclusion, this study demonstrates that hepatocyte-specific regulation of autophagy and inflammasome pathway via MyD88 is distinct than MyD88 signaling in macrophages during fatal ehrlichiosis. Understanding hepatocyte-specific signaling is critical for the development of new therapeutics against liver-targeting pathogens such as Ehrlichia.

Detailed Sub-study Analysis of the SECRAB Trial: Quality of Life, Cosmesis and Chemotherapy Dose Intensity

AIMS

SECRAB was a prospective, open-label, multicentre, randomised phase III trial comparing synchronous to sequential chemoradiotherapy (CRT). Conducted in 48 UK centres, it recruited 2297 patients (1150 synchronous and 1146 sequential) between 2 July 1998 and 25 March 2004. SECRAB reported a positive therapeutic benefit of using adjuvant synchronous CRT in the management of breast cancer; 10-year local recurrence rates reduced from 7.1% to 4.6% (P = 0.012). The greatest benefit was seen in patients treated with anthracycline-cyclophosphamide, methotrexate, 5-fluorouracil (CMF) rather than CMF. The aim of its sub-studies reported here was to assess whether quality of life (QoL), cosmesis or chemotherapy dose intensity differed between the two CRT regimens.

MATERIALS AND METHODS

The QoL sub-study used EORTC QLQ-C30, EORTC QLQ-BR23 and the Women's Health Questionnaire. Cosmesis was assessed: (i) by the treating clinician, (ii) by a validated independent consensus scoring method and (iii) from the patients' perspective by analysing four cosmesis-related QoL questions within the QLQ-BR23. Chemotherapy doses were captured from pharmacy records. The sub-studies were not formally powered; rather, the aim was that at least 300 patients (150 in each arm) were recruited and differences in QoL, cosmesis and dose intensity of chemotherapy assessed. The analysis, therefore, is exploratory in nature.

RESULTS

No differences were observed in the change from baseline in QoL between the two arms assessed up to 2 years post-surgery (Global Health Status: -0.05; 95% confidence interval -2.16, 2.06; P = 0.963). No differences in cosmesis were observed (via independent and patient assessment) up to 5 years post-surgery. The percentage of patients receiving the optimal course-delivered dose intensity (≥85%) was not significantly different between the arms (synchronous 88% versus sequential 90%; P = 0.503).

CONCLUSIONS

Synchronous CRT is tolerable, deliverable and significantly more effective than sequential, with no serious disadvantages identified when assessing 2-year QoL or 5-year cosmetic differences.

Pathogens identified in the internal tissues and placentas of stillbirths: results from the prospective, observational PURPOSe study

OBJECTIVE

To examine internal organ tissues and placentas of stillbirths for various pathogens.

DESIGN

Prospective, observational study.

SETTINGS

Three study hospitals in India and a large maternity hospital in Pakistan.

POPULATION

Stillborn infants delivered in a study hospital.

METHODS

A prospective observational study.

MAIN OUTCOME MEASURES

Organisms identified by pathogen polymerase chain reaction (PCR) in internal organs and placental tissues of stillbirths.

RESULTS

Of 2437 stillbirth internal tissues, 8.3% (95% CI 7.2-9.4) were positive. Organisms were most commonly detected in brain (12.3%), cerebrospinal fluid (CSF) (9.5%) and whole blood (8.4%). Ureaplasma urealyticum/parvum was the organism most frequently detected in at least one internal organ (6.4% of stillbirths and 2% of all tissues). Escherichia coli/Shigella was the next most common (4.1% one or more internal organ tissue sample and 1.3% of tissue samples), followed by Staphylococcus aureus in at least one internal organ tissue (1.9% and 0.9% of all tissues). None of the other organisms was found in more than 1.4% of the tissue samples in stillbirths or more than 0.6% of the internal tissues examined. In the placenta tissue, membrane or cord blood combined, 42.8% (95% CI 40.2-45.3) had at least one organism identified, with U. urealyticum/parvum representing the most commonly identified (27.8%).

CONCLUSIONS

In about 8% of stillbirths, there was evidence of a pathogen in an internal organ. Ureaplasma urealyticum/parvum was the most common organism found in the placenta and in the internal tissues, especially in the fetal brain.

Oncogenic ERRB2 signals through the AP-1 transcription factor to control mesenchymal-like properties of oesophageal adenocarcinoma

Oesophageal adenocarcinoma (OAC) is a deadly disease with poor survival statistics and few targeted therapies available. One of the most common molecular aberrations in OAC is amplification or activation of the gene encoding the receptor tyrosine kinase ERBB2, and ERBB2 is targeted in the clinic for this subset of patients. However, the downstream consequences of these ERBB2 activating events are not well understood. Here we used a combination of phosphoproteomics, open chromatin profiling and transcriptome analysis on cell line models and patient-derived datasets to interrogate the molecular pathways operating downstream from ERBB2. Integrated analysis of these data sets converge on a model where dysregulated ERBB2 signalling is mediated at the transcriptional level by the transcription factor AP-1. AP-1 in turn controls cell behaviour by acting on cohorts of genes that regulate cell migration and adhesion, features often associated with EMT. Our study therefore provides a valuable resource for the cancer cell signalling community and reveals novel molecular determinants underlying the dysregulated behaviour of OAC cells.

Abstract P412: The Effect of Targeted Therapeutic Management in ST-Elevation Myocardial Infarction Cardiac Arrest

Introduction: ST-elevation myocardial infarction (STEMI) is a known cause of cardiac arrest (CA). Little is known about the impact of targeted therapeutic management in CA patients with STEMI (SCA). Our aim was to investigate the effect of TTM on SCA.

Methods: This was a retrospective cohort study using the 2019 Nationwide Inpatient Sample database to identify admissions in adults with diagnoses of CA and STEMI. Regression models were adjusted for demographic variables. Primary outcome was mortality, and secondary outcomes were length of stay (LOS) and total charge in USD.

Results: Out of 13895 admissions with SCA, 440 underwent TTM. Compared to Non-TTM-SCA cohort, TTM-SCA cohort had fewer females (18.18% vs 31.03,p<0.05), more males (81.82% vs 68.97,p<0.05), lower mean age (62.17 vs 64.57,p<0.05), more Native American (2.27% vs 0.63%,p<0.05), less South region hospitals (25.00% vs 39.95%,p<0.05), less acute respiratory failure with hypercapnia (0.47% vs 8.53%,p<0.05), acute respiratory failure with hypoxia (1.94% vs 38.90%,p<0.001), history of cardiac arrest (0.11% vs 0.61%,p<0.01), ventricular fibrillation (2.27% vs 50.59%,p<0.001), cerebral infarction (0.29% vs 4.28%,p<0.05), more alcohol abuse (12.50% vs 4.72%,p<0.001), and more persistent vegetative state (1.14% vs 0.15%,p<0.05). Compared to Non-TTM-SCA, TTM-SCA group had similar mortality rates (38.64% vs 42.96%,p=0.3940), mortality OR 1.04 (95%CI 0.66-1.62,p=0.869), higher mean LOS 10.69 vs 6.25 days (95%CI 2.39-6.17,p<0.001), and higher mean total hospitalization charge $238960.90 vs $179880.10 (95%CI 18772.87-98404.78,p<0.01).

Conclusion: In SCA patients, TTM presence had no difference in mortality rate, odds of mortality, but had higher mean LOS and total hospitalization charge. TTM was associated with fewer females, more males, lower mean age, more Native Americans, less acute respiratory failure, history of cardiac arrest, ventricular fibrillation, cerebral infarction, and more alcohol abuse and persistent vegetative state.

eRNA profiling uncovers the enhancer landscape of oesophageal adenocarcinoma and reveals new deregulated pathways

Cancer is driven by both genetic and epigenetic changes that impact on gene expression profiles and the resulting tumourigenic phenotype. Enhancers are transcriptional regulatory elements that are key to our understanding of how this rewiring of gene expression is achieved in cancer cells. Here, we have harnessed the power of RNA-seq data from hundreds of patients with oesophageal adenocarcinoma (OAC) or its precursor state Barrett's oesophagus coupled with open chromatin maps to identify potential enhancer RNAs and their associated enhancer regions in this cancer. We identify ~1000 OAC-specific enhancers and use these data to uncover new cellular pathways that are operational in OAC. Among these are enhancers for JUP, MYBL2, and CCNE1, and we show that their activity is required for cancer cell viability. We also demonstrate the clinical utility of our dataset for identifying disease stage and patient prognosis. Our data therefore identify an important set of regulatory elements that enhance our molecular understanding of OAC and point to potential new therapeutic directions.

Abstract TP197: Obstructive Sleep Apnea Associated With Lower All-Cause Mortality In Ischemic Stroke Patients

Introduction: Obstructive sleep apnea (OSA) is a sleep disorder associated with cardiovascular risk factors similar to those associated with cerebral infarction (CI). Our aim was to characterize patient demographics and to investigate the effect of OSA in CI.

Methods: Retrospective cohort study using 2019 National Inpatient Sample. Adults with diagnoses of CI and OSA were included. Primary outcome was all-cause mortality, and secondary outcomes were length of stay (LOS) and total charge in USD.

Results: Out of 700175 CI patients, 49735 had OSA. Compared to Non-OSA-CI cohort, OSA-CI cohort were younger (67.38 vs 69.67 years,p<0.001) and had fewer females (37.36% vs 50.09%,p<0.001), Black (15.50% vs 17.38%,p<0.001), Hispanic (5.21% vs 8.26%,p<0.001), API (1.91% vs 3.15%,p<0.001), Medicaid (7.79% vs 10.26%,p<0.001), alcohol abuse (3.53% vs 4.75%,p<0.001), dementia (7.25% vs 12.06%,p<0.001), drug abuse (2.56% vs 3.33%,p<0.001), systolic heart failure (0.55% vs 6.36%,p<0.001), atrial fibrillation (1.12% vs 10.25%,p<0.001). OSA-CI cohort had more White (72.59% vs 65.58%,p<0.001), depression (17.25% vs 10.97%,p<0.001), chronic pulmonary disease (28.79% vs 16.25%,p<0.001), complicated hypertension (45.72% vs 33.57%,p<0.001), complicated diabetes mellitus (36.67% vs 23.80%,p<0.001), hypothyroidism (16.19% vs 14.02%,p<0.001), and obesity (43.22% vs 12.87%,p<0.001). OSA-CI cohort had lower all-cause mortality rate (4.32% vs 6.50%,p<0.001), mortality OR 0.73 (95%CI 0.65-0.81,p<0.001), lower mean LOS (6.17 vs 6.67 days,p<0.001), lower mean total hospitalization charge ($91,762.00 vs $99,993.00,p<0.001).

Conclusion: Among patients admitted with CI, the presence of OSA was associated with lower all-cause mortality, odds of mortality, mean LOS and mean total hospitalization charge. OSA had a higher prevalence in younger White males and was associated with more depression, hypertension, diabetes mellitus, and obesity.

Abstract HUP8: Higher Prevalence Of Ischemic Stroke In Black Down Syndrome Patients

Introduction: Ischemic cerebrovascular accidents (CVA) contribute to major morbidity in hospitalized patients. Little is known of its impact in Down Syndrome (DS) patients. Our aim was to characterize the patient demographic and to investigate the impact of CVA on hospitalized DS patients.

Method: This was a retrospective cohort study utilizing 2019 National Inpatient Sample database. Adults with DS and CVA diagnoses were included. Regression models adjusted for demographic variables were used. Primary outcome was evaluating all-cause mortality, and secondary outcomes were evaluating length of stay (LOS) and total hospitalization charge.

Results: Out of 44720 admissions with Down Syndrome, 355 had a ischemic cerebrovascular accident. Compared to Non-CVA-DS cohort, CVA-DS cohort were older (39.04 vs 24.71 years,p<0.001), more Black (19.72% vs 10.83%,p<0.05), Medicare (57.75% vs 35.03%,p<0.001), more hypertension (21.13% vs 6.16%,p<0.001), PVD (11.27% vs 1.75%,p<0.001), diabetes mellitus (18.31% vs 3.93%,p<0.001), but less Hispanic (9.86% vs 19.73%,p<0.05), private insurance (12.68% vs 23.96%,p<0.05), and West region hospital (11.27% vs 23.10%,p<0.05). There was no statistically significant difference in the prevalence of females, White, API, household income, hospital teaching status, dementia, chronic pulmonary disease, obesity, hypothyroidism. CVA-DS cohort had a similar all-cause mortality rate (3.19% vs 1.28%,p=0.1029), all-cause odds of mortality 1.48 (95%CI 0.39-5.63,p=0.563), mean LOS (9.79 vs 8.40 days,p=0.498), and mean total hospitalization charge ($172327.20 vs $99913.84,p=0.076).

Conclusion: In patients admitted with DS, the presence of CVA was not associated with an increase in all-cause mortality, odds of mortality, mean LOS, or total charge, however it was associated with a higher prevalence in Black patients, older age, Medicare, hypertension, diabetes mellitus, and PVD, and a lower prevalence in Hispanic patients.

Paroxysmal Nocturnal Hemoglobinuria in Systemic Lupus Erythematosus: A Rare Manifestation

Paroxysmal nocturnal haemoglobinuria (PNH) is a rare disorder of hematopoietic stem cells. The occurrence of PNH in a patient with systemic lupus erythematosus (SLE) is even rarer. One such presentation was seen in a 19 years old woman who presented with fever, multiple joint pain, photosensitivity, oral ulcer, hair loss and was diagnosed as a case of SLE and was admitted in Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh on 7th February 2019. Subsequently she developed progressive anaemia and passing of dark colored urine. Flow cytometry analysis showed PNH clone within red cells. We report this case so that clinicians are aware about this association between PNH and SLE. Informed written consent was obtained from the patient for the publication of this case report, the copy of which is available with the authors.

Regulatory chromatin rewiring promotes metabolic switching during adaptation to oncogenic receptor tyrosine kinase inhibition

Oesophageal adenocarcinoma (OAC) patients show poor survival rates and there are few targeted molecular therapies available. However, components of the receptor tyrosine kinase (RTK) driven pathways are commonly mutated in OAC, typified by high frequency amplifications of the RTK ERBB2. ERBB2 can be therapeutically targeted, but this has limited clinical benefit due to the acquisition of drug resistance. Here we examined how OAC cells adapt to ERBB2 inhibition as they transition to a drug resistant state. ERBB2 inhibition triggers widespread remodelling of the accessible chromatin landscape and the underlying gene regulatory networks. The transcriptional regulators HNF4A and PPARGC1A play a key role in this network rewiring. Initially, inhibition of cell cycle associated gene expression programmes is observed, with compensatory increases in the programmes driving changes in metabolic activity. Both PPARGC1A and HNF4A are required for the acquisition of resistance to ERBB2 inhibition and PPARGC1A is instrumental in promoting a switch to dependency on oxidative phosphorylation. Our work therefore reveals the molecular pathways that support the acquisition of a resistant state and points to potential new therapeutic strategies to combat cellular adaptation and ensuing drug resistance.

Abstract P053: Causes And Predictors Of Readmission In Hypertensive Emergency - A Nationwide Inpatient Analysis

Introduction: Hypertensive emergency (HE) is a common medical emergency requiring inpatient admission. Our aim was to characterize HE patient demographics and analyze the factors that increases the likelihood for HE readmissions.

Methods: This was a retrospective cohort study using the 2019 Nationwide Readmissions Database to identify admissions in adults with a diagnosis HE. Regression models were used. Primary outcome was all-cause 30-day readmission rate, mortality rate, causes and predictors for readmission.

Results: Out of a total of 56,648 admissions with HE, 7,753 were readmitted, with a readmission rate of 13.72%. The most common causes for readmissions were CHF exacerbation in setting of CKD stage 1-5 11.51% (892 of 7753), hypertensive emergency 11.48% (890 of 7753), hypertensive urgency 7.92% (614 of 7753), AKI 4.67% (362 of 7753), Sepsis 3.12% (241 of 7753), NSTEMI 2.44% (189 of 7753), and ischemic CVA 1.79% (139 of 7753). Compared to index admissions, readmissions had higher mortality rate (1.39% vs 0.35%), LOS (5.13 days vs 3.65 days), and total charge ($58,172.50 vs $42,273.43). See table 1 for index admission group demographics. The top predictors for readmissions were, reported in odds ratio, ESRD 3.43, hypertension 2.30, discharged AMA 2.29, diabetes mellitus 1.92, transfer to nursing facility 1.5, drug abuse 1.40, depression 1.28.

Conclusion: HE has a high readmission rate of 13.72% with the most common cause for readmission being CHF exacerbation, followed by recurrence of HE, AKI, sepsis, NSTEMI, and ischemic CVA. The best predictor for HE readmission was ESRD, followed by hypertension, discharged AMA, and diabetes mellitus.

Abstract P052: Recurrent Major Depressive Disorder And Hypertension - A Nationwide Analysis Of Patient Demographics And In-hospital Outcomes

Introduction: Hypertension (HTN) is a condition that contributes significantly cardiovascular disease. Little is known about the effect of recurrent major depressive disorder (rMDD) on HTN.

Methods: This was a retrospective cohort study using the Nationwide Inpatient Sample database to identify admissions in adults with a diagnosis of HTN and rMDD in 2019. Regression models were adjusted for demographic variables and hospital characteristics. Primary outcome was all-cause mortality, and secondary outcomes were length of stay (LOS) and total charge in USD.

Results: Out of 9,582,450 admissions with hypertension, 114,480 had rMDD. Compared to Non-rMDD-HTN cohort, rMDD-HTN cohort had more females, younger age, White, Medicaid, private insured, self-pay, median household income, and fewer Black, Hispanic, API , highest household income. rMDD-HTN cohort had more AIDS, alcohol abuse, drug abuse, chronic pulmonary disease, and less arthropathies, dementia, PVD, and diabetes mellitus. rMDD-HTN cohort had lower all-cause mortality rate (0.40% vs 1.70%,p<0.001), all-cause lower mortality OR 0.38 (95%CI 0.30-0.47,p<0.001), longer mean LOS of 1.90 days (95%CI 1.74-2.05,p<0.001) with mean LOS of 6.73 days vs 4.63 days, and total hospitalization charge -$15,428.93 (95%CI -$16,964.47- -$13,893.38,p<0.001).

Conclusion: In patients admitted with HTN, the presence of rMDD was associated with a lower all-cause mortality rate, lower odds of all-cause mortality, longer LOS, and lower total hospitalization charge. rMDD was associated with more female, younger age, White, Medicaid as well as higher prevalence of AIDS, alcohol abuse, drug abuse and chronic pulmonary disease.

Mesh fixation techniques for inguinal hernia repair: an overview of systematic reviews of randomised controlled trials

PURPOSE

Inguinal hernia repair using surgical mesh is a very common surgical operation. Currently, there is no consensus on the best technique for mesh fixation. We conducted an overview of existing systematic reviews (SRs) of randomised controlled trials to compare the risk of chronic pain and recurrence following open and laparoscopic inguinal hernia repairs using various mesh fixation techniques.

METHODS

We searched major electronic databases in April 2020 and assessed the methodological quality of identified reviews using the AMSTAR-2 tool.

RESULTS

We identified 20 SRs of variable quality assessing suture, self-gripping, glue, and mechanical fixation. Across reviews, the risk of chronic pain after open mesh repair was lower with glue fixation than with suture and comparable between self-gripping and suture. Incidence of chronic pain was lower with glue fixation than with mechanical fixation in laparoscopic repairs. There were no significant differences in recurrence rates between fixation techniques in open and laparoscopic mesh repairs, although fewer recurrences were reported with suture. Many reviews reported wide confidence intervals around summary estimates. Despite no clear evidence of differences among techniques, two network meta-analyses (one assessing open repairs and one laparoscopic repairs) ranked glue fixation as the best treatment for reducing pain and suture for reducing the risk of recurrence.

CONCLUSION

Glue fixation may be effective in reducing the incidence of chronic pain without increasing the risk of recurrence. Future research should consider both the effectiveness and cost-effectiveness of fixation techniques alongside the type of mesh and the size and location of the hernia defect.

Association between sociodemographic characteristics and knowledge and practice of COVID-19 measures among households in Mombasa and Kilifi County, Kenya

BACKGROUND

Coronavirus disease 2019 (COVID-19), declared a global pandemic by the World Health Organization (WHO), is a severe acute respiratory disease. The Kenyan Ministry of Health (MoH) put in place measures that included mandatory face masking, hand and cough hygiene and social and physical distancing to reduce disease transmission and increase prevention efforts. The primary objective of this study was to determine how sociodemographic characteristics affect knowledge and practice of the above measures.

METHODS

A cross-sectional study was conducted to assess water, sanitation and hygiene practices for the prevention and control of COVID-19 in Kilifi and Mombasa Counties, Kenya. Data collection was accomplished through a mobile data collection tool. Principal component analysis was used to create a wealth index using data on asset ownership and housing characteristics. Bloom cut-off points of 80-100%, 60-79% and ≤59% were used to determine knowledge and practice.

RESULTS

Of the 612 households, 339 (55.4%) were from Kilifi County and 273 (44.6%) were from Mombasa County. A total of 431 (70.4%) were female and the mean age of the household members was 38.2±14.8 y.Almost all (99.2%) respondents were aware of COVID-19, with 60% knowing prevention, symptoms and persons at a higher risk of contracting the virus. Females had the highest knowledge of COVID-19 and were likely to practice prevention and control measures, unlike males. Age was significant (p<0.05) with knowledge and practice.

CONCLUSIONS

The sociodemographic characteristics of populations play a key role in behavioural aspects as far as prevention and control of COVID-19 are concerned. There is a need for partnerships between the MoH and county governments to put in place a multisectoral community approach to advance feasible behavioural interventions among targeted populations towards combating the spread of COVID-19.

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.

Outcomes from LDCT screening for lung cancer in an undeserved population: A quality initiative

e13504

Background: Lung cancer is the leading cause of cancer-related mortality worldwide. USPSTF recommends annual lung cancer screening with low dose computed tomography (LDCT) for adults aged 50-80 years with 20-pack year smoking history and are currently smoking or have quit within the past 15 years. Unfortunately, adherence rates with screenings remain suboptimal. This study aimed to assess the compliance rates with LDCT recommendations in a community hospital and propose an implementation plan to enhance patient adherence. Methods: A retrospective study was conducted by analyzing the medical charts of 1090 patients who underwent LDCT screenings at Mercy Catholic Medical Center between January 2018 and June 2021. Medical records were reviewed to determine whether patients had appropriate follow-ups done based on the LUNG-RADs category with focus on those with higher LUNG-RADs designations. A survey was administered to current internal medicine residents to evaluate their understanding of screening guidelines. Based on the survey results and literature review, a plan to enhance adherence with screenings is proposed. Results: Total 1090 patients underwent LDCT screenings, comprising of 522 males and 568 females. 166 patients were assigned LUNG-RADs category 3, 4A, 4B, or 4X. Amongst these 166 patients, compliance rate with recommended follow-up imaging and/or biopsies was only 51.2% (95% confidence interval [CI], 44.0-59.0). 15% of patients had biopsies that were positive for malignancies. 70% of the residents participated in the survey. Only 57% demonstrated knowledge of the recommended age group for screening; only 47% knew the pack-year criteria for screening. Questions gauging the understanding of when to stop screening, implications of imaging findings, and estimated mortality reduction from LDCT screenings underscored the knowledge gap amongst physicians as a factor needing improvement. Conclusions: This study comprised of a patient population primarily from poor socioeconomic and educational background. Therefore, many of the patients in this study may not have fully comprehended the LDCT implications solely from receiving a letter with radiology impressions, leading to the high non-compliance rate observed. To enhance follow-ups, residents should be educated on LDCT screening indications and benefits so they can promote patient health better. After receiving LDCT results, providers should inform patients about the findings either via phone calls or in-person office visits and emphasize the importance of specific follow-ups. We propose the appointment of a designated coordinator to call patients who failed to follow-up to re-emphasize the importance and identify barriers to adherence (i.e., transportation, cost). Studies found an increase in adherence to screening from 22% to 66% after hiring a coordinator. Adherence rates can, thus, be improved by a collaborative team approach.

Staphylococcus aureus native mitral valve endocarditis associated with bed bug bites - A case report and review of the literature

Staphylococcus aureus is a leading cause of community acquired bacteremia and infective endocarditis. S. aureus is a part of the normal skin flora in approximately one third of the human population. Infective endocarditis due to S. aureus can cause several complications and is associated with increased mortality. A 48-year-old female with no significant medical history presented with S. aureus bacteremia and native mitral valve endocarditis. Multiple cutaneous skin lesions were identified, which she reported were due to recent bed bug bites. No source of infection was found except for the skin lesions. Her hospital course was complicated by pulmonary and cerebral septic emboli, left pleural empyema, and acute renal injury. We suspected the bed bug skin bites were the most likely source of bacteremia. Bed bugs carry many human pathogens but have not been shown to be a competent vector. We did not find any literature on endocarditis associated with bed bug bites; thus, our case will be a novel finding.

Evaluation of water footprint in sugar industries and bioethanol distilleries in two different water basins toward water sustainability

Sugarcane farming and bioethanol production are water-intensive activities that result in high water competition. The competition, in turn, can exacerbate water scarcity. Therefore, this study aims to evaluate the water footprint (WF) of the sugar and bioethanol production at the Finchaa and Metehara sugarcane farms, which are located in different river basins in Ethiopia. The climatic data (minimal and maximum temperature, relative humidity, wind speed, and sunshine duration), meteorological data (rainfall), CROPWAT 8.0 model, nitrogen fertilizer application rates, sugarcane yield, and sugar and bioethanol production over 12 years (2008-2019) were used. Penman-Monteith method-based sugarcane water requirements of Finchaa and Metehara were found to be 2021.1 and 3605.4 mm/growing period, respectively. The sugarcane WF of Finchaa was 188.01 m³/t, which was composed of green (67.45 m³/t), blue (113.42 m³/t), and grey (7.14 m³/t) components, whereas the WF of Metehara was 239.11 m³/t consisting of green (29.42 m³/t), blue (204.13 m³/t), and grey (5.56 m³/t). The low sugarcane WF recorded was attributed to the high yield of sugarcane that was harvested in the study areas. Hence, the irrigation (blue WF) requirement is the major concern of water management in the basins. Similarly, the WF of bioethanol at the Finchaa distillery (2067.62 L/L) was much higher than that of the Metehara distillery (1441.54 L/L). However, both WFs were within the global range. Significant differences were observed between the two water basins. The sugarcane estate farm and bioethanol production processes require water management intervention to reduce the impact of WF in the basins.

Teenager Presenting With Chest Pain and ST-Segment Changes on Electrocardiogram After SARS-CoV-2 Illness: Early Repolarization vs. Acute Pericarditis

The ST-segment elevation is commonly associated with acute myocardial Infarction. However, there are other non-ischemic causes of ST-elevation. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a highly contagious illness that continues to plague the world since the first case was reported in China over two years ago. As cases of the diseases become rampant, we have learned more of its complications which can include cardiac and pericardial disease. We present a case report of a young African American male who presented with chest pain six weeks after being diagnosed with SARS-Cov-2 pneumonia. Electrocardiogram (EKG) showed ST-segment changes that were initially presumed to be acute pericarditis. The patient was initially treated with colchicine. After further workup and a second opinion, ST-segment changes were thought to be likely benign early repolarization changes rather than pericarditis. Differential diagnosis of ST-segment changes on EKG in the patient with chest pain is broad. Subtle findings on EKG are important in distinguishing these differentials and should be well known and understood.

Phytochemicals and in silico investigations of Sudanese roselle

We analysed four different Sudanese roselle samples for their potential as novel xanthine oxidase (XO) inhibitors. Phytochemical screening showed the presence of polyphenols, flavonoids, organic acids, saponins and sterols in all samples. Liquid chromatography with tandem mass spectrometry (LC-MS/ MS) was used to identify and characterise five anthocyanins in all samples: cyanidin-3-glucoside (cy-3-glu), delphinidin-3-sambubioside (dp-3-sam), cyanidin-3-rhamnoside (cy-3-rhm), delphinidin-3‑rhamnoside (dp-3-rhm) and pelargonidin-3-glucoside (pg-3-glu). Identification of cy-3-rhm, dp-3-rhm and pg-3-glu confirmed the selectivity and sensitivity of LC-MS as a powerful technique for identifying anthocyanins. In silico studies of the identified anthocyanins were performed to explore their promising inhibitory activity toward XO. Interactions between the ligand and the enzyme were via the H-bond, and hydrophobic (π-alkyl, π-sigma and alkyl) and/or electrostatic (π-cation) bonds. Inhibition of the anthocyanins was compared with that of topiroxostat, a commercial drug for hyperuricaemia. Dp-3-rhm was the most active inhibitor with a binding energy of ca. -10.90 kcal/mol compared to topiroxostat’s binding energy of ca. -8.60 kcal/mol. The good inhibition results obtained from anthocyanins toward XO suggest their application as a drug candidate to treat gout and other diseases related to the activity of XO.

Age of First Oral Health Examination and Dental Treatment Needs of Medicaid-Enrolled Children

INTRODUCTION

Early childhood caries (ECC), despite being preventable, remains the most prevalent disease of childhood, particularly in children between the ages of 2 and 5 y. The association between the type of health care provider completing initial oral health examinations and subsequent dental caries in children under 6 y of age is unclear.

OBJECTIVE

The objective of the current study is to longitudinally assess the association between age at first oral health examination and provider type at first oral health examination on dental treatment for children under 6 y of age.

METHODS

Deidentified administrative claims data were used from the IBM Marketscan Multi-State Medicaid Database (n = 2.41 million Medicaid-enrolled children younger than 6 y in 13 states from 2012 to 2017). A Kaplan-Meier survival analysis was used to examine the association between age at first oral health examination and provider type with first treatment of dental caries at follow-up.

RESULTS

The adjusted hazard ratio (HR) of dental caries for children whose first oral health examination at 4 y of age is 5.425 times higher than for children whose first oral health examination was before 1 y of age (95% confidence interval [CI], 5.371-5.479). The adjusted HR of dental caries for children seen by pediatric dentists (HR = 1.215; 95% CI, 1.207-1.223) and physicians (HR = 2.618; 95% CI, 2.601-2.635) was higher than those seen by a general dentist.

CONCLUSIONS

Findings from this study highlight the importance of children having their first oral health examination no later than 12 mo of age in accordance with existing guidelines and referrals from physicians to prevent the need for invasive treatment.

KNOWLEDGE OF TRANSFER STATEMENT

Results of this study emphasize the need for a child's first oral health examination to be completed no later than 12 mo of age to prevent dental caries. Reinforcement and referrals by physicians based on this recommendation facilitate early establishment of a dental home in young children.

Assessment of water, sanitation and hygiene practices for prevention and control of COVID-19 in Kenya

Background

Safely managed water, sanitation and hygiene (WASH) services are an essential part of preventing and protecting human health during infectious disease outbreaks, including the current coronavirus disease 2019 (COVID-19) pandemic. Additionally, adherence to COVID-19 measures, including washing hands using soap and proper waste disposal, no doubt can improve containment of the virus.

Methods

A cross-sectional survey was conducted in Kilifi and Mombasa Counties in Kenya. A total of 612 quantitative data were collected using a mobile data collection tool Open Data Kit. Parametric and non-parametric tests were used to examine factors associated with WASH practices and control of COVID-19 in Kenya.

Results

More than half of the respondents were from Kilifi, 431 (70.4%) were female and the mean age was 38.2±14.8 y. Households in Kilifi were most likely not to have enough water, while Mombasa households were more likely to pay for water. Sanitation coverage was 47.6%, with more than half sharing sanitation facilities. Sharing of latrines was significantly associated with county and income level. Accessing soap was worse compared with the month prior to the survey, only 3.9% had their garbage collected by formal service providers and only 17% reported wearing any protective gear while handling waste at home.

Conclusions

Water is disproportionately available in the two counties, with low sanitation coverage. There is low knowledge on hand washing and inadequate waste disposal services.

Outcomes of pediatric patients with therapy-related myeloid neoplasms

Long-term outcomes after allogeneic hematopoietic cell transplantation (HCT) for therapy-related myeloid neoplasms (tMNs) are dismal. There are few multicenter studies defining prognostic factors in pediatric patients with tMNs. We have accumulated the largest cohort of pediatric patients who have undergone HCT for a tMN to perform a multivariate analysis defining factors predictive of long-term survival. Sixty-eight percent of the 401 patients underwent HCT using a myeloablative conditioning (MAC) regimen, but there were no statistically significant differences in the overall survival (OS), event-free survival (EFS), or cumulative incidence of relapse and non-relapse mortality based on the conditioning intensity. Among the recipients of MAC regimens, 38.4% of deaths were from treatment-related causes, especially acute graft versus host disease (GVHD) and end-organ failure, as compared to only 20.9% of deaths in the reduced-intensity conditioning (RIC) cohort. Exposure to total body irradiation (TBI) during conditioning and experiencing grade III/IV acute GVHD was associated with worse OS. In addition, a diagnosis of therapy-related myelodysplastic syndrome and having a structurally complex karyotype at tMN diagnosis were associated with worse EFS. Reduced-toxicity (but not reduced-intensity) regimens might help to decrease relapse while limiting mortality associated with TBI-based HCT conditioning in pediatric patients with tMNs.

NATIONAL DIAGNOSTIC REFERENCE LEVELS AND ACHIEVABLE DOSES FOR STANDARD CT EXAMINATIONS IN SUDAN

Radiation doses were determined to propose national diagnostic reference levels (NDRLs) and achievable doses (ADs) for computed tomography (CT) examinations in Sudan. Doses were estimated from retrospectively collected scan parameters for 1336 CT examinations of adult patients from 14 Sudanese hospitals using CT Expo 2.5 software. ADs and NDRLs were set at the 50th and 75th percentile of the hospital median dose distribution, respectively. The proposed CTDIvol (mGy) ADs ranged from: 10 (chest) to 64 (head), and that of the dose-length product (DLP; mGy.cm) ranged from 366 (chest) to 1225 (head). The proposed CTDIvol (mGy) NDRLs ranged from 15 kidney-ureter-bladder (KUB) to 79 (head), whereas that of the DLP (mGy.cm) ranged from 690 (chest) to 1490 (head). Current doses fell within the upper range of the doses presented in the literature emphasizing the need for implementation of the current ADs and NDRLs for CT to enhance patient protection and dose optimization in Sudan.

TP5.2.14 A quality improvement project: Engaging and educating our thyroidectomy patients

Aims

Hypocalcaemia can occur in up to 30% of patients post-total thyroidectomy. Severe hypocalcaemia can lead to life-threatening tetany and seizures. As part of the consent process, risks are discussed typically face-to-face, often with the aid of anatomy illustrations. As tele-consultations become increasingly commonplace, patient-information leaflets (PILs) can be invaluable in enhancing informed consent, and empowering patients regarding their own care. We performed a quality improvement project to assess the feasibility and effects of distributing PILs following consultations to improve patients’ understanding of post-operative complications (specifically hypocalcaemia).

Methods

A retrospective review of post-total thyroidectomy patients was performed from January 2019 to January 2020. A telephone survey was conducted to assess each patient’s understanding of post-operative complications. As tele-consultations began to be utilised during the COVID-19 pandemic, we designed a simple PIL to distribute to patients awaiting elective total thyroidectomy aiming to improve health literacy. Following distribution of PILs, the survey was repeated to evaluate feasibility and effectiveness.

Results

Conclusions

A simple and inexpensive intervention, PILs can be distributed to patients awaiting elective surgery to improve health literacy, and reduce potential patient harm.

1131 The Integration of Cardiothoracic Practical Skills Workshop in The Undergraduate Medical School Curriculum and Its Impact on Promoting Interest in Cardiothoracic Surgery

Aim

Assess if WETLAB workshop encourages the engagement of medical students in CTS surgery

Method

We hosted a cardiac WETLAB workshop, led by a consultant cardiothoracic surgeon. Attendees were taught how to carry out an end-to-side anastomosis on animal tissue. We used pre-and -post exposure questionnaires composed of 10 items to assess the ability of the workshop to improve undergraduate interest in cardiothoracic surgery. The questionnaire included questions around students’ interest in the speciality, previous exposure to the speciality and whether students want to pursue a career in the speciality.

Results

Out of the 12 attendees, 10 completed both questionnaires. The workshop was well received with the overall satisfaction of 9.64 out of 10. It significantly increased respondents’ interest in CTS(z=-0.06, p = 0.01) but did not show any significant difference in encouraging them to pursue surgery. 100% of respondents agreed that specialised practical workshops should be incorporated within the medical school curriculum and that if the opportunity arises, they will attend another in the future.

Conclusions

Specialised practical workshops have the potential to play a significant role in the medical school curriculum in order to enhance exposure to the field of cardiothoracic surgery. This may lead to a positive impact on the number of doctors wishing to pursue this speciality in the future.

783 Digital Weekend Handover an Effective Documentation

Aim

To assess quality of completion for weekend handover for surgical weekend and to plan and design a Digital handover, the implementation and effect of which is studied.

Method

Data collection from TRAKCARE for documentation completion criteriae including diagnosis, further investigations to chase (e.g., bloods, imaging), discharge plans, escalation and DNAR status identified.

First cycle collected in August 2020 for pre-implementation status and standard. Second cycle was collected after implementation and raising awareness about new system in October 2020.

Exclusion criteria: patients discharged prior to weekend

Results

32 (10f 22m) and 22 (9 f 13m) patients were studied in first and second cycle with a respective median length stay of 243 hours and 161.5 hours. Handover entries had improved from 40.6% completion rate to 77.3% these included a diagnosis and management plan. Required blood investigation plans were recorded in 54.5% patients (previously 9.4%). Escalation plans including DNACPR and ceiling of care were improved from 25% to 31%.

Conclusions

Digital Medical recording left a gap in documentation for weekend ward rounds when personnels are thinned and busy. To optimize clinical care, the use of a E weekend handover has improved documentation greatly. Future Ongoing project includes improving escalation plans further.

64 Seizing an Opportunity: Setting Up A Virtual Wetlab During the COVID19 Pandemic

Aim

The COVID19 pandemic has negatively impacted surgical training across the globe. In the UK, educational events and training days were cancelled for trainees at all levels. However, these unusual times provide opportunity to develop novel teaching methods. Our aim was to design a “virtual cardiac surgery wetlab” that allows real-time skills training.

Method

With support from industry partners Edwards Lifesciences, Wetlab and Connexon365 (Webinar Hosting Platform) all the necessary materials were distributed. A package was sent to trainer and trainees that included microinstruments, sutures, synthetic vessels and valve models, high-definition camera, along with printed instructions and video to outline set-up of the rig. Trainees only need to provide is a computer. A consultant surgeon demonstrated how to perform a coronary anastomosis and aortic valve replacement and was then able to supervise trainees and provide real-time feedback using the online platform.

Results

Feedback from trainer and trainees has shown that the system is an easy-to-set-up, effective training tool for teaching cardiac surgery skills including coronary anastomosis and valve surgery. The online platform enabled good vision and engagement between trainer and trainee and also enabled recording of the session. Distributing all of the materials nationwide means the virtual wetlab can take place anywhere, including in the comfort of home, for both trainee and trainer.

Conclusions

Surgical skills training can still take place effectively in the absence of “real life” wetlabs. Given the current COVID19 pandemic continues to interrupt traditional surgical teaching, this method has potential to be adopted nationwide to minimise the disruption.

Frequency of Neuropathic Sensory Symptoms Among Patients With Uncontrolled Diabetes Mellitus in Security Forces Hospital, Riyadh, Saudi Arabia

Background

Diabetic peripheral neuropathy (DPN) is a chronic sensorimotor length-dependent and symmetrical polyneuropathy. Some peripheral neuropathies have painful presentations, and some are painless. DPN can have a potential impact on the patient's life.

Objectives

This study was conducted in order to investigate the frequency of neuropathic sensory symptoms among patients with uncontrolled diabetes mellitus.

Methods

This is a cross-sectional study conducted in the Security Forces hospital using the Neuropathy Total Symptom Score-6 (NTSS-6) questionnaire. The questionnaire was administered by contacting patients through the phone. Patients with uncontrolled diabetes (HbA1C >9) were included in the study.

Results

This study included 285 participants; 58.9% had type II diabetes and 41.1% had type I diabetes, 156 (54.7%) were females, and 129 (45.3%) were males. Most of the patients (51.1%) were 45-64 years old and the majority were non-smokers (77.9%). Patients with neuropathic pain were 182 (63.9%); 79 (43.4%) of them were males and 103 (56.6%) were females. The prevalence of neuropathic symptoms was much higher in females than in males.

Conclusion

The prevalence of painful DPN is high among patients with long-term uncontrolled diabetes mellitus. Older, unemployed, and low-educated patients are at higher risk of developing painful DPN. Proper glycemic control and lifestyle modifications are essential in preventing the progression of this condition.

Folic acid supplementation in postmenopausal women with hot flushes: phase III randomised double-blind placebo-controlled trial

OBJECTIVE

To assess whether folic acid supplementation ameliorates hot flushes.

DESIGN

Double-blind, placebo-controlled randomised trial.

SETTING

Nine hospitals in England.

POPULATION

Postmenopausal women experiencing ≥50 hot flushes weekly.

METHODS

Women (n = 164) were randomly assigned in a 1:1 ratio to receive folic acid 5 mg tablet or placebo daily for 12 weeks. Participants recorded frequency and severity of hot flushes in a Sloan Diary daily and completed Greene Climacteric and Utian Quality of Life (UQoL) Scales at 4-week intervals.

MAIN OUTCOME MEASURES

The change in daily Hot Flush Score at week 12 from randomisation based on Sloan Diary Composite Score B calculation.

RESULTS

Data of 143 (87%) women were available for the primary outcome. The mean change (SD) in Hot Flush Score at week 12 was -6.98 (10.30) and -4.57 (9.46) for folic acid and placebo group, respectively. The difference between groups in the mean change was -2.41 (95% CI -5.68 to 0.87) (P = 0.149) and in the adjusted mean change -2.61 (95% CI -5.72 to 0.49) (P = 0.098). Analysis of secondary outcomes indicated an increased benefit in the folic acid group regarding changes in total and emotional UQoL scores at week 8 when compared with placebo. The difference in the mean change from baseline was 5.22 (95% CI 1.16-9.28) and 1.88 (95% CI 0.23-3.52) for total and emotional score, respectively.

CONCLUSIONS

The study was not able to demonstrate that folic acid had a statistically significant greater benefit in reducing Hot Flush Score over 12 weeks in postmenopausal women when compared with placebo.

TWEETABLE ABSTRACT

Folic acid may ameliorate hot flushes in postmenopausal women but confirmation is required from a larger study.

40 Across the Pond: Why Are Junior Doctors Seeking Surgical Training Abroad?

Introduction

The loss of junior doctors from the NHS has been an ongoing issue. A subset are now seeking surgical training in other systems, such as the US. This is a costly and difficult process and many enter into undesignated positions with no guarantee of a job. With so much career uncertainty, why are trainees willing to take the risk?

Method

We performed a survey of trainees who graduated from British medical schools; all are currently enrolled in a US surgical training programme. They were asked about their experiences and perceptions of

Results

Nine trainees completed the survey. The most common time for trainees to move was during or after foundation training and the majority initially matched into preliminary positions. The most common reason cited to move was to receive better quality training. Many perceived the US training to be better and felt that they had a reasonable work-life balance.

Conclusions

The potential loss of the future NHS surgical workforce is worrying. Our survey highlights that surgical trainees place a high value on the quality of their training and were willing to enter an intense and uncertain process to achieve it. This needs to be addressed to retain potential trainees.