Drug-related deaths at Australian music festivals

BACKGROUND

Illicit drug use is overrepresented in music festival attendees compared with the general population. Drug use often involves a wide range of substances with the potential to cause drug toxicity. Law enforcement-centred strategies intended to deter drug use and supply at these mass gatherings have been implemented throughout Australia. However, many have been criticised for their lack of effectiveness, with evidence suggesting that they can inadvertently increase the risk of drug harm. Drug deaths are often multifactorial, providing added challenges in the development of prevention strategies. This study aimed to determine the frequency of deaths involving alcohol and other drugs at music festivals in Australia and to identify potential risk factors that may inform future harm reduction strategies.

METHODS

A descriptive case series study was conducted using the National Coronial Information System (NCIS) to investigate drug-related deaths at music festivals throughout Australia between 1 July 2000 (Queensland from 1 January 2001) and 31 December 2019, using a list of keywords comprising music festival names and terms.

RESULTS

There were 64 deaths, of which most involved males (73.4%) aged in their mid-20s (range 15-50 years). Drug toxicity was the most common primary cause of death (46.9%) followed by external injuries (37.5%). The drug most commonly detected or reported as being used was MDMA (65.6%), followed by alcohol (46.9%) and cannabis (17.2%), with most cases reporting the use of two or more drugs (including alcohol) and 36% reporting a history of drug misuse in the coroner's findings. Most deaths were unintentional, with less than a fifth of cases (17.2%) involving intentional self-harm. Clinical intervention was involved in 64.1% of cases and most festivals occurred in inner city locations (59.4%).

CONCLUSIONS

The findings suggest that drug-related deaths at music festivals in Australia typically involve young people using multiple illicit substances in combination with alcohol. Most are unintentional and could potentially be prevented through the implementation of a range of harm reduction strategies, including mobile medical care, drug checking services, and increased consumer education and awareness.

Australian radiographers' awareness of cardiac implantable electronic devices (CIEDs) in mammographic imaging

INTRODUCTION

Women presenting for mammography occasionally have pacemakers or other cardiac-implantable electronic devices (CIEDs) in situ. This research investigates Australian radiographers' awareness of CIEDs in the diagnostic and screening settings.

METHODS

A survey of radiographers with mammography experience in Australia was conducted using SurveyMonkey™. Respondents were asked if they could confidently identify images of devices and whether they had imaged them mammographically. A Chi-squared test of independence was used to compare the association between demographics and CIED awareness. A value of p < 0.05 was deemed statistically significant.

RESULTS

There were 220 valid responses. All CIED types had been imaged. Most respondents had imaged a pacemaker (94.5%) and implantable cardioverter-defibrillator (ICD) (85.6%), compared to the three different implantable loop recorders (ILRs) (ILR-1: 63.4%; ILR-2: 14.1%; and IRL-3: 26.9% and the emerging subcutaneous ICDs (S-ICDs) (11.9%). Most respondents felt confident identifying the pacemaker (95%) and the ICD (86.1%). Only 19.4% of respondents could confidently identify the emerging S-ICD.

CONCLUSION

A lack of awareness of new and emerging devices may impact approaches to imaging and present significant risk to patients. The lack of studies comprehensively describing devices and their mammographic appearance to support radiographers' knowledge and awareness highlights an urgent need to progress research in this area.

IMPLICATIONS FOR PRACTICE

As a part of continuing professional development, radiographers performing mammography must ensure they remain up to date with current and emerging technology, including CIEDs. This study has identified a lack of awareness of the different types of CIEDs currently being implanted and imaged, which may translate to unsafe imaging practices. There is an urgent need for further education to bridge this knowledge gap and ensure the safety of practice in imaging women with CIEDs.

FOOTLINE

Mammography: CIED Imaging.

POS1097 TREATMENT KNOWLEDGE AND PREFERENCES FOR BLACK PEOPLE WITH HIP AND KNEE OSTEOARTHRITIS: A SYSTEMATIC LITERATURE REVIEW AND META-ANALYSIS

Background:

Black people are less likely to undergo total joint arthroplasties, despite reporting more severe symptoms. (1) While racial disparities exist in treatment utilization for osteoarthritis, comprehensive studies of the treatment preferences of Black people have not been conducted.

Objectives:

The purpose of this manuscript is to systematically review the literature and identify Black osteoarthritis patients’ treatment preferences to understand how they may contribute to racial differences in the utilization of different treatment options.

Methods:

Searches ran on April 8, 2019 and April 7, 2020 in the following databases: Ovid MEDLINE (ALL - 1946 to Present); Ovid EMBASE (1974 to present); and The Cochrane Library (Wiley). Using the Patient/Population-Intervention-Comparison/Comparator-Outcome (PICO) format, our population of interest was Black people with hip and/or knee osteoarthritis, our intervention was preferences and opinions about treatment options for osteoarthritis, our comparator was white people with hip and/or knee osteoarthritis, and our outcome was preferences of osteoarthritis therapies. The protocol was registered under the PROSPERO international register, and the Preferred Reporting Items of Systematic reviews and Meta-Analyses (PRISMA) guidelines were followed.

Results:

Searches across the chosen databases retrieved 10,894 studies after de-duplication, 182 full text, and 31 selected for inclusion in this review. Black people were less likely to use NSAIDs or narcotic analgesics compared to white people. (Figure 1) Black people were more likely than white people to use spirituality and prayer, as well as topical treatments. Utilization of meditation, supplement/vitamin use, and hot/cold treatments was not significantly different between groups. Black people were less willing than white people to consider or undergo joint replacements, even if the procedure was needed and recommended by a physician.

Conclusion:

Racial differences persist in OA care across the spectrum of options. Future interventions should focus on providing accessible information surrounding treatment options and targeting perceptions of the importance of joint health.

References:

[1]Suarez-Almazor ME, Souchek J, Kelly PA, et al. Ethnic Variation in Knee Replacement: Patient Preferences or Uninformed Disparity? Arch Intern Med. 2005;165(10):1117-1124. doi:10.1001/archinte.165.10.1117

Figure 1.

Meta-analysis describing the odds ratios of Black people using NSAIDs and Narcotic Analgesics compared to white people

Disclosure of Interests:

Collin Brantner: None declared, Diyu Pearce-Fisher: None declared, Carine Moezinia: None declared, Haley Tornberg: None declared, John FitzGerald: None declared, Michael Parks Consultant of: Zimmer Biomet, Peter Sculco Consultant of: EOS Imaging, Intellijoint Surgical, DePuy Synthes, Lima Corporate, Cynthia Kahlenberg: None declared, Curtis Mensah: None declared, Ajay Premkuar: None declared, Nicholas Williams: None declared, Michelle Demetres: None declared, Susan Goodman Consultant of: UCB, Grant/research support from: Novartis, Horizon Therapeutics.

POS1124 IDENTIFYING POTENTIAL CLASSIFICATION CRITERIA FOR CALCIUM PYROPHOSPHATE DEPOSITION DISEASE (CPPD): RESULTS FROM THE INITIAL PHASES

Background:

Classification criteria for calcium pyrophosphate deposition disease (CPPD) will facilitate clinical research on this common crystalline arthritis. ACR/EULAR are jointly sponsoring development of CPPD classification criteria using a multi-phase process.

Objectives:

To report preliminary results from the first two phases of a four-phase process for developing CPPD classification criteria.

Methods:

CPPD classification criteria development is overseen by a 12-member Steering Committee. Item generation (Phase I) included a scoping literature review of five literature databases and contributions from a 35-member Combined Expert Committee and two Patient Research Partners. Item reduction and refinement (Phase II) involved a Combined Expert Committee meeting, discussions among Clinical, Imaging, and Laboratory Advisory Groups, and an item rating exercise to assess the influence of individual items toward classification. The Steering Committee reviewed the modal rating score for each item (range -3 [strongly pushes away from CPPD] to +3 [strongly pushes toward CPPD]) to determine items to retain for future phases of criteria development.

Results:

Item generation yielded 420 items (312 from the literature, 108 from experts/patients). The Advisory Groups eliminated items they agreed were unlikely to distinguish between CPPD and other forms of arthritis, yielding 127 items for the item rating exercise. Fifty-six items, most of which had a modal rating of +/- 2 or 3, were retained for future phases (see Table 1). As numerous imaging items were rated +3, the Steering Committee recommended focusing on imaging of the knee, wrist, and one additional affected joint for calcification suggestive of CPP crystal deposition.

Conclusion:

The ACR/EULAR CPPD classification criteria working group has adopted both data- and expert-driven approaches, leading to 56 candidate items broadly categorized as clinical, imaging, and laboratory features. Remaining steps for criteria development include domain establishment, item weighting through a multi-criteria decision analysis exercise, threshold score determination, and criteria validation.

Table 1.

Categories of items retained for future phases of classification criteria development

Age in decade at symptom onsetAcute inflammatory arthritis (e.g. knee, wrist, 1st MTP joint*)Recurrence and pattern of joint involvement (e.g. 1 self-limited episode, >1 self-limited episode)Physical findings (e.g. palpable subcutaneous tophus*, psoriasis*)Co-morbidities and family history (e.g. Gitelman disease, hemochromatosis, familial CPPD)Osteoarthritis location and features (e.g. 2nd or 3rd MCP joint, wrist)Synovial fluid findings (e.g. CPP crystals present, CPP crystals absent on 1 occasion* or 2 occasions*, monosodium urate crystals present*)Laboratory findings (e.g. hypomagnesemia, hyperparathyroidism, rheumatoid factor*, anti-CCP*)Plain radiograph: calcification in regions of fibro- or hyaline cartilage+Plain radiograph: calcification of the synovial membrane/capsule/tendon+Conventional CT: calcification in regions of fibro- or hyaline cartilage+Conventional CT: calcification of the synovial membrane/capsule/tendon+Ultrasound: CPP crystal deposition in fibro- or hyaline cartilage+Ultrasound: CPP crystal deposition in synovial membrane/capsule/tendons+Dual-energy CT: CPP crystal deposition in fibro- or hyaline cartilage+Dual-energy CT: CPP crystal deposition in synovial membrane/capsule/tendon+

*Potential negative predictor +Assessed in the knee, wrist, and/or 1 additional affected joint

Disclosure of Interests:

Sara Tedeschi Consultant of: NGM Biopharmaceuticals, Tristan Pascart: None declared, Augustin Latourte Consultant of: Novartis, Cattleya Godsave: None declared, Burak Kundaki: None declared, Raymond Naden: None declared, William Taylor: None declared, Nicola Dalbeth Speakers bureau: Abbvie and Janssen, Consultant of: AstraZeneca, Dyve, Selecta, Horizon, Arthrosi, and Cello Health, Tuhina Neogi: None declared, Fernando Perez-Ruiz: None declared, Ann Rosenthal: None declared, Fabio Becce Consultant of: Horizon Therapeutics, Grant/research support from: Siemens Healthineers, Eliseo Pascual: None declared, Mariano Andrés: None declared, Thomas Bardin: None declared, Michael Doherty: None declared, Hang Korng Ea: None declared, Georgios Filippou: None declared, John FitzGerald: None declared, Marwin Gutierrez: None declared, Annamaria Iagnocco: None declared, Tim Jansen Speakers bureau: Abbvie, Amgen, BMS, Grunenthal, Olatec, Sanofi Genzyme, Consultant of: Abbvie, Amgen, BMS, Grunenthal, Olatec, Sanofi Genzyme, Minna Kohler Speakers bureau: Lilly, Consultant of: Novartis, Frederic Lioté: None declared, Mark Matza: None declared, Geraldine McCarthy Consultant of: PK Med, Roberta Ramonda: None declared, Anthony Reginato: None declared, Pascal Richette: None declared, Jasvinder Singh Speakers bureau: Simply Speaking, Consultant of: Crealta/Horizon, Medisys, Fidia, UBM LLC, Trio health, Medscape, WebMD, Adept Field Solutions, Clinical Care options, Clearview healthcare partners, Putnam associates, Focus forward, Navigant consulting, Spherix, Practice Point communications, Francisca Sivera: None declared, Alexander So: None declared, Lisa Stamp: None declared, Janeth Yinh: None declared, Chio Yokose: None declared, Robert Terkeltaub Consultant of: Sobi, Horizon Therapeutics, Astra-Zeneca, Selecta, Grant/research support from: Astra-Zeneca, Hyon Choi: None declared, Abhishek Abhishek Consultant of: NGM Biopharmaceuticals.

Atrial fibrillation substrate mapping with decrement evoked potential mapping

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): Sociedad Española de Cardiologia.

OnBehalf

DEFINE-AF

Background

Identifying and targeting atrial substrate zones that are vulnerable to unidirectional block and slow conduction may be critical to improve the outcomes of atrial fibrillation (AF) ablation. Functional mapping of the atrial substrate with Decrement Evoked Potential (DeEP) and a single extrastimulus in this population could potentially lead to novel therapeutic strategies.

Aim

1) To systematically analyze whether the DEEP are present in the atrial tissue and their locations after pulmonary vein isolation. 2) To assess their relationship with the underlying voltage.  3) To assess the presence of DEEP as a function of the subtype of AF.

Methods

Consecutive patients with AF undergoing ablation were prospectively enrolled at 3 institutions. A biatrial voltage map was created and after pulmonary vein isolation (PVI). A drive train and an extrastimulus (atrial refractory period + 20ms) was delivered from an epicardial site (proximal CS) and an endocardial site (left atrial appendage (LAA). A multipolar mapping catheter was sequentially placed at 8 left atrial sites and 5 right atrial sites. Electrograms (EGMs) that showed a local delay of &gt;10ms in activation with the extrastimulus were identified as DEEPs. Patients were followed for a mean of 11 ± 5 months

Results

74 patients, 63 pers AF (85%), mean age 62 ± 8, mean LA size 41 ±12 mm were enrolled. Of 19240 EGMs analyzed, 8.2% showed DEEPs (54.6% with CS pacing and 45.4% with LAA pacing, p = 0.0001). The mean local decrement seen was 39 ms. Most DEEPs (76.2%) were identified in sites with a normal EGM at baseline with preserved voltages. DEEPs were differentially distributed within the regions mapped, more frequently in LA than RA (9.2% vs 6.6%, p &lt; 0.0001). Patients with persistent AF had a higher proportion of DEEPs than patients with paroxysmal AF (9.7% vs 5.1%, p &lt; 0.001).

Conclusions

Atrial DEEPs are: 1) More often identified when pacing endocardially. 2) More common in patients with persistent AF. 3) More frequent in the LA than in the RA. 4) Mostly located in regions with normal voltages at baseline. All those findings suggest the importance of the functional substrate mapping in the atrium and could lead to novel therapeutic targets. Abstract Figure. Example of atrial DEEP

O32: TRANSPARENCY IN SURGICAL RANDOMISED CONTROLLED TRIALS: CROSS-SECTIONAL, OBSERVATIONAL STUDY

Introduction

Randomised controlled trials (RCT) often provide the scientific basis on which commissioning and treatment decisions are made. It is essential that their results and methods are reported transparently. The aim of this study was to explore transparency with respect to trial registration, disclosure of funding sources, conflicts of interest (COI), and data sharing.

Method

This was a cross-sectional review of surgical RCTs. Data were extracted from RCTs in ten high-impact journals published in the years 2009, 2012, 2015, and 2018. Outcomes of interest were the incidence of reported trial registration, disclosure of funding sources, disclosure of investigator COI, and presence of a statement of data sharing plans.

Result

A total of 475 were eligible for analysis. Trial registration was present in 73 (67%) studies in 2009, 137 (84%) in 2012, 111 (89%) in 2015 and 110 (93%) in 2018. Funding statements were provided in 55%, 65%, 69.4%, and 75.4% of manuscripts, respectively. Conflicts of interest statements were provided in 49.5%, 89.1%, 94.6%, and 98.3% of manuscripts, respectively. Data sharing statements were present in only 15 (3.2%) RCTs. Eleven of these were in studies published most recently in 2018.

Conclusion

Trial registration, presence of funding statements, and disclosure of personal conflicts of interest in surgical RCTs have improved rapidly over the last 10 years. In contrast, disclosure of data sharing plans is exceptionally low. This may contribute to research waste and represents an essential target for improvement.

Take-home message

Trial registration, presence of funding statements, and disclosure of personal conflicts of interest in surgical RCTs have improved rapidly over the last 10 years. In contrast, disclosure of data sharing plans is exceptionally low. This may contribute to research waste and represents an essential target for improvement.

Transparency in surgical randomized clinical trials: cross-sectional observational study

BACKGROUND

RCTs provide the scientific basis upon which treatment decisions are made. To facilitate critical review, it is important that methods and results are reported transparently. The aim of this study was to explore transparency in surgical RCTs with respect to trial registration, disclosure of funding sources, declarations of investigator conflicts and data-sharing.

METHODS

This was a cross-sectional review of published surgical RCTs. Ten high-impact journals were searched systematically for RCTs published in years 2009, 2012, 2015 and 2018. Four domains of transparency were explored: trial registration, disclosure of funding, disclosure of investigator conflicts, and a statement relating to data-sharing.

RESULTS

Of 611 RCTs, 475 were eligible for analysis. Some 397 RCTs (83.6 per cent) were registered on a trial database, of which 190 (47·9 per cent) had been registered prospectively. Prospective registration increased over time (26 per cent in 2009, 33·0 per cent in 2012, 54 per cent in 2015, and 72·7 per cent in 2018). Funding disclosure was present in 55·0, 65·0, 69·4 and 75·4 per cent of manuscripts respectively. Conflict of interest disclosure was present in 49·5, 89·1, 94·6 and 98·3 per cent of manuscripts across the same time periods. Data-sharing statements were present in only 15 RCTs (3·2 per cent), 11 of which were published in 2018.

CONCLUSION

Trial registration, disclosure of funding and disclosure of investigator conflicts in surgical RCTs have improved markedly over the past 10 years. Disclosure of data-sharing plans is exceptionally low. This may contribute to research waste and represents a target for improvement.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

What is 'global surgery'? Defining the multidisciplinary interface between surgery, anaesthesia and public health

'Global surgery' is the term adopted to describe a rapidly developing multidisciplinary field aiming to provide improved and equitable surgical care across international health systems. Sitting at the interface between numerous clinical and non-clinical specialisms, it encompasses multiple aspects that surround the treatment of surgical disease and its equitable provision across health systems globally. From defining the role of, and need for, optimal surgical care through to identifying barriers and implementing improvement, global surgery has an expansive remit. Advocacy, education, research and clinical components can all involve surgeons, anaesthetists, nurses and allied healthcare professionals working together with non-clinicians, including policy makers, epidemiologists and economists. Long neglected as a topic within the global and public health arenas, an increasing awareness of the extreme disparities internationally has driven greater engagement. Not necessarily restricted to specific diseases, populations or geographical regions, these disparities have led to a particular focus on surgical care in low-income and middle-income countries with the greatest burden and needs. This review considers the major factors defining the interface between surgery, anaesthesia and public health in these settings.

Five short screening tests in the detection of prevalent delirium: diagnostic accuracy and performance in different neurocognitive subgroups

BACKGROUND

Delirium is prevalent and serious, yet remains under-recognised. Systematic screening could improve detection; however, consensus is lacking as to the best approach. Our aim was to assess the diagnostic accuracy of five simple cognitive tests in delirium screening: six-item cognitive impairment test (6-CIT), clock-drawing test, spatial span forwards, months of the year backwards (MOTYB) and intersecting pentagons (IPT).

METHODS

A cross-sectional study was conducted. Within 36 h of admission, older medical patients were assessed for delirium using the Revised Delirium Rating Scale. They also underwent testing using the five cognitive tests outlined above. Sensitivity, specificity, positive and negative predictive values (PPV; NPV) were calculated for each method. Where appropriate, area under the receiver operating characteristic curve (AUC) was also calculated.

RESULTS

Four hundred seventy patients were included, and 184 had delirium. Of the tests scored on a scale, the 6-CIT had the highest AUC (0.876), the optimum cut-off for delirium screening being 8/9 (sensitivity 89.9%, specificity 62.7%, NPV 91.2%, PPV 59.2%). The MOTYB, scored in a binary fashion, also performed well (sensitivity 84.6%, specificity 58.4%, NPV 87.4%, PPV 52.8). On discriminant analysis, 6-CIT was the only test to discriminate between patients with delirium and those with dementia (without delirium), Wilks' Lambda = 0.748, p < 0.001.

CONCLUSION

The 6-CIT measures attention, temporal orientation and short-term memory and shows promise as a delirium screening test. This study suggests that it may also have potential in distinguishing the cognitive impairment of delirium from that of dementia in older patients. Copyright © 2016 John Wiley & Sons, Ltd.

Population Pharmacokinetics of Liposomal Irinotecan in Patients With Cancer

Nanoliposomal irinotecan (nal‐IRI) is a liposomal formulation of irinotecan with a longer half‐life (t_1/2), higher plasma total irinotecan (tIRI), and lower SN‐38 maximum concentration (C_max) compared with nonliposomal irinotecan. Population pharmacokinetic (PK) analysis of nal‐IRI was performed for tIRI and total SN‐38 (tSN38) using patient samples from six studies. PK‐safety association was evaluated for neutropenia and diarrhea in 353 patients. PK‐efficacy association was evaluated from a phase III study in pancreatic cancer NAPOLI1. Efficacy was associated with longer duration of unencapsulated SN‐38 (uSN38) above a threshold and higher C_avg of tIRI, tSN38, and uSN38. Neutropenia was associated with uSN38 C_max and diarrhea with tIRI C_max. Baseline predictive factors were race, body surface area, and bilirubin. Analysis identified PK factors associated with efficacy, safety, and predictive baseline factors. The results support the benefit of nal‐IRI dose of 70 mg/m² (free‐base; equivalent to 80 mg/m² salt base) Q2W over 100 mg/m² Q3W.

Abstract P6-12-16: Delivery and anti-tumor activity of nanoliposomal irinotecan (Nal-IRI, MM-398) in metastatic xenograft models of triple negative breast cancer

This abstract was not presented at the symposium.

Social media in colorectal surgery

The engagement of social media in healthcare continues to expand. For members of the colorectal community, social media has already made a significant impact on practice, education and patient care. The applications are unique such that they provide a platform for instant communication and information sharing with other users worldwide. The purpose of this article is to provide an overview of how social media has the potential to change clinical practice, training, research and patient care in colorectal surgery.

Biomimetic Cross-Reactive Sensor Arrays: Prospects in Biodiagnostics

Biomimetic cross-reactive sensor arrays have been used to detect and analyze a wide variety of vapour and liquid components in applications such as food science, public health and safety, and diagnostics. As technology has advanced over the past three decades, these systems have become selective, sensitive, and affordable. Currently, the need for non-invasive and accurate devices for early disease diagnosis remains a challenge. This review provides an overview of the various types of Biomimetic cross-reactive sensor arrays (also referred to as electronic noses and tongues in the literature), their current use and future directions, and an outlook for future technological development.

Reassessing critical maternal antibody threshold in RhD alloimmunization: a 16-year retrospective cohort study

OBJECTIVE

To determine the critical maternal antibody threshold for specialist referral in cases of RhD alloimmunization.

METHODS

This was a retrospective cohort study, covering a 16-year period at the national tertiary fetal medicine center for management of alloimmunization. Data concerning RhD alloimmunized pregnant women were extracted from an institutional database and maternal anti-D antibody levels were cross-checked with the national reference laboratory. Fetal hemoglobin (Hb) levels were determined only at the first intrauterine transfusion (IUT) and were compared with the pretransfusion maternal anti-D antibody level (IU/mL). Sensitivity, specificity and positive and negative predictive values of maternal antibody thresholds for detecting moderate to severe (Hb ≤ 0.64MoM) fetal anemia were calculated.

RESULTS

Between 1996 and 2011, 66 women underwent a first IUT for RhD alloimmunization at our institution. The highest serum anti-D antibody level was extracted for 208 RhD alloimmunized women who did not require IUT during the last 10 years of the study period. The traditional maternal antibody threshold of > 15 IU/mL failed to detect 20% of cases of moderate to severe fetal anemia. The ≥ 4 IU/mL threshold had 100% sensitivity but a 45% false-positive rate. The optimal anti-D antibody threshold for specialist referral in our population was ≥ 6 IU/mL; at this level, no case of moderate to severe anemia was missed and specificity was 61%. Use of this threshold would have eliminated 10% of referrals to our fetal medicine unit without compromising fetal outcomes.

CONCLUSIONS

Setting the critical maternal RhD antibody level at >15 IU/mL does not provide sufficient sensitivity. The lower threshold of ≥ 4 IU/mL, though sensitive, is associated with a 45% false-positive rate. In our population, a threshold of ≥ 6 IU/mL minimizes false-positive referrals while maintaining 100% sensitivity for moderate to severe fetal anemia.

Sonographic discrimination between benign and malignant adnexal masses in premenopause

PURPOSE

The aim of this study was to assess the diagnostic value of sonographic pattern recognition by experts, a standardized morphological scoring system, the risk malignancy index (RMI) and CA 125 assay for the preoperative assessment of ovarian lesions in premenopausal patients.

MATERIAL AND METHODS

Diagnostic work-up of 1320 patients who underwent surgical exploration due to an adnexal mass at a tertiary referral center were included. We assessed the discriminative value of pattern recognition, a sonographic morphological scoring system, RMI and CA 125 by calculating sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and Cohen's kappa for each diagnostic approach while using histopathology as the reference standard.

RESULTS

Pattern recognition showed the highest discriminative power with an observed kappa of 0.53. Sensitivity and specificity yielded 0.76 and 0.97 respectively. Combining pattern recognition with CA 125 serum measurement in the context of a triage system diminished the diagnostic value (kappa: 0.24; sensitivity: 0.29 specificity: 0.97). For the RMI we observed a sensitivity of 0.54 and a specificity of 0.96 and estimated kappa value yielded 0.37. Omitting the CA 125 assay and using a morphological sonographic assessment system increased the kappa value to 0.45 with sensitivity and specificity observed at 0.61 and 0.97 respectively.

CONCLUSION

Expert pattern recognition was found to be the method with the highest discriminative power in assessing an adnexal mass during premenopause. Additional assessment of serum CA 125 diminished the diagnostic accuracy. Standardized morphological sonographic assessment resulted in a moderate diagnostic accuracy. Supplementing the morphological sonographic assessment with CA 125 by using the RMI algorithm did not improve the diagnostic value.

A correlation between severe haemolytic disease of the fetus and newborn and maternal ABO blood group

OBJECTIVE

To analyse anti-D quantification levels and frequency of intrauterine transfusion (IUT), per maternal ABO blood group.

BACKGROUND

Maternally derived red cell allo-antibodies can target fetal red cell antigens in utero leading to haemolytic disease and fetal anaemia. When a clinically significant allo-antibody is formed the priority is ascertaining the risk to the fetus and maternal ABO blood groups are not considered relevant.

MATERIALS AND METHODS

This was a 10-year retrospective, observational study carried out on women referred for anti-D quantification (n = 1106), and women whose fetuses required an IUT to treat fetal anaemia (n = 62) due to anti-D, in the Republic of Ireland.

RESULTS

Relative to the overall incidence of RhD allo-immunisation by blood group, women of blood group A were more likely to require IUT compared with those who were blood group O (P = 0.002).

CONCLUSION

It is known that ABO feto-maternal compatibility can influence the incidence and level of red cell allo-antibodies in pregnancy; however, it does not account for the significantly high rate of severe haemolytic disease requiring IUT seen in blood group A women.

Single timepoint models of dynamic systems

Many interesting studies aimed at elucidating the connectivity structure of biomolecular pathways make use of abundance measurements, and employ statistical and information theoretic approaches to assess connectivities. These studies often do not address the effects of the dynamics of the underlying biological system, yet dynamics give rise to impactful issues such as timepoint selection and its effect on structure recovery. In this work, we study conditions for reliable retrieval of the connectivity structure of a dynamic system, and the impact of dynamics on structure-learning efforts. We encounter an unexpected problem not previously described in elucidating connectivity structure from dynamic systems, show how this confounds structure learning of the system and discuss possible approaches to overcome the confounding effect. Finally, we test our hypotheses on an accurate dynamic model of the IGF signalling pathway. We use two structure-learning methods at four time points to contrast the performance and robustness of those methods in terms of recovering correct connectivity.

Epidemiology of invasive pneumococcal disease and vaccine provision in a tertiary referral center

Invasive pneumococcal disease (IPD) has an all-cause mortality of 5-35 % in the developed world. Pneumococcal vaccination is recommended for at-risk groups, including those infected with human immunodeficiency virus (HIV) and those over 65 years of age. However, adherence to vaccination guidelines is low. We reviewed all cases of IPD in our tertiary referral hospital from 2006 to 2010. IPD was defined as the isolation of Streptococcus pneumoniae from a normally sterile site with a compatible clinical syndrome. Demographics, risk factors, susceptibilities, pneumococcal serotype, mortality, and vaccination status for each patient were analyzed. There were 127 IPD episodes in 122 patients. The overall case fatality rate was 21.2 %. Seventy-two percent of the patients had two or more risk factors that should have prompted pneumococcal vaccination. However, the overall pneumococcal vaccination provision was only 9 %: 64.6 % of all typed isolates were contained in the pneumococcal polysaccharides vaccine 23 (PPV23), 48.8 % in the 7-valent pneumococcal conjugate vaccine (PCV7), and 60.1 % in PCV13. All isolates were fully sensitive to penicillin and cefotaxime. Recurrent IPD was seen in 11 % of the HIV-infected patients, highlighting a particular at-risk group. IPD has a high mortality rate. There is low vaccine provision in our study, although most IPD patients had risk factors that should have prompted vaccination. HIV-positive people are particularly at risk; vaccinating those with persisting CD4 counts less than 200 cells/mm(3) and the use of "prime-boost" strategies may decrease incidence in the future. Newer models of care such as a dedicated vaccine clinic as described in this study may help increase vaccine provision and uptake.