A phase II randomised controlled trial of intranasal oxytocin in anorexia nervosa

BACKGROUND

Anorexia nervosa (AN) is an eating disorder (ED) with high mortality rates and limited response to existing treatments, prompting the need to identify effective agents and adjuncts. There is evidence for an emerging role for the neuropeptide oxytocin (OT) in the pathophysiology of AN, with studies showing a perturbed oxytocinergic system in patients with AN. Preliminary evidence has demonstrated that intranasal OT (IN-OT) can produce anxiolytic effects in AN, as well as reducing concern about eating, and dysfunctional attentional biases related to the disorder. IN-OT is a non-invasive treatment option for AN that requires investigation as an adjunct to nutritional rehabilitation.

METHODS

This multi-site study (Trial Registration:ACTRN1261000897460) sought to replicate and extend a previous randomised placebo-controlled pilot trial of repeated dose IN-OT in patients with AN hospitalised for nutritional rehabilitation. Patients with AN (N=61) received daily IN-OT (18 IU twice per day) or placebo for four weeks, whilst undergoing inpatient hospital treatment. Outcome measures included ED psychopathology (primary) as measured by the Eating Disorder Examination (EDE) and Body Mass Index (BMI; secondary). Participants were assessed pre- and post-treatment, and at six months following the intervention. The effects of the first and last doses of IN-OT on responses (anxiety ratings and salivary cortisol) to a high-energy snack were also examined.

RESULTS

Sixty-one female inpatients (Mage=24.36,SD=7.87) with an average BMI of 16.24 (range: 11.43-18.55), were recruited into the study. No significant differences were found between placebo and OT groups at any of the time points on the outcomes of interest, but significant improvements in almost all psychological parameters in both groups were evident over time. IN-OT did not significantly reduce anxiety nor salivary cortisol in response to a high-calorie snack.

CONCLUSION

This is the largest randomised placebo-controlled trial of repeated dose intranasal OT in people with AN, during refeeding. The therapeutically promising findings of the pilot study were not replicated. Limitations and reasons for the non-replication included relatively large variance, baseline psychopathology scores being higher in this patient group, potential ceiling effects in BMI and ED psychopathology as well as differing comorbidities.

Implications of the composite free flap harvest site on quality of life after head and neck surgery: a prospective series

Quality of life (QOL) has become a primary determinant of the treatment outcome. There is a poor evidence base regarding the QOL implications of free flap harvest from the various different osseous composite donor sites. This prospective study assessed the impact of free flap harvest on QOL and compared QOL morbidity between fibula, scapula, and iliac crest (deep circumflex iliac artery; DCIA) donor sites in head and neck reconstructive surgery. This was a single-site prospective cohort clinical research study. Fifty-nine patients were recruited between 2017 and 2021; 30 underwent fibula flap reconstructive surgery, 17 scapula flap, and 12 DCIA flap. The patients were assessed using the University of Washington Quality of Life Questionnaire version 4 (UW-QOL v4) preoperatively and again at >12 months postoperatively. The results showed no significant change in the mean global QOL score postoperatively when compared to the preoperative baseline in any of the donor site groups. However, the mean postoperative scores for the appearance domain were significantly lower than the preoperative scores in all of the donor site groups. In addition, fibula flap patients had significantly reduced physical activity and recreation QOL domain scores postoperatively when compared to the preoperative scores.

Validating and developing a shortened version of the detail and flexibility (DFlex) questionnaire for eating disorders, anxiety and depression

OBJECTIVE

To validate the original and a shortened version of the Detail and Flexibility (DFlex) Questionnaire.

METHOD

Confirmatory factor analyses, internal consistency, and discriminant validity estimates were conducted within individuals with a diagnosis of an eating disorder (ED) (n = 124), an anxiety disorder and/or depression (n = 219), and a community sample (n = 852) (Part 1). Convergent validity of the DFlex through comparisons with the Autism Spectrum Quotient, Wisconsin Card Sorting Task, and Group Embedded Figures Task was undertaken within a combined ED and community sample (N = 68). Test-retest reliability of the DFlex was also examined across 2 years in a community sample (N = 85) (Part 2).

RESULTS

The original factor structure of the DFlex was not supported. Hence, a shortened version, the DFlex-Revised, was developed. Good discriminant validity was obtained for the DFlex and DFlex-Revised, however, support for convergent validity was mixed. Finally, the 2-year test-retest reliability for the two DFlex versions was found to be low, suggesting potential malleability in construct over this timeframe.

CONCLUSIONS

Further research is needed to validate the DFlex in clinical and non-clinical populations using different neurocognitive tests. Test-retest, using varied time intervals, should also be assessed.

International consensus on patient-centred outcomes in eating disorders

The effectiveness of mental health care can be improved through coordinated and wide-scale outcome measurement. The International Consortium for Health Outcomes Measurement has produced collaborative sets of outcome measures for various mental health conditions, but no universal guideline exists for eating disorders. This Position Paper presents a set of outcomes and measures for eating disorders as determined by 24 international experts from professional and lived experience backgrounds. An adapted Delphi technique was used, and results were assessed through an open review survey. Final recommendations suggest outcomes should be tracked across four domains: eating disorder behaviours and cognitions, physical health, co-occurring mental health conditions, and quality of life and social functioning. Outcomes are collected using three to five patient-reported measures. For children aged between 6 years and 12 years, the measures include the Children's Eating Attitude Test (or, for those with avoidant restrictive food intake disorder, the Eating Disorder in Youth Questionnaire), the KIDSCREEN-10, and the Revised Children's Anxiety and Depression Screener-25. For adolescents aged between 13 years and 17 years, the measures include the Eating Disorder Examination Questionnaire (EDE-Q; or, for avoidant restrictive food intake disorder, the Nine-Item Avoidant Restrictive Food Intake Disorder Screener [NIAS]), the two-item Patient Health Questionnaire (PHQ-2), the nine-item Patient Health Questionnaire (PHQ-9), the two-item Generalised Anxiety Disorder (GAD-2), the seven-item Generalised Anxiety Disorder (GAD-7), and the KIDSCREEN-10. For adults older than 18 years, measures include the EDE-Q (or, for avoidant restrictive food intake disorder, the NIAS), the PHQ-2, the PHQ-9, the GAD-2, the GAD-7, the Clinical Impairment Assessment, and the 12-item WHO Disability Assessment Schedule 2.0. These questionnaires should be supplemented by information on patient characteristics and circumstances (ie, demographic, historical, and clinical factors). International adoption of these guidelines will allow comparison of research and clinical interventions to determine which settings and interventions work best, and for whom.

The utility of parathyroid autofluorescence as an adjunct in thyroid and parathyroid surgery 2023

Thyroid and parathyroid surgery requires careful dissection around the vascular pedicle of the parathyroid glands to avoid excessive manipulation of the tissues. If the blood supply to the parathyroid glands is disrupted, or the glands are inadvertently removed, temporary and/or permanent hypocalcemia can occur, requiring post-operative exogenous calcium and vitamin D analogues to maintain stable levels. This can have a significant impact on the quality of life of patients, particularly if it results in permanent hypocalcemia. For over a decade, parathyroid tissue has been noted to have unique intrinsic properties known as "fluorophores," which fluoresce when excited by an external light source. As a result, parathyroid autofluorescence has emerged as an intra-operative technique to help with identification of parathyroid glands and to supplement direct visualization during thyroidectomy and parathyroidectomy. Due to the growing body of literature surrounding Near Infrared Autofluorescence (NIRAF), we sought to review the value of using autofluorescence technology for parathyroid detection during thyroid and parathyroid surgery. A literature review of parathyroid autofluorescence was performed using PubMED. Based on the reviewed literature and expert surgeons' opinions who have used this technology, recommendations were made. We discuss the current available technologies (image vs. probe approach) as well as their limitations. We also capture the opinions and recommendations of international high-volume endocrine surgeons and whether this technology is of value as an intraoperative adjunct. The utility and value of this technology seems promising and needs to be further defined in different scenarios involving surgeon experience and different patient populations and conditions.

A randomised controlled trial of clinician supported vs self-help delivery of online cognitive behaviour therapy for Bulimia Nervosa

High dropout rates and poor adherence associated with digital interventions have prompted research into modifications of these treatments to improve engagement and completion rates. This trial aimed to investigate the added benefit of clinician support when paired alongside a ten-session, online cognitive behaviour therapy (CBT) self-help intervention for bulimia nervosa (BN). As part of a three-arm, phase II randomised controlled trial, 114 participants (16 years or over) with full or subthreshold BN were randomly assigned to complete the intervention in a self-help mode (with administrative researcher contact; n = 38), with adjunct clinician support (weekly 30-minute videoconferencing sessions; n = 37), or a no-treatment waitlist control (WLC; n = 39). Baseline to post-treatment (12-weeks) decreases in objective binge episode frequency were significantly greater for clinician-supported participants as compared to WLC, but not for self-help when compared to WLC. However, due to continued improvements for self-help across follow-up (24-weeks), both arms outperformed WLC when analysed as an overall rate of change across three timepoints. Clinician-supported participants outperformed self-help in regards to laxative use and dietary restraint. Our results demonstrate that good clinical outcomes can be achieved with a relatively brief online CBT-based program even in the absence of structured clinical support, indicating a possible overreliance upon clinician support as a primary adherence-facilitating mechanism.

Universal DNA methylation age across mammalian tissues

Aging, often considered a result of random cellular damage, can be accurately estimated using DNA methylation profiles, the foundation of pan-tissue epigenetic clocks. Here, we demonstrate the development of universal pan-mammalian clocks, using 11,754 methylation arrays from our Mammalian Methylation Consortium, which encompass 59 tissue types across 185 mammalian species. These predictive models estimate mammalian tissue age with high accuracy (r > 0.96). Age deviations correlate with human mortality risk, mouse somatotropic axis mutations and caloric restriction. We identified specific cytosines with methylation levels that change with age across numerous species. These sites, highly enriched in polycomb repressive complex 2-binding locations, are near genes implicated in mammalian development, cancer, obesity and longevity. Our findings offer new evidence suggesting that aging is evolutionarily conserved and intertwined with developmental processes across all mammals.

Oxytocin and eating disorders: Knowledge gaps and future directions

Eating disorders continue to be a major public health issue and important cause of morbidity and premature mortality, particularly for young people. Yet in a concerning dialectic, this occurs in the context of an epidemic of obesity which, with its medical complications, constitutes another vexing public health challenge. While it is not an eating disorder per se obesity is often comorbid with eating disorders. Effective treatment for both eating disorders and obesity has proven to be elusive and in the search for novel therapeutic interventions, the prosocial, anxiolytic, brain plasticity and metabolic effects of oxytocin (OT) have been examined from this perspective. The availability of intranasal oxytocin (IN-OT) has led to a number of interventional treatment studies in anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED), their atypical and subclinical forms and in medical and psychiatric conditions co-occurring or comorbid with these, obesity with BED would be included here. The aim of this mini review is to collate recent findings on OT as a novel therapeutic intervention in eating disorders and obesity and to identify and address some of the knowledge gaps in the use of IN-OT. The wider clinical perspective utilised here might better address some of the gaps and identify future directions of research. Clearly much remains to be done for OT to fulfil its therapeutic promise in eating disorders. OT might yet be of therapeutic promise and will be appreciated where treatment advances have been hard to come by and prevention challenging for these disorders.

Methods to expose subsurface objects of interest identified from 3D imaging: The intermediate sample preparation stage in the correlative microscopy workflow

The correlative imaging workflow is a method of combining information and data across modes (e.g. SEM, X-ray CT, FIB-SEM), scales (cm to nm) and dimensions (2D-3D-4D), providing a more holistic interpretation of the research question. Often, subsurface objects of interest (e.g. inclusions, pores, cracks, defects in multilayered samples) are identified from initial exploratory nondestructive 3D tomographic imaging (e.g. X-ray CT, XRM), and those objects need to be studied using additional techniques to obtain, for example, 2D chemical or crystallographic data. Consequently, an intermediate sample preparation step needs to be completed, where a targeted amount of sample surface material is removed, exposing and revealing the object of interest. At present, there is not one singular technique for removing varied thicknesses at high resolution and on a range of scales from cm to nm. Here, we review the manual and automated options currently available for targeted sample material removal, with a focus on those methods which are readily accessible in most laboratories. We summarise the approaches for manual grinding and polishing, automated grinding and polishing, microtome/ultramicrotome, and broad-beam ion milling (BBIM), with further review of other more specialist techniques including serial block face electron microscopy (SBF-SEM), and ion milling and laser approaches such as FIB-SEM, Xe plasma FIB-SEM, and femtosecond laser/LaserFIB. We also address factors which may influence the decision on a particular technique, including the composition, shape and size of the samples, sample mounting limitations, the amount of surface material to be removed, the accuracy and/or resolution of peripheral parts, the accuracy and/or resolution of the technique/instrumentation, and other more general factors such as accessibility to instrumentation, costs, and the time taken for experimentation. It is hoped that this study will provide researchers with a range of options for removal of specific amounts of sample surface material to reach subsurface objects of interest in both correlative and non-correlative workflows.

Food Insecurity and Hearing Loss Are Interrelated: A Cross-Sectional Population-Based Study

OBJECTIVES

We aimed to assess whether objectively measured hearing loss and self-perceived hearing handicap in adults are independently associated with food insecurity, and vice versa.

DESIGN

Cross-sectional population-based study.

POPULATION

2,500 participants aged 50+ years from the Blue Mountains Hearing Study, with both complete pure-tone audiometry data and information on food security status.

MEASUREMENTS

The pure-tone average of frequencies 0.5, 1.0, 2.0 and 4.0 kHz (PTA0.5-4KHz) >25 dB HL in the better ear, established the presence of hearing loss. Self-perceived hearing handicap was assessed by administering the Hearing Handicap Inventory for Elderly Screening (HHIE-S total scores of ≥8 indicates hearing handicap). A 12-item food security survey was administered, comprising statements related to individual and household food situations.

RESULTS

Food insecurity was reported by 12.8% of study participants. After adjusting for all potential confounders, any self-perceived hearing handicap significantly increased the likelihood of participants reporting food insecurity by 94% (p<0.0001). Participants reporting any, mild or severe self-perceived hearing handicap had around 2-fold greater odds of experiencing food insecurity. Objectively measured hearing loss did not significantly influence the food security status of study participants. Conversely, food insecurity was significantly associated with both objectively measured hearing loss and self-perceived hearing handicap: multivariate-adjusted OR 1.37 (95% CI 1.01-1.88) and OR 1.83 (95% CI 1.40-2.39), respectively.

CONCLUSIONS

Food insecurity was an important social determinant of hearing health among community-dwelling adults. Conversely, participants with a significant self-perceived hearing handicap were more likely to experience food insecurity. These findings add to our understanding of the substantial public health impact of both food insecurity and hearing loss and may highlight areas for future intervention.

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.

Suture lateralization in congenital bilateral vocal cord immobility in neonates and infants: A hybrid approach

INTRODUCTION

Bilateral vocal cord immobility (BVCI) is a leading cause of stridor and airway obstruction in neonates which may arise idiopathically, as a result of birth trauma, or in the setting of Central nervous system lesions such as Arnold-Chiari malformation. Although many children with BVCI may be managed conservatively, surgical intervention may be necessary in those patients with ongoing upper airway obstruction. Many interventions have been described including, tracheostomy, cordotomy, cricoid splitting procedures, and arytenoidectomy. Vocal cord suture lateralization has the advantage of being both reversible and less morbid than other surgical interventions for BVCI. This study describes a novel variation of the suture lateralization procedure which aids in correct placement of the suture thus minimizing multiple needle passes and associated laryngeal edema.

METHODS

A retrospective chart review was undertaken of five patients undergoing suture lateralization of the vocal cord for BVCI at a single institution over a 10 year period. Post-operative voice and swallow outcomes were recorded.

RESULTS

Of five patients undergoing this procedure four returned to normal diet. One was diagnosed with a progressive neurological disorder and was persistently fed via gastrostomy tube. Three of the five patients spontaneously recovered vocal cord function and went on to have normal voice after suture removal.

CONCLUSION

Suture lateralization is a safe and effective means of alleviating upper airway obstruction in BVCI. It has the advantages of being reversable and minimally invasive; however, optimal suture placement is both vital and challenging. The novel technique described in this study allows identification of landmarks as and aid to suture placement thus reducing the need for multiple needle passes into the lumen of the larynx.

Distinguishing delusional beliefs from overvalued ideas in Anorexia Nervosa: An exploratory pilot study

BACKGROUND

Characterised by the belief that more weight needs to be lost-despite emaciation, failing organs, medical instability and prospect of death-Anorexia Nervosa (AN) is a condition in which irrational, and highly-skewed, beliefs can be of delusional intensity. However, the nexus between delusion and rational awareness and how this is related to body image acceptance and perception has yet to be examined in AN. The current study aims to investigate the relationship between body dissatisfaction and beliefs of delusional intensity in an adult AN inpatient sample.

METHODS

Twenty-one adults (n_(women) = 20; n_(men) = 1), with a mean age of 27 years old (SD = 10), presenting for inpatient treatment for AN (ranging in severity from mild to severe; M_{(Body Mass Index)} = 17 kg/m²; M_{(Length of Stay)} = 22 days) participated in the study. Participants' dominant beliefs (related to AN) and level of insight (delusional; overvalued idea; or fair insight) were measured using either the Brown Assessment of Beliefs Scale (BABS) or the Nepean Beliefs Scale (NBS). The degree of body dissatisfaction was determined by examining the discrepancy between "perceived" and "ideal" body perception. To determine subjective and objective beliefs both the Contour Drawing Rating Scale (subjective) and computerised Body Image Assessment Software (objective) were used.

RESULTS

Almost one quarter (23.7%; n = 5) of participants appeared to have beliefs of delusional intensity related to their body shape (M = 27.4; SD = 23.03). Although a positive linear trend was indicated, there were no significant differences in body dissatisfaction scores between level-of-insight. Individuals whose belief was categorised as delusional were more likely to hold a negative affective body image state based on their ratings on the body image state survey when compared to the group who had good/fair insight (95% CI [0.53, 18.19]; p = 0.03).

CONCLUSIONS

The current exploratory pilot study concurs with others in the published literature that demonstrate that approximately 25 percent of participants with AN may have delusional ideas. The implications for treatment in similar samples warrant attention. Future research should also seek to understand the clinical significance of this delusional categorisation, the benefits of its utility in this population, and its relation to the severity of AN or stage of illness.

Screening, assessment and diagnosis in the eating disorders: findings from a rapid review

BACKGROUND

Limited screening practices, minimal eating disorder training in the healthcare professions, and barriers related to help-seeking contribute to persistent low rates of eating disorder detection, significant unmet treatment need, and appreciable associated disease burden. The current review sought to broadly summarise the literature and identify gaps relating to the screening, assessment, and diagnosis of eating disorders within Western healthcare systems.

METHODS

This paper forms part of a Rapid Review series scoping the evidence base for the field of eating disorders, conducted to inform the Australian National Eating Disorders Research and Translation Strategy 2021-2031, funded and released by the Australian Government. ScienceDirect, PubMed and Ovid/Medline were searched for studies published between 2009 and mid 2021 in English. High-level evidence such as meta-analyses, large population studies and Randomised Control Trials were prioritised through purposive sampling. Data from selected studies relating to Screening, Assessment and Diagnosis of eating disorders were synthesised and are disseminated in the current review.

RESULTS

Eighty seven studies were identified, 38% relating to screening and 62% to assessment and diagnosis. The majority of screening studies were conducted in university student samples, showing high prevalence but only modest improvements in help-seeking in those studies that followed up post-screen. In healthcare settings, clinicians continue to have difficulty identifying eating disorder presentations, particularly Binge Eating Disorder, Other Specified Feeding or Eating Disorders, and sub-threshold eating disorders. This is preceded by inadequate and frequently homogenous screening mechanisms and exacerbated by considerable personal and health-system barriers, including self-stigma and lack of resourcing. While all groups are at risk of delayed or no diagnosis, those at particular risk include LGBTQ+ and gender diverse individuals, individuals living in larger bodies, and males.

CONCLUSIONS

A majority of individuals with eating disorders remain undiagnosed and untreated despite a high prevalence of these conditions and increased advocacy in recent years. Research into improving detection and clinician diagnostic skill is extremely limited. Innovative empirical research is strongly recommended to address significant individual and health-system barriers currently preventing appropriate and timely intervention for many. Limited screening in healthcare settings and low rates of eating disorder training in the healthcare professions are just some of the barriers to help-seeking which may contribute to delayed intervention and diagnosis in the eating disorders. This has significant impacts, prolonging treatment when it is finally received, and increasing healthcare costs for both the individual and the healthcare system. The current review is part of a larger Rapid Review series conducted to inform the development of Australia's National Eating Disorders Research and Translation Strategy 2021-2031. A Rapid Review is designed to comprehensively summarise a body of literature in a short timeframe, often to guide policy-making and address urgent health concerns. The Rapid Review synthesises the current evidence-base and identifies gaps in eating disorder research and care, in order to guide decision making and address urgent health concerns. This paper gives a critical overview of the scientific literature relating to the current state of screening, assessment, and diagnosis of eating disorders within Western healthcare systems that may inform health policy and research in an Australian context. It covers screening initiatives in both general and high-risk populations; personal, clinician and healthcare system challenges relating to help-seeking; and obstacles to accurate and timely clinical diagnosis across the eating disorders.

Neural Response to Low Energy and High Energy Foods in Bulimia Nervosa and Binge Eating Disorder: A Functional MRI Study

Objective

Bulimia nervosa (BN) and binge eating disorder (BED) are eating disorders (EDs) characterized by recurrent binge eating (BE) episodes. Overlap exists between ED diagnostic groups, with BE episodes presenting one clinical feature that occurs transdiagnostically. Neuroimaging of the responses of those with BN and BED to disorder-specific stimuli, such as food, is not extensively investigated. Furthermore, to our knowledge, there have been no previous published studies examining the neural response of individuals currently experiencing binge eating, to low energy foods. Our objective was to examine the neural responses to both low energy and high energy food images in three emotive categories (disgust; fear; and happy) in BN and BED participants.

Methods

Nineteen females with BN (n = 14) or BED (n = 5), comprising the binge eating group (BEG; N = 19), and 19 age-matched healthy control (HC)’s completed thorough clinical assessment prior to functional MRI (fMRI). Neural response to low energy and high energy foods and non-food images was compared between groups using whole-brain exploratory analyses, from which six regions of interest (ROI) were then selected: frontal, occipital, temporal, and parietal lobes; insula and cingulate.

Results

In response to low energy food images, the BEG demonstrated differential neural responses to all three low energy foods categories (disgust; fear; and happy) compared to HCs. Correlational analyses found a significant association between frequency of binge episodes and diminished temporal lobe and greater occipital lobe response. In response to high energy food images, compared to HC’s, the BEG demonstrated significantly decreased neural activity in response to all high energy food images. The HC’s had significantly greater neural activity in the limbic system, occipital lobe, temporal lobe, frontal lobe, and limbic system in response to high energy food images.

Conclusion

Results in the low energy food condition indicate that binge frequency may be related to increased aberrant neural responding. Furthermore, differences were found between groups in all ROI’s except the insula. The neural response seen in the BEG to disgust food images may indicate disengagement with this particular stimuli. In the high energy food condition, results demonstrate that neural activity in BN and BED patients may decrease in response to high energy foods, suggesting disengagement with foods that may be more consistent with those consumed during a binge eating episode.

The mind-in-mind study: A pilot randomised controlled trial that compared modified mentalisation based treatment with supportive clinical management for patients with eating disorders without borderline personality disorder

OBJECTIVE

Mentalisation-based treatment (MBT) aims to improve reflective functioning. There is a growing evidence base outlining positive clinical outcomes for the use of MBT in eating disorder patients with co-morbid borderline personality disorder (BPD). The use of MBT has not been studied for eating disorder patients without BPD. This pilot study is an exploratory randomised controlled trial in which outcomes from MBT are compared with standard clinical management in a cohort of patients diagnosed with an eating disorder but not BPD. The main objectives were two-fold-to explore the use of MBT as a therapeutic modality and to test the acceptability and feasibility of the protocol design.

METHOD

Thirty-two participants were randomised to receive either MBT or standard treatment during an inpatient eating disorders program. All patients enrolled in the study were diagnosed with an eating disorder but did not meet DSM-5 criteria for BPD. On admission patients were categorised as very underweight (BMI 15.0-16.4 kg/m² ), underweight (BMI 16.5-18.4 kg/m² ) or healthy weight range (BMI ≥ 18.5-24.9 kg/m² ). Upon discharge participants were further categorised as weight restored (BMI ≥ 18.5 kg/m² ) or non-weight restored (BMI < 18.5 kg/m² ). The primary outcome was the subscale score on the Reflective Functioning Questionnaire (RFQ-8). Secondary outcomes were subscale scores on the Eating Disorder Examination Questionnaire and the Depression, Anxiety and Stress Scale (DASS)-21. Participants were assessed at baseline and on discharge. Statistical significance was determined using repeated measurements analysis of variance (ANOVA).

RESULTS

Both groups experienced improvements in eating disorder symptoms and measures of psychological well-being. Participants within the MBT group exhibited greater improvements in reflective capacity as defined by the RFQ-8 however these benefits appeared to be limited to patients who achieved weight restoration at discharge. The eligibility criteria-which excluded comorbid BPD-led to challenges in recruitment which limited the power of the study analysis. As participants with a range of different eating disorder diagnoses were included this led to complexities in estimating the treatment effect within a defined cohort.

CONCLUSIONS

Although the small sample size must be noted as a limitation-the finding that weight restoration appears to be associated with improvements in reflective capacity in MBT would be worth exploring in a subsequent larger study. Modification of eligibility criteria and recruitment from a defined cohort may increase the efficiency of a future study.

A standard enteral formula versus an iso-caloric lower carbohydrate/high fat enteral formula in the hospital management of adolescent and young adults admitted with anorexia nervosa: a randomised controlled trial

BACKGROUND

The nutritional rehabilitation of malnourished patients hospitalised with anorexia nervosa is essential. The provision of adequate nutrition must occur, while simultaneously, minimising the risk of refeeding complications, such as electrolyte, metabolic, and organ dysfunction. The aim of this study was to compare the efficacy and safety of an iso-caloric lower carbohydrate/high fat enteral formula (28% carbohydrate, 56% fat) against a standard enteral formula (54% carbohydrate, 29% fat).

METHODS

Patients (aged 15-25 years) hospitalised with anorexia nervosa were recruited into this double blinded randomised controlled trial. An interim analysis was completed at midpoint, when 24 participants, mean age 17.5 years (± 1.1), had been randomly allocated to lower carbohydrate/high fat (n = 14) or standard (n = 10) feeds.

RESULTS

At baseline, there was no significant difference in degree of malnutrition, medical instability, history of purging or serum phosphate levels between the two treatment arms. A significantly lower rate of hypophosphatemia developed in patients who received the lower carbohydrate/high fat formula compared to standard formula (5/14 vs 9/10, p = 0.013). The serum phosphate level decreased in both feeds, however it decreased to a larger extent in the standard feed compared to the lower carbohydrate/high fat feed (standard feed 1.11 ± 0.13 mmol/L at baseline vs 0.88 ± 0.12 mmol/L at week 1; lower carbohydrate/high fat feed 1.18 ± 0.19 mmol/L at baseline vs 1.06 ± 0.15 mmol/L at week 1). Overall, serum phosphate levels were significantly higher in the lower carbohydrate/high fat feed compared with standard feed treatment arm at Week 1 (1.06 ± 0.15 mmol/L vs 0.88 ± 0.12 mmol/L, p < 0.001). There was no significant difference in weight gain, number of days to reach medical stability, incidence of hypoglycaemia, or hospital length of stay.

CONCLUSIONS

The results of this study indicate that enteral nutrition provided to hospitalised malnourished young people with anorexia nervosa using a lower carbohydrate/high fat formula (28% carbohydrate, 56% fat) seems to provide protection from hypophosphatemia in the first week compared to when using a standard enteral formula. Further research may be required to confirm this finding in other malnourished populations.

TRIAL REGISTRATION

ANZCTR, ACTRN12617000342314. Registered 3 March 2017, http://anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12617000342314.

Safety of elective paediatric surgery during the coronavirus disease 2019 pandemic

INTRODUCTION

Corona-virus Disease 2019 (COVID-19) has had a huge impact on the delivery of healthcare worldwide, particularly elective surgery. There is a lack of data regarding risk of postoperative COVID-19 infection in children undergoing elective surgery, and regarding the utility of pre-operative COVID-19 testing, and preoperative "cocooning" or restriction of movements. The purpose of this present study was to examine the safety of elective paediatric Otolaryngology surgery during the COVID-19 pandemic with respect to incidence of postoperative symptomatic COVID-19 infection or major respiratory complications.

MATERIALS AND METHODS

Prospective cohort study of paediatric patients undergoing elective Otolaryngology surgery between September and December 2020. Primary outcome measure was incidence of symptomatic COVID-19 or major respiratory complications within the 14 days after surgery. Parents of prospectively enrolled patients were contacted 14 days after surgery and enquiry made regarding development of postoperative symptoms, COVID-19 testing, or diagnosis of COVID-19.

RESULTS

302 patients were recruited. 125 (41.4%) underwent preoperative COVID-19 RT-PCR testing. 66 (21.8%) restricted movements prior to surgery. The peak 14-day COVID-19 incidence during the study was 302.9 cases per 100,000 population. No COVID-19 infections or major respiratory complications were reported in the 14 day follow-up period.

CONCLUSION

The results of our study support the safety of elective paediatric Otolaryngology surgery during the pandemic, in the setting of community incidence not exceeding that observed during the study period.

Supported online cognitive behavioural therapy for bulimia nervosa: a study protocol of a randomised controlled trial

BACKGROUND

Despite the availability of effective treatments for bulimia nervosa (BN), a number of barriers to accessibility exist. Examples include access to trained clinicians, the expense of treatment, geographical limitations, and personal limitations such as stigma regarding help seeking. Self-help interventions, delivered via a digital platform, have the potential to overcome treatment gaps by providing patients with standardised, evidence-based treatments that are easily accessible, cost-effective, and require minimal clinician support. Equally, it is important to examine the shortcomings of digital interventions when compared to traditional to face-to-face delivery (e.g., high dropout rates) in order to maximise the therapeutic effectiveness of online, self-help interventions.

METHODS

A three-arm, multisite randomised controlled trial will be conducted in Australia examining the effectiveness and cost-effectiveness of a newly developed online self-help intervention, Binge Eating eTherapy (BEeT), in a sample of patients with full or sub-threshold BN. The BEeT program consists of 10, multimedia sessions delivering the core components of cognitive behaviour therapy. Eligible participants will be randomised to one of three groups: independent completion of BEeT as a purely self-help program, completion of BEeT alongside clinician support (in the form of weekly telemedicine sessions), or waitlist control. Assessments will take place at baseline, weekly, post-intervention, and three-month follow up. The primary outcome is frequency of objective binge episodes. Secondary outcomes include frequency of other core eating disorder behavioural symptoms and beliefs, psychological distress, and quality of life. Statistical analyses will examine treatment effectiveness, feasibility, acceptability and cost effectiveness.

DISCUSSION

There is limited capacity within the mental health workforce in Australia to meet the demand of people seeking treatment for eating disorders. This imbalance has only worsened following outbreak of the COVID-19 pandemic. Further research is required into innovative digital modes of treatment delivery with the capacity to service mental health needs in an accessible and affordable manner. Self-help programs may also appeal to individuals who are more reluctant to engage in traditional face-to-face treatment formats. This study will provide rigorous evidence on how to diversify treatment options for individuals with BN, ensuring more people with the illness can access evidence-based treatment. The study has been registered with the Australia New Zealand Clinical Trials Registry (ANZCTR Registration Number: ACTRN12619000123145p). Registered 22 January 2019, https://www.australianclinicaltrials.gov.au/anzctr/trial/ACTRN12619000123145 .

Outcomes of preoperative real-time polymerase chain reaction testing for SARS CoV-2 in elective otolaryngology surgical patients during the pandemic: a prospective cohort study

Real-time polymerase chain reaction (RT-PCR) is used to rule out SARS-CoV-2 prior to surgery, however few studies have evaluated patients with negative testing after surgery. Some 499 patients with negative tests were followed for 14 days after surgery, 39 were retested but none developed positive RT-PCR after operation. The risk of developing a positive RT-PCR after surgery was 0.74 per cent.

Comparing the medical coverage provided by four contemporary military combat helmets against penetrating traumatic brain injury

INTRODUCTION

Modern military combat helmets vary in their shapes and features, but all are designed to protect the head from traumatic brain injury. Recent recommendations for protection against energised projectiles that are characteristic of secondary blast injury is to ensure coverage of both the brain and brainstem.

METHOD

Graphical representations of essential coverage of the head (cerebral hemispheres, cerebellum and brainstem) within an anthropometrically sized model were superimposed over two standard coverage helmets (VIRTUS helmet, Advanced Combat Helmet (ACH)) and two 'high-cut' helmets (a Dismounted Combat Helmet (DCH)) and Combat Vehicle Crewman (CVC) helmet), both of which are designed to be worn with communications devices. Objective shotline coverage from representative directions of projectile travel (-30 to +30 degrees) was determined using the Coverage of Armour Tool (COAT).

RESULTS

VIRTUS and ACH demonstrated similar overall coverage (68.7% and 69.5%, respectively), reflecting their similar shell shapes. ACH has improved coverage from below compared with VIRTUS (23.3% vs 21.7%) due to its decreased standoff from the scalp. The 'high-cut' helmets (DCH and CVC) had reduced overall coverage (57.9% and 52.1%), which was most pronounced from the side.

CONCLUSIONS

Both the VIRTUS and ACH helmets provide excellent overall coverage of the brain and brainstem against ballistic threats. Coverage of both would be improved at the rear by using a nape protector and the front using a visor. This is demonstrated with the analysis of the addition of the nape protector in the VIRTUS system. High-cut helmets provide significantly reduced coverage from the side of the head, as the communication devices they are worn with are not designed to provide protection from ballistic threats. Unless absolutely necessary, it is therefore recommended that high-cut helmets be worn only by those users with defined specific requirements, or where the risk of injury from secondary blast is low.

An assessment of the current status of children's toothpaste in Australia

BACKGROUND

Despite recommendations that pre-school children use toothpaste containing 500-550 ppm of fluoride, there has been an increase in non-fluoridated toothpastes marketed for children. This study investigated children's toothpaste in Australia.

METHODS

A comprehensive audit of all toothpastes marketed for pre-school children and available in store in the Macarthur region of NSW, Australia, was carried out. All toothpastes available for purchase were obtained and examined; size and price were catalogued, along with ingredient lists and fluoride levels.

RESULTS

One hundred and seven individual toothpastes were identified in the audit, with 67 (62.6%) containing no fluoride. Of the 40 fluoridated toothpastes, only 11 (10.3%) contained the recommended level of fluoride of 500-550 ppm. Twenty-two (20.6%) of all toothpastes were made in Australia, all of which were non-fluoridated. Six (5.6%) of the toothpastes studied contained excessive levels of fluoride (1350-1500 ppm). Seventeen of the 20 least expensive toothpastes contained fluoride, while 18 of the 20 most expensive toothpastes were non-fluoridated.

CONCLUSIONS

Despite expert recommendations, the majority of children's toothpaste available in Australia contains either no fluoride or the wrong levels of fluoride. Further study is needed to determine why this change is occurring and what is influencing the increase in non-fluoride toothpastes on the market.

Prospects for beyond the Standard Model physics searches at the Deep Underground Neutrino Experiment: DUNE Collaboration

The Deep Underground Neutrino Experiment (DUNE) will be a powerful tool for a variety of physics topics. The high-intensity proton beams provide a large neutrino flux, sampled by a near detector system consisting of a combination of capable precision detectors, and by the massive far detector system located deep underground. This configuration sets up DUNE as a machine for discovery, as it enables opportunities not only to perform precision neutrino measurements that may uncover deviations from the present three-flavor mixing paradigm, but also to discover new particles and unveil new interactions and symmetries beyond those predicted in the Standard Model (SM). Of the many potential beyond the Standard Model (BSM) topics DUNE will probe, this paper presents a selection of studies quantifying DUNE's sensitivities to sterile neutrino mixing, heavy neutral leptons, non-standard interactions, CPT symmetry violation, Lorentz invariance violation, neutrino trident production, dark matter from both beam induced and cosmogenic sources, baryon number violation, and other new physics topics that complement those at high-energy colliders and significantly extend the present reach.

Donor site morbidity of composite free flaps in head and neck surgery: a systematic review of the prospective literature

Composite free flaps represent the cornerstone for the repair of osseous defects in the head and neck. For many patients, there are often multiple defect-suitable donor sites that may be utilised as part of the reconstructive process. Therefore, to optimise patient outcomes, an evidence-based approach to donor site selection is required to maximise quality of life and long-term functionality. A systematic review of the literature was conducted in accordance with PRISMA guidelines to evaluate the evidence for donor site selection based on minimising the associated donor site morbidity and optimising patient functionality postoperative. The fibula is associated with the greatest potential risk for wound healing complications. Fibula and scapula harvest has the potential to have a significant impact on physical performance. The iliac crest is most favourable in terms of aesthetic scar healing outcomes. Overall, however, the quality and quantity of evidence for all donor sites is limited. Each site is associated with specific complications and morbidity, of which the surgeon and patient must both be aware. Whilst a cross-sectional informed opinion of the likely advantages/disadvantages of one donor site over another can thus be made, there are few head-to-head studies available that directly compare donor sites.

Focused Acute Medicine Ultrasound (FAMUS): uptake, completion and barriers to accreditation after two years

The Society for Acute Medicine launched their ultrasound accreditation in September 2016, involving a practical course alongside completion of scanning competencies. Candidates require a registered supervisor to oversee their training. We present here the results of a survey of attendees of practical courses approximately 2 years after launch. The majority of respondents were Consultants or trainees within AIM. Fourteen of 76 (18.4%) respondents had completed the whole accreditation process, whilst 51 (67.1%) had not completed any of the three individual modules. The biggest barriers to accreditation were seen to be lack of supervisors, and lack of dedicated training time. There was good uptake of available online learning resources with good feedback. These results will be used to help develop the training pathway further and widen access to ultrasound training within the specialty and beyond.

First marine litter survey on beaches in Solomon Islands and Vanuatu, South Pacific: Using OSPAR protocol to inform the development of national action plans to tackle land-based solid waste pollution

The increasing abundance of marine litter is impacting the environment, human health and economies in the South Pacific. Small Islands Developing States are particularly affected by marine litter, primarily due to insufficient waste management systems. For the first time, marine litter was quantified and characterised on 13 beaches in Solomon Islands and Vanuatu in the South Pacific region using the OSPAR beach litter monitoring guidelines. A total of 1053 (±1017) and 974 (±745) items of litter per 100 m beach were recorded in Solomon Islands and Vanuatu respectively. Litter composition and distribution show that the majority of the litter comes from local land-based sources and large quantities of fragments and single use plastics were found by cities and river mouths. Actions to reduce single use plastic, improve collection, reuse and recycling, together with outreach campaigns would reduce marine litter significantly in these countries. Furthermore, there is great potential to develop a more circular economy to manage the substantial quantities of recyclable items that were found stranded on the beaches.

Study protocol for a randomised controlled trial investigating two different refeeding formulations to improve safety and efficacy of hospital management of adolescent and young adults admitted with anorexia nervosa

INTRODUCTION

Providing effective nutritional rehabilitation to patients hospitalised with anorexia nervosa (AN) is challenging, partly due to conservative recommendations that advocate feeding patients at low energy intakes. An 'underfeeding syndrome' can develop when patients are not provided with adequate nutrition during treatment, whereby malnourished patients fail to restore weight in a timely matter, and even lose weight. Of particular concern, the reintroduction of carbohydrate in a starved patient can increase the risk of developing electrolyte, metabolic and organ dysfunction. The proposed trial assesses the efficacy and safety of a lower carbohydrate enteral formula (28% carbohydrate) against a standard enteral formula (54% carbohydrate), in adolescent and young adult patients (aged 15-25 years), hospitalised with AN.

METHODS AND ANALYSIS

The study employs a double-blind randomised controlled trial design. At admission to hospital, malnourished adolescent and young adults with AN will be randomly allocated to commence feeding on a standard enteral feeding formula (1.5 kcal/mL, 54% carbohydrate) or a lower carbohydrate isocaloric enteral feeding formula (1.5 kcal/mL, 28% carbohydrate). Assessments of nutritional intake, weight and biochemistry (phosphate, magnesium, potassium) will be conducted at baseline and during the first 3 weeks of hospital admission. The primary outcome measure will be incidence of hypophosphatemia. Secondary outcomes include weight gain, oedema, other electrolyte distortion, length of hospital admission, admission to the Intensive Care Unit (ICU) and number of days to reach medical stability, using defined parameters.

ETHICS AND DISSEMINATION

The protocol was approved by the Western Sydney Local Health District Human Research Ethics Committee and institutional research governance approvals were granted. Written informed consent will be sought prior to study enrolment. Study findings will be widely disseminated through peer-reviewed publications and conference presentations.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry (ACTRN12617000342314); Pre-results.

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.

The SLAC RCE Platform for ProtoDUNE

The ProtoDUNE-SP is a single-phase liquid argon time projection chamber (LArTPC) prototype for the Deep Underground Neutrino Experiment (DUNE). Signals from 15,360 electronic channels are received by 60 Reconfigurable Cluster Elements (RCEs), which are processing elements designed at SLAC for a wide range of applications and are based upon the “system-onchip” Xilinx Zynq family of FPGAs. The RCEs are housed in industry-standard ATCA shelves on a custom blade, called the Cluster on Board (COB). The RCE platform and its processing functions for the ProtoDUNE-SP will be presented.

Harm minimization in severe and enduring anorexia nervosa

For many sufferers of anorexia nervosa, the time course is long, and the prospect of disability and family burden great. This is all too often the case, even with early diagnosis and treatment. The term severe and enduring anorexia nervosa has been applied to these survivors. Yet, a majority of patients do eventually recover and, even where this is not the case, adaptive medical stability and function can be maintained despite alarming dilapidation. Managing the years of illness so as to have the best outcome physically and psychologically, even where full weight recovery does not occur, or has not yet occurred, is the topic of this article. Literature pertaining to harm minimization in chronic, severe, enduring, and long-standing anorexia nervosa was selectively reviewed using an Ovid data base and Google Scholar. The authors' own clinical experience over almost four decades in public and private hospital and community settings has also informed much of what has been written. The authors would like to think that it is possible to do better than the familiar injunction (variously attributed to Hippocrates, Galen, and others) of 'primum non nocere'-although this is a good place to start.

A relationship-based approach to improving the clinical trial experience

e14055

Background: The rapidly evolving field of Cancer Immunotherapy (CIT) has mobilized biopharma to develop promising new treatments while at the same time created a need to expedite the pathway of those new therapies from bench to bedside. This race to bring innovative treatments to patients has engendered heightened levels of competition for the attention of and partnership with the best research institutions in the biopharma industry. Methods: Recognizing this reality, Roche created the immunotherapy Centers of Research Excellence (imCORE) Network: a network of leading cancer immunotherapy centers worldwide. The vision of this network was to partner with sites to streamline the operational delivery of the Roche Genentech portfolio while deepening the collective understanding of the science to prioritize and accelerate the most promising new treatment options for our patients. Creation of a network was not a novel idea, but Roche set out to build a network unique to the biopharma industry – one which was relationship-based where the site/sponsor relationship serves as the foundation for driving both collaborative scientific investigations and operational efficiencies in support of Roche’s clinical trials. While the identification and optimization of promising candidate drugs in the preclinical and translational settings are critical first steps in the drug development process, the initiation and operationalization of early phase clinical trials are equally important in the multidimensional cycle of drug development. Results: See Conclusions. Conclusions: This white paper will provide an overview of imCORE’s origins with a focus on the strategic importance of the site-sponsor relationship and the mutual value that is derived from the combined benefits of these relationships and in conducting early clinical trials more efficiently across Roche’s CIT portfolio. Further examination of communication and operational improvement to support the network will be highlighted as key drivers in creating and sustaining meaningful site/sponsor relationships that better facilitate the operationalization of clinical trials and ultimately brings novel therapies to patients in a more efficient manner than in the past.

Pediatric tracheostomy first tube change: When is it safe?

OBJECTIVES

The first tracheostomy tube change is typically performed on days 5-7 post-operatively, however recent international consensus guidelines suggested that, with maturation sutures, days 3-5 is appropriate. We evaluate whether a first tube change on day 2 post-operatively is safe and effective.

METHODS

We carried out a retrospective review of all patients undergoing tracheostomy between 2009 and 2018. Exclusion criteria were patients on whom the senior authors did not operate, operations done elsewhere, cases where maturation sutures were not used or a patient died prior to first tube change. We noted patient details, indication for tracheostomy, the need for long-term ventilation, timing of the first tube change, decannulation and need for surgical closure of persistent tracheocutaneous fistula.

RESULTS

93 patients were identified, of which 83 were included. The age range was 0-16 years, with the youngest day one of life and an overall mean age of 1.91 years. 59% of patients required long-term ventilation due to various co-morbidities. 26 patients (31%) underwent a first tube change on day 2 post-operatively. All these were uneventful and were irrespective of the patient's need for ventilation. Of the 42 patients who have subsequently been decannulated, 33 (79%) were noted to have a persistent tracheocutaneous fistula requiring surgical closure, four of whom needed revision closure.

CONCLUSIONS

This study shows that a first tube change on day 2 post-operatively is safe, facilitating earlier discharge from intensive care, allowing shorter length of sedation, earlier start to parent/carer training and wound assessment.

Novel Role of T Cells and IL-6 (Interleukin-6) in Angiotensin II-Induced Microvascular Dysfunction

Hypertension is an established risk factor for subsequent cardiovascular diseases, with Ang II (angiotensin II) playing a major role in mediating thrombotic and inflammatory abnormalities. Although T cells and IL-6 (interleukin-6) play an important role in adaptive immune responses, little is known about their role(s) in the thromboinflammatory responses associated with Ang II. Here we show using intravital microscopy coupled with the light/dye injury model that Rag-1 deficient (Rag-1-/-) and IL-6 deficient (IL-6-/-) mice are afforded protection against Ang II-induced thrombosis. Blocking IL-6 receptors (using CD126 and gp130 antibodies) significantly diminished Ang II-mediated thrombosis and inflammatory cell recruitment in mice. Furthermore, the adoptive transfer of IL-6-/--derived T cells into Rag-1-/- mice failed to accelerate Ang II-induced thrombosis compared with Rag-1-/- mice reconstituted with wild-type-derived T cells, suggesting T cell IL-6 mediates the thrombotic abnormalities associated Ang II hypertension. Interestingly, adoptive transfer of WT T cells into Rag-1-/-/Ang II mice resulted in increased numbers of immature platelets, which constitutes a more active platelet population, that is, prothrombotic and proinflammatory. To translate our in vivo findings, we used clinical samples to demonstrate that IL-6 also predisposes platelets to an interaction with collagen receptors, thereby increasing the propensity for platelets to aggregate and cause thrombosis. In summary, we provide compelling evidence for the involvement of IL-6, IL-6R, and T-cell-dependent IL-6 signaling in Ang II-induced thromboinflammation, which may provide new therapeutic possibilities for drug discovery programs for the management of hypertension.

P100 Removing the orbital bar in fronto-orbital advancement and reconstruction

Objectives

To describe our technique of using reverse frontal bone graft for FOAR for patients with metopic or coronal synostosis.

Design

Retrospective analysis of digital records for operation notes and radiological images.

Subjects

Since April 2014, 16 patients underwent FOAR without using orbital bar.

Methods

We plan a frontal bone graft using Marchac template and increase the angles on side by 1 cm. This graft is then reversed and supra orbital margins are drilled out. The orbital bar is then removed and drilled down to make bone dust which is then used to fill gaps on exposed dura. The reversed frontal graft is then placed in front and secured via absorbable sutures, plate and screws.

Results

All 16 patients who underwent this technique have shown excellent cosmetic results with no complications or non healing. Removing orbital bar does not cause any cosmetic defect since orbital rims are drilled out in reverse frontal bone graft. The removed orbital bar provides an excellent source of bone dust to cover gaps on exposed dura.

Conclusions

We present our technique of FOAR without using orbital bar, which is drilled down to bone dust to fill gaps. This has shown excellent cosmetic results so far with no complications. This addresses the issue of temporal thinning.

Multidisciplinary guidelines for the management of paediatric tracheostomy emergencies

Temporary and permanent tracheostomies are required in children to manage actual or anticipated long-term ventilatory support, to aid secretion management or to manage fixed upper airway obstruction. Tracheostomies may be required from the first few moments of life, with the majority performed in children < 4 years of age. Although similarities with adult tracheostomies are apparent, there are key differences when managing the routine and emergency care of children with tracheostomies. The National Tracheostomy Safety Project identified the need for structured guidelines to aid multidisciplinary clinical decision making during paediatric tracheostomy emergencies. These guidelines describe the development of a bespoke emergency management algorithm and supporting resources. Our aim is to reduce the frequency, nature and severity of paediatric tracheostomy emergencies through preparation and education of staff, parents, carers and patients.

Beliefs about Binge Eating: Psychometric Properties of the Eating Beliefs Questionnaire (EBQ-18) in Eating Disorder, Obese, and Community Samples

Binge eating is a core diagnostic feature of bulimia nervosa, binge eating disorder, anorexia nervosa binge/purge type, and is a common feature of "other specified" and "unspecified" feeding and eating disorders. It has been suggested that specific metacognitive beliefs about food, eating, and binge eating may play a key role in the maintenance of binge eating behaviour. The Eating Beliefs Questionnaire (EBQ-18) provides a brief self-report assessment tool measuring three types of metacognitive beliefs: negative, positive, and permissive beliefs about food and eating. This study aimed to build on past research by validating the factor structure and psychometric properties of the EBQ-18 using both a clinical and non-clinical sample. A sample of 688 participants (n = 498 non-clinical participants, n = 161 participants seeking treatment for an eating disorder, and n = 29 participants seeking treatment for obesity) completed a battery of questionnaires, including the EBQ-18 and other measures of eating disorder symptoms and relevant constructs. A subset of 100 non-clinical participants completed the test battery again after an interval of two-weeks, and 38 clinical participants completed the EBQ-18 before and after receiving psychological treatment for their eating disorder. A confirmatory factor analysis (CFA) was conducted and psychometric properties of this measure were assessed. The results of this study provide support for the three-factor model of the EBQ-18. In addition, the EBQ-18 was found to be a valid and reliable measure, with excellent internal consistency, good test-retest reliability in the non-clinical sample, and also demonstrated evidence of sensitivity to treatment in clinical samples with binge eating pathology. Receiver operating characteristic (ROC) curve analyses were used to identify optimal cut-off scores for the EBQ-18. This study provides valuable information about the utility of the EBQ-18 as a measure for use in both clinical and research settings.

Depression and cardiac dysautonomia in eating disorders

PURPOSE

Individuals with eating disorder (ED) are at an increased risk of cardiac arrhythmias due to cardiac dysautonomia, which may be exacerbated if depression is also present. The aim of the study was to use heart rate analysis as a marker for cardiac dysautonomia in patients with eating disorders and depression as a comorbidity.

METHODS

Clinical data, including presence of depression, was obtained from all participants. A three-lead ECG was used to determine interbeat intervals, and these were analyzed using time domain, frequency domain, and nonlinear heart rate variability measures.

RESULTS

Thirty ED patients and 44 healthy controls participated in the research. The presence of depression was associated with additional decreased time domain (RMSSD 36.8 ± 26 vs. 22.9 ± 12.3; p < 0.05), frequency domain (HF power 788 ± 1075 vs. 279 ± 261; p < 0.05), and nonlinear domain (DFAα₂ 0.82 ± 0.1 vs. 0.97 ± 0.1; p < 0.01) which results in the ED group compared to patients with no depression.

CONCLUSIONS

The presence of depression in ED patients decreased HRV even further compared to the non-depressed patient group and controls, suggesting that higher vigilance and a holistic treatment approach may be required for these patients to avoid cardiac arrhythmia complications.

Comprehensive genomic profiles of metastatic and relapsed salivary gland carcinomas are associated with tumor type and reveal new routes to targeted therapies

Background

Relapsed/metastatic salivary gland carcinomas (SGCs) have a wide diversity of histologic subtypes associated with variable clinical aggressiveness and response to local and systemic therapies. We queried whether comprehensive genomic profiling could define the tumor subtypes and uncover clinically relevant genomic alterations, revealing new routes to targeted therapies for patients with relapsed and metastatic disease.

Patients and methods

From a series of 85 686 clinical cases, DNA was extracted from 40 µm of formalin-fixed paraffin embedded (FFPE) sections for 623 consecutive SGC. CGP was carried out on hybridization-captured, adaptor ligation-based libraries (mean coverage depth, >500×) for up to 315 cancer-related genes. Tumor mutational burden was determined on 1.1 Mb of sequenced DNA. All classes of alterations, base substitutions, short insertions/deletions, copy number changes, and rearrangements/fusions were determined simultaneously.

Results

The clinically more indolent SGC including adenoid cystic carcinoma, acinic cell carcinoma, polymorphous low-grade adenocarcinoma, mammary analog secretory carcinoma, and epithelial-myoepithelial carcinomas have significantly fewer genomic alterations, TP53 mutations, and lower tumor mutational burden than the typically more aggressive SGCs including mucoepidermoid carcinoma, salivary duct carcinoma, adenocarcinoma, not otherwise specified, carcinoma NOS, and carcinoma ex pleomorphic adenoma. The more aggressive SGCs are commonly driven by ERBB2 PI3K pathway genomic alterations. Additional targetable GAs are frequently seen.

Conclusions

Genomic profiling of SGCs demonstrates important differences between traditionally indolent and aggressive cancers. These differences may provide therapeutic options in the future.