Animal factors that affect enteric methane production measured using the GreenFeed monitoring system in grazing dairy cows

Similar to all dairy systems internationally, pasture-based dairy systems are under increasing pressure to reduce their greenhouse gas (GHG) emissions. Ireland and New Zealand are 2 countries operating predominantly pasture-based dairy production systems where enteric CH4 contributes 23% and 36% of total national emissions, respectively. Ireland currently has a national commitment to reduce 51% of total GHG emissions by 2030 and 25% from agriculture by 2030, as well as striving to achieve climate neutrality by 2050. New Zealand's national commitment is to reduce 10% of methane emissions by 2030 and between 24% and 47% reduction in methane emissions by 2050. To achieve these reductions, factors that affect enteric methane (CH4) production in a pasture-based system need to be investigated. The objective of this study was to assess the relationship between enteric CH4 and other animal traits (feed intake, metabolic liveweight, energy corrected milk yield, milk urea concentration, and body condition score [BCS]) in a grazing dairy system. Enteric CH4 emissions were measured on 45 late lactation (213.8 ± 29 d after calving) grazing Holstein-Friesian and Holstein-Friesian × Jersey crossbred cows (lactation number 3.01 ± 1.65, 538.64 ± 59.37 kg live weight, and 3.14 ± 0.26 BCS) using GreenFeed monitoring equipment for 10 wk. There was a training period for the cows to use the GreenFeed of 3 wk before the 10-wk study period. The average enteric CH4 produced in the study was 352 g ± 45.7 g per day with an animal to animal coefficient of variation of 13%. Dry matter intake averaged 16.6 kg ± 2.23 kg per day, while milk solids (fat plus protein) averaged 1.62 kg ± 0.29 kg per day. A multiple linear regression model indicated that each one unit increase in energy corrected milk yield, metabolic liveweight and milk urea concentration, resulted in an increase in enteric CH4 production per day by 3.9, 1.74, and 1.38 g, respectively. Although each one unit increase in BCS resulted in a decrease in 39.03 g CH4 produced per day. When combined, these factors explained 47% of the variation in CH4 production, indicating that there is a large proportion of variation not included in the model. The repeatability of the CH4 measurements was 0.66 indicating that cows are relatively consistently exhibiting the same level of CH4 throughout the study. Therefore, enteric CH4 production is suitable for phenotyping.

Bee Well: a positive psychological impact of a pro-environmental intervention on beekeepers' and their families' wellbeing

Bees are excellent pollinators and serve an essential environmental purpose. However, little is known about the wellbeing impact of bees on humans. This research addressed the knowledge gap concerning the impact of beekeeping on the wellbeing of beekeepers and their families, focusing on the often-overlooked psychological, emotional, and social dimensions. Thirty farmers in Ireland participating in the Let it Bee project, aimed at promoting biodiversity and water source protection, were provided with bee hives. Twelve participants were interviewed to explore the effects of beekeeping on their wellbeing. Thematic Analysis was employed to analyze the data, revealing five central themes. (1) The centrality of pride in accomplishing environmental and community objectives in the farmers' beekeeping activities; (2) the evolving sense of togetherness with nature, family, and community throughout the project; (3) a profound sense of contributing significantly to the greater good; (4) the recognized value of beekeeping for beekeepers' psychological growth, flow, and relaxation; and (5) the opportunity for beekeepers to leverage their character strengths. The implications of these findings are discussed within the framework of their impact on environmental conservation, healthcare policymaking, and implications for research and practice.

The Association of Surgeons in Training (ASiT) Consensus Statement on Major Trauma Training in the UK

INTRODUCTION

Since the establishment of the Major Trauma Networks in 2012, it is estimated that an extra 1,600 lives have been saved across England. Although the delivery of trauma care has improved significantly, the provision of trauma training has not and remains fragmented. The Association of Surgeons in Training (ASiT), an independent organisation run by trainees, is dedicated to excellence in surgical training within the United Kingdom (UK) and Republic of Ireland (ROI). The aim of this study was to develop a consensus statement representing the views of the ASiT on the future of trauma surgery training.

METHODS

A modified nominal group technique was used in five stages: 1, scoping exercise; 2, virtual consultation; 3, nominal group consensus meeting; 4, virtual feedback from stakeholders; and 5, virtual confirmation by the ASiT Council. The design and reporting of the consensus followed best practice methodology for consensus research.

RESULTS

Overall, 62 participants gave 90 statements across stages 1-3. Eleven key themes were identified, all of which met the consensus of the ASiT Council. The key findings were widespread support for increased exposure to trauma for medical students and early surgical trainees as well as an increased use of simulation methods and improved focus on non-technical skills within trauma surgery.

CONCLUSIONS

This study sets out the position of the ASiT on the future of trauma surgery training and how training in major trauma surgery in the UK and ROI could be improved.

Measures of performance and proficiency in robotic assisted surgery: a systematic review

Robotic assisted surgery (RAS) has seen a global rise in adoption. Despite this, there is not a standardised training curricula nor a standardised measure of performance. We performed a systematic review across the surgical specialties in RAS and evaluated tools used to assess surgeons' technical performance. Using the PRISMA 2020 guidelines, Pubmed, Embase and the Cochrane Library were searched systematically for full texts published on or after January 2020-January 2022. Observational studies and RCTs were included; review articles and systematic reviews were excluded. The papers' quality and bias score were assessed using the Newcastle Ottawa Score for the observational studies and Cochrane Risk Tool for the RCTs. The initial search yielded 1189 papers of which 72 fit the eligibility criteria. 27 unique performance metrics were identified. Global assessments were the most common tool of assessment (n = 13); the most used was GEARS (Global Evaluative Assessment of Robotic Skills). 11 metrics (42%) were objective tools of performance. Automated performance metrics (APMs) were the most widely used objective metrics whilst the remaining (n = 15, 58%) were subjective. The results demonstrate variation in tools used to assess technical performance in RAS. A large proportion of the metrics are subjective measures which increases the risk of bias amongst users. A standardised objective metric which measures all domains of technical performance from global to cognitive is required. The metric should be applicable to all RAS procedures and easily implementable. Automated performance metrics (APMs) have demonstrated promise in their wide use of accurate measures.

Lifestyle medicine pillars as predictors of psychological flourishing

Positive Psychology Interventions (PPI) are widely applied to improving wellbeing and helping individuals flourish. At the same time, Lifestyle Medicine (LM) offers an opportunity to boost PPI and psychological research, by expanding its capacity beyond psychology, to include the body and social environment. However, little is known about the relationship between LM and positive psychology flourishing models. Flourishing is as a stage of optimal human functioning that goes beyond moderate wellbeing. The objective of this cross-sectional study was to, (1) identify which of the six LM pillars (sleep, physical exercise, eating well, alcohol intake, social engagement, stress management) best-predicted flourishing; (2) examine the relationship between the number of LM pillars used by individuals and flourishing; and (3) determine the odds of using LM pillars by flourishers. A total of 1,112 participants, mostly female professionals (73%), aged 40-59 (77%), based in Ireland, completed an online survey. Regression analysis showed that all six LM pillars predicted flourishing as measured by the PERMA Profiler (including the Physical Health component) and the Mental Health Continuum (MHC). Moreover, the chi-square and odds ratio analysis showed that those who flourished were three times more likely to use 3-6 LM pillars than those who were moderately well; and nine times more likely than languishers. The results are discussed in the context of their contribution to enhancing the population's health and wellbeing.

126 The Theatre Training Checklist: A Toolkit to Improve Operative Training

Aim

The operating theatre is expensive, costing approximately £1200 per hour to run. It is a crucial learning environment for many different trainees: anaesthetists, surgeons, operation department practitioners, etc. For individuals to achieve their training requirements, the operating theatre as a training environment must be shared between all trainees, requiring excellent teamwork and leadership. This could be improved by the adoption of innovative training strategies.

Method

The Theatre Training Checklist is a simple framework that aims to facilitate awareness, understanding, coordination and cooperation of training for all team members. It is a practical strategy that can be adopted in any setting. Usually, trainers discuss informally with their trainees about their individual skills, experience, expectations and what is achievable in a theatre list. However, there is currently limited opportunity to discuss this between different disciplines and the wider team. This tool aims to refine communication, optimize training, manage expectations, and ensure equity across the board.

Results

The checklist is completed at the start of the list during the theatre brief. It identifies all trainees and their specific needs within the operating theatre session to the whole team. An agreed strategy is developed on how to achieve identified training goals. Feedback undertaken from the MDT after local trailing of the checklist has been positive.

Conclusions

The toolkit is available for use and consists of the checklist tool and an instructional video. The checklist is being piloted in some centres and we hope to have the opportunity to present some early findings to the ASiT Innovation Summit.

231 ESTABLISHING AN INTERVENTIONS BUNDLE TO IMPROVE INPATIENT CARE FOR PATIENTS WITH PARKINSON’S DISEASE: A MULTIDISCIPLINARY QUALITY IMPROVEMENT PROJECT

Background

Patients with Parkinson’s (PwP) are at a higher risk of complications once admited to hospital compared to their age-matched peers. Medication mismanagement is a well-known obstacle, which puts PwP at risk of sub-optimal treatment leading to an unnecessary deterioration of baseline and potentially increases risk of adverse sequelae.

Methods

Retrospective electronic patient records (EPR)/chart review of 47 admissions was conducted, across three hospital sites.

Data attaining to correct prescribing of medication on admission and discharge, prescribing of contraindicated medications, reasons for medication lapses and complications of inpatient stay were collected. EPR of 17 patients’ were reviewed to assess if Parkinson’s disease (PD) medication administrations occurred within 30 minutes of patient schedule, as recommended by NICE guidelines. Key areas for improvement were identified based on the results.

Results

47 charts (30 Males, 17 Females) with mean age 72 (range:57–90), were reviewed. Average number of co-morbidities:4.5 and Clinical Frailty Scale ranged 5–9 (n = 30). LOS averaged 12.4 days and 43% of patients had ≥2 hospital admissions in the preceeding year.

38% (17/44) of admissions correctly documented patient specific medication times. Only 48% of patients (n = 638) received their medications within 30 minutes of the scheduled time. 47% (22/47) experienced complications attributable to PD. Contraindicated medications were noted in 5 cases. 84% of discharging prescriptions did not mention timing of PD medication and 3 prescriptions had errors with regards to dosage/omission of medication.

Conclusion

We implemented across two sites: 1) Care protocol flag in patient’s chart highlighting simple avoidable complications. 2) Laminated over the bed signpost alerting ‘time critical medication’. 3) ‘Time critical medication’ stickers in drug kardex 4) Education sessions for Medical, Nursing and Ward staff. 6) Establishing out of hours access to PD medications and protocols for NPO/poor swallow. We plan to reassess significance of efforts post intervention.

1020 Delay to Surgery in Acute Perforated and Ischaemic Gastrointestinal Pathology

Introduction

Patients with acute abdominal pathology requiring emergency laparotomy who experience a delay to theatre have an increased risk of morbidity, mortality, and complications. The timeline between symptom onset and operation is ill-defined with international variance in assessment and management. This systematic review aims to define where delays to surgery occur and assess the evidence for previous interventions.

Method

A systematic review was performed searching MEDLINE and EMBASE databases (January 1st 2005 to May 6th 2020). All studies assessing the impact of time to theatre in patients with acute abdominal pathology requiring emergency laparotomy were considered.

Results

Eighty-five results were assessed to include 19 papers in the analysis. Fifteen unique timepoints were identified in the patient pathway between symptom onset and operation which could be classified into four distinct phases. Time from admission to theatre (1 to 72 hours), and mortality rate (10.6-74.5%) varied greatly between studies. Mean time to surgery was significantly higher in deceased patients compared to survivors. Delays were related to imaging, diagnosis, decision-making, theatre availability and staffing. Four of five interventional studies showed a reduced mortality following introduction of an acute laparotomy pathway.

Conclusions

There is wide variation in the definition and measurement of time delays prior to emergency surgery with few studies exploring interventions. Given the heterogenous nature of the patient population and pathologies, an assessment and management framework from onset of symptoms to operation is proposed. This could be incorporated into national mortality prediction and audit tools and assist in the assessment of interventions.

1289 Gender Representation in The Authorship of Surgical Journals

Introduction

Despite the increase in female doctors graduating from medical schools internationally, gender disparity in surgery remains. This disparity is also evident in academic surgery. This study aims to quantify the extent of gender disparity in the authorship of articles in major surgical journals.

Method

The Top 10 Surgical Journals were identified using SCImago Journal Rank indicator. Authorship details for papers published in 2019 were collected. Authors were assigned as female, male or unknown using Gender API software (Gender API, Germany). For each journal, the percentage of first author, last author, corresponding author and all authors split by gender was interrogated. Gender differences by publication type were also identified.

Results

9 of the 10 journals had full names publicly available. Overall, 2414 manuscripts were interrogated which included 16,277 number of authors. Respectively, females and males accounted for 29.8% [22.9-34.9%] (N = 655) and 62.4% [56.3-70.2%] (N = 1419) of first authors, 20.6% [11.8-27.1%] (N = 453) and 74.2% [65.6-84.1%] (N = 1706) of last authors, 23.9% [14.9-29.6%] (N = 510) and 69.9% [60.5-79.3%] (N = 2341) of corresponding authors and in total 27% [19.4-31.6%] (N = 4298) and 65.5% [58.6-73.4%] (N = 9982) of all authors. The wide range in these results could be a result of various factors.

Conclusions

This study has identified a gender imbalance in authorship positions, with the greatest difference observed in the most senior author position. Whether this is reflective of the current disparity observed in senior academic surgery positions or due to gender discrimination is unclear.

1308 Investigating the Use of a Novel Pre-Hospital Triage Tool for Acute Abdominal Surgical Emergencies – A Two-Phase Single Centre Cohort Study

Background

Despite the recent improvements in mortality in patients undergoing emergency laparotomy(EL) within the UK, delay to theatre continues to be associated with increased mortality. This study aimed to assess if patients requiring urgent surgical intervention for acute abdominal surgical pathology could be identified in the pre-hospital setting.

Method

A two-phase, single-centre, cohort study was performed. Phase 1 retrospectively investigated patients who underwent emergency laparotomy between 01/01/2019-31/12/2019 at Leeds Teaching Hospital Trust (LTHT) through the NELA database. Phase 2 prospectively assessed NEWS2 for all patients presenting to LTHT Surgical Admissions Unit with abdominal pain between 01/01/2020-31/01/2020.

Results

Phase 1: 45 patients were coded through NELA and confirmed through operation note review as undergoing EL for gastrointestinal perforation. 66%(n = 30) were assessed by the ambulance service and 80% (n = 24) had a NEWS2 of 3 or greater. Phase 2: 319 patients were assessed in SAU/ED, of which 69 initially treated by the ambulance service. 30% (n = 21) of these patients had an initial NEWS2 of 3 or above. Sensitivity of a NEWS2 score of >/3 in predicting the need for immediate surgical intervention including EL was 95%(95%CI, 74-99) and specificity was 95% (95%CI, 83-99) with a PPV of 86%(95%CI 67-95) and NPV of 98% (95%CI, 87-99).

Conclusions

A NEWS2 score of >/3 predicts the need for emergency surgical intervention including laparotomy for gastrointestinal perforation with reasonable sensitivity in this cohort. A pre-hospital triage tool for patients presenting with abdominal pain could utilise NEWS2 as an adjunct to decision-making in an acute abdominal pathway.

389 Impact of Surgical Drain Output Monitoring on Patient Outcomes in Gastrointestinal Surgery: A Systematic Review

Aim

Surgical drains are widely utilised in Gastrointestinal Surgery to prevent intra-abdominal collections and identify post-operative complications. Surgical drain monitoring ranges from simple output measurements through to specific analysis for constituents such as amylase. This systematic review aimed to determine whether surgical drain monitoring can detect post-operative complications and impact on patient outcomes.

Method

A systematic review was performed, and the following databases searched between 02/03/20 and 26/04/20: MEDLINE, EMBASE, The Cochrane Library and Clinicaltrials.gov. All studies describing surgical drain monitoring of output and content in adult patients undergoing gastrointestinal surgery were considered. Other invasive methods of intra-abdominal sampling were excluded.

Results

The search returned 396 articles. Following abstract review, 383 were excluded and 13 articles were included for full review. The studies were classified according to speciality: Oesophagogastric (1), Pancreatic (6), Hepatobiliary (2), Colorectal (3) and Emergency General Surgery (1). Post-operative monitoring of amylase and bilirubin decreased the incidence of post-operative complications (pancreatic fistulas, intra-abdominal infections, surgical site infections), length of stay and mortality rate in Pancreatic and Hepatobiliary Surgery. Testing of drain contents following Colorectal Surgery can aid anastomotic leak and the detection of peritonitis, however this did not confer any improvement in patient outcome. Surgical drain monitoring did not improve patient outcomes in Oesophagogastric Surgery.

Conclusions

Surgical drain monitoring has established advantages in the post-operative care for patients undergoing Gastrointestinal Surgery. Enhanced surgical drain monitoring involving the testing of drain amylase, bilirubin, lactate, and cytokines may improve detection of complications in the immediate post-operative period.

1404 NELA Risk Mortality Scores from Admission to Theatre in Emergency Gastrointestinal Perforation – A Retrospective Cohort Study

Background

Patients with acute abdominal pathology requiring emergency laparotomy who experience a delay to theatre have an increased risk of morbidity, mortality and complications. The aim of this study was to assess delay, from symptom onset to theatre in patients with gastrointestinal perforation and its effect on perioperative risk.

Method

A single-centre retrospective study was performed in the Leeds Trust Hospitals, UK investigating the NELA database for patients requiring emergency laparotomy for perforated gastrointestinal viscus who presented to the acute surgical unit or emergency department between 1st February 2018 and 31st January 2020.

Results

101 patients met the inclusion criteria (47% F and 53% M), mean age 59 [21-91]. 37% of patients’ NELA scores worsened from admission to pre-op (median change of + 5.9% IQR 1.3-11.5]), 14% stayed the same and 49% improved (median change of -4.4%[IQR 0.4-9.1]) 3% had their NELA score documented at the time of consent. 18% did not wait for a CT report or went straight to theatre. Mean time from admission to scan report was 9.3 hours (0.9-22.0). Median time from symptom onset to presentation (2 days [IQR 1-13]) was greater in patients with an Index of Multiple Deprivation Decile of 1-5, (n = 64, median 2 days [IQR 1-6]) compared to those in deciles 6-10, (n = 37, median 1 day[IQR 1-3]), p = 0.097.

Conclusions

NELA mortality risk score changes from presentation to surgery in patients with acute gastrointestinal perforation requiring emergency laparotomy. There is suggestion that delay in symptom onset to presentation may correlate with Index of Multiple Deprivation Decile.

Discrimination in the surgical discipline: an international European evaluation (DISDAIN)

Background

Negative workplace experiences (NWPEs), such as gender discrimination, bullying, sexual harassment and ethnic discrimination, are concerns in today’s surgical society. These negative experiences potentially impair surgeons’ performance and might impact patient care or outcomes negatively. This study aimed to assess the experience of NWPEs across the European surgical workforce.

Methods

A prospective online 34-point questionnaire was designed using a combination of Likert scale, multiple-choice and short-answer questions. Invitations were distributed through surgical associations via email/social media between 1 September and 15 November 2019. Data were analysed using non-parametric methods.

Results

Some 840 complete responses were included in the analysis. The distribution across genders and stage of surgical training was even. Of the respondents, 20 per cent (168 respondents) considered quitting their job, 4.5 per cent (38) took time off and 0.5% (4) left surgery due to NWPEs; 12.9 per cent of females and 4.4 per cent of males experienced some form of physical harassment. Females and those in training were significantly more likely to experience or witness gender discrimination and sexual harassment. Just over half of the respondents (448) did not report negative experiences, with most of these (375 respondents) being unaware of whom to report to. Nearly a fifth of respondents felt that NWPEs influenced patient care or outcomes negatively.

Conclusion

NWPEs were frequent, especially among females and those in training. While a substantial proportion of respondents experienced physical harassment, many individuals were unaware of how to raise concerns. Adverse effects on patient outcomes, surgical training and workforce retention indicate a need for urgent action.

524 Anaesthetic Use and Packing in Subcutaneous Abscess Management: A Retrospective Before and After Analysis Within A Two-Cycle Audit

Introduction

In the United Kingdom, there are no widely used guidelines within the management of subcutaneous abscesses by incision and drainage (I&D) to direct the use of local anaesthesia (LA) vs genal anaesthesia (GA); or the use of wound packing vs no packing.

Method

Two cohorts of patients undergoing I&D procedures were retrospectively identified from attendance records over a 3.5-month period. The first cohort was between 16th October 2018 to 31st January 2019. The second cohort of patients was during the COVID-19 pandemic following the introduction of new RCS guidance (intervention) between 29th March 2020 and 15th June 2020.

Results

Seventy-one patients before and 63 after the intervention were included. There were significantly more procedures performed under LA after the introduction of the intervention (n = 52; 82.5%) vs before (n = 4; 5.6%) p < 0.0001. The incidence of wound packing decreased after the intervention (n = 43; 68.3% vs n = 62; 87.3%) p = 0.00452.

Conclusions

The results demonstrate that during the pandemic, change in practice resulted in more subcutaneous abscesses being treated with LA. The majority of abscesses were packed in both cohorts although the incidence declined after the intervention. Future research should explore the patient satisfaction regarding pain management and the abscess recurrence rate.

P15: EVALUATING THE INTERNATIONAL USABILITY OF A LOW-COST LAPAROSCOPIC TRAINER IN LOW- AND HIGH-INCOME SETTINGS

Introduction

Limited access to equipment and trained personnel restrict the adoption of laparoscopic surgery globally. There are a wide range of laparoscopic trainers available; however, most of these are not affordable. We propose an ultra-low-cost laparoscopic trainer (Lap-Pack), designed for portability, ease of assembly and compatibility with smart devices. The study aims to evaluate the usability of Lap-Pack as a training tool in low- and high-income settings.

Method

An international usability study was conducted in India and the UK in 2019. The participants (n=60), consisting of senior surgeons (n=18), junior trainees (n=20) and medical students (n=22), were asked to complete two tasks using Lap-Pack. Participants then scored Lap-Pack in a 25-point questionnaire, including a pre-established Face-Validity Criteria and four major evaluation categories – Usability, Camera, View, Material.

Result

Lap-Pack scored highly in Face-Validity with a combined mean score of 4.63 (95%CI: 4.31, 4.95, p &lt;0.05) of a possible 6. In both cohorts, the Usability and Camera categories scored highest, with combined values respectively of 6.10 (95%CI: 6.01, 6.19, p &lt;0.05) and 6.09 (95%CI: 5.88, 6.31, p &lt;0.05) of a possible 7. For both centres, the highest-scoring individual criteria were its light weight and portability.

Conclusion

Overall, Lap-Pack was received positively by medical students and consultants alike, suggesting it is a suitable device for development of skills as part of a larger laparoscopic training curriculum. Its ease of assembly, portability and versatility show promise of increasing access to training opportunities worldwide.

Take-home message

Lap-Pack is an ultra-low-cost, portable laparoscopic simulator featuring compatibility with smart devices designed to help increase access to laparoscopic training worldwide. An international usability study found medical students, junior trainees and senior surgeons rated its usability and camera features highly, suggesting its employability as a laparoscopic training tool on a global scale.

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.

AB0026 SELECTIVE INHIBITION OF TYROSINE KINASE 2 WITH AN ORAL AGENT, BMS-986165, COMPARED WITH JANUS KINASE INHIBITORS

Background:

BMS-986165 is an oral, selective inhibitor of tyrosine kinase 2 (TYK2) with a unique mode of binding to the pseudokinase domain of the enzyme rather than the active site within the kinase domain. This unique mode of binding provides high functional selectivity for TYK2 versus other tyrosine kinases (TYKs) in cellular and other in vitro assays.1This approach may provide robust efficacy with a differentiated safety profile due to decreased off-target activity on other kinases. In a 12-week, placebo-controlled Phase 2 trial in patients with moderate to severe plaque psoriasis,2BMS-986165 had a favorable safety profile, and 67%–75% of patients achieved Psoriasis Area and Severity Index 75 (PASI 75) after 12 weeks at doses ≥3 mg twice daily versus 7% with placebo. BMS-986165 is currently under investigation in multiple autoimmune disorders such as psoriatic arthritis, psoriasis, and systemic lupus erythematosus.

Objectives:

To understand the selectivity of BMS-986165 compared with JAK inhibitors, such as tofacitinib (Tofa), upadacitinib (Upa), and baricitinib (Bari), at clinically relevant doses and plasma concentrations.

Methods:

In vitro whole blood assays were developed to measure the activity of common pairings of JAKs (JAK 1/3, JAK2/2, and TYK2/JAK2) and concentrations providing half-maximal inhibition (IC50) for BMS-986165, Tofa, Upa, and Bari were determined. The whole blood IC50values were plotted against pharmacokinetic profiles of these agents at approved doses and/or doses evaluated in their respective Phase 2/3 trials. The time that concentrations were >IC50and projected average daily inhibition were evaluated.

Results:

At clinically relevant doses and exposures, BMS-986165 plasma concentrations were higher than the TYK2 whole blood IC50value for a considerable part of the dosing interval. Additionally, the maximal plasma concentration (Cmax) of BMS-986165 was approximately >9- to 18-fold lower than the JAK 1/3 whole blood IC50value and >52- to >109-fold lower than JAK2/2 whole blood IC50, indicating lack of meaningful inhibition of the JAK 1-3 pathways by BMS-986165 at therapeutic doses. At clinically relevant doses, projected Cmaxvalues of Tofa, Upa, and Bari were many-fold lower than TYK2 IC50, indicating minimal or no meaningful inhibition of the TYK2 pathway. As expected, Tofa, Upa, and Bari had varying degrees of inhibition against JAK1/3 (daily average inhibition range: 70%–94%) and JAK2/2 pathways (daily average inhibition range: 24%–67%) at clinically relevant doses and exposures.

Conclusion:

These results demonstrate the high TYK2 functional selectivity of BMS-986165 at clinically relevant doses and plasma concentrations compared with Tofa, Upa, and Bari and indicate that BMS-986165 is in a different class compared with JAK 1–3 inhibitors. Ongoing studies in psoriasis and other conditions may confirm the expected safety of BMS-986165 based on the above results. The daily average inhibition of JAK1 and JAK2 likely explains some common laboratory observations and adverse events reported for the JAK1–3 inhibitors.

References:

[1]Burke JR et al.Sci Transl Med. 2019 Jul 24;11(502); eaaw1736.

[2]Papp K et al.N Engl J Med. 2018;379(14):1313-1321.

Acknowledgments:

This study was sponsored by Bristol-Myers Squibb. Editorial assistance was provided by Peloton Advantage, LLC, an OPEN Health company, Parsippany, NJ, and was funded by Bristol-Myers Squibb.

Disclosure of Interests:

Anjaneya Chimalakonda Shareholder of: Bristol-Myers Squibb, Employee of: Bristol-Myers Squibb, James Burke Shareholder of: Bristol-Myers Squibb, Employee of: Bristol-Myers Squibb, Lihong Cheng Shareholder of: Bristol-Myers Squibb, Employee of: Bristol-Myers Squibb, Joann Strnad Shareholder of: Bristol-Myers Squibb, Employee of: Bristol-Myers Squibb, Ian Catlett Shareholder of: Bristol-Myers Squibb, Employee of: Bristol-Myers Squibb, Aditya Patel Shareholder of: Bristol-Myers Squibb, Employee of: Bristol-Myers Squibb, Jun Shen Shareholder of: Bristol-Myers Squibb, Employee of: Bristol-Myers Squibb, Ihab Girgis Shareholder of: Bristol-Myers Squibb, Employee of: Bristol-Myers Squibb, Subhashis Banerjee Shareholder of: AbbVie, Bristol-Myers Squibb, Lily, Pfizer, Employee of: Bristol-Myers Squibb (current); AbbVie, Lily, Pfizer (past), John Throup Shareholder of: Bristol-Myers Squibb, Employee of: Bristol-Myers Squibb

The development and evaluation of a nationwide training program for oncology health professionals in the provision of genetic testing for ovarian cancer patients

BACKGROUND

BRCA1/2 mutation status has increasing relevance for ovarian cancer treatments, making traditional coordination of genetic testing by genetic services unsustainable. Consequently alternative models of genetic testing have been developed to improve testing at the initial diagnosis for all eligible women.

METHODS

A training module to enable mainstreamed genetic testing by oncology healthcare professionals was developed by genetic health professionals. Oncology healthcare professionals completed questionnaires before and 12 months post-training to assess perceived skills, competence and barriers to their coordinating genetic testing for women with high-grade non-mucinous epithelial ovarian cancer. Genetic health professionals were surveyed 12 months post-training to assess perceived barriers to implementation of mainstreaming.

RESULTS

185 oncology healthcare professionals were trained in 42 workshops at 35 Australasian hospitals. Of the 273 tests ordered by oncology healthcare professionals post-training, 241 (93.1%) met national testing guidelines. The number of tests ordered by genetic health professionals reduced significantly (z = 45.0, p = 0.008). Oncology healthcare professionals' perceived barriers to mainstreamed testing decreased from baseline to follow-up (t = 2.39, p = 0.023), particularly perceived skills, knowledge and attitudes. However, only 58% reported either 'always' or 'nearly always' having ordered BRCA testing for eligible patients at 12 months, suggesting oncology healthcare professionals' perceived barriers were not systematically addressed through training.

CONCLUSIONS

Oncology healthcare professionals have demonstrated a willingness to be involved in the provision of genetic testing in a mainstreaming model. If oncology services are to hold responsibility for coordinating genetic testing, their readiness will require understanding of barriers not addressed by training alone to inform future intervention design.

Determination of Patulin in Apple Juice by Liquid Chromatography: Collaborative Study

An AOAC International-International Union of Pure and Applied Chemistry-International Fruit Juice Union (AOAC-IUPAC-IFJU) collaborative study was conducted to evaluate a liquid chromatographic (LC) procedure for determination of patulin in apple juice. Patulin is a mold metabolite found naturally in rotting apples. Patulin is extracted with ethyl acetate, treated with sodium carbonate solution, and determined by reversed-phase LC with UV detection at 254 or 276 nm. Water, water-tetrahydrofuran, or water-acetonitrile was used as mobile phase. Levels determined in spiked test samples were 20, 50,100, and 200 μg/L. A test sample naturally contaminated at 31 μg/L was also included. Twenty-two collaborators in 10 countries analyzed 12 test samples of apple juice. Recoveries averaged 96%, with a range of 91-108%. Repeatability relative standard deviations (RSDr) ranged from 10.9 to 53.8%. The reproducibility relative standard deviation (RSDR) ranged from 15.1 to 68.8%. The LC method for determination of patulin in apple juice has been adopted first action by AOAC INTERNATIONAL.

Determination of D-Malic Acid in Apple Juice by Liquid Chromatography: Collaborative Study

Eleven laboratories collaboratively studied a liquid chromatographic (LC) method for determination of D-malic acid in apple juice. The mobile phase consisted of 16 mM L-valine and 8 mM copper acetate adjusted to pH 5.5 with NaOH. The UV detector was set at 330 nm, and a single reversed-phase LC column was used. Seven paired samples containing various amounts of D-malic acid ranging from 0 to 188 mg/100 mL of 12 Brix pasteurized apple juice were tested by each collaborator. Repeatability and reproducibility coefficients of variation ranged from 1.0 to 3.5% and 7.7 to 11.7%, respectively, within the range of 26 to 188 mg D-malic acid/100 mL of 12 Brix apple juice. The collabora tive study results demonstrated that the method could quantitate the economic adulteration of ap ple juice with DL-malic acid at lower levels than those reported with previous methods. The LC method for determination of D-malic acid in apple juice has been adopted first action by AOAC INTERNATIONAL.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

A hot and fast ultra-stripped supernova that likely formed a compact neutron star binary

Compact neutron star binary systems are produced from binary massive stars through stellar evolution involving up to two supernova explosions. The final stages in the formation of these systems have not been directly observed. We report the discovery of iPTF 14gqr (SN 2014ft), a type Ic supernova with a fast-evolving light curve indicating an extremely low ejecta mass (≈0.2 solar masses) and low kinetic energy (≈2 × 10⁵⁰ ergs). Early photometry and spectroscopy reveal evidence of shock cooling of an extended helium-rich envelope, likely ejected in an intense pre-explosion mass-loss episode of the progenitor. Taken together, we interpret iPTF 14gqr as evidence for ultra-stripped supernovae that form neutron stars in compact binary systems.

Saving Women's Lives in Latin America and the Caribbean: Improving Cervical Cancer Screening and Treatment Quality and Access

Background and context: It is the third leading cause of cancer deaths among females in Latin America and the Caribbean, and yet cervical cancer is almost entirely preventable and treatable. In a region where many lack even basic access to quality sexual and reproductive healthcare, screening and treatment services for HPV and cervical cancer are far from universally available. International Planned Parenthood Federation/Western Hemisphere Region (IPPF/WHR) and its member associations (MAs) are working to reverse this trend, identifying and bridging local gaps in access and services wherever possible. Aim: IPPF/WHR and its MAs seek to improve both providers' ability to deliver - and women's ability to access - quality cervical cancer screening and treatment through institutional capacity building, the introduction of new technologies, advocacy and community awareness efforts. Strategy/Tactics: 1) Increase cervical cancer services by training providers in the provision of low cost, high capacity screening and treatment methods, including visual inspection with acetic acid (VIA), HC2 and HPV DNA screening technologies, and a single-visit approach (SVA) to treatment using cryotherapy, thermocoagulation and LEEP. 2) Educate populations and increase demand for cervical cancer services by implementing public awareness campaigns and community information, education and communication (IEC) activities promoting the importance of early detection and treatment. 3) Improve and standardize clinical protocols and referral pathways by advocating among and collaborating with key decision-makers and local ministries of health. Program/Policy process: MAs are implementing small-scale pilot studies to incorporate VIA, HC2 and HPV DNA screening and new treatment to provide even greater numbers of women with potentially life-saving diagnostics and care in Belize, Honduras, El Salvador and Bolivia. As leading clinical experts and advocates, several MAs are also working with public sector counterparts to refine two-way referral pathways, standardize screening protocols and clinical guidelines, and to ensure data quality and collection. A range of Caribbean MAs have also been trained in the use of VIA, cryo and LEEP. Outcomes: From 2016 to 2017, MAs from Belize, Grenada, Suriname, and several additional Caribbean countries who received training in VIA and other screening and treatment techniques saw an average 7% increase in the number of direct cervical cancer services provided. MAs from Belize, Bolivia and Honduras also contributed to updated national cervical cancer protocols. What was learned: An effective national response to cervical cancer requires the support and collaboration of civil society organizations, which can deliver direct services and play a catalytic role in advancing technical recommendations and policy dialogue. Countries should continue to improve the quality of VIA services, until more advanced screening technologies become available and can be scaled up.

Surgical pleth index: prediction of postoperative pain and influence of arousal

BACKGROUND

There are conflicting reports concerning the outcome after anaesthesia guided by the surgical pleth index (SPI; GE Healthcare, Helsinki, Finland). One potential explanation may be the lack of evidence for the selection of SPI cut-off values. The aim of this trial was to investigate the correlation between SPI, arousal, and postoperative pain and to define a cut-off value for SPI to predict moderate-to-severe pain.

METHODS

After obtaining ethical approval and written informed consent, 70 patients undergoing non-emergency surgery were enrolled. Data relating to SPI, heart rate, mean arterial pressure, and state entropy were recorded every 10 s for the last 10 min of surgery (state entropy <60 at all times). Subsequently, recordings continued during the phase of arousal. After recovery room admission, pain scores (numerical rating scale 0-10) were obtained every 3 min for 15 min.

RESULTS

Data from 65 patients were analysed. Receiver-operating characteristic curve analysis revealed an optimal intraoperative cut-off SPI value of 30 to discriminate between numerical rating scale scores 0-3 and 4-10. For this value, the negative and positive predictive values to discriminate between numerical rating scale scores 0-3 and 4-10 were 50 and 89.7%, respectively. The SPI was significantly affected by arousal, and SPI scores obtained during this phase were not predictive of postoperative pain.

CONCLUSIONS

Surgical pleth index values are predictive of postoperative pain only if obtained before patient arousal. In contrast to previous studies, a relatively low SPI, >30, appears to predict pain with a high positive predictive value and may therefore be suggested for future studies of SPI-guided anaesthesia.

CLINICAL TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry: ACTRN12615000804583.

Open versus laparoscopic appendicectomy in acute appendicitis: results of a district general hospital

BACKGROUND

Despite multiple studies comparing the two methods, the real advantages of laparoscopic appendicectomy (LA) compared to open appendicectomy (OA) are still unclear. Purpose of the current study was to compare the results between the two techniques in a district general hospital.

METHODS

The electronic records of all patients who underwent OA or LA in a one year period were reviewed retrospectively. The comparative data points assessed included age, gender, overall complications, length of stay and Clavien-Dindo Classification of Surgical Complications, including the rates of the main types of complications.

RESULTS

300 patients were included in the study. 166 patients underwent OA and 134 patients LA. Postoperative complications were documented in 26 patients (8.7%). LA was employed predominantly in female patients (p = 0.004) and in older patients (p = 0.0015) and was associated with significantly more negative appendicectomies than OA (p = 0.002). No statistically significant difference was noted with regards to the length of hospital stay (p = 0.577), overall postoperative morbidity (p = 0.543) and grading of complications (p = 0.460). Finally, following comparison of the incidence of specific types of complications, only wound infections were significantly different, in favour of LA.

CONCLUSION

LA is safe and effective, however, besides the lower incidence of wound sepsis, demonstrates no clear advantage over OA. The selection between OA and LA should thus be tailored to the clinical scenario and the surgeon's preference.